Esophageal Submucosal Lesions Research Articles

Atypical esophageal submucosal tumor lesion with aortoesophageal fistula after thoracic endovascular aortic repair.

Atypical esophageal submucosal tumor lesion with aortoesophageal fistula after thoracic endovascular aortic repair.

Demystify esophageal submucosal tumor: angiomas.

A 51-year-old man presented to the gastroenterology department with a history of abdominal discomfort. Computed tomography was unremarkable. Upper gastrointestinal endoscopy showed a submucosal mass lesion at the esophagus, with a 36cm distance from the incisors. The esophageal submucosal mass lesion with mixed echo was confirmed by endoscopic ultrasound (EUS). Endoscopic submucosal dissection (ESD) was performed, and the mass lesion was resected in a whole piece. Histopathological examination showed lymphatic and blood vessels, which demonstrated an esophageal vascular tumor. Further immunohistochemistry revealed tumor cells that stained positive for CD34 and D2-40.

S2818 Endoscopic Removal of a Symptomatic Benign Esophageal Sub-Mucosal Lesion

Introduction: The esophagus is a rare site for benign mucous duct cyst(mucocele). Mucoceles commonly occur from an obstructing salivary gland duct or rupture of the salivary gland. Therefore, mucoceles are most often found in the oral cavity. Symptomatic esophageal polyps or cysts have traditionally required surgical intervention. Endoscopic resection has become an option over the last few years and includes endoscopic mucosal resection or submucosal dissection. We present a case of an esophageal submucosal polypoid lesion that was removed endoscopically and revealed a rare and interesting pathology Case Description/Methods: A 70 year old female was referred for evaluation of reflux symptoms. During her initial outpatient visit she described worsening reflux symptoms and dysphagia. initially having dysphagia just to liquids but now progressing to solids. A trial of pantoprazole significantly improved her reflux symptoms but her esophageal dysphagia persisted. An upper endoscopy revealed a polypoid lesion at least 2.5 cm in length in the upper third of the esophagus (Figure a). A 2.5 cm heterogenous polypoid lesion without vascularity was seen on endoscopic ultrasound and doppler exam. Given lack of vascularity, the decision was made to attempt endoscopic resection. An endoloop was used to place at the base of the lesion, followed by resection(Figure b) Endoscopic appearance was most consistent with a fibrous polyp. Histologic study demonstrated the wall consisted of two muscle layers consistent with benign mucous cyst (Figure c). On follow up patients’ symptoms had resolved Discussion: A symptomatic esophageal polyp identified on an endoscopy carries an extensive differential diagnosis ranging from benign to malignant. Esophageal mucoceles are thought to occur due to recanalization of the upper digestive tract with subsequent coalescence of vacuoles. Histologically, benign mucous cysts are lined with two muscle layers. Prior cases have reported mucoceles emerging in the esophageal remnant directly following bypass surgery or secondary to tracheoesophageal fistula. We report a unique case of spontaneous emergence of mucocele without an obvious prior etiology or pre-disposing surgical intervention. Rarely, an esophageal cyst causes symptoms of dysphagia or regurgitation requiring removal. Endoscopic resection has gained popularity in recent years, due to the low rates of morbidity and mortality. Additional reports of esophageal mucoceles will help in understanding this rare condition better.Figure 1.: a: Endoscopic appearance of an esophageal submucosal lesion; b: nodule post-resection; c: Histologic study demonstrated the wall consisted of two muscle layers consistent with benign mucous cyst.

Deep Learning-Based Ultrasound Combined with Gastroscope for the Diagnosis and Nursing of Upper Gastrointestinal Submucous Lesions.

