대한흉부영상의학회 Weekly Chest Cases

Case No : 303 Date 2003-08-16

Courtesy of Hyun Ju Lee, M.D. / Seoul National University College of Medicine, Seoul, Korea
Age/Sex 32 / M
Chief ComplaintDysphagia for six months

Figure 1
Figure 2
Figure 3

Diagnosis With Brief Discussion

Diagnosis: Esophageal Leiomyoma
Radiologic Findings: Figs 1. Chest PA shows left paravertebral mass opacity that obliterates descending aortic shadow.

Fig 2. Chest CT scan shows a circumferential wall thickening of the esophagus. The length of the thickened esophagus was 7.5 cm to just above the gastroesophageal junction (not shown).

Figs 3. Esophagography shows segmental luminal narrowing in the distal esophagus. The mucosal folds are well preserved.

According to surgeons, the esophageal mucosa was intact and the mass peeled easily from the muscle layer. Enucleation of the mass was successfully performed. On gross examination, the surface of the mass was smooth and multi-lobulated (Figs 4-5). Final histologic diagnosis was esophageal leiomyoma.
Brief Review: Although it is the most common benign esophageal tumor, esophageal leiomyoma is relatively rare, its overall incidence being 8-43 per 10,000 autopsy series (1, 2). The reported radiographic findings of esophageal leiomyoma describe it as a smoothly marginated, round or lobulated mass projecting to one or both sides of the mediastinum along the course of the esophagus (3, 4). Esophagography reveals it as a localized intramural mass contrasting with the surrounding air column (4, 5). According to the reported CT findings, esophageal leiomyomas are smoothly marginated, round or ovoid masses of muscle attenuation, lying intramurally or eccentrically within the esophageal wall. Surrounding mediastinal fat is not usually disrupted (4, 6, 7).

Approximately 60 % of leiomyomas occur in the lower third of the esophagus, 33% in the middle third and 7% in the upper third (8). Their relative rarity in the upper esophagus reflects the smaller amount of smooth muscle in that region. About 50 percent of patients remain asymptomatic, while varying degrees of dysphagia and substernal pain are the most common presenting symptoms. Esophageal leiomyomas grow slowly and usually produce intermittent, insidiously progressive symptoms. Occasionally, they encircle the esophagus in a serpentine or U-shaped fashion and cause obstructive symptoms. Recourse to surgery depends on a tumor's size and location, as well as mucosal fixation, stomach involvement, and its adherence to contiguous structures (9). Enucleation without entering the esophageal lumen, or esophageal resection, is successful even with a large tumor (10).
References: 1. Seremetis MG, Lyons WS, Deguzman VC, Peabody JW. Leiomyomata of the esophagus. Cancer 1976;38:2166-2175

2. Moersch HJ, Harrington SW. Benign tumor of the esophagus. Ann Otol 1944;53:800-817

3. Barreiro F, Seco JL, Molina J, et al. Giant esophageal leiomyoma with secondary megaesophagus. Surgery 1976;79:436-439

4. Gallinger S, Steinhardt MI, Goldger M. Giant leiomyoma of the esophagus. Am J Gastroenterol 1983;78:708-711

5. Montesi A, Pesaresi A, Graziani L, Salmistraro D, Dini L, Bearzi I. Small benign tumors of the esophagus: radiological diagnosis with double-contrast examination. Gastrointest Radiol 1983;8:207-212

6. Megibow AJ, Balthazar EJ, Hulnick DH, Naidich DP, Bosniak MA. CT evaluation of gastrointestinal leiomyomas and leiomyosarcomas. Am J Roentgenol AJR 1985;144:727-731

7. Yang PS, Lee KS, Lee SJ, Kim TS, Choo IW, Shim YM, Kim K, Kim Y. Esophageal leiomyoma:
radiologic findings in 12 patients. Korean J Radiol. 2001;2:132-137

8. Storey CF, Adams WC. Leiomyoma of the esophagus: report of four cases and a review of the surgical literature. Am J Surg 1956;91:3-23
9. Seremetis MG, Lyons WS, de Guzman VC, et al. Leiomyomata of the esophagus: an analysis of 838 cases. Cancer 1976;38:2166-2177

10. Seremetis MG, de Guzman VC, Lyons WS, et al. Leiomyoma of the esophagus: a report of 19 surgical cases. Ann Thorac Surg 1973;16:308-316
Keywords: Esophagus, Benign tumor,

No. of Applicants : 30

▶ Correct Answer : 23/30, 76.7%

- Annecy Hospital, France Gilles Genin
- Asan Medical Center, Korea Eun Jin Chae
- Centre d'imagerie Jacques Callot. Nancy, France Lionel Cannard
- Chonnam National University Hospital, Korea Seok Kyun Chung
- Chonnam National University Hospital, Korea Jin Woong Kim
- Chonnam National University Hospital, Korea Seul-Kee Kim
- CHR Annecy, France Rafik Mahdi
- CHU Nancy-Brabois, France Denis Regent
- Chung Li Ten-Chen Hospital,Taiwan Kui-Lin Zheng
- Chungju Hospital Konkuk University, Korea Chang Hee Lee
- CIM Saint Dizier, France JC Leclerc
- Gwangmyoung Sung-Ae Hospital, Korea Jiyong Rhee
- Hangang Sacred Heart Hospital, Korea Eil Seong Lee
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Jecheon Public Health Center, Korea Seung Hun Ryu
- Kangbuk Samsung Hospital, Korea Semin Chong
- MD anderson cancer center, TX, USA Jeong-Geun Yi
- Ondokuz Mayis University, Samsun, Turkey Cetin Celenk
- Shinmasan Hospital, Korea Kyung Hwa Jung
- Social Security Hospital, Ankara, Turkey Meric Tuzun
- St Stephen's Hospital, Tis Hazari, Delhi, India Jasdev S Sawhney
- Upasana Hospital, Kollam, India Joy A Thomas

▶ Semi-Correct Answer : 4/30, 13.3%

- Chonnam National University Hospital, Korea Nam-Yeol Lim
- Ewha Womans University MokDong Hospital, Korea Yookyung Kim
- Gochang hoispital. Korea Seung-Hyung Kim
- Gyeong-sang National University Hospital, Jinju, Korea. Seok-Hyun Kim

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 303 Date 2003-08-16

Discussion

No. of Applicants : 30