Esophageal Leiomyoma

Esophageal leiomyoma is a rare benign tumor arising from the smooth muscle layer of the esophageal wall. It usually grows slowly and remains asymptomatic. When it reaches a large size, it may cause complaints such as difficulty swallowing, chest pain, or obstruction in the esophagus.

Diagnostic methods and imaging techniques are performed with endoscopy, endosonography (EUS), and computed tomography (CT). Leiomyomas are generally seen as well-circumscribed submucosal masses. Biopsy is often not recommended because the diagnosis is usually made through imaging.

Treatment options and surgical approach are surgical in lesions that cause symptoms or show growth. The tumor is removed with a method called enucleation, while preserving the esophageal wall. Minimally invasive surgical techniques shorten the recovery time and reduce the risk of complications.

Differential diagnosis and the need for follow-up are important in order to distinguish it from malignant lesions such as leiomyosarcoma. Therefore, histopathological examination is performed in suspicious cases. Recurrence after surgery is rare, but patients should be monitored at certain intervals.

What Is Esophageal Leiomyoma?

Esophageal leiomyoma is a generally benign tumor arising from the smooth muscle layer of the esophagus. It is the most common benign tumor of the esophagus and usually grows slowly. Small lesions generally do not cause symptoms, while larger ones may lead to difficulty swallowing, chest pain, or a feeling of fullness. Diagnosis is made through endoscopy and imaging methods. In symptomatic cases, surgical removal is preferred.

What are the common symptoms seen in patients with leiomyoma?

The most characteristic feature of leiomyomas is that they grow very slowly. This slow growth allows the body to adapt to the situation. That is why, while the tumor is still small, the vast majority of our patients do not feel anything. It is usually found incidentally during a check-up, on tomography scans taken for another complaint, or during endoscopy performed for stomach-related complaints, when someone says, “Oh, there is a bulge here”:

However, when the mass grows to a certain size (usually 4–5 centimeters) or settles in a very narrow part of the esophagus, symptoms begin. The tumor narrows the tunnel by pressing toward the inner lumen of the esophagus.

The complaints we encounter frequently are as follows:

• Difficulty swallowing
• Chest pain
• Sensation of pressure
• Burning
• Food coming back into the mouth
• Weight loss
• Indigestion
• Pain radiating to the back

Let me explain difficulty swallowing a little more. Our patients usually describe it as, “The bite doesn’t get stuck in my throat, but somewhere in the middle of my chest, and I have to push it down by drinking water.” At first, this feeling occurs only with solid foods such as large pieces of meat or bread, but if the tumor grows too much, it may even progress to difficulty with liquids.

Which leiomyoma diagnostic methods are used in diagnosing these masses?

When one of our patients comes in saying, “I feel like something gets stuck when I swallow,” or when a mass is detected incidentally, the detective process begins for us. Because not every mass seen in the esophagus is a leiomyoma; sometimes cysts, and unfortunately sometimes malignant tumors, can give similar images. Making this distinction is of vital importance.

The methods we use in the diagnostic process, in order, are as follows:

• Contrast Esophagus X-ray (Esophagogram):

This is one of the oldest but still very valuable methods. The patient drinks a chalky liquid that appears on X-ray. As this liquid passes through the esophagus, we take its image. If there is a leiomyoma, we see a smooth-bordered, crescent-shaped area of compression on the passageway of the liquid. This gives us the first idea about the location of the mass and the narrowing it creates.

• Computed Tomography (CT):

Tomography is our map. It shows us the exact size of the mass, which wall of the esophagus it is on, and more importantly, its relationship with the lungs, major vessels, or lymph nodes around it. When planning surgery, we usually decide whether to approach from the right or the left by looking at the tomography.

• Endoscopy:

This is the procedure performed by entering through the mouth with a lighted camera. Since leiomyomas are located under the mucosa (inner lining), the mucosa over them generally appears completely healthy on endoscopy. Only a bulging structure protruding inward is seen. This “intact mucosa” appearance is very valuable for us because in cancers we usually see an ulcer or disruption on the mucosal surface.

• Endoscopic Ultrasonography (EUS):

This is our “gold standard” in diagnosis. This device is a special endoscope that has both a camera and an ultrasound probe at its tip. It enters the esophagus and examines the wall layers from the inside by sending sound waves. It shows us with millimetric precision which muscle layer the leiomyoma originates from, its exact structure, and its size. Once EUS is performed, the diagnosis is almost 100% confirmed.

