Esophageal Leiomyoma and Simultaneous Overlying Squamous Cell Carcinoma: A Case Report and Review of the Literature

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Upper endoscopy with multiple minimally invasive biopsies should be performed to confirm the diagnosis. Leiomyoma of esophagus is rare, but it’s the most common benign submucosal mesenchymal tumor of the esophagus. The simultaneous occurrence of an overlying epithelial lesion and a mesenchymal lesion is very rare. This study aims to show a case operated due to squamous cell carcinoma of esophagus that was postoperatively diagnosed with coexistent esophageal leiomyoma and provide a clear overview of the existing literature on it. Case presentation: The patient was a 41-year-old lady who underwent three field esophagectomy (McKeown). In reviewing the pathology slides, the patient had poorly differentiated squamous cell carcinoma and also multiple leiomyomas. A leiomyoma was coexisted with an invading overlying squamous cell carcinoma. Conclusion: It is concluded that esophageal carcinomas may coexist with leiomyomas; preexisting benign tumors may have played an important role in the development of carcinoma by inducing constant stimulation of the overlying mucosa; endoscopic ultrasonography is recommended to avoid overestimating the extent of tumor invasion and the resultant aggressive radical surgery; and esophageal resection is still the modality of choice in treatment in developing countries and also countries with limited equipment. Oncology Esophageal squamous cell carcinoma Leiomyoma of esophagus simultaneous occurrence overlying esophageal resection Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background: Leiomyoma of esophagus is rare, but it’s the most common benign submucosal mesenchymal tumor (SMT) of the esophagus; it originates in the smooth muscle cells, and accounts for two-thirds (60–70%) of all benign esophageal tumors ( 1 – 3 ). It almost appears as a single tumor, and multiple leiomyomas of the esophagus are extremely rare ( 1 , 4 ). Since esophageal leiomyoma is generally a slow-growing tumor and the size of tumor may not change for many years, most affected patients are asymptomatic ( 2 ). Often, a diagnosis of esophageal leiomyoma is made as an incidental finding during routine investigation or screening for upper gastrointestinal (GI) pathology ( 3 ). Endoscopic ultrasonography (EUS) and computerized tomography (CT) are used for the diagnosis of leiomyoma. The diagnosis is difficult when multiple leiomyomas coexist with carcinoma lesions. In cases where carcinoma overlies a submucosal leiomyoma, there is a possibility of overestimating the extent of tumor invasion, and multiple minute leiomyomas are sometimes misdiagnosed as intramural metastasis ( 2 ). Although esophageal leiomyoma is conventionally treated by surgical removal via open thoracotomy for the tumors in the upper two‑thirds of the esophagus, minimally invasive approaches like video-assisted thoracoscopic surgery (VATS) and endoscopic resection are other alternative ways used for enucleation of the tumor ( 3 , 5 ). Squamous cell carcinoma (SCC) is the most common epithelial tumor of the esophagus ( 2 ). Upper endoscopy with multiple minimally invasive biopsies should be performed to confirm the diagnosis. Computed tomography of the thorax and abdomen should be performed to evaluate the extent of the primary tumor and search potential liver metastases and celiac lymphadenopathy. An accurate preoperative staging will guide the most appropriate treatment selection. The general treatment recommendations are as follows: Endoscopic resection for superficial, limited mucosa disease (less than T1a), direct surgical resection with lymphadenectomy for lesions penetrating the submucosa with negative lymph nodes (more than T1b), neoadjuvant chemoradiation of resectable lesions invading muscularis propria with positive lymph nodes (less than T2N1), palliative systemic therapy for those locally advanced unresectable or metastatic disease ( 6 ). The simultaneous occurrence of an overlying epithelial lesion (SCC) and a mesenchymal lesion (leiomyoma) is very rare. This study aims to show a case operated due to SCC of esophagus that was postoperatively diagnosed with coexistent esophageal leiomyoma and provide a clear overview of the existing literature on it. Case Presentation: The patient was a 41-year-old lady who was first seen at Shahid Mofateh clinic affiliated to Yasuj University of medical sciences in 2019 with complaints of having progressive dysphagia to solid foods and a ten kilograms weight loss for the preceding 6 months; the patient had also anorexia, decreased intake, and general fatigue and lethargy as accompanying symptoms, but the patient had no nausea and vomiting. In past medical and drug history, the patient had asthma and used fexofenadine and salbutamol spray. There was no family history of malignancy in her parents and siblings. The patient didn’t use tobacco, smoke cigarette and drink alcohol. Laboratory values were all within normal limits. The patient underwent upper GI endoscopy. In esophagus, upper esophageal sphincter, cricopharyngeus and upper third of esophagus were normal. A large fungating and ulcerative mass was found in middle and lower third of esophagus, 25–33 cm from the upper incisors. Z line was normal (Fig. 1 ). In stomach, cardia (retro-vision maneuver), fundus, body and antrum were normal. In duodenum, bulb and 2nd part were normal. The patient underwent incisional biopsy and was found to have poorly differentiated squamous cell carcinoma in pathology evaluation. In spiral chest CT scan with and without intravenous (IV) contrast, obtained axial images, represented a 29*18 mm soft tissue fullness at middle to distal esophagus (at the level of carina to the level of main pulmonary artery), which was suggestive for tumoral lesion. No lung metastasis was found. In spiral abdomen and pelvic CT scan with oral and IV contrast, there was a 12*9 mm lymph node within gastrohepatic ligament (Fig. 2 ). In abdomen and pelvic sonography, there was a 10*9 mm hypoechoic lesion between left liver lobe and greater curvature which was suggestive of lymphadenopathy (LAP) (Fig. 3 .). The patient received 3 sessions of chemotherapy before undergoing operation. The patient underwent three field esophagectomy (McKeown) including laparotomy, right thoracotomy, and gastric pull-up with cervical anastomosis including extended thoracotomy, esophagectomy, gastric pull-up, pyloroplasty, cervical esophagostomy, jejunostomy, and chest tube insertion. An abdominal lymph node at the gastrohepatic ligament was also resected. The postoperative course was uncomplicated. There was no evidence of leak at the anastomotic site by administration of methylene blue dye on the fifth postoperative day and then nasogastric tube was removed and the patient was begun on liquids by mouth. The patient advanced to a regular diet by the tenth postoperative day. She was discharged from the hospital on the 14th day of admission. At a follow-up visit of 1 week and then 2 weeks after discharge from