What is Esophageal Leiomyoma?
Esophageal leiomyomas are the most common non-cancerous tumors of the esophagus, which is the tube that connects your mouth and stomach. Despite this, they’re actually quite rare, making up less than 1% of all esophageal tumors. Around two-thirds of these non-cancerous esophageal tumors are leiomyomas, while the rest are typically cysts, polyps, or cysts.
What Causes Esophageal Leiomyoma?
Leiomyomas are a type of benign (non-cancerous) tumor found most often in the esophagus, the tube that connects your throat to your stomach. Benign means that they don’t spread to other parts of the body. They are the most common type of ‘mesenchymal’ tumors, which account for two-thirds of all benign conditions in the esophagus. ‘Mesenchymal’ refers to tumors that originate from the body’s connective tissues, in this case, the smooth muscle cells.
However, it’s not exactly clear why leiomyomas form in the first place or how they develop. ‘Etiology’ refers to the cause or origin of a disease, while ‘pathogenesis’ is the way a disease develops. For leiomyomas, these aspects remain uncertain.
Risk Factors and Frequency for Esophageal Leiomyoma
Leiomyoma of the esophagus is a condition that is more commonly seen in men than women, with a ratio of 2:1. It usually affects people between the ages of 20 and 50. These tumors most often develop in the lower two-thirds of the esophagus. Tumors in the upper third of the esophagus make up only 10% of all cases of esophageal leiomyomas. Most of these tumors are discovered when they are smaller than 5 cm. It’s unusual for them to grow larger than 10 cm, and if they do, they’re referred to as giant esophageal leiomyomas. These can occur as a single tumor or multiple ones.
Signs and Symptoms of Esophageal Leiomyoma
Leiomyomas of the esophagus, which are rare types of tumors, often do not cause any symptoms when they are less than 5 cm in size. However, when these tumors get bigger, they can lead to various symptoms. The most common ones include difficulty swallowing, chest pain, undefined discomfort behind the breastbone, heartburn, and sometimes, regurgitation. In rare instances, these tumors might lead to gastrointestinal bleeding if they wear away the lining of the esophagus.
Despite these symptoms, physical examinations often do not reveal any specific findings related to esophageal leiomyomas. The symptoms do not follow a consistent pattern based on where the tumor is located in the esophagus. On rare occasions, a patient may have a persistent cough if they have a significantly large leiomyoma in their esophagus.
Interestingly, large leiomyomas in the esophagus typically grow outward, so difficulty swallowing is not a guaranteed symptom and is not an indicator of the tumor’s size. Many of these tumors are unexpectedly discovered during endoscopic procedures or radiological examinations. With the increasing use of these testing procedures, more cases of esophageal leiomyomas are being identified.
Testing for Esophageal Leiomyoma
An esophageal leiomyoma is often diagnosed by chance during a regular check-up or screening for issues related to the upper part of the stomach and digestive track, also known as the upper gastrointestinal (GI) tract. The most common imaging test used to check for suspected problems in the esophagus is an upper GI barium contrast study, or oesophagogram. It’s a simple and less invasive test that is widely available. This test involves drinking a chalky liquid that contains barium, which helps doctors see the esophagus more clearly on x-rays.
In these x-rays (barium contrast series), an esophageal leiomyoma, which is a kind of tumor in the esophagus, appears as an area that blocks the barium from filling the entire esophagus. It typically looks like a smooth bump sticking out into the opening of the esophagus, underneath an area of normal lining tissue. It’s easy to spot a clear angle where the tumor meets healthy tissue.
When an endoscopy is done, which is a procedure where a flexible tube with a light and camera attached to it is inserted down the throat for doctors to examine your esophagus, these tumors can be seen as movable bumps underneath the tissue lining. The endoscopy confirms there’s a growth by clearly showing a lump extending into the opening of the esophagus, with healthy-looking lining tissue covering the bump.
A CT scan, which is an advanced X-ray that provides more detail than regular X-rays, is another valuable test that can help confirm the diagnosis. A CT scan shows a tumor of uniform density (meaning it looks solid and is the same throughout) coming from the wall of the esophagus.
Today, endoscopic ultrasonography has become a critical test in diagnosing esophageal leiomyoma. This test combines endoscopy and ultrasound to give doctors a detailed view of the layers of the esophageal wall. The tumor appears as a solid mass of uniform density, causes a low-intensity acoustic (sound wave) shadow, and has clear boundaries. This test can also show if there’s no enlargement of lymph nodes in the area between the lungs (mediastinum), which can be a sign of cancer.
Treatment Options for Esophageal Leiomyoma
There’s no universally agreed-upon protocol for treating tumors based on their size. That said, removal (excision) or extraction (enucleation) of the tumor is commonly recommended for patients showing symptoms. The standard surgical procedure to do this includes making an incision (open thoracotomy) into the chest wall.
Depending on the tumor size and location, surgeons may either remove the tumor along with part of the food pipe (esophagus) or just remove the tumor. For example, particularly large tumors or tumors affecting long segments of the esophagus often require the removal of a part of the esophagus (esophageal resection). Sometimes, tumors located in the middle third of the esophagus can be accessed via an incision on the right side of the chest. Similarly, tumors in the lower third of the esophagus may be approached through an incision on the left side.
The downside with a traditional chest-wall incision is that patients often suffer from wound pain and a potential lung complication known as atelectasis (the partial or complete collapse of the lung).
Recently, minimally invasive surgeries, such as video-assisted thoracoscopic surgery, have been increasingly embraced by the medical community. These techniques make use of video equipment to visualize and operate on the tumor through small incisions. This approach is often preferred to remove leiomyomas (a type of tumor) in the upper two-thirds of the esophagus. The minimally invasive surgical approach has been reported to result in a shorter hospital stay, fewer lung complications, and less wound pain compared with the open procedure.
Presently, other methods such as endoscopic submucosal dissection (a technique where the tumor is precisely cut from the surrounding tissue using an endoscope) are gaining popularity. Some medical centers have even started leveraging robotics, such as the Da Vinci system, to assist with surgery. Typically, after removing the tumor, the muscle layer is closed up. However, some reports suggest that large incisions can be left open without causing additional complications.
An esophageal resection is generally reserved for those with very large tumors. On the other hand, small, symptom-free tumors, those less than 1 cm in size, are typically managed by regular check-ups and keeping the condition under observation.
What else can Esophageal Leiomyoma be?
If you have been diagnosed with esophageal leiomyoma, your doctor would have also considered other diseases with similar symptoms. These could have been:
- Achalasia
- Esophageal cancer
- Esophageal diverticula
- Esophageal hematoma
- Esophageal lymphoma
- Esophageal motility disorders
- Esophageal spasm
- Esophageal stricture
- Esophageal varices
- Esophagitis
- Foreign body aspiration
- Vascular surgery for arteriovenous
Your doctor made a diagnosis after considering these other possible conditions.
