Large Submucosal Tumor Research Articles

Successful resection of large submucosal tumor in the esophagus: Novel thoracoscopic-endoscopic combined surgery with submucosal tunneling method.

Successful resection of large submucosal tumor in the esophagus: Novel thoracoscopic-endoscopic combined surgery with submucosal tunneling method.

Role of intraoperative patients positioning in endoscopic full-thickness resection of large gastric tumors under general anesthesia.

Full thickness endoscopic resection of large submucosal gastric tumors (>3 cm) is a big challenge for endoscopists. Issues include how to efficiently resect the lesion, obtain homeostasis, and suture the defect. There are no guidelines regarding the importance of patient position on the success of endoscopic resections in anesthetized patients. Typically, the patient is placed in left lateral position for the endoscopic therapy and during the procedure patient’s position is changed to maintain the tumor above the gastric fluids to prevent gastric juices and tumor or tumor fragments from falling into the peritoneal cavity in the event of perforation. This study emphasized the importance of planning the procedure to ensure that the patient’s position and anesthetist’s concerns are met and allow optimal access to the lesion for endoscopic resection. Prior to sedation the patient should be positioned so that the tumor is in the up position which also prevents blood obscuring the operative field, helps detect bleeding points for immediately hemostasis. In addition, due to gravitational effect, the resected tumor will fall into the gastric cavity exposing the root of the tumor making resection easier and reduce procedure time. Preplanning avoids unnecessary readjustment of positioning and improves the ease and safety of the procedure.

Giant esophageal liposarcoma with squamous cell carcinoma resected via the cervical approach: a case report

BackgroundLiposarcoma is one of the most common soft tissue sarcomas, but is extremely rarely found in the esophagus. There have been no reports of esophageal liposarcoma together with superficial carcinoma of the esophagus. Here, we report a patient who underwent complete resection of esophageal liposarcoma with carcinoma via a cervical approach.Case presentationA 66-year-old man was diagnosed with an esophageal tumor 11 years ago, but he left it untreated. He presented to our hospital with progressive dysphagia and appetite loss since the previous year. Esophagogastroduodenoscopy (EGD) showed a large pedunculated submucosal tumor (SMT) originating at the esophageal entrance, extending to the gastroesophageal junction. Additionally, there was a superficial carcinoma on the surface of the SMT, 30 cm from the incisor teeth. Three-dimensional computed tomography (3D-CT) showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus. We diagnosed a giant esophageal polyp accompanied by a superficial carcinoma and performed tumor resection via a cervical approach. The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass. The final diagnosis by histopathological and immunohistochemical examination was well-differentiated liposarcoma and esophageal squamous cell carcinoma. He was discharged on postoperative day 14 with drastic improvement in his swallowing ability.ConclusionWe reported an extremely rare case of esophageal liposarcoma together with esophageal squamous cell carcinoma that was successfully resected through a small cervical incision.

Submucosal Tunneling Endoscopic Resection for Submucosal Tumors in the Proximal Esophagus.

Submucosal tunneling endoscopic resection (STER) is widely applied for treatment of gastrointestinal submucosal tumors (SMTs) originating from the muscularis propria layer. However, the tumor location within the proximal esophagus makes STER a challenge for the endoscopists. The aim of this study was to summarize the technique skill and evaluate the outcomes of proximal esophageal STER. A total of 72 patients with SMTs in the proximal esophagus undergoing STER were included from February 2019 to March 2021. Imaging 3-dimensional reconstruction was used for patients with large SMTs. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. In this study, all the tumors were removed completely and no gross disease was remaining. The en bloc resection was achieved in 90.28% of patients, and the complications rate was 6.95%. Three-dimensional reconstruction was used for 30 patients (41.67%) with large SMTs (transverse diameter >2.0 cm). Based on statistical analysis, tumors with irregular shape and larger size were the significant contributors to piecemeal resection. Larger tumors increase the risk of long operation time, and irregular tumor shapes increase the risk of complications. The median hospitalization time was 4 days. All of the complications were cured by conservative treatment. A median follow-up of 12 months was available, and all patients were free from local recurrence or distant metastasis during the study period. STER is an effective and safe methodology for the resection of proximal esophageal SMTs. Tumor size and shape mainly impact the piecemeal resection rate, STER-related complications, and procedural difficulty.