hospital she was feeling well. The patient’s condition after surgery came back to her normal habitual life within 3 months. The patient had no complaint at the 9th month follow-up visit after surgery. Spiral chest and abdomen CT scan was done and showed a pulled-up stomach, filled with fluid and air at the right paraspinal region (Fig. 4 ). The specimen was sent in formalin for pathology and immunohistochemistry evaluation. The received specimen was consisted of esophagus and a segment of stomach. Resected esophagus was 12 cm in length and 3 cm in greatest diameter. Adventitial surface was congested. On opening, there were four intramural creamy round firm masses measuring from 1 to 2 cm. No perforation site was found. Proximal and distal margins were not grossly involved. The resected segment of stomach was 8 cm in greater curvature and 6 cm in lesser curvature and showed no mass (Fig. 5 ). Multiple lymph nodes were identified measuring from 0.5 to 1 cm in diameter. In reviewing the slides, the patient had small groups of residual poorly differentiated squamous cell carcinoma and also multiple leiomyomas. A leiomyoma was coexisted with an invading overlying SCC (Fig. 6 ). There were 5 isolated lymph node within the pathology specimen, of which two were involved with the tumor, but pathology didn’t show any sign of metastasis in the lymph node resected at the gastrohepatic ligament. Tumor pathology characteristics are summarized and shown in Table 1. Discussion: There are several reports of co-existing overlying esophageal SCC and leiomyoma in the literature. In this situation, the esophageal submucosal layer is overlaid by the superficial cancer. This coexistence is very rare, and this is usually detected following surgery. Callanan et al, reported the first case of its kind in 1954 ( 7 ). In this regard, all previously published reports on cases with leiomyoma overlying with esophageal SCC were searched and found on the web and only available full-text original articles were encountered. As a result, 15 cases in 14 reports were elucidated. These reports were evaluated and summarized in Table 2 according to the originated country and published year of case report, patient’s gender, age, chief complaints, risk factors, and comorbid diseases, and upper GI endoscopy, EUS, other diagnostic modalities and pathologic results, location of tumor and treatments applied ( 1 , 2 , 4 , 8 – 18 ). Of the previous published reports, 10 reports were from Japan, 2 reports were from South Korea, and one report from Iran and Turkey each. It shows that this pathology is much more common in the East Asia, especially in Japan. There was only one female patient previously reported, so our case was the second one. It shows the male predominance pattern in this regard. Ishida et al. reported male to female ratio of 4:1 in patients with SCC overlying leiomyoma ( 16 ). Mean age was 59.62 +/- 9.46 years (minimum 41 and maximum 75 years). Our case was the youngest patient in all, as the youngest patient was previously from Turkey with age of 44 years ( 4 ). In chief complains, there were 5 cases with dysphagia or stenotic sensation in the pharyngeal region, 3 cases with significant weight loss, 3 cases with esophageal tumor which were found at the routine health checkups, and one patient with epigastric pain. From the reports in which risk factors were mentioned, heavy smoking was seen in three cases. Comorbid diseases were found negative in 4 cases, and malignant lymphoma of the thyroid and hyperglycemia and osteoporosis were found in one case each. Upper GI endoscopy showed an elevated or protruding lesion in 5 cases, a sessile polypoid lesion in 3 cases, and a submucosal tumor in 3 cases. Chromoendoscopy with iodine staining was done in 7 cases and showed a non-staining area in all. EUS was done in 8 cases and showed a hypoechoic homogeneous submucosal tumor with a well demarcated and clear margin in the muscularis mucosae (MM) covered with intraepithelial layer indicative of leiomyoma in most of the cases. Barium esophagogram study was done in 4 cases. In pathologic evaluation, squamous cell carcinoma in situ (high-grade intraepithelial neoplasia) was seen in 4 cases, poorly differentiated SCC in 2, moderately differentiated SCC in 2, and malignant SCC in one case. More than one leiomyoma was seen in 3 cases. According to the location of the lesions, proximal, middle and distal third of the esophagus accounted for 5, 6 and 4 cases each retrospectively. Surgery (esophageal resection) was done in 9 cases, and this is comparable with endoscopic submucosal dissection (ESD) which was done in 6 cases. There are two types of coexistence: 1. Overlying type in which the carcinoma covers the benign tumor, and 2. the two lesions are completely separated and encountered during or after esophagectomy for esophageal SCC ( 2 , 12 , and 19 ). In our case study, the two types exist and this result was as the same as the two other studies done by Iwaya et al. and Geramizadeh et al. ( 2 , 15 ). There are two theories on the etiology of carcinoma development over the leiomyoma: 1. protrusion of leiomyoma into the esophageal lumen and chronic irritation of the esophageal mucosa and predisposing it to dysplasia may be the pathogenesis of the disease; 2. Underlying leiomyoma prevents the SCC from dissemination and widespread invasion ( 2 , 13 , and 15 ). An upper GI endoscopy is usually used for the differential diagnosis of esophageal carcinoma and leiomyoma, but it may not always lead to an accurate diagnosis, because esophageal leiomyomas are submucosal lesions. Availability of EUS provides an advantage in the detection and management of these tumors as it clearly reveals the five-layered structure of the gastrointestinal wall as well as by enabling exact localization and origin, tumor margin, echogenic pattern, and accurate size measurement ( 4 , 5 ); but unfortunately we didn’t have EUS in our hospital, so we were unaware about coexistence of any leiomyoma until it had been removed through esophagectomy. Narrow band imaging (NBI) endoscopy uses optical filters that improve absorbance and scattering of light, enhancing the appearance of vessels and other structures, thus providing a high contrast of tissue surface during endoscopy. Along with magnifying endoscopes and chromoendoscopy, a close to histological tissue description is possible. These have been used to improve the assessment of esophageal lesions ( 5 ); but unfortunately we did not have any of these to help evaluate the tumor or esophageal mucosa. When choosing treatment for SMT, it is important to determine by endoscopic ultrasonography from which layer the tumor originates. If a small SMT is diagnosed as originating from the muscularis mucosa, endoscopic submucosal resection (EMR) is the treatment of choice. When the tumors are large and originate in the muscularis propria, this technique has the risk of severe complications, such as esophageal perforation and massive bleeding. Hence, in those cases, open surgery or thoracoscopic resection is chosen. In this case, as we didn’t have EUS and EMR, so open surgery was performed. Conclusion: To sum up it can be concluded that 1. it must kept in mind that esophageal carcinomas may coexist with leiomyomas, 2. preexisting benign tumors may have played an important role in the development of carcinoma by inducing constant stimulation of the overlying mucosa, 3. EUS is recommended to avoid overestimating the extent of tumor invasion and the resultant aggressive radical surgery 4. Esophageal resection is still the modality of choice in treatment in developing countries and also countries with limited equipment. Abbreviations: Submucosal mesenchymal tumor (SMT) Endoscopic ultrasonography (EUS) Computerized tomography (CT) Gastrointestinal (GI) Video-assisted thoracoscopic surgery (VATS) Squamous cell carcinoma (SCC) Intravenous (IV) Muscularis mucosae (MM) Endoscopic submucosal dissection (ESD) Endoscopic submucosal resection (EMR) Narrow band imaging (NBI) endoscopy Declarations Ethics approval and consent to participate Written informed consent was obtained from the patient for participation. