Leiomioma gigante del esófago. Presentación de un caso / Giant leiomyoma of the esophagus. Presentation of a case

RESUMEN Los leiomiomas esofágicos gigantes son neoplasias raras con un curso clínico impreciso; la mayoría se origina en la porción media e inferior del órgano. Para identificar el diagnóstico y tratamiento adecuado se utilizan pruebas de imágenes y endoscópicas. Compartir y divulgar un nuevo reporte de leiomioma esofágico gigante es el propósito de este trabajo, basado en un nuevo caso. El paciente ingresó por disfagia. Las pruebas para el diagnóstico incluyeron radiografía de esófago, estómago y duodeno, endoscopía digestiva superior, tomografía axial computarizada y resonancia magnética nuclear. El paciente se sometió a cirugía mediante toracotomía derecha, se realizó enucleación de un tumor de 10x6x5cm, y se constató integridad de la mucosa. No hubo evidencias de malignidad en el estudio histopatológico. Fue dado de alta ocho días después de cirugía. La toracotomía con enucleación del tumor esofágico es un procedimiento eficaz para tratar a pacientes con leiomioma gigante.

ABSTRACT Giant esophageal leiomyomas are rare neoplasms with an imprecise clinical course; most originate from the middle and lower portion of the organ. Imaging and endoscopic tests are used to identify the proper diagnosis and treatment. The purpose of this work, based on a new case, is to share and disseminate a new report of giant esophageal leiomyoma. The patient was admitted for dysphagia. Diagnostic tests included radiography of the esophagus, stomach, and duodenum, upper digestive endoscopy, computed tomography, and MRI. The patient underwent surgery by right thoracotomy, enucleation of a 10x6x5cm tumor was performed, and the integrity of the mucosa was verified. There was no evidence of malignancy in the histopathological study. He was discharged eight days after surgery. Thoracotomy with enucleation of the esophageal tumor is an effective procedure to treat patients with giant leiomyoma.

The role of endoscopic ultrasound in the staging of tracheal neoplasm: a brief review

SUMMARY Our case report shows the complexity of dealing with tracheal tumors, highlighting the importance of the method used for staging. In this report, endoscopic ultrasound (EUS) was crucial to identify the involvement of the esophageal muscular propria in a tracheal tumor and change the surgical planning of the case. Staging this kind of tumor represents a challenge for physicians. There is no evidence in the literature on which methods represent the gold standard for T staging.

RESUMO Neste relato de caso mostramos a complexidade em lidar com tumores traqueais, destacando a importância do método usado para estadiamento. Neste relato, a ecoendoscopia (EUS) foi fundamental para identificar o envolvimento da camada muscular própria esofágica por um tumor traqueal e alterar o planejamento cirúrgico do caso. O estadiamento desse tipo de tumor representa um desafio para os médicos. Não há evidências na literatura sobre quais métodos representam o padrão ouro para o estadiamento T.

Utilização da cromoendoscopia com azul de toluidina mais solução de Lugol para diagnóstico precoce de lesões pré-malignas esofágicas e neoplasias superficiais em pacientes de alto risco / Chromoendoscopy using toluidine blue plus lugol's solution for early diagnosis of esophageal premalignant lesions and superficial neoplasms in high-risk patients

ABSTRACT BACKGROUND: Esophageal cancer is the eighth most common cancer. The prognosis is bleak in patients with advanced stages. Patients with early disease have a better prognosis than those with advanced stage. There are several techniques for the screening of premalignant and superficial lesions including chromoendoscopy. OBJECTIVE: This article aimed to determine the effectiveness of chromoendoscopy with toluidine blue combined with Lugol's solution for diagnosis of esophageal premalignant and superficial neoplastic lesions in high risk patients. METHODS: Routine white light upper endoscopy was performed. Toluidine blue was sprayed from the gastroesophageal junction to 20 cm of the dental arch. Then the uptake dye areas were characterized. Later Lugol's solution was sprayed. Areas with less-intense staining were characterized. Biopsy of the toluidine blue capturing areas and areas with less-intense staining of Lugol's solution were taken. In the cases where lesions were not evidenced after application of dyes, biopsies four quadrants of the esophageal mucosa were taken. The samples were evaluated by a digestive pathologist. RESULTS: Barrett's esophagus was the most common premalignant lesion and the early neoplastic lesion was adenocarcinoma with a sensitivity of 100%, specificity 85.7%, positive predictive value 30%, negative predictive value 100%, positive likelihood ratio 7 negative likelihood ratio 0. CONCLUSION: Chromoendoscopy with toluidine blue combined with Lugol's solution is a useful tool in the screening of esophageal premalignant lesions and superficial neoplasms.