Why is biopsy not performed when leiomyoma is suspected?

This is the part we discuss most with our patients and sometimes the part where we have the most difficulty convincing them. Normally, the rule in medicine is: “If you see a mass, take a sample (do a biopsy) and name it.” However, in esophageal leiomyomas, this rule works in reverse.

If radiological images and especially EUS tell us that this is a leiomyoma, we definitely do not perform a biopsy, nor do we want it to be performed.

Our reasons for not doing a biopsy are as follows:

• Insufficient diagnostic value
• Risk of adhesions
• Risk of mucosal perforation
• Surgical difficulty
• Risk of infection

Let us explain this in more detail. A leiomyoma lies deep within the muscle. Standard biopsy instruments remain superficial; they only take the healthy tissue above and do not provide a diagnosis. Trying to go deeper is risky. But the main reason is surgery. During the operation, we want to peel the tumor away from the covering lining (mucosa) without causing any damage, just like peeling a fruit from its skin. If a biopsy has been done, scar tissue forms in that area and the mucosa adheres to the tumor. While trying to separate this adhered area during surgery, the risk of perforating the esophagus increases greatly. Therefore, do not ask, “Can I have surgery without a biopsy?” In this disease, that is the correct approach.

Is leiomyoma surgery necessary for a benign tumor?

Our patients naturally ask: “If it is benign, if it is not cancer, why should I have surgery? Wouldn’t it be enough to just follow it?”

The answer to this question is quite clear in modern thoracic surgery practice. Yes, leiomyoma is benign, but it is not an innocent guest that just stays where it is. Even if slowly, it continues to grow.

The main reasons we recommend surgery are as follows:

• Growth of the mass
• Development of symptoms
• Diagnostic certainty
• Risk of malignant transformation

A mass that is 3 cm today and causes no complaints may become 6 cm in 5 years and cause serious difficulty swallowing. As the mass grows, the operation becomes more difficult and the risk of complications increases. An operation that would take 1 hour with a closed method (VATS) when the tumor is small may progress to open surgery or even complete removal of the esophagus when it turns into a giant mass.

Moreover, although our imaging methods are highly developed, we cannot say with 100% certainty that “This is definitely benign” without removing the entire mass and having a pathologist examine it under the microscope. Very rarely, malignant types called leiomyosarcoma or potentially risky tumors called GIST can mimic leiomyoma. With surgery, both treatment is provided and this “What if?” question disappears completely. For these reasons, when the diagnosis is established and the patient’s general condition is suitable, we recommend surgical excision as the standard approach.

How is the enucleation method used in surgical treatment performed?

The standard surgery for esophageal leiomyomas is the “Enucleation” procedure. It is a medical term, but its logic is actually similar to some things we do in the kitchen. Think of a fresh broad bean; we try to remove the seed inside (the tumor) without damaging the green outer shell (the mucosa). Or you can imagine separating the segments of an orange without harming its peel.

This surgery is an “organ-preserving” procedure. In other words, we do not cut out and remove the esophagus; we only remove the diseased lump.

The steps of the procedure are as follows:

• Opening of the muscle layer (Myotomy)
• Finding the tumor
• Dissection (Separation)
• Removal of the tumor
• Leak test
• Muscle repair

First, we carefully cut the outer muscle layer of the esophagus along the line where the tumor is located. The whitish, firm tumor tissue appears underneath. This is where surgery turns into an art. We separate the tumor millimeter by millimeter from the mucosa underneath it, which is as thin as onion skin. The mucosa must not be perforated. After the tumor is removed, we inflate the esophagus to test whether the mucosa is intact. Finally, we suture the muscle layer we opened back together. This repair is very important because if we leave it open, the mucosa may herniate outward in the future (pseudodiverticulum), which can lead to swallowing problems.

What advantages does leiomyoma surgery performed with a closed method provide?

In the past, these operations were performed through large incisions (thoracotomy) extending from the patient’s back toward the side, approximately 15–20 centimeters long. The ribs were spread apart with special instruments and sometimes cut. This caused very serious pain after surgery and prolonged recovery times.

Today, however, “Minimally Invasive Surgery,” meaning closed methods, is the gold standard. These may be Video-Assisted Thoracoscopic Surgery (VATS) or Robotic Surgery. We enter the chest cavity through only 1 to 3 small openings (ports). A camera is inserted through one opening and reflects the image onto a screen, while thin long surgical instruments enter through the others.