The study focused on the diagnostic value of deep learning-based ultrasound combined with gastroscope examination for upper gastrointestinal submucous lesions and nursing. A total of 104 patients with upper gastrointestinal submucous lesions diagnosed in hospital were selected as the research subjects. In this study, the feed forward denoising convulsive neural network (DnCNN) was improved, and the n-DnCNN model was designed and applied to ultrasonic image processing. The peak signal-to-noise ratio (PSNR) and structural similarity (SSIM) of Gaussian filtering, NL-means, and DnCNN were then compared with n-DnCNN. Subsequently, the distribution and types of submucosal lesions in different parts of the upper digestive tract were analyzed by ultrasound combined with gastroscope and gastroscope examination alone, and the diagnostic performance of this method was evaluated. The results showed that the average PSNR and SSIM of the n-DnCNN model were 33.01 dB and 0.87, respectively, which were significantly higher than GF, NL-means, and DnCNN algorithms, and the difference was statistically significant (P < 0.05). Of the 116 lesions detected, 49 were located in the esophagus (42.24%), 52 in the stomach (44.83%), and 15 in the duodenum (12.93%). Of the 49 esophageal submucosal lesions, 6.12% were located in the upper esophagus, 55.1% in the middle esophagus, and 38.79% in the lower esophagus, and the difference was statistically significant (P < 0.05). Of the gastric submucosal lesions, the lesions in the gastric cardia were significantly less than in other parts, and the difference was statistically significant (P < 0.05). The accuracy of ultrasound combined with gastroscope in the diagnosis of upper gastrointestinal submucous episodes was 82.32%, higher than that of gastroscope examination, and the difference was statistically significant (P < 0.05). In conclusion, the n-DnCNN model has a good noise reduction effect, and the obtained image is of high quality. Ultrasound combined with gastroscope examination can effectively improve the accuracy of diagnosis of upper gastrointestinal submucous lesions.

Clip band ligation ablation.

Band ligation–assisted endoscopic mucosal resection (BL-EMR) is an established procedure to remove esophageal, gastric, and rectal mucosal and submucosal lesions.1 Not infrequently, small duodenal carcinoids or neuroendocrine tumors (NETs) are found during routine endoscopy. These tumors are located in the submucosal and mucosal layers. Although there are reports of managing small duodenal NETs with BL-EMR,2 there are risks of perforation.3

Esophageal lymphangioma: a case report and review of literature

BackgroundLymphangioma of the esophagus is an exceedingly rare benign tumor. Herein, we reported a case of lymphangioma in the thoracic esophagus.Case presentationThe patient was a 48-year-old woman who presented to our hospital with a one-month history of dysphagia. Upper endoscopy revealed an esophageal submucosal lesion that was completely removed by endoscopic submucosal dissection. Pathologic examination of the resected specimen secured the diagnosis of lymphangioma. A review of the PUBMED indexed literature in English with the key words of esophagus and lymphangioma was carried out and the results were discussed.ConclusionEsophageal lymphangioma is a rare submucosal tumor and should be included in the differential diagnosis of esophageal submucosal tumors.

Esophageal Metastatic Sub-mucosal Lesion of Hepatocellular Carcinoma Diagnosed by EUS

Esophageal Metastatic Sub-mucosal Lesion of Hepatocellular Carcinoma Diagnosed by EUS

Clinical value of endoscopic ultrasonography for esophageal leiomyoma in elder patients.

It's hard for conventional endoscopy to make a distinction between esophageal leiomyoma and submucosal lesions. The clinical features of elder patients with esophageal leiomyoma may be different with non-elder ones. This study examined the clinical value of endoscopic ultrasonography (EUS) in patients with esophageal leiomyoma, conclude the clinical characteristics of them, especially elder ones. During 2005-2015, 2,134 patients were diagnosed with esophageal leiomyoma by EUS, there are 249 elder patients (65 years and older) and 1,885 non-elder patients (under 65 years). We analyzed the clinical features, auxiliary examinations features, treatment outcomes and follow-up results of these patients, especially elder ones. EUS were well tolerable in elder and non-elder patients. There was no difference in number, location, origin, size of lesions and in symptoms related esophageal leiomyoma between two groups. Elder patients had more positive changes in serological examinations. Preoperative diagnostic accuracy of EUS for esophageal leiomyoma was obviously superior to conventional endoscopy and computed tomography (CT). The misdiagnosis rate of malignant tumors was higher in elder ones. Fewer elder patients chose to be treated. Elder patients had higher complication incidence and hospitalization rate. During follow-up, most lesions showed no changes in patients without treatment, no recurrence in patients received treatments. Esophageal leiomyoma progresses slowly and has a benign course. EUS is of great value in patients with esophageal leiomyoma. The diagnosis and treatment of elder patients with esophageal leiomyoma are different with non-elder ones, and EUS can provide scientific and reasonable methods to manage elder patients.