RESUMO CONTEXTO: O câncer de esôfago é o oitavo câncer mais comum. O prognóstico é sombrio em pacientes com estágios avançados. Pacientes com doença precoce têm um melhor prognóstico do que aqueles com estágio avançado. Existem várias técnicas para a triagem de lesões pré-malignas e superficiais, incluindo cromoendoscopia. OBJETIVO: Este artigo objetivou determinar a efetividade da cromoendoscopia com azul de toluidina combinada com a solução de Lugol para o diagnóstico de lesões neoplásicas pré-malignas e superficiais esofágicas em pacientes de alto risco. MÉTODOS - A endoscopia de luz branca de rotina foi realizada de forma rotineira. O azul do toluidina foi pulverizado desde a junção gastroesofágica até 20 cm da arcada dentária. As áreas impregnadas pela tintura da tomada foram então caracterizadas. Mais adiante a solução de Lugol foi pulverizada. Áreas com coloração menos intensa foram caracterizadas. Foram realizadas biópsias das áreas de captura de azul de toluidina e áreas com coloração menos intensa da solução de Lugol. Nos casos onde as lesões não foram evidenciadas após a aplicação das tinturas, foram feitas biópsias em quatro quadrantes da mucosa esofágica. As amostras foram avaliadas por um patologista especializado. RESULTADOS: O esôfago de Barrett foi a lesão pré-maligna mais frequente e a lesão neoplásica precoce foi adenocarcinoma com sensibilidade de 100%, especificidade de 85,7%, valor preditivo positivo de 30%, valor preditivo negativo 100%, razão de verossimilhança positiva 7 e razão de verossimilhança negativa 0. CONCLUSÃO: A cromoendoscopia com azul de toluidina combinada com a solução de Lugol é uma ferramenta útil na triagem de lesões pré-malignas esofágicas e neoplasias superficiais.

Carcinoma neuroendocrino de esófago: reporte de caso / Neoendocrine carcinoma of the esophagus: report of a case

El carcinoma neuroendocrino de esófago representa menos del 2% de casos de cáncer de esófago. Esta forma de presentación es extremadamente inusual, ya que este tipo de carcinoma se suele presentar con mayor frecuencia en zonas broncopulmonares. Los síntomas suelen asociarse a la obstrucción esofágica e incluyen odinofagia, disfagia y pérdida de peso, siendo infrecuente la clínica de síndrome carcinoide. Para el diagnóstico se requiere de uno o más de los siguientes marcadores de inmunohistoquímica positivos: cromogranina A, sinaptofisina o CD56 positivos, así como la presencia de los anticuerpos EMA y PANCK positivos. Se reporta el caso de un paciente varón con diagnóstico de tumor neuroendocrino de esófago.

Neuroendocrine carcinoma of esophagus represents less than 2% of cases of cancer of the esophagus. This presentation is extremely unusual, as this type of carcinoma typically presents with greater frequency in bronchopulmonary regions. The symptoms are usually associated with esophageal obstruction and include odynophagia, dysphagia and weight loss and are not usually associated with Carcinoid syndrome. The diagnosis requires one or more of the following positive immunohistochemical markers: Chromogranin A, synaptophysin or CD56 positive, as well as the presence of EMA and PANCK positive. We report the case of a male patient with diagnosis of neuroendocrine tumor of esophagus.

Comparative study of computed tomography (CT) and pathological diagnosis toward mediastinal lymph node metastasis in esophageal carcinoma

Summary Objective: To investigate the diagnostic criteria of mediastinal lymph node metastasis (MLNM) in esophageal carcinoma (EC) by comparing the lymph node sizes measured by computed tomography (CT) and obtained by postoperative pathological examination. Method: A total of 305 EC patients were selected. MLNM location, shortest diameter and number were investigated one week before surgery, and then compared with their pathological findings. Results: The receiver operating characteristic (ROC) curve analysis revealed that the minimum diameters of MLNM in the thoracic cavity was 8 mm (area under curve [AUC] = 0.766, Youden index = 0.424), 5 mm in supraclavicular fossa (AUC = 0.785, Youden index = 0.494), 6 mm in tracheoesophageal groove (AUC = 0.755, Youden index = 0.405); the sensitivity was increased significantly, and the Youden index was increased significantly when compared with 10 mm. Conclusion: The shortest diameter of diagnostic criteria of lymph nodes in EC could be less than 10 mm on CT.