The benefits of the closed method are as follows:

• Less pain
• Small scar
• Early discharge
• Less bleeding
• Fast recovery
• Better visualization

Especially robotic surgery or advanced VATS techniques provide us with great comfort while performing that delicate separation procedure in a narrow space. The camera magnifies the image, allowing us to see details we could not detect with the naked eye. Our patients usually begin walking the day after surgery and can return home within 3–4 days. The weeks-long convalescence period of open surgery has now become history, so to speak. Of course, in giant tumors or in situations with adhesions, it may rarely be necessary to convert to open surgery, but our first choice is always the closed method.

In which situations is removal of the esophagus (resection) necessary?

Although our aim is always to remove only the tumor (enucleation), sometimes the condition does not allow this. Some leiomyomas grow so large (usually over 8–10 cm) that they completely distort the structure of the esophagus.

The situations requiring resection are as follows:

• Giant masses
• Ring-shaped tumors surrounding the esophagus
• Multiple tumors (Leiomyomatosis)
• Mucosal damage
• Suspicion of cancer

For example, if the tumor surrounds the esophagus like a ring, it is impossible to peel it off; even if you remove it, what remains would be a functionless, flaccid esophagus. Or if the tumor is very large, once removed, it may leave behind such a huge gap in the muscle layer that it cannot be closed. In such situations, we do not take unnecessary risks for the patient’s long-term comfort in eating and drinking. We completely remove that diseased part of the esophagus (esophagectomy) and pull the stomach upward to create a new passage. This is a larger operation, but sometimes it is unavoidable and the most correct solution.

How does the recovery process after leiomyoma surgery progress?

After a successful minimally invasive operation, we transfer our patients to the ward. The first night passes with pain control and monitoring. The day after the operation, if everything is going well, we get the patient out of bed and walking in the corridor. Early mobilization is very important for lung expansion and reducing the risk of blood clots.

The feeding process begins gradually. We do not rush. Usually on the 1st or 2nd postoperative day, we have the patient swallow a sip of contrast liquid and take an X-ray. On this image, we confirm that there is no leak in the esophagus and that the liquid passes comfortably into the stomach. Once we have this confirmation, water intake is started.

The dietary stages are as follows:

• Clear liquids
• Soups with fine particles
• Yogurt and pudding
• Puréed foods
• Soft solids

For the first 2–3 weeks after discharge, a “soft diet” continues at home. We give our patients this advice: “There is a suture line in your esophagus, do not strain it.” Therefore, very hot, very cold, hard-edged foods (such as toasted bread), and heavily spiced foods should be avoided for a while. Bites should be chewed very well. By around 1 month, the patient can usually return completely to a normal table diet.

What are the risks of untreated leiomyoma?

Sometimes our patients may refuse surgery due to fear or neglect. So what happens if this tumor is left there?

First of all, the symptoms gradually worsen. Difficulty swallowing may increase to the point that the patient can no longer eat solid food, leading to malnutrition and serious weight loss. As the tumor grows, it may thin the esophageal wall and create pockets called diverticula.

The risks that may occur if it is left untreated are as follows:

• Complete obstruction
• Bleeding
• Increased pain
• Nutritional deficiency
• Malignant transformation

The possibility of malignant transformation, that is, turning into cancer, is extremely low in leiomyomas, but it is not “zero.” Cases of transformation into leiomyosarcoma have been reported in medicine. Another risk is diagnostic error; that is, the mass thought to be a leiomyoma may actually be a GIST (Gastrointestinal Stromal Tumor). GISTs may behave more aggressively. Therefore, this is not a situation that should be left to chance.

What is the likelihood of recurrence after surgery and how is leiomyoma followed up?

I saved the best news for last: The chance of recurrence after leiomyoma surgery is almost negligible. If the tumor has been successfully and completely removed, we do not expect it to grow again from the same site. This is a great psychological relief for our patients.

Even so, as part of our surgical discipline, we do not simply say “Goodbye” and send our patients off after surgery. We call them back for follow-up at certain intervals (for example, at the 6th month and 1st year).

The issues we pay attention to during follow-up are as follows:

• Swallowing function
• Reflux complaints
• Wound sites
• General health status

Since muscle repair is performed at the surgical site, a stricture may rarely develop or, conversely, reflux complaints may increase. These are conditions that can be managed with simple medical treatments or endoscopic interventions.

Frequently Asked Questions