Esophageal insufflation computed tomography for the diagnosis and management of esophageal submucosal tumors.

The selection of therapy for benign esophageal lesions depends in part on whether the lesion extends to or through the esophageal muscle wall. The advent of endoscopic dissection of deep lesions has made this distinction important in the choice between different forms of advanced endoscopic therapy. The goal of this study was to evaluate esophageal insufflation computed tomography (EICT) for the diagnosis and management of esophageal submucosal tumors (SMTs). Between April 2011 and May 2013 at the Second Affiliated Hospital of Harbin Medical University, 27 patients with esophageal SMTs diagnosed by gastroscopy were studied observationally. Entry criteria included tumors larger than 0.5cm. We compared endoscopic ultrasound (EUS) and EICT to assess lesion depth and the relationship between the submucosal lesion and the esophageal wall using the resected lesion as the gold standard. Twenty-seven esophageal SMTs were evaluated. EUS and EICT accurately identified nine as superficial to the muscularis propria. EICT correctly identified the relation of the tumor extension and the outer esophageal wall in all 18 lesions that originated from the muscularis propria; only nine were correctly assessed by EUS (P<0.001). EICT enables improved judgment of the relation of esophageal lesions and the esophageal-mediastinal border. We propose EICT as a new, safe, effective, useful, simple and high-tolerance method for assessing the depth and relationships of esophageal submucosal lesions.

Multidrug-Resistant Tuberculous Mediastinal Lymphadenitis, with an Esophagomediastinal Fistula, Mimicking an Esophageal Submucosal Tumor.

Mediastinal tuberculous lymphadenitis rarely mimics esophageal submucosal tumor, particularly in the case of multidrug-resistant tuberculosis (MDR-TB). Herein, we report the case of a 61-year-old woman who visited a local hospital complaining of odynophagia. An initial esophagogastroduodenoscopy revealed an esophageal submucosal tumor, and subsequent chest computed tomography showed subcarinal lymphadenopathy with an esophagomediastinal fistula. The patient was then referred to Samsung Medical Center, and a second esophagogastroduodenoscopy showed deep central ulceration, as well as a suspicious fistula in the esophageal submucosal tumor-like lesion. A biopsy examination of the ulcerative lesion confirmed focal inflammation only. Next, an endobronchial, ultrasound-guided lymph node biopsy was performed, and TB was confirmed. The patient initially began a course of isoniazid, rifampicin, ethambutol, and pyrazinamide. However, after a drug sensitivity test, she was diagnosed with MDR-TB, and second-line anti-TB medications were prescribed. She recovered well subsequently.

Clinical value of miniprobe sonography for detection of esophageal submucosal lesions.

The purpose of this study was to evaluate the clinical value of catheter-based miniprobe sonography for diagnosis of esophageal submucosal lesions. A total of 199 patients with esophageal submucosal lesions underwent miniprobe sonography via gastroscopy. The sonograms were reviewed, and the sonographic findings were compared with pathologic findings from specimens obtained by endoscopic or surgical dissection. The diagnoses for the 199 patients were as follows: 54 cysts, 58 leiomyomas, 25 stromal tumors, 26 venous aneurysms, 15 lipomas, and 21 extramural compressions. A total of 145 lesions were verified by surgery and pathologic examinations. The results for 139 lesions were confirmed by miniprobe sonography; 6 lesions were misdiagnosed. The diagnostic accuracy rate for miniprobe sonography was 95.9%. Miniprobe sonography can provide precise information about the size, location, border, and echogenicity of esophageal submucosal lesions. It has high diagnostic accuracy. Preoperative miniprobe sonography via gastroscopy may play an important role in the choice of therapy for esophageal submucosal lesions.