Baixa prevalência de esôfago de Barrett em área de risco para câncer esofágico no Sul do Brasil / Low prevalence of barrett's esophagus in a risk area for esophageal cancer in south of brazil

ABSTRACT BACKGROUND: Barrett's esophagus a complication of gastroesophageal reflux disease (GERD) is a precursor of esophageal adenocarcinoma. The incidence of esophageal adenocarcinoma has been increasing in most Western countries. Rio Grande do Sul (RS), the Southernmost state of Brazil has the highest rates of esophageal cancer with low prevalence of esophageal adenocarcinoma. OBJECTIVE: To investigate the prevalence of Barrett's esophagus among patients underwent to upper gastrointestinal endoscopy in the last 5 years. METHODS: The records of patients underwent upper gastrointestinal endoscopy between 2011 and 2015 were analyzed. Demographic data, GERD symptoms, endoscopic findings, extension and histological diagnosis of columnar epithelia of the esophagus were recorded. Significance among the variables was accessed by chi-square test and Fisher's exact test with 95% CI. RESULTS: A total of 5996 patients underwent to upper gastrointestinal endoscopy in the period were included. A total of 1769 (30%) patients with GERD symptoms or esophagitis and 107 (1.8%) with columnar lined esophagus were identified. Except for eight patients, the others with columnar lined esophagus had GERD symptoms or esophagitis. Barrett's esophagus defined by the presence of intestinal metaplasia occurred in 47 patients; 20 (43%) with segments over 3 cm and 27 (57%) with segments shorter than 3 cm. The global prevalence of Barrett's esophagus was 0.7% and in GERD patients 2.7%. The odds ratio for the occurrence of columnar lined esophagus in patients with GERD was 30 (95%CI=15.37-63.34). The odds ratio for the presence of intestinal metaplasia in long segments was 8 (95%CI=2.83-23.21). CONCLUSION: GERD patients had a risk 30-folds greater to present columnar lined esophagus than patients without GERD symptoms. Long segments of columnar lined esophagus, had a risk eight-folds higher to have Barrett's esophagus than short segments. Barrett's esophagus overall prevalence was 0.7%. In GERD patients, the prevalence was 2.7%. Long Barrett's esophagus represented globally 0.3% and 1.1% in GERD patients.

RESUMO CONTEXTO: Esôfago de Barrett, complicação da doença do refluxo gastroesofágico (DRGE), é lesão precursora do adenocarcinoma esofágico. O adenocarcinoma esofágico apresenta incidência crescente principalmente no ocidente. O estado do Rio Grande do Sul apresenta as taxas mais altas de câncer esofágico no Brasil, porém com baixa prevalência de adenocarcinoma. OBJETIVO: Investigar a prevalência de esôfago de Barrett em pacientes submetidos a endoscopia digestiva alta nos últimos 5 anos. MÉTODOS: Revisão de prontuários dos pacientes submetidos a endoscopia digestiva alta entre 2011 e 2015. Registrados dados demográficos, sintomas de DRGE, achados endoscópicos, extensão e diagnóstico histológico de epitelização colunar do esôfago. A significância entre as variáveis foi acessada pelos testes do qui-quadrado e exato de Fisher com IC95%. RESULTADOS: Foram incluídos 5996 pacientes. Identificamos 1769 (30%) com sintomas de DRGE ou esofagite e 107 (1,8%) com epitelização colunar. À exceção de oito pacientes com epitelização colunar, os demais apresentavam sintomas de DRGE ou esofagite. Esôfago de Barrett definido pela presença de metaplasia intestinal ocorreu em 47 pacientes; 20 (43%) com segmentos acima de 3 cm e em 27 (57%) com segmentos menores. A prevalência global de esôfago de Barrett foi 0,7% e em pacientes com DRGE foi 2,7%. A razão de chances para a ocorrência de epitelização colunar em pacientes com DRGE foi 30 (IC95%=15,37-63,34) e para a ocorrência de metaplasia intestinal em segmentos longos foi 8 (IC95%=2,83-23,21). CONCLUSÃO: Pacientes com DRGE apresentaram risco 30 vezes maior que pacientes sem DRGE para a ocorrência de epitelização colunar. O risco de ocorrência de esôfago de Barrett em segmentos longos foi oito vezes maior. A prevalência global de esôfago de Barrett foi 0,7%. Em pacientes com DRGE a prevalência foi 2,7%. Segmentos longos de esôfago de Barrett representaram globalmente 0,3% e em pacientes com DRGE 1,1%.

