Figure 1: Endoscopic view of the lesion.
The patient underwent a distal esophagectomy and an esophagogastrostomy together with a laparotomy and thoracotomy (Ivor-Lewis approach). Postoperatively, the pathological findings of the resected specimen revealed SCC infiltrated to the submucosa (2 cm in diameter) and two separated leiomyoma nodules in the submucosa along with five reactive and three metastatic lymph nodules.
There were no problems during the nine-month follow-up period after the surgery, and the patient had no sign of pathology seen on control thorax CT.
Optimum treatment options including the type of surgery needed for leiomyoma is controversial, but the curative treatment for esophageal SCC is resection combined with anastomosis. However, resection of the leiomyoma is only recommended in symptomatic patients, whereas observation is recommended for asymptomatic patients with lesions smaller than 5 cm and for cases in which the preoperative evaluations exclude malignancy.[8] Although malignant transformation of the leiomyoma is possible, malignancy can only be ruled out by resection.[9,10] The coexistence of esophageal SCC and leiomyoma shows two different types. In the overlying type, the carcinoma covers the benign SMT, and in the separate type, the carcinoma and the benign SMT are separate entities. Generally, most SMTs in the separate category are tiny leiomyomata that are discovered only during the postoperative examination of pathology specimens after an esophagectomy for esophageal SCC.[10,11] This was the case with our patient.
In our case, the esophagoscopy revealed an ulcerative mucosal lesion over the elevated lesion, and the biopsy showed that the lesion was an SCC. In our clinic, EUS is not available, so after the general investigations that were mentioned above, dissection of the distal esophagus with esophagogastric anastomosis was performed along with a laparotomy and thoracotomy (Ivor-Lewis approach).
In recent years, EUS has emerged as a valuable tool and has been recommended for the preoperative staging of the tumor and to assist in the planning of the surgery. However, in our case, even if EUS had been utilized, the same surgical approach would have been needed due to the coexistence of esophageal SSC.
In conclusion, in the management of esophageal malignancies, preoperative evaluations are crucial. Examinations using EUS are especially informative as they make it possible to detect tumor size and margins. They can also be used to discover the tumoral invasion of the esophageal wall along with the coexistence of SMTs with SCC. It must kept in mind that esophageal carcinomas may coexist with SMTs.
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