Intraoperative esophagoscopy provides accuracy and safety in video-assisted thoracoscopic enucleation of benign esophageal submucosal tumors

Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non-diagnostic lesions should be resected for both diagnostic and therapeutic indications. Video-assisted thoracic surgery has become a popular treatment in the field of thoracic surgery; however, thoracoscopic esophageal surgery may lead to an increase in operative complications. The effect and safety of thoracoscopic surgery for esophageal submucosal lesions were evaluated. A retrospective study evaluated patients undergoing thoracoscopic treatment of benign submucosal tumors. Between March 2011 and December 2013, 17 patients underwent thoracoscopic resection of benign submucocal tumors. Intraoperative esophagoscopy was performed for tumor localization by transillumination and confirmation of mucosal integrity after enucleation in every patient. Median patient age was 47 years (range 30-65). The median surgery time was 170 minutes (range 80-429). The median tumor size was 3.8 cm (range 1.3-9). The median hospital stay was 4 days (range 2-12). There were 16 leiomyoma and 1 neurogenic tumor. There was one case of conversion to thoracotomy because of residual tumor after enucleation. Mucosal injuries occurred in three patients, two accidentally and one intentionally; each patient was treated with primary repair and confirmed integrity with flexible esophagoscopy at operating room. The small sized tumor with intraoperative esophagoscopy could be localized. Esophagoscopic assistance was necessary in eight patients to have better idea where to make myotomy. There were no major morbidities such as postoperative leakage or mortality. Esophageal submucosal tumors can be treated safely with thoracoscopic surgery. However, intraoperative esophagoscopy allows accurate tumor localization, direction of esophageal access incision, and decreases complications during VATS enucleation of esophageal submucosal tumors.

Endoscopic Removal of Rare Esophageal Tumors: A Report of 2 Cases with Histopathological Correlation

The introduction of endoscopic ultrasound (EUS) and endoscopic resection has offered a new alternative to simple observation or surgical resection for the management of esophageal submucosal tumors and polypoidal lesions. With the development of endoscopic techniques, there has been a marked increase in local treatment modalities for early esophageal neoplasms. Granular cell tumor and carcinosarcoma of the esophagus are rare neoplasms and their diagnosis is mainly based on histopathologic examination of endoscopic biopsies. In this case series, we describe the removal of a granular cell tumor presenting as submucosal nodule and a carcinosarcoma presenting as polypoidal mass by the endoscopic submucosal dissection technique, and briefly discuss the literature on clinicopathologic aspects and their management.

Endoscopic Submucosal Tunnel Dissection for Esophageal Granular Cell Tumor Resection

Endoscopic submucosal tunnel dissection (ESTD) was recently described for the resection of upper gastrointestinal submucosal tumors, namely leiomyomas, GISTs and aberrant pancreas. Granular cell tumors (GCT) are usually benign, but should be removed when symptomatic, significantly increase in size or have atypical histological or ultrasonographic features.We aim to describe the role of ESTD for the resection of an esophageal GCT. A 51 year-old patient was referred to us due to the presence of an esophageal submucosal lesion with increased size in the follow-up. Deep biopsy specimens were positive for granular cell tumor. Suboptimal submucosal lifting precluded conventional endoscopic submucosal dissection (ESD). In this context an ESTD was performed. First, a submucosal tunnel was created starting 5 cm above the tumor. Afterwards, the GCT was carefully dissected from the overlying submucosa and muscularis propria using TT knife and IT knife2. The ESTD procedure was possible and en bloc resection achieved, being the 25 mm long lesion retrieved. The mucosal orifices were closed using conventional clips. The patient started oral diet 1 day after ESTD and was discharged at day 4 without any complications. In this first report of ESTD for esophageal GCT resection, this technique shown to be feasible, reliable and safe, enabling complete resection, even in this case with poor submucosal lifting.

Thoracoscopic surgical management of esophageal benign tumor

Background Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non-diagnostic lesions should be resected for both diagnostic and therapeutic indications. VATS has become a popular treatment in the thoracic surgery, however thoracoscopic esophageal surgery may lead to increased operative complications. We evaluated the effect and safety of thoracoscopic surgery foe esophageal submucosal lesions..