Endoscopic Ultrasonography in the Diagnosis and Treatment Strategy Choice of Esophageal Leiomyoma

OBJECTIVES: Esophageal leiomyoma is the most common benign tumor of the esophagus, and it originates from mesenchymal tissue. This study analyzed the clinicopathological characteristics of esophageal leiomyoma and aimed to evaluate the role of endoscopic ultrasonography in the diagnosis and treatment selection for these lesions. METHODS: Two hundred and twenty-five patients who had suspected esophageal leiomyomas in endoscopic ultrasonography were enrolled at the Endoscopy Center of The First Affiliated Hospital, Zhejiang University from January 1st, 2009 to May 31th, 2015. The main outcomes included the demographic and morphological characteristics, symptoms, comparisons of diagnosis and treatment methods, adverse events, and prognosis. RESULTS: One hundred and sixty-seven patients were diagnosed as having an esophageal leiomyoma by pathological examination. The mean patient age was 50.57±9.983 years. In total, 62.9% of the lesions originated from the muscularis mucosa, and the others originated from the muscularis propria. The median distance to the incisors was 30±12 cm. The median diameter was 0.72±0.99 cm. As determined by endoscopic ultrasonography, most existing leiomyomas were homogeneous, endophytic, and spherical. The leiomyomas from the muscularis mucosa were smaller than those from the muscularis propria and much closer to the incisors (p<0.05). SMA (smooth muscle antibody) (97.2%) and desmin (94.5%) were positive in the majority of patients. In terms of treatments, patients preferred endoscopic therapies, which led to less adverse events (e.g., intraoperative bleeding, local infection, pleural effusion) than surgical operations (p<0.05). The superficial leiomyomas presented less adverse events and better recovery (p<0.05) than deep leiomyomas. CONCLUSION: Endoscopic ultrasonography has demonstrated high accuracy in the diagnosis of esophageal leiomyomas and provides great support in selecting treatments; however, EUS cannot completely avoid misdiagnosis, so combining it with other examinations may be a good strategy to solve this problem.

Esophageal transit time scintigraphy in the assessment of the esophagus motility

The esophagus is 25 cm long muscular tube, which acts as a passage of food from the mouth to the stomach

Many diseases affect the esophagus, which may affect its morphology and function. Hence, several diagnostic modalities are used to assess the esophagus abnormalities, such as endoscopy, manometry, barium contrast studies and gastroesophageal scintigraphy studies

Gastroesophageal scintigraphy is a simple, non-invasive and well-tolerated method used to assess mainly the upper GI tract motility

We present a case of gastroesophageal adenocarcinoma where an esophageal scintigraphy was performed to assess the esophageal motility

Synchronous second primary cancers in patients with squamous esophageal cancer: clinical features and survival outcome

BACKGROUND/AIMS: Unexpected diagnosis of synchronous second primary cancers (SPC) complicates physicians' decision-making because clinical details of squamous esophageal cancer (EC) patients with SPC have been limited. We evaluated clinical features and treatment outcomes of patients with synchronous SPC detected during the initial staging of squamous EC. METHODS: We identified a total of 317 consecutive patients diagnosed with squamous EC. Relevant clinical and cancer-specific information were reviewed retrospectively. RESULTS: EC patients with synchronous SPC were identified in 21 patients (6.6%). There were significant differences in median age (70 years vs. 63 years, p = 0.01), serum albumin level (3.3 g/dL vs. 3.9 g/dL, p < 0.01) and body mass index (20.4 kg/m2 vs. 22.8 kg/m2, p = 0.01) between EC patients with and without SPC. Head and neck, lung and gastric cancers accounted for 18.2%, 22.7%, and 18.2% of SPC, respectively. Positron emission tomography-computed tomography (PET-CT) detected four cases (18.2%) of SPC that were missed on CT. Management plans were altered in 13 of 21 patients (61.9%) with detected SPC. Curative esophagectomy was attempted in 28.6% of EC patients with SPC (vs. 59.1% of patients without SPC; p = 0.006). EC patients with SPC had significantly lower 5-year survival than patients without SPC (10.6% vs. 36.7%, p = 0.008). CONCLUSIONS: Synchronous SPC were found in 6.6% of squamous EC patients, and PET-CT contributed substantially to the detection of synchronous SPC. EC patients with SPC had poor survival due to challenges of providing stage-appropriate treatment.

