Severe dysphagia caused by oesophgeal leiomyoma. Radiological findings

A 45-year old woman, with apparent healthy status, manifested retrosternal pain and a progressively worsening solid and liquid dysphagia with weight loss in the last weeks. Laboratory tests were normal. Esophagram with oral water-soluble contrast medium was first performed after followed by contrast-enhanced Computed Tomography (CECT) study.

Esophagram with oral water-soluble contrast medium showed a filling defect in the middle part of the oesophagus without any signs of mucosal abnormality as an extrinsic compression (figure 1). The CECT scan showed an intraluminal oesophagal soft-tissue mass (3,5x3x6 cm) of uniform density, that could not clearly be distinguished from the oesophagal wall (figure 2.a). The lesion didn’t have any calcifications and showed homogeneous contrast enhancement. Oesophageal wall resulted mildly compressed by it, but there were no signs of invasion into adjacent tissue (figure 2. b,c). There were no pathological lymph nodes in the mediastinum. The lesion was resected operatively and histological analysis confirmed diagnosis of oesophageal leiomyoma.

Oesophageal leiomyoma is the most common benign tumour of the oesophagus. It usually originates in the middle or distal part of the organ’s wall from mesenchymal tissue (smooth muscle cells) and its size doesn’t usually overcome 5 cm [1]. It is more frequently diagnosed in males than in females [2].

Its diagnosis is often accidental, due to the lack or inconsistency of symptoms (3). When increasing in size (i.e. > 1000 gr), it is defined “giant leiomyoma”, which is more likely associated to gastrointestinal symptoms, such as retrosternal pain, dysphagia, regurgitation, hypertension, bleeding and weight loss [2, 4]. It could be associated with Alport syndrome, in the form of a diffuse oesophageal leiomyomatosis [2].

The diagnosis is based on imaging techniques and biopsy. X-ray oesophageal transit study is usually the first investigation to be executed: it demonstrates a smooth filling defect in the lumen without any signs of mucosal abnormality and it appears to be helpful in differentiating benign from malignant tumours. CECT scan is particularly useful in diagnosing larger tumours, especially those localized in the distal oesophageal wall; it is also useful in determining the extension of the lesion and eventual lymphadenopathies. At CECT exam, leiomyomas appear as homogeneous, regular-shaped lesions indivisible from the oesophageal wall, with coarse calcification and moderate contrast enhancement. Conversely, endoscopy helps to detect superficial lesions, showing submucosal movable masses that don’t infiltrate the mucosa; however, endoscopy has limits in identifying the origination and growth direction of the tumour. Endoscopic Ultrasonography (EUS) has demonstrated good sensitivity in detecting the origin, nature and development of these lesions. On EUS, oesophageal leiomyoma appears as a homogenous, hypoechoic lesion surrounded by a hyperechoic region [2, 3, 5].

There are actually two different possibilities of treating an oesophageal leiomyoma, depending on the size and location of the lesion: endoscopic resection and surgery. Endoscopy is preferred for more superficial tumours, especially those arising from muscularis mucosa, and has better prognoses and less adverse effects (such as haemorrhage) then surgical treatment. Surgery, mainly in the form of thoracotomy, is preferred for more profound tumours or giant lesions [2,4].

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