Mo1998 Novel Technique for Submucosal Tunneling and Endoscopic Resection (STER) of Submucosal Tumors

Background: Submucosal tunneling and endoscopic resection (STER) of submucosal tumors (SMT) of the esophagus and stomach was recently described based on concepts of submucosal tunneling and flap closure. STER provides definitive histologic diagnosis of SMT and allows for a minimally-invasive therapeutic approach for SMT. However, STER is time consuming with majority of procedural time needed for the creation of submucosal tunnel and dissecting tumor off its attachment to submucosal fibers. We have previously shown that a novel viscous gel (Cook Medical) has submucosal dissecting properties and can facilitate submucosal dissection. Aims: To present our experience with using the novel gel for facilitating STER of simulated esophageal submucosal lesions in four non-survival pig experiments. Methods: An esophageal submucosal injection of 5ml of saline with 0.3% indigo carmine was performed to create a mucosal bleb. A 10mm embolization coil was loaded into a 19-gauge EUS-FNA needle. The needle was advanced through the working channel of the endoscope and the bleb was punctured. The coil was delivered into the submucosa through the FNA needle by using the stylet as a pusher. A submucosal injection of 5ml of saline with 0.3% indigo carmine was performed to create a mucosal bleb 5cm proximal to site of coil placement and prior to injection of the dissecting gel. Subsequently, 10-15ml of the gel was injected into the submucosal bleb using a 19-gauge needle and a custom-made injector apparatus. A 2-cm longitudinal incision was created with a triangle-tip knife. The gastroscope was then advanced into the submucosal space. The esophageal submucosal space was noted to be already formed in all pigs and there was no need to perform any esophageal submucosal dissection. Results: STER was performed in four consecutive pigs as described above. Although the gel is viscous, it was easily suctioned through the working channel of the gastroscope and did not interfere with endoscopic visualization. Esophageal submucosal dissection was not required in any case. Auto-tunneling by the dissecting gel stopped at the level of the lower esophageal sphincter and the distal end of the formed tunnel was at the level of the gastroesophageal junction in all pigs. The submucosal coil was seen floating freely within the tunnel. There were no submucosal fibers attached to the coils in all four experiments. The coils were removed by suctioning or using a biopsy forceps. All STER procedures were completed in less than 10 minutes. There were no complications. Conclusions: Our novel technique of using dissecting gel during STER made the procedure safe and efficient. In addition, the gel rendered this complex procedure relatively simple.

Primary Esophageal CD30-Positive ALK-Positive Anaplastic Large Cell Lymphoma: A Case Report and Literature Review

To introduce a case of primary esophageal CD30-positive ALK-positive anaplastic large cell lymphoma (ALCL) and discuss its diagnosis and treatment. Esophagectomy was done for a 37-year-old male with a submucosal lesion after a frozen section failed to give a definite diagnosis. Samples were sent for hematoxylin-eosin staining and immunohistochemical analysis. Six cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy were given and the patient was followed up. The operation was uneventful. Postoperative pathologic and immunohistochemical examination yielded a diagnosis of primary CD30-positive and ALK-positive ALCL of the esophagus. The patient was in complete remission at the 14-month follow-up. ALCL of the esophagus should be considered in the differential diagnosis of esophageal submucosal lesions. Biopsy through either esophagoscopy or surgical exploration, chemotherapy, and radiotherapy can be chosen for long-term survival.