Spontaneous regression of a rectal tonsil presenting as a large submucosal tumor

Rectal tonsils are localized hyperplastic lymphoid tissues in the rectum, and the initial endoscopic findings are consistent with those for neoplastic lesions. However, rectal tonsils are benign entities, and the diagnosis should be made cautiously. A 70‐year‐old man presented with pain on defecation with rectal bleeding. Colonoscopy revealed a 3‐cm protruding mass in the rectum with mucosal erosion, but no malignant features were observed on forceps biopsy. Endoscopic ultrasonography (EUS) showed that the lesion was a hypoechoic mass without blood flow. Fine needle aspiration under EUS revealed no malignant components, although the size of the lesion had shrunk, and symptoms, such as blood‐stained stool, tenesmus, and discomfort during defecation, had resolved. A second forceps biopsy showed intermediate‐sized lymphocytes without lymphoepithelial lesions. Based on immunostaining, the lesion was diagnosed as a rectal tonsil.Rectal tonsils occur due to localized proliferation of reactive lymphoid follicles in the submucosa or muscularis mucosa. However, endoscopic diagnosis is difficult since less invasive treatment is performed for neoplastic lesions of the rectum to preserve the function of the anal sphincter. Diagnosis and treatment of small lesions might be possible by endoscopic resection; however, for relatively large lesions, formulating a diagnosis based only on biopsy specimens becomes even more difficult. Therefore, repeated biopsies might be helpful for the diagnosis of rectal tonsils and for excluding other neoplasms.

Gastric lipoma: a rare cause of upper gastrointestinal bleed

Lipoma is a rare mesenchymal tumour of stomach (less than 1% of gastric tumours) to present as gastrointestinal bleed. We report a case of upper gastrointestinal bleed from a gastric lipoma in a 42 year male patient who underwent distal gastrectomy for resection of the large submucosal tumour situated in antropyloric region. Most common age of presentation of gastric lipoma is fifth or sixth decade of life and most of these are located in submucosal plane (90% cases) and in antropyloric region (75% cases). Gastric lipomas can be diagnosed by endoscopic means but most often with CT scan which shows characteristic fat attenuation. Small asymptomatic incidentally diagnosed can be safely observed while larger symptomatic tumours are treated by endoscopic or surgical resection which offers cure from this benign lesion.

3D-printed model in the guidance of tumor resection: a novel concept for resecting a large submucosal tumor in the mid-esophagus.

3D-printed model in the guidance of tumor resection: a novel concept for resecting a large submucosal tumor in the mid-esophagus.

Submucosal tunneling endoscopic resection of large submucosal tumors originating from the muscularis propria layer in the esophagus and gastric cardia.

The aim of this study was to evaluate the short-term complications of submucosal tunneling endoscopic resection (STER) for large submucosal tumors (SMTs) originating from the muscularis propria (MP) layer in the esophagus and gastric cardia. We performed 286 cases of STER from September 2012 to December 2017. The clinical data of patients with SMTs originating from the MP layer of 3.0-7.0 cm, who underwent STER procedure at the endoscopy center of Tianjin Medical University General Hospital, were collected retrospectively. Epidemiological data, tumor location, tumor size, procedure-related parameters, complications, and follow-up were included. A total of 27 (9.4 % [27/286]) patients were large-size SMTs, with a mean age of 51.9 ± 9.4 years. The male/female ratio was 19:8. Of the 27 SMTs, 23 were located in the esophagus and 4 in the gastric cardia. The mean tumor size was 4.0 ± 1.1 cm. The en bloc resection rate was 85.2 % (23/27), and the complete resection rate was 100 % (27/27). Intra-operative perforation occurred in 2 patients (7.4 %) and post-operative perforation occurred in 2 patients (7.4 %). No other complications were observed. The average cost of the procedure was $3357.99 ± $1171.60 per inpatient stay (including both the procedure and an additional inpatient stay). The mean follow-up time was 15 ± 10.1 months. No recurrence and metastasis occurred during the follow-up period. There is low risk of STER for the large-sized SMTs in the esophagus and gastric cardia, and the most common complication occurred during or after the procedure is perforation.

Submucosal Tunneling Endoscopic Resection for Large and Irregular Submucosal Tumors Originating from Muscularis Propria Layer in Upper Gastrointestinal Tract.