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors of this manuscript declare no competing of interests Funding Not received. Acknowledgment We all express our gratitude to the patient who kindly gave consent for this case to be presented in this paper. The authors also wish to thank Dr. Aida Iraji at the Central research laboratory, Shiraz University of Medical Sciences, Shiraz, Iran for her assistance in editing this manuscript. Contributions Principal author: SM evaluated the patient clinically, operated the patient (main surgeon), read and revised the paper. Corresponding-author: MJYB evaluated the patient clinically, helped to operate the patient (co-surgeon), prepared the first draft and revised the paper. Co-author: SH evaluated the pathology slides (our pathologist and revised the manuscript. Co-author: HS helped in collecting the patient data, assisted with the administration and monitoring of anesthesia during patients operation and upper GI endoscopy (our anesthetic technician). All authors read and approved the final manuscript. References Seo M, Kim DH, Cho YW, et al. Superficial Esophageal Neoplasms Overlying Leiomyomas Removed by Endoscopic Submucosal Dissection: Case Reports and Review of the Literature. Clin Endosc. 2015; 48(4):322‐ https://doi:10.5946/ce.2015.48.4.322 Iwaya T, Maesawa C, Uesugi N, et al. Coexistence of esophageal superficial carcinoma and multiple leiomyomas: A case report. World J Gastroenterol. 2006; 12(28):4588‐ https://doi:10.3748/wjg.v12.i28.4588 Mathew G, Carter YM. Esophageal Leiomyoma. [Updated 2019 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459298/ Erol M. Coexistence of esophageal squamous cell carcinoma and leiomyoma: a case report. Turkish Journal of Thoracic and Cardiovascular Surgery. 2012; 20: 944-946. https://doi:10.5606/tgkdc.dergisi.2012.188 Ismaila BO, Davwar PM. Endoscopic resection of an esophageal leiomyoma with overlying dysplasia without specialized equipment. Niger J Clin Pract. 2016; 19(3):418‐ https://doi:10.4103/1119-3077.179294 Recio-Boiles A, Waheed A, Babiker HM. Cancer, Esophageal. [Updated 2019 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459267/ Callanan JG. Simultaneous occurrence of simple and malignant tumors in the esophagus. J Thorac Surg. 1954; 28(1):4-10. Iizuka T, Kato H, Watanabe H, Itabashi M, Hirota T. Superficial carcinoma of the esophagus coexisting with esophageal leiomyoma: a case report and review of the Japanese literature. Jpn J Clin Oncol. 1984; 14(1):115‐ https://doi:10.1093/oxfordjournals.jjco.a038944 Kuwano H, Sadanaga N, Watanabe M, Yasuda M, Nozoe T, Sugimachi K. 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Endoscopic resection of the esophageal squamous cell carcinoma overlying leiomyoma. Gastrointest Endosc. 2008; 67(4):745‐ https://doi:10.1016/j.gie.2007.09.021 Geramizadeh B, Ziyaian B, Safari A. Invasion of esophageal leiomyoma by coexistent overlying squamous cell carcinoma. J Gastrointest Cancer. 2009; 40(3-4):131‐ https://doi:10.1007/s12029-009-9093-8 Niimi K, Kodashima S, Ono S, Goto O, Yamamichi N, Fujishiro M. Curative ESD for intraepithelial esophageal carcinoma with leiomyoma mimicking submucosal invasive carcinoma. World J Gastrointest Endosc. 2009; 1(1):68‐ https://doi:10.4253/wjge.v1.i1.68 Ishida M, Mochizuki Y, Iwai M, Yoshida K, Kagotani A, Okabe H. Esophageal squamous cell carcinoma in situ overlying leiomyoma: a case report with review of the literature. Int J Clin Exp Pathol. 2013; 6(12):3026‐ Oh WJ, Lee EJ, Lee YS, Kim TJ. Esophageal squamous cell carcinoma in situ overlying leiomyoma mimicking invasive cancer: a brief case report. 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Tumor pathology and immunohistochemistry characteristics Tumor type SCC, poorly differentiated (G3) Residual tumor size 0.6 cm Tumor extension Tumor invaded submucosal (at least) Proximal margin Free of tumor Distal margin Free of tumor Radial margin Free of tumor Treatment effect Near complete response, score 1 (single cell and small groups of cancer cells Lymphovascular invasion Present Perineural invasion Present Lymph-node invasion Total: 5, involved: 2; metastatic poorly differentiated squamous cell carcinoma (LN2) Additional pathologic findings Multiple leiomyomas, the largest one measuring: 2 cm in diameter Pathologic staging ypT1bN1Mx Immunohistochemistry Negative for C-KIT and CDX2 proto-oncogenes Positive for Desmin and P63 proto-oncogenes Note This staging categorizes the extent of tumor actually present at the time of examination (after the chemotherapy). The “y” categorization is not an estimate of tumor before chemotherapy. Table 2. Summarized previous published reports on leiomyoma with overlying SCC Country and year Gender and age Chief complaints Risk factors Comorbid diseases Upper GI Endoscopy EUS Other diagnostic modalities (1) Other diagnostic modalities (2) Pathology Location Treatment Japan, 1984 (8) Male/ 75 Stenotic sensation in the pharyngeal region Heavy smoking An elevated erosive lesion in the posterior wall of the esophagus Barium esophagogram: a tumorous shadow,5cm, middle thoracic esophagus Leiomyoma with overlying SCC Middle third of the esophagus Surgery: blunt dissection of the esophagus without thoracotomy, esophagogastroanastomosis Japan, 1995 (9) Male/45 Dysphagia Leiomyoma with overlying SCC Middle third of the esophagus Esophageal resection and reconstruction Japan, 1995 (9) Male/71 Not mentioned, referred for treatment of an esophageal tumor A mucosal irregularity on the surface of the submucosal tumor Leiomyoma with overlying SCC Middle third of esophagus Esophageal resection and reconstruction Japan, 1995 (10) Male/52 Asymptomatic Heavy smoking Negative Sessile polypoid lesion at abdominal esophagus A 9mm submucosal tumor with smooth contour, leiomyoma Barium swallow: as health checkup Double contrast barium esophagogram: semispherical tumor, 1.5 cm Leiomyoma with overlying poorly differentiated SCC Distal third of the esophagus Surgical Resection Japan, 1997 (11) Male/61 Sessile polypoid lesion with a smooth surface at the esophagus