EUS based strategy for surgical resection of mesenchymal tumors (MTs) of upper gastrointestinal tract

Mesenchymal tumors of upper g.i. tract are often benign but, some of them, as GISTs or GANTs may have a malignant behaviour. Therefore a precise diagnosis would be important for their management and surgical treatment, if needed; but it is very difficult to achieve preoperatively. The aim of the study was to verify if a more detaliled classification of MTs, based on EUS imaging, could improve therapeutic planning. From 2000 to 2005, 259 pts underwent EUS examination for a suspected esophageal, gastric or duodenal submucosal lesion. In 121 pts EUS showed a hypoechoic intramural mass, that represents the basic feature of MTs. According to EUS criteria settled by us, these patients were divided into four groups, corresponding to a specific diagnostic hypothesis. Group 1 (leiomyoma): very low echogenicity (equal to that of the normal proper muscle) and homogeneous internal echo, regular margins, often bordered by a thin echorich line. Group 2 (GIST): low echogenicity, but higher than that of proper muscle and slightly heterogeneous internal echo, regular margins, sometimes with a hypoechoic halo. Group 3 (GIST suspicious of malignancy): echofeatures similar to group 2, but markedly heterogeneous internal echo. Group 4 (malignant MTs): echofeatures similar to group 3, but irregular margins and infiltration of adjacent layers. 38 pts were operated on. Surgical treatment, planned on the basis of EUS diagnosis, ranged from extramucosal enucleation of the tumor to wide resections. Compared with histology, EUS overall accuracy was 76%. Sensitivity and specificity were 87% and 91% for diagnosis of leiomyoma; 100% and 75% for diagnosis of GIST; 69% and 92% for diagnosis of malignant MT. Surgical procedure resulted to be adequate in all but three cases. Although the number of patients is small, criteria we adopted for EUS diagnosis seem to be helpful to plan surgical therapy.

Prospective evaluation of a jelly-like conducting medium for catheter US probe imaging of esophageal and duodenal lesions

The catheter probe EUS(C-EUS) relies on luminal water for acoustic coupling. However, in tubular structures, such as the esophagus and the duodenum, instilled water drains away rapidly. The use of water-filled balloons is limited by air artifact and other problems. This study evaluated the image quality, the penetration depth, the tumor staging accuracy, and the safety of C-EUS by using carboxymethylcellulose, an edible, nontoxic, transparent jelly-like substance (JC-EUS). Forty patients with an esophageal or a duodenal submucosal lesion or an esophageal carcinoma were evaluated prospectively in a crossover study with both C-EUS and JC-EUS when using a 12-MHz US catheter probe. Based on still images, depth of US penetration and image quality (by using a predefined 1 to 5 scale) were assessed by a blinded, independent endosonographer. JC-EUS was superior in image quality compared with C-EUS overall (mean score: 4.9 vs. 2.6; p <0.001), as well as in each subgroup (esophageal carcinoma, esophageal submucosal lesion, duodenal submucosal lesion). Penetration depth was not significantly different (2.5 cm). Staging was 100% accurate in 14 patients with esophageal cancer who underwent surgery. There was no procedure-related complication. JC-EUS is safe, provides superior image quality to C-EUS, and is accurate for local staging of esophageal cancer.

A 49 YEAR OLD MAN WITH DYSPHAGIA AND A LARGE PEDUNCULATED ESOPHAGEAL MASS

A 49-year-old gentleman presented with one year of intermittent solid food dysphagia and regurgitation without nausea, vomiting or weight loss. Upper GI series and CT scan showed an esophageal submucosal lesion [Figures available]. The patient could regurgitate a smooth appearing soft tissue mass that was without erythema or ulceration [AttachedFigure]. [figure 1]Endoscopy revealed a ten centimeter mobile, extrinsic, smooth, polypoid mass arising from the area of the upper esophageal sphincter [Figure available].FigureSurgical excision was performed through a cervical incision. Pathology was consistent with a benign giant fibrovascular polyp (fibrolipoma) [Figureavailable]. Pedunculated polyps of the esophagus are rare and described under different terms including fibrovascular polyp, fibrolipoma, lipoma and myxomas. They can grow until they develop symptoms and may present with asphyxial death.[1] Most of these lesions are pedunculated and have a narrow stalk. They are typically benign and usually found in males age 40–60 in the proximal esophagus. [2] Diagnosis is often difficult due to the prolonged presentation and difficulty interpreting radiographic studies. Endoscopy is imperative for the diagnosis. These lesions are typically removed surgically secondary to the risk of asphyxia or theoretical risk of malignant degeneration.