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DOI: 10.1055/s-0043-103402
Endoscopic dissection of a symptomatic giant gastric leiomyoma arising from the muscularis propria
Publication History
Publication Date:
29 March 2017 (online)
![](https://www.thieme-connect.de/media/endoscopy/2017S01/lookinside/thumbnails/0058_10-1055-s-0043-103402-1.jpg)
Gastrointestinal (GI) subepithelial masses represent a heterogeneous group of lesions, ranging from benign to malignant, for which management is sometimes challenging [1] [2]. We report the case of an 85-year-old woman, with a history of coronary artery disease and chronic atrial fibrillation being treated with anticoagulant therapy, who underwent urgent upper GI endoscopy for hemorrhagic shock and melena. During this procedure, a giant, 15-cm, non-pedunculated mass that was ulcerated on top was found at the greater curvature of the anterior wall of the stomach ([Fig. 1]).
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-103402-i0058cl1.jpg)
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The patient then underwent radial endoscopic ultrasonography (EUS; GF-UE160-AL5; Olympus), which showed a hypoechoic homogeneous intramural mass that was arising from the muscularis propria and was suspected to be a leiomyoma ([Fig. 2]). In order to achieve a definitive diagnosis, EUS with fine needle aspiration (FNA) was performed (GF-UCT180; Olympus) using a 22-gauge needle (Expect-SlimLine; Boston Scientific). Histology and immunohistochemical staining revealed that the specimen was compatible with a leiomyoma (SMA positive, CD117 and CD34 negative). Total body computed tomography (CT) excluded metastatic disease.
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-103402-i0058cl2.jpg)
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Because this was a symptomatic hemorrhagic lesion and there was a need to continue anticoagulant therapy, an endoscopic dissection was performed. We used the HybridKnife T-type (ERBE Elektromedizin GmbH) and a solution composed of 250 mL normal saline, 2 mL indigo carmine, and 1 mL epinephrine. The procedure took 115 minutes and resulted in an en bloc specimen, with no complications occurring ([Fig. 3]; [Video 1]). However, because of its size, it was not possible to retrieve the whole lesion, which resulted in it being completely digested by gastric secretions by the following day ([Fig. 4]).
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-103402-i0058cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Quality:
![](https://www.thieme-connect.de/media/endoscopy/2017S01/thumbnails/10-1055-s-0043-103402-i0058cl4.jpg)
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Low molecular weight heparin was re-introduced 24 hours after the procedure and the patient was discharged 2 days later. Upper GI endoscopy and EUS performed 3 months later revealed a regular scar, without any remnant pathological tissue.
This case illustrates the feasibility and safety of endoscopic dissection of a symptomatic giant gastric leiomyoma, even in a high risk patient who was receiving ongoing anticoagulant therapy, in whom surgery would have carried considerable risk. Moreover, EUS-FNA achieved an accurate evaluation of the lesion’s layer of origin and its histopathologic characteristics, thereby allowing a definitive diagnosis to be made and the appropriate therapeutic option to be chosen.
Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB
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References
- 1 He G, Wang J, Chen B. et al. Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in pre-operation assess and post-operation follow-up: a prospective study of 224 cases in a single medical center. Surg Endosc 2016; 30: 4206-4213
- 2 Salah W, Faigel DO. When to puncture, when not to puncture: submucosal tumors. Endosc Ultrasound 2014; 3: 98-108