The majority of submucosal tumors (SMTs) are benign. However, large SMTs with irregular outer shapes are proved to harbor a higher risk for malignancy. Submucosal tunneling endoscopic resection (STER) has emerged as a feasible technique for resecting SMTs. To evaluate the safety and efficacy of STER for large and irregular SMTs with a diameter no <35 mm originating from the muscularis propria layer, and to share the technical skills of STER for complete and en bloc resection. We retrospectively reported 10 cases in which the new technique of STER was performed to remove large and irregular SMTs with a diameter no <35 mm of upper gastrointestinal tract in our hospital between April 2014 and April 2017. All 10 (100%) patients underwent STER successfully, with a mean operation time of 156 minutes. Among the 10 SMTs, 3 (30%) were located in the esophagus, 7 (70%) were in the cardia. All the SMTs had a maximum diameter no <35 mm, ranging from 35 to 100 mm. The mean size was 57.2 mm. En bloc resection was achieved in 8 (80%) of the tumors. Only two (20%) of the SMTs were resected into more than one piece. Complication occurred in 1 (10%) of the patients as a representation of pneumothorax. No recurrence was noted during a median follow-up of 15 months. In this retrospective study, STER may be an effective and safe technique resecting large and irregular SMTs with a diameter no >40 mm in transverse diameter and no >100 mm in longitudinal diameter.

A case of duodenal gangliocytic paraganglioma with regional lymph node metastasis

Introduction: Gangliocytic paraganglioma derived from neural crest is an unusual neuroendocrine tumor having a characteristic triphasic microscopic appearance with epitheloid cells, spindle cells, and ganglion cells. It is generally considered to be a benign. Here, we report a case of gangliocytic paraganglioma with regional lymph node metastasis. Case: A 41-year-old man was admitted due to hematemesis. Upon arrival, he was evaluated and underwent an esophagogastroduodenoscopy that revealed a large submucosal tumor at second portion of duodenum near ampulla of Vater. Surgical resection was planned. On exploration, there was an 1.5 cm-sized lymph node in the paraduodenal area. The lymph node was proven to be a metastatic malignant lesion in the frozen biopsy. Therefore we decided to perform pancreaticoduodenectomy. Grossly, the mass was soft, 2.5 × 1.7 × 0.9 cm in size, well demarcated, located near the ampulla of Vater. Pathologically, the duodenal mass was a gangliocytic paragangliomoa. The tumor was positive cellular reaction for chromogranin, synaptophysin, neurofilament by immunohistochemistry. There was one metastatic lymph node among 11 retrieved lymph nodes. He was recovered without complication and discharged at postoperative day 9. After 7 year after operation, he was alive without recurrence. Conclusion: Radical surgery was necessary in a patient with lymph node metastasis. Close follow-up was advocated because gangliocytic paraganglioma with lymph node metastasis was considered as tumors with uncertain malignant potential.

Submucosal Tunneling Endoscopic Resection vs Thoracoscopic Enucleation for Large Submucosal Tumors in the Esophagus and the Esophagogastric Junction

Submucosal tunneling endoscopic resection (STER) is regarded as a promising method for resection of submucosal tumors (SMTs); however, little is known about a comprehensive comparison of STER and thoracoscopic enucleation (TE). The aim of this study was to compare the clinical outcomes of STER and TE for large symptomatic SMTs in the esophagus and esophagogastric junction, as well as to analyze the factors that affect the feasibility and safety of STER. We enrolled 166 patients with large symptomatic SMTs in the esophagus and esophagogastric junction from September 2011 to March 2016 in this retrospective study. The clinicopathologic features and treatment results were collected and analyzed. En bloc resection was achieved in 84.6% of the patients in the STER group and 86.7% of the patients in the TE group (p= 0.708). Notably, the procedure time and hospital stay in the STER group were considerably shorter than those in the TE group. Tumor transverse diameter is a significant risk factor for piecemeal resection, adverse events, and technical difficulties. No recurrence or metastasis was found during a mean follow-up period of more than 2 years. Submucosal tunneling endoscopic resection is effective and safe for large SMTs in the esophagus and esophagogastric junction. This procedure has the advantage of being more minimally invasive with a shorter procedure time and hospital stay compared with TE. Submucosal tunneling endoscopic resection for tumors with a transverse diameter ≥3.5cm and an irregular shape is associated with relatively high risk for piecemeal resection, adverse events, and technical difficulties.

Successful resection of giant esophageal liposarcoma by endoscopic submucosal dissection combined with surgical retrieval: a case report and literature review.

Liposarcoma of the esophagus is very rare. We experienced a huge (27.5 × 11.6 cm) liposarcoma of the esophagus. A 73-year-old man presented with severe dyspnea requiring emergency tracheal intubation. Computed tomography and esophagogastroduodenoscopy showed a large submucosal tumor arising from the esophageal entrance and extending intraluminally to the lower esophagus. We successfully performed endoscopic submucosal dissection (ESD) and esophagotomy to remove the tumor, which preserved swallowing and phonation. The final diagnosis by histopathologic and immunohistologic examination was well-differentiated liposarcoma of the esophagus. Treatment by the combination of ESD and esophagotomy can be performed even for a very large tumor. This method preserves deglutition with a lower risk of recurrent laryngeal nerve paralysis than that with esophagectomy.