A hypoechoic tumor just below the epithelial layer Moderately differentiated SCC on leiomyoma originating from muscularis mucosa Proximal third of the esophagus Endoscopic resection by aspiration lumpectomy Japan, 2002 (12) Male/62 Not mentioned, referred for treatment of an esophageal tumor A protruding lesion, resembling a submucosal tumor, in the proximal third of the esophagus A hypoechoic tumor confined to the submucosa with a well demarcated, smooth outline Chromoendoscopy: non-staining Moderately differentiated SCC overlying the leiomyoma Proximal third of the esophagus Endoscopic submucosal dissection (ESD) Japan, 2004 (13) Male/65 A sessile polypoid lesion with a smooth surface in the proximal third of the esophagus A hypoechoic tumor, 13 mm in diameter, located in the submucosa, with clear margins and a smooth contour, with the muscularis propria layer intact Chromoendoscopy: non-staining Leiomyoma with overlying poorly differentiated SCC Proximal third of the esophagus Endoscopic submucosal dissection (ESD) Japan, 2006 (2) Male/71 malignant lymphoma of the thyroid A superficial ulcerative tumor (24 mm in diameter) in the lower third of the esophagus, overlying the smaller leiomyoma Cancer overlaid the smaller leiomyoma and invaded the submucosal layer Barium swallow Esophagogram: two smoothly rounded defects Chromoendoscopy: non-staining Squamous cell carcinoma in situ overlying a leiomyoma, separated multiple leiomyomas Distal third of the esophagus Surgery: esophagectomy, gastric pull-up reconstruction, cervical anastomosis via abdominal, left cervical and right thoracotomy incisions Japan, 2008 (14) Male/61 Mild epigastralgia A submucosal tumor with a smooth and mildly red surface mucosa in the proximal third of the esophagus A hypoechoic lesion originating from the muscularis mucosae with a clear margin Chromoendoscopy with iodine staining: non-staining area Leiomyoma with overlying SCC Proximal third of the esophagus Endoscopic submucosal dissection (ESD) Iran, 2009 (15) Male/47 Progressive dysphagia and epigastric pain and about 20 kg weight loss. A depressed area with uneven and irregular border Several leiomyomas, the largest of which was covered by malignant SCC. Laparotomy, transhiatal esophagectomy, cervical esophagastrostomy (Orringer), and bilateral chest tube insertion Japan, 2009 (16) Male/65 Asymptomatic Heavy smoking and alcohol consumption Negative An esophageal tumor in the middle thoracic esophagus Hypoechoic tumor in the muscularis mucosae covered with intraepithelial layer indicative of leiomyoma Chromoendoscopy with iodine staining: non-staining area Magnifying endoscopy with narrow band imaging (NBI): dilated and elongated intrapapillary capillary loop (IPCL), indicated intraepithelial carcinoma Leiomyoma with overlying SCC Middle third of the esophagus Endoscopic submucosal dissection (ESD) Turkey 2012 (4) Male/44 Weight loss and dysphagia for two month Negative Negative A tumoral mass with a partially irregular surface in the distal third of the esophagus CT scan of the thorax and abdomen: minimally diffuse esophageal wall enlargement in a 5 cm segment of the distal esophagus with no lymph node involvement or distant metastasis SCC infiltrated to the submucosa and two separated leiomyoma along with five reactive and three metastatic lymph nodules. Distal third of the esophagus Distal esophagectomy and an esophagogastrostomy together with a laparotomy and thoracotomy (Ivor-Lewis approach) Japan, 2013 (17) Female/75 Esophageal tumor at health checkup hyperglycemia and osteoporosis A submucosal tumor, measuring 5 x 4 mm in diameter, 20 cm from the incisors Coexistence of esophageal SCC in situ (high-grade intraepithelial neoplasia) overlying leiomyoma Endoscopic submucosal dissection (ESD) South Korea, 2014 (18) Male/53 Esophageal tumor at health checkup An elevated mass, 1.8 cm in diameter, with irregular central small erosion in the upper thoracic esophagus. Chromoendoscopy with iodine staining: non-staining area Squamous cell carcinoma in situ overlying submucosal leiomyoma Proximal third of the esophagus Subtotal esophagectomy South Korea, 2015 (1) Male/66 Esophageal tumor at health checkup A protruding mass that measured 1×1 cm in diameter and was located 25 cm from the upper incisors. A hypoechoic and homogeneous lesion that originated from the muscularis mucosa (MM) below the epithelial layer. Chromoendoscopy with iodine staining: non-staining area Squamous cell carcinoma in situ overlying submucosal leiomyoma Middle third of the esophagus En bloc resection using ESD Iran, 2020 Female/41 Progressive dysphagia and significant weight loss for the preceding 6 months Negative Negative A large fungating and ulcerative mass, middle and lower third of esophagus, 25-33 cm from the upper incisors. Chest CT scan: a 29*18 mm soft tissue fullness at middle to distal esophagus, suggestive for tumoral lesion. Multiple leiomyomas, SCC overlying a leiomyoma Middle and distal third of the esophagus Extended thoracotomy, esophagectomy, gastric pull-up, pyloroplasty, cervical esophagostomy (Orringer) Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-38770","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":743623,"identity":"e34730b6-b794-4bbb-b294-8bfb439c77c9","order_by":0,"name":"Saadat Mehrabi","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Saadat","middleName":"","lastName":"Mehrabi","suffix":""},{"id":743624,"identity":"a2908118-48ba-4e9c-bfbc-2bd65122f5f6","order_by":1,"name":"Mohammad Javad Yavari Barhaghtalab","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABSklEQVRIie2QP0vDQBTAXwjE5VLXFFP6CYQHhUqxpPhNWgLtUtCx0kITKudi3P0WdTJuFw6SJepWLF3avULBxYAFLwYlNlVXwfyW9+fux7t7ADk5fxKWBAUIgGQBoAhMsuqfF8jviiJ6ktX+QUkfpRT+7b19mylaRI3jAqje86lrGDfl0ZxF7kNrPAnm8DIA/cD6olQZU4oONWsUCmbxLjTNW6qg54Sz1njWRenCB6KzjKKRUBbPIVi0qWyiD8hU+q4AqBYQDbJTXsNhrFQimw6FsrPy1vReKJ25tN6u7JEej5WqmMIN9AlylTKhNFHeOsUbHeq9ABW50K7ZNGii3z3hpdCsXIm/cN3XMsoj96ZL7GP53OFTm/YbyIPrxZNrlC5nncViOag3NhTQvLOkJSd162OjR3EidrUpAOxa8ipdNzJJTk5Ozr/nDTg3faPEAxA5AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2859-044X","institution":"Yasuj University of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Javad Yavari","lastName":"Barhaghtalab","suffix":""},{"id":743625,"identity":"9490cd50-eb73-4bc2-a089-84975d3eb194","order_by":2,"name":"Safoora Hejazinia","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Safoora","middleName":"","lastName":"Hejazinia","suffix":""},{"id":743626,"identity":"87957002-84c2-46df-b9e0-f08956c5df32","order_by":3,"name":"Hossein Saedi","email":"","orcid":"","institution":"Yasuj University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hossein","middleName":"","lastName":"Saedi","suffix":""}],"badges":[],"createdAt":"2020-06-29 09:12:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-38770/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-38770/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1526580,"identity":"aea86609-afdc-4ba0-a13c-58324c5fa073","added_by":"auto","created_at":"2020-07-09 16:56:42","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76090,"visible":true,"origin":"","legend":"Upper GI endoscopy: large fungating and ulcerative mass in middle (A and B) and lower third (C and D) of esophagus, Z-line (E), Cardia (F)","description":"","filename":"Fig1.