Modified Radiology-Guided Percutaneous Gastrostomy (MRPG) for Patients with Complete Obstruction of the Upper Digestive Tract and Who are without Endoscopic or Nasogastric Access

OBJECTIVE: We wanted to report on our experience with modified radiology-guided percutaneous gastrostomy (MRPG) without endoscopic or nasogastric access for treating patients with complete obstruction of the upper digestive tract. MATERIALS AND METHODS: Fourteen oncology patients (13 had hypopharyngeal cancer and 1 had upper esophageal cancer) with complete obstruction of the upper digestive tract were recruited. Conventional percutaneous endoscopic gastrostomy (PEG) and radiologic (fluoroscopy-guided) percutaneous gastrostomy (RPG) were not feasible in all the patients. An MRPG technique (with a combination of ultrasound, an air enema and fluoroscopic guidance) was performed in these patients. RESULTS: We achieved successfully percutaneous gastrostomy using the modified technique in all patients without any major or minor complications after the procedure. CONCLUSION: A modified radiology-guided percutaneous gastrostomy technique can be safely performed in patients who failed to receive conventional PEG or RPG due to the absence of nasogastric access in the completely obstructed upper digestive tract.

18F-Fluorodeoxyglucose PET/CT in a Patient with Esophageal and Genital Leiomyomatosis

Diffuse esophageal leiomyomatosis is a rare benign tumor, which can be associated with leiomyoma in female genital tracts involving the uterus, vagina, and vulva. Alport syndrome, an inherited disorder that includes the kidneys, eyes, and sensorineural hearing loss, is also rarely associated with these multiple leiomyomatosis. In our case, 18F-fluoroseoxyglucose positron emission tomography/computed tomography was used to distinguish esophageal and genital leiomyomatosis from malignant masses.

Vascular tethering of the megaoesophagus by the azygos arch masquerading as a malignancy.

We report the case of a 50-year-old male, a known case of achalasia cardia for 15 years, who after being successfully treated earlier by pneumatic dilatation, presented with recurrent dysphagia due to vascular tethering of the megaoesophagus by the azygos arch simulating a malignant oesophageal stricture. The patient underwent oesophagectomy because of our inability to rule out the possibility of a malignancy developing in the mid-portion of the long-standing megaoesophagus. We wish to highlight the existence of this new clinical entity and the diagnostic as well as therapeutic dilemmas posed by it.

A Case of Primary Esophageal B-cell Lymphoma of MALT type, Presenting as a Submucosal Tumor

The primary esophageal lymphoma is extremely rare, and shows various morphologic characteristics. Only a single case of mucosa-associated lymphoid tissue (MALT) type lymphoma confined to the esophagus has been reported in the literature. A 61-yr-old man was referred to our hospital for evaluation of an esophageal submucosal tumor (SMT) that had been detected incidentally by endoscopy. He had a history of pulmonary tuberculosis with long-term anti-tuberculosis medication 15 yr before, and also had a history of syphilis, which had been treated one year before. He had been taking a synthetic thyroid hormones for the past 10 months because of an autoimmune thyroiditis. Endoscopy showed a longitudinal round and tubular shaped smooth elevated lesion, which was covered with intact mucosa and located at the mid to distal esophagus, 31 cm to 39 cm from the incisor teeth. Endoscopic ultrasonography (EUS) showed a huge longitudinal growing intermediate- to hypo-echoic mass located in the submucosal layer with internal small, various sized honeycomb-like anechoic lesions suggesting germinal centers. Subsequently, he underwent a surgery, which confirmed the mass as a primary esophageal low-grade B-cell lymphoma of MALT type.

Leiomyoma of esophagus [a case report]

A leiomyoma of oesophagus is a rare tumour, but it is considered the commonest benign tumour involving the oesophagus. We report a case of leiomyoma of oesophagus as we believe this is the first case which as been reported in Bahrain. The clinical, radiological and pathological findings are discussed

Computed tomography evaluation of esophageal carcinoma.

Forty patients of histologically proven esophageal carcinoma were subjected to computed tomography (CT) with the objective to assess its reliability in preoperative evaluation of these patients. The findings were confirmed on surgery in twenty five of these patients, thought to be resectable. Bronchoscopy was performed to evaluate bronchial tree in cases of tumor of upper and middle third of esophagus. CT was found to be sensitive in predicting the location and size of tumor, in assessing invasion of tracheo-bronchial tree, spread to liver, celiac and left gastric nodes. However, it was not successful in picking up metastatic spread to local periesophageal nodes in five cases and celiac in one case. The study concluded CT should be carried out for preoperative evaluation of esophageal carcinoma to select operable cases and avoid unnecessary radicle surgery in advanced cases.

Palliative endoscopic electrocautery of esophageal cancer.

Six patients with obstructing esophageal carcinoma who were poor candidates for surgery were treated by endoscopic electrocautery. All of them were able to swallow well after 3 sessions of treatment. Endoscopic electrocautery is effective in palliative management of esophageal carcinoma, inexpensive and can be done with acceptable complications.