Nonpuerperal Acute Uterine Inversion in a Nullipara

Background: Nonpuerperal acute inversion of the uterus is a rare condition that occurs as a complication of intrauterine tumors, especially large submucosal leiomyomas. This inversion is so rare that many gynecologists may not encounter it in their entire professional careers. The condition causes severe pain, vaginal bleeding, and shock. Case: A-28 year old nullipara had a large submucosal fibroid tumor. She presented with vaginal bleeding, lower abdominal pain, and a mass protruding from her vagina of 8 hours duration. This case was initially managed by vaginal myomectomy; then, the patient's uterus was repositioned manually. Results: The patient's postoperative period was uneventful. Histopathology testing of the tumor revealed that it was a leiomyoma, weighing ∼150 g. She recovered fully and resumed her normal activity after 2 weeks. Conclusions: Acute nonpuerperal inversion of the uterus is uncommon and is usually associated with a fundal submucousal myoma extrusion. A high index of suspicion is imperative to limit morbidity and enhance prompt management. (J GYNECOL SURG 32:185)

Endoloop-assisted endoscopic resection of a large bleeding submucosal tumor of the duodenum after endoscopic ultrasound evaluation

Endoloop-assisted endoscopic resection of a large bleeding submucosal tumor of the duodenum after endoscopic ultrasound evaluation

Uterine Sub Mucosal Leiomyoma (Fibroid) – A Case Report

Submucosal fibroids are the least common of the various types of fibroid tumors. These fibroids develop just under the lining of the uterine cavity. Large submucosal fibroid tumors may increase the size of the uterine cavity and can block the fallopian tubes. This can cause complications if one is trying to get pregnant. Some fibroids do not produce any symptoms at all while others can be severely symptomatic. Associated symptoms with submucosal fibroids include very heavy menstrual bleeding or excessive and prolonged menstruation. The passage of clots and frequent soiling can take its toll on one’s everyday lifestyle. Untreated, prolonged or excessive bleeding can cause more complicated problems such as fatigue or anemia which could potentially lead to a need for blood transfusions. This case report is about a 44 years old lady having two kids, complaining of very heavy menstrual bleeding, pelvic pain and an enlarged abdomen.

Duodenal Metastasis from Head and Neck Cancer with an Intestinal Obstruction

Small intestinal metastasis from head and neck tumors is very rare. We herein report the case of a 71-yearold male with severe duodenal stricture due to duodenal metastasis from head and neck cancer whose duodenal stricture was conservatively relieved by endoscopic stenting. The patient had been treated with total laryngectomy and postoperative radiotherapy 13 months before visiting our department with complaints of a loss of appetite and vomiting. Esophagogastroscopy revealed a large submucosal tumor with severe obstruction in the duodenum. The histological findings of biopsy specimens showed moderately differentiated squamous cell carcinoma. He was thus diagnosed to have duodenal metastasis from the original supraglottic larynx cancer. Because his general condition was not sufficient to allow additional chemo-radiotherapy or surgery to be performed, conservative endoscopic stenting was employed to relieve the obstructive symptoms. After the stenting, the symptoms all immediately disappeared. When patients with head and neck tumors present with gastrointestinal bleeding and/or symptoms such as intestinal obstruction, endoscopic stenting appears to be useful for the palliative relief of such symptoms.

Primary Mucosa-associated Lymphoid Tissue Lymphoma of the Esophagus, Manifesting as a Submucosal Tumor

We report a case of primary mucosa-associated lymphoid tissue (MALT) lymphoma in the esophagus that manifested as a large submucosal tumor (SMT). Primary esophageal lymphoma is very rare, occurring in less than 1% of all patients with gastrointestinal lymphoma. Only a few cases of MALT lymphoma in the esophagus have been reported in the English literature. A 53-year-old man was referred to Dongguk University Ilsan Hospital (Goyang, Korea) in July 2012 for further evaluation and treatment of an esophageal SMT. Endoscopy showed a cylindrically elongated submucosal mass with normal overlying mucosa in the mid esophagus, 25-30 cm from the incisor teeth. He underwent surgery to confirm the diagnosis. Pathologic findings showed diffuse small atypical lymphoid cells which were stained with Bcl-2, CD20, but not with CD3, CD5, CD23, Bcl-6, or cyclin D1. These cells showed a positive monoclonal band for immunoglobulin heavy chain gene rearrangement. Based on the pathological, immunohistochemical, and molecular biological features, the esophageal mass was diagnosed as extranodal marginal zone B-cell lymphoma of the MALT type.