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig1.JPG"},{"id":1526581,"identity":"30627ff0-b42c-46c1-a908-2fcc70a82f0c","added_by":"auto","created_at":"2020-07-09 16:56:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59328,"visible":true,"origin":"","legend":"Spiral chest CT scan with and IV contrast (yellow arrows show the tumor); A: Axial view with IV contrast; B: Axial view without contrast; C: Coronal view with IV contrast; D: Sagittal View with IV contrast","description":"","filename":"Fig2.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig2.JPG"},{"id":1526582,"identity":"80097a39-8d4e-489f-8c83-c89094c78f30","added_by":"auto","created_at":"2020-07-09 16:56:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21011,"visible":true,"origin":"","legend":"Spiral abdomen and pelvic CT scan: a lymph node within gastrohepatic ligament shown with yellow arrow","description":"","filename":"Fig3.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig3.JPG"},{"id":1526583,"identity":"8dcc7e71-53f1-421c-8665-0e196d2127dc","added_by":"auto","created_at":"2020-07-09 16:56:42","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21319,"visible":true,"origin":"","legend":"Spiral chest CT scan: pulled-up stomach at the right paraspinal region shown in yellow arrow.","description":"","filename":"Fig4.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig4.JPG"},{"id":1526584,"identity":"ad11c5ff-b9d2-44d1-a288-3548f630c97d","added_by":"auto","created_at":"2020-07-09 16:56:43","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":53749,"visible":true,"origin":"","legend":"A. Gross Pathology of the specimen, B. Three Three leiomyomas in gross pathology of the specimen","description":"","filename":"Fig5.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig5.JPG"},{"id":1526585,"identity":"8e901725-2648-49cb-af13-51a66e19fdaf","added_by":"auto","created_at":"2020-07-09 16:56:43","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":72459,"visible":true,"origin":"","legend":"A. A leiomyoma with normal overlying epithelium, B. A small separated leiomyoma, C. Overlying submucosal SCC on a leiomyoma, D. SCC residual tumor cell nests","description":"","filename":"Fig6.JPG","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/Fig6.JPG"},{"id":13550129,"identity":"80ca4c25-4339-4866-bdbe-08e6fe5701f9","added_by":"auto","created_at":"2021-09-17 02:23:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":584787,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-38770/v1/4df803f7-5a74-4e0c-a1ba-6b35d66e8c52.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eEsophageal Leiomyoma and Simultaneous Overlying Squamous Cell Carcinoma: A Case Report and Review of the Literature\u003c/p\u003e","fulltext":[{"header":"Background:","content":" \u003cp\u003eLeiomyoma of esophagus is rare, but it\u0026rsquo;s the most common benign submucosal mesenchymal tumor (SMT) of the esophagus; it originates in the smooth muscle cells, and accounts for two-thirds (60\u0026ndash;70%) of all benign esophageal tumors (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It almost appears as a single tumor, and multiple leiomyomas of the esophagus are extremely rare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Since esophageal leiomyoma is generally a slow-growing tumor and the size of tumor may not change for many years, most affected patients are asymptomatic (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Often, a diagnosis of esophageal leiomyoma is made as an incidental finding during routine investigation or screening for upper gastrointestinal (GI) pathology (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Endoscopic ultrasonography (EUS) and computerized tomography (CT) are used for the diagnosis of leiomyoma. The diagnosis is difficult when multiple leiomyomas coexist with carcinoma lesions. In cases where carcinoma overlies a submucosal leiomyoma, there is a possibility of overestimating the extent of tumor invasion, and multiple minute leiomyomas are sometimes misdiagnosed as intramural metastasis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although esophageal leiomyoma is conventionally treated by surgical removal via open thoracotomy for the tumors in the upper two‑thirds of the esophagus, minimally invasive approaches like video-assisted thoracoscopic surgery (VATS) and endoscopic resection are other alternative ways used for enucleation of the tumor (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSquamous cell carcinoma (SCC) is the most common epithelial tumor of the esophagus (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Upper endoscopy with multiple minimally invasive biopsies should be performed to confirm the diagnosis. Computed tomography of the thorax and abdomen should be performed to evaluate the extent of the primary tumor and search potential liver metastases and celiac lymphadenopathy. An accurate preoperative staging will guide the most appropriate treatment selection. The general treatment recommendations are as follows: Endoscopic resection for superficial, limited mucosa disease (less than T1a), direct surgical resection with lymphadenectomy for lesions penetrating the submucosa with negative lymph nodes (more than T1b), neoadjuvant chemoradiation of resectable lesions invading muscularis propria with positive lymph nodes (less than T2N1), palliative systemic therapy for those locally advanced unresectable or metastatic disease (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe simultaneous occurrence of an overlying epithelial lesion (SCC) and a mesenchymal lesion (leiomyoma) is very rare. This study aims to show a case operated due to SCC of esophagus that was postoperatively diagnosed with coexistent esophageal leiomyoma and provide a clear overview of the existing literature on it.\u003c/p\u003e "},{"header":"Case Presentation:","content":" \u003cp\u003eThe patient was a 41-year-old lady who was first seen at Shahid Mofateh clinic affiliated to Yasuj University of medical sciences in 2019 with complaints of having progressive dysphagia to solid foods and a ten kilograms weight loss for the preceding 6 months; the patient had also anorexia, decreased intake, and general fatigue and lethargy as accompanying symptoms, but the patient had no nausea and vomiting. In past medical and drug history, the patient had asthma and used fexofenadine and salbutamol spray. There was no family history of malignancy in her parents and siblings. The patient didn\u0026rsquo;t use tobacco, smoke cigarette and drink alcohol. Laboratory values were all within normal limits.\u003c/p\u003e \u003cp\u003eThe patient underwent upper GI endoscopy. In esophagus, upper esophageal sphincter, cricopharyngeus and upper third of esophagus were normal. A large fungating and ulcerative mass was found in middle and lower third of esophagus, 25\u0026ndash;33\u0026nbsp;cm from the upper incisors. Z line was normal (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In stomach, cardia (retro-vision maneuver), fundus, body and antrum were normal. In duodenum, bulb and 2nd part were normal. The patient underwent incisional biopsy and was found to have poorly differentiated squamous cell carcinoma in pathology evaluation.\u003c/p\u003e \u003cp\u003eIn spiral chest CT scan with and without intravenous (IV) contrast, obtained axial images, represented a 29*18\u0026nbsp;mm soft tissue fullness at middle to distal esophagus (at the level of carina to the level of main pulmonary artery), which was suggestive for tumoral lesion. No lung metastasis was found. In spiral abdomen and pelvic CT scan with oral and IV contrast, there was a 12*9\u0026nbsp;mm lymph node within gastrohepatic ligament (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In abdomen and pelvic sonography, there was a 10*9\u0026nbsp;mm hypoechoic lesion between left liver lobe and greater curvature which was suggestive of lymphadenopathy (LAP) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.).\u003c/p\u003e \u003cp\u003eThe patient received 3 sessions of chemotherapy before undergoing operation. The patient underwent three field esophagectomy (McKeown) including laparotomy, right thoracotomy, and gastric pull-up with cervical anastomosis including extended thoracotomy, esophagectomy, gastric pull-up, pyloroplasty, cervical esophagostomy, jejunostomy, and chest tube insertion. An abdominal lymph node at the gastrohepatic ligament was also resected. The postoperative course was uncomplicated. There was no evidence of leak at the anastomotic site by administration of methylene blue dye on the fifth postoperative day and then nasogastric tube was removed and the patient was begun on liquids by mouth. The patient advanced to a regular diet by the tenth postoperative day. She was discharged from the hospital on the 14th day of admission. At a follow-up visit of 1 week and then 2 weeks after discharge from hospital she was feeling well. The patient\u0026rsquo;s condition after surgery came back to her normal habitual life within 3 months. The patient had no complaint at the 9th month follow-up visit after surgery. Spiral chest and abdomen CT scan was done and showed a pulled-up stomach, filled with fluid and air at the right paraspinal region (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe specimen was sent in formalin for pathology and immunohistochemistry evaluation. The received specimen was consisted of esophagus and a segment of stomach. Resected esophagus was 12\u0026nbsp;cm in length and 3\u0026nbsp;cm in greatest diameter. Adventitial surface was congested. On opening, there were four intramural creamy round firm masses measuring from 1 to 2\u0026nbsp;cm. No perforation site was found. Proximal and distal margins were not grossly involved. The resected segment of stomach was 8\u0026nbsp;cm in greater curvature and 6\u0026nbsp;cm in lesser curvature and showed no mass (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Multiple lymph nodes were identified measuring from 0.5 to 1\u0026nbsp;cm in diameter. In reviewing the slides, the patient had small groups of residual poorly differentiated squamous cell carcinoma and also multiple leiomyomas. A leiomyoma was coexisted with an invading overlying SCC (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e6\u003c/span\u003e). There were 5 isolated lymph node within the pathology specimen, of which two were involved with the tumor, but pathology didn\u0026rsquo;t show any sign of metastasis in the lymph node resected at the gastrohepatic ligament. Tumor pathology characteristics are summarized and shown in Table\u0026nbsp;1.\u003c/p\u003e "},{"header":"Discussion:","content":" \u003cp\u003eThere are several reports of co-existing overlying esophageal SCC and leiomyoma in the literature. In this situation, the esophageal submucosal layer is overlaid by the superficial cancer. This coexistence is very rare, and this is usually detected following surgery. Callanan et al, reported the first case of its kind in 1954 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In this regard, all previously published reports on cases with leiomyoma overlying with esophageal SCC were searched and found on the web and only available full-text original articles were encountered. As a result, 15 cases in 14 reports were elucidated. These reports were evaluated and summarized in Table\u0026nbsp;2 according to the originated country and published year of case report, patient\u0026rsquo;s gender, age, chief complaints, risk factors, and comorbid diseases, and upper GI endoscopy, EUS, other diagnostic modalities and pathologic results, location of tumor and treatments applied (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the previous published reports, 10 reports were from Japan, 2 reports were from South Korea, and one report from Iran and Turkey each. It shows that this pathology is much more common in the East Asia, especially in Japan. There was only one female patient previously reported, so our case was the second one. It shows the male predominance pattern in this regard. Ishida et al. reported male to female ratio of 4:1 in patients with SCC overlying leiomyoma (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Mean age was 59.62 +/- 9.46\u0026nbsp;years (minimum 41 and maximum 75\u0026nbsp;years). Our case was the youngest patient in all, as the youngest patient was previously from Turkey with age of 44\u0026nbsp;years (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn chief complains, there were 5 cases with dysphagia or stenotic sensation in the pharyngeal region, 3 cases with significant weight loss, 3 cases with esophageal tumor which were found at the routine health checkups, and one patient with epigastric pain. From the reports in which risk factors were mentioned, heavy smoking was seen in three cases. Comorbid diseases were found negative in 4 cases, and malignant lymphoma of the thyroid and hyperglycemia and osteoporosis were found in one case each. Upper GI endoscopy showed an elevated or protruding lesion in 5 cases, a sessile polypoid lesion in 3 cases, and a submucosal tumor in 3 cases. Chromoendoscopy with iodine staining was done in 7 cases and showed a non-staining area in all. EUS was done in 8 cases and showed a hypoechoic homogeneous submucosal tumor with a well demarcated and clear margin in the muscularis mucosae (MM) covered with intraepithelial layer indicative of leiomyoma in most of the cases. Barium esophagogram study was done in 4 cases. In pathologic evaluation, squamous cell carcinoma in situ (high-grade intraepithelial neoplasia) was seen in 4 cases, poorly differentiated SCC in 2, moderately differentiated SCC in 2, and malignant SCC in one case. More than one leiomyoma was seen in 3 cases. According to the location of the lesions, proximal, middle and distal third of the esophagus accounted for 5, 6 and 4 cases each retrospectively. Surgery (esophageal resection) was done in 9 cases, and this is comparable with endoscopic submucosal dissection (ESD) which was done in 6 cases.