Metastatic Esophageal Gastrointestinal Stromal Tumor (GIST) in a Patient with Dysphagia: A Case Report

Purpose: Gastrointestinal stromal tumors (GISTs) have been definitively defined since 1998 with the advent of immunohistochemical staining with CD117. While most commonly seen in the stomach (60-70%), GISTs can be found as small incidental lesions in the esophagus (≤1%), and very rarely as large symptomatic lesions. A 64-year-old male presented to the ER with chest pain for 2 days. His medical history was significant for coronary artery disease, status-post stent placement 1 year ago. On review of symptoms he admitted to progressively worsening dysphagia to solids, then liquids, for 3 months with an associated 15lb. weight loss. His social history was positive for a 42-year pack history. In the ER, the patient also complained of RUQ pain for a few weeks, which prompted a Computed Tomography (CT) of the abdomen and pelvis. The CT scan revealed multiple hypodense areas seen within the left lobe of the liver, concerning for neoplasm. Notable laboratory results on admission revealed an iron deficient microcytic anemia (Hemoglobin-8.7 g/dL, MCV-64fL, Iron-22 μg/dL). He was admitted to the medical floor for further workup and GI was consulted. Esophagogastroduodenoscopy (EGD) revealed a large submucosal tumor measuring ˜10cm in length, which occupied ˜90% of the circumference of the distal esophagus and extended into the cardia of the stomach. While the tumor was not noted to be bleeding, it was ulcerated and friable. The remainder of the exam was normal. Pathologic examination of the biopsies revealed a single cellular focus of spindle cells, with immunohistochemical staining strongly positive for CD117, supporting a diagnosis of GIST. Subsequent CT guided biopsy of a liver lesion was also positive for spindle cells with a similar profile. While rare (≤1%), esophageal GISTs can be found incidentally on EGD as small lesions. Rarer still, they can present as large symptomatic lesions that have already metastasized, as was the case with our patient.Figure: [574] Retroflexed view of esophageal GIST protruding into the cardia.

Synchronous Facing Submucosal Tumors of the Duodenum in Neurofibromatosis Type 1

A 58-year-old woman, who presented with no specific abdominal symptoms, noticed bloody stools and came to the emergency room. At presentation, she was anemic with a markedly low hemoglobin level (5.3 g/dL); an emergent gastroduodenoscopy revealed a large submucosal tumor in the posterolateral wall of the second portion of the duodenum (Figure A). The tumor occupied the duodenal lumen, and oozing was observed at the top of the tumor. The contralateral duodenal wall where the tumor had attached was thickened, and ulcerative changes were visible.

Radiotherapy for mucosa-associated lymphoid tissue (MALT) lymphoma of the esophagus: a case report with a diagnostic and therapeutic discussion

Mucosa-associated lymphoid tissue (MALT) lymphoma is increasing common in various sites; however, MALT lymphoma in the esophagus is still rare, so its diagnostic features have not yet been well recognized and optimal treatment has not been properly discussed. Though radiotherapy is widely preferred for gastric and orbital MALT lymphoma, surgery has been the most frequently reported treatment for esophageal MALT lymphoma. This raises the question: why not radiotherapy for esophageal MALT lymphoma instead of surgery? The only reported case of definitive radiotherapy for esophageal MALT lymphoma lacks follow-up data. Three years ago (2007), we treated a 59-year-old male patient with a large esophageal submucosal tumor, diagnosed as MALT lymphoma, with 36 Gy of solo external beam radiotherapy. The tumor was 15 cm in craniocaudal length, homogeneously weakly contrast-enhanced on X-ray computed tomography (CT), homogeneously hypoechoic and clearly demarcated from the surrounding adventitia, and had a concave pattern between the folds. During and after radiotherapy, no treatment-related complications occurred except for transient Grade 2 leukocytopenia. The tumor showed remarkable reduction and histological negativity in the next month. Over the follow-up period, no recurrence was observed in semiannual PET/CT/MRI studies. Taking the current observation with the well known effectiveness of radiotherapy for MALT lymphoma in various other sites, we recommend considering radiotherapy as a reasonable less-invasive treatment for this rare entity.