\u003c/p\u003e \u003cp\u003eThere are two types of coexistence: 1. Overlying type in which the carcinoma covers the benign tumor, and 2. the two lesions are completely separated and encountered during or after esophagectomy for esophageal SCC (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, and \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our case study, the two types exist and this result was as the same as the two other studies done by Iwaya et al. and Geramizadeh et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). There are two theories on the etiology of carcinoma development over the leiomyoma: 1. protrusion of leiomyoma into the esophageal lumen and chronic irritation of the esophageal mucosa and predisposing it to dysplasia may be the pathogenesis of the disease; 2. Underlying leiomyoma prevents the SCC from dissemination and widespread invasion (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, and \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAn upper GI endoscopy is usually used for the differential diagnosis of esophageal carcinoma and leiomyoma, but it may not always lead to an accurate diagnosis, because esophageal leiomyomas are submucosal lesions. Availability of EUS provides an advantage in the detection and management of these tumors as it clearly reveals the five-layered structure of the gastrointestinal wall as well as by enabling exact localization and origin, tumor margin, echogenic pattern, and accurate size measurement (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e); but unfortunately we didn\u0026rsquo;t have EUS in our hospital, so we were unaware about coexistence of any leiomyoma until it had been removed through esophagectomy.\u003c/p\u003e \u003cp\u003eNarrow band imaging (NBI) endoscopy uses optical filters that improve absorbance and scattering of light, enhancing the appearance of vessels and other structures, thus providing a high contrast of tissue surface during endoscopy. Along with magnifying endoscopes and chromoendoscopy, a close to histological tissue description is possible. These have been used to improve the assessment of esophageal lesions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e); but unfortunately we did not have any of these to help evaluate the tumor or esophageal mucosa.\u003c/p\u003e \u003cp\u003eWhen choosing treatment for SMT, it is important to determine by endoscopic ultrasonography from which layer the tumor originates. If a small SMT is diagnosed as originating from the muscularis mucosa, endoscopic submucosal resection (EMR) is the treatment of choice. When the tumors are large and originate in the muscularis propria, this technique has the risk of severe complications, such as esophageal perforation and massive bleeding. Hence, in those cases, open surgery or thoracoscopic resection is chosen. In this case, as we didn\u0026rsquo;t have EUS and EMR, so open surgery was performed.\u003c/p\u003e "},{"header":"Conclusion:","content":" \u003cp\u003eTo sum up it can be concluded that 1. it must kept in mind that esophageal carcinomas may coexist with leiomyomas, 2. preexisting benign tumors may have played an important role in the development of carcinoma by inducing constant stimulation of the overlying mucosa, 3. EUS is recommended to avoid overestimating the extent of tumor invasion and the resultant aggressive radical surgery 4. Esophageal resection is still the modality of choice in treatment in developing countries and also countries with limited equipment.\u003c/p\u003e "},{"header":"Abbreviations:","content":"\u003cp\u003eSubmucosal mesenchymal tumor (SMT)\u003c/p\u003e\n\u003cp\u003eEndoscopic ultrasonography (EUS)\u003c/p\u003e\n\u003cp\u003eComputerized tomography (CT)\u003c/p\u003e\n\u003cp\u003eGastrointestinal (GI)\u003c/p\u003e\n\u003cp\u003eVideo-assisted thoracoscopic surgery (VATS)\u003c/p\u003e\n\u003cp\u003eSquamous cell carcinoma (SCC)\u003c/p\u003e\n\u003cp\u003eIntravenous (IV)\u003c/p\u003e\n\u003cp\u003eMuscularis mucosae (MM)\u003c/p\u003e\n\u003cp\u003eEndoscopic submucosal dissection (ESD)\u003c/p\u003e\n\u003cp\u003eEndoscopic submucosal resection (EMR)\u003c/p\u003e\n\u003cp\u003eNarrow band imaging (NBI) endoscopy\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for participation. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors of this manuscript declare no competing of interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNot received.\u003c/p\u003e\n\u003ch2\u003eAcknowledgment\u003c/h2\u003e\n\u003cp\u003eWe all express our gratitude to the patient who kindly gave consent for this case to be presented in this paper. The authors also wish to thank Dr. Aida Iraji at the Central research laboratory, Shiraz University of Medical Sciences, Shiraz, Iran for her assistance in editing this manuscript.\u003c/p\u003e\n\u003ch2\u003eContributions\u003c/h2\u003e\n\u003cp\u003ePrincipal author: SM evaluated the patient clinically, operated the patient (main surgeon), read and revised the paper.\u003c/p\u003e\n\u003cp\u003eCorresponding-author: MJYB evaluated the patient clinically, helped to operate the patient (co-surgeon), prepared the first draft and revised the paper.\u003c/p\u003e\n\u003cp\u003eCo-author: SH evaluated the pathology slides (our pathologist and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eCo-author: HS helped in collecting the patient data, assisted with the administration and monitoring of anesthesia during patients operation and upper GI endoscopy (our anesthetic technician).\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSeo M, Kim DH, Cho YW, et al. Superficial Esophageal Neoplasms Overlying Leiomyomas Removed by Endoscopic Submucosal Dissection: Case Reports and Review of the Literature. Clin Endosc. 2015; 48(4):322‐ \u003ca href=\"https://doi:10.5946/ce.2015.48.4.322\"\u003ehttps://doi:10.5946/ce.2015.48.4.322\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eIwaya T, Maesawa C, Uesugi N, et al. Coexistence of esophageal superficial carcinoma and multiple leiomyomas: A case report. World J Gastroenterol. 2006; 12(28):4588‐ \u003ca href=\"https://doi:10.3748/wjg.v12.i28.4588\"\u003ehttps://doi:10.3748/wjg.v12.i28.4588\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eMathew G, Carter YM. Esophageal Leiomyoma. [Updated 2019 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: \u003ca href=\"https://www.ncbi.nlm.nih.gov/books/NBK459298/\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK459298/\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eErol M. Coexistence of esophageal squamous cell carcinoma and leiomyoma: a case report. Turkish Journal of Thoracic and Cardiovascular Surgery. 2012; 20: 944-946. \u003ca href=\"https://doi:10.5606/tgkdc.dergisi.2012.188\"\u003ehttps://doi:10.5606/tgkdc.dergisi.2012.188\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eIsmaila BO, Davwar PM. Endoscopic resection of an esophageal leiomyoma with overlying dysplasia without specialized equipment. Niger J Clin Pract. 2016; 19(3):418‐ \u003ca href=\"https://doi:10.4103/1119-3077.179294\"\u003ehttps://doi:10.4103/1119-3077.179294\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eRecio-Boiles A, Waheed A, Babiker HM. Cancer, Esophageal. [Updated 2019 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: \u003ca href=\"https://www.ncbi.nlm.nih.gov/books/NBK459267/\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK459267/\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eCallanan JG. Simultaneous occurrence of simple and malignant tumors in the esophagus. J Thorac Surg. 1954; 28(1):4-10.\u003c/li\u003e\n\u003cli\u003eIizuka T, Kato H, Watanabe H, Itabashi M, Hirota T. Superficial carcinoma of the esophagus coexisting with esophageal leiomyoma: a case report and review of the Japanese literature. Jpn J Clin Oncol. 1984; 14(1):115‐ \u003ca href=\"https://doi:10.1093/oxfordjournals.jjco.a038944\"\u003ehttps://doi:10.1093/oxfordjournals.jjco.a038944\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eKuwano H, Sadanaga N, Watanabe M, Yasuda M, Nozoe T, Sugimachi K. Esophageal squamous cell carcinoma occurring in the surface epithelium over a benign tumor. J Surg Oncol. 1995; 59(4):268‐ \u003ca href=\"https://doi:10.1002/jso.2930590414\"\u003ehttps://doi:10.1002/jso.2930590414\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eYoshikane H, Tsukamoto Y, Niwa Y, et al. The coexistence of esophageal submucosal tumor and carcinoma. Endoscopy. 1995; 27(1):119‐ \u003ca href=\"https://doi:10.1055/s-2007-1005645\"\u003ehttps://doi:10.1055/s-2007-1005645\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eNagashima R, Takeda H, Motoyama T, Tsukamoto O, Takahashi T. Coexistence of superficial esophageal carcinoma and leiomyoma: case report of an endoscopic resection. Endoscopy. 1997; 29(7):683‐ \u003ca href=\"https://doi:10.1055/s-2007-1004280\"\u003ehttps://doi:10.1055/s-2007-1004280\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eFu KI, Muto M, Mera K, et al. Carcinoma coexisting with esophageal leiomyoma. Gastrointest Endosc. 2002; 56(2):272‐ \u003ca href=\"https://doi:10.1016/s0016-5107(02)70191-0\"\u003ehttps://doi:10.1016/s0016-5107(02)70191-0\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eMizobuchi S, Kuge K, Matsumoto Y, et al. Co-existence of early esophageal carcinoma and leiomyoma: a case report. Jpn J Clin Oncol. 2004; 34(12):751‐ \u003ca href=\"https://doi:10.1093/jjco/hyh133\"\u003ehttps://doi:10.1093/jjco/hyh133\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eIshihara R, Yamamoto S, Yamamoto S, et al. Endoscopic resection of the esophageal squamous cell carcinoma overlying leiomyoma. Gastrointest Endosc. 2008; 67(4):745‐ \u003ca href=\"https://doi:10.1016/j.gie.2007.09.021\"\u003ehttps://doi:10.1016/j.gie.2007.09.021\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eGeramizadeh B, Ziyaian B, Safari A. Invasion of esophageal leiomyoma by coexistent overlying squamous cell carcinoma. J Gastrointest Cancer. 2009; 40(3-4):131‐ \u003ca href=\"https://doi:10.1007/s12029-009-9093-8\"\u003ehttps://doi:10.1007/s12029-009-9093-8\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eNiimi K, Kodashima S, Ono S, Goto O, Yamamichi N, Fujishiro M. Curative ESD for intraepithelial esophageal carcinoma with leiomyoma mimicking submucosal invasive carcinoma. World J Gastrointest Endosc. 2009; 1(1):68‐ \u003ca href=\"https://doi:10.4253/wjge.v1.i1.68\"\u003ehttps://doi:10.4253/wjge.v1.i1.68\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eIshida M, Mochizuki Y, Iwai M, Yoshida K, Kagotani A, Okabe H. Esophageal squamous cell carcinoma in situ overlying leiomyoma: a case report with review of the literature. Int J Clin Exp Pathol. 2013; 6(12):3026‐\u003c/li\u003e\n\u003cli\u003eOh WJ, Lee EJ, Lee YS, Kim TJ. Esophageal squamous cell carcinoma in situ overlying leiomyoma mimicking invasive cancer: a brief case report. Korean J Pathol. 2014; 48(2):162‐ \u003ca href=\"https://doi:10.4132/KoreanJPathol.2014.48.2.162\"\u003ehttps://doi:10.4132/KoreanJPathol.2014.48.2.162\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eLu YK, Li YM, Keng CC. The coexistence of benign and malignant tumors of the esophagus. Chin Med J. 1963; 82:805-808.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\"\u003e\u003ccaption\u003eTable 1. Tumor pathology and immunohistochemistry characteristics\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eTumor type\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eSCC, poorly differentiated (G3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eResidual tumor size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003e0.6 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eTumor extension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eTumor invaded submucosal (at least)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eProximal margin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eFree of tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eDistal margin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eFree of tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eRadial margin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eFree of tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eTreatment effect\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eNear complete response, score 1 (single cell and small groups of cancer cells\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eLymphovascular invasion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003ePresent\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003ePerineural invasion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003ePresent\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eLymph-node invasion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eTotal: 5, involved: 2; metastatic poorly differentiated squamous cell carcinoma (LN2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eAdditional pathologic findings\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eMultiple leiomyomas, the largest one measuring: 2 cm in diameter\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003ePathologic staging\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eypT1bN1Mx\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eImmunohistochemistry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eNegative for C-KIT and CDX2 proto-oncogenes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003ePositive for Desmin and P63 proto-oncogenes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eNote\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"460\"\u003e\n\u003cp\u003eThis staging categorizes the extent of tumor actually present at the time of examination (after the chemotherapy). The \u0026ldquo;y\u0026rdquo; categorization is not an estimate of tumor before chemotherapy.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003eTable 2. Summarized previous published reports on leiomyoma with overlying SCC\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eCountry and year\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender and age\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u003cstrong\u003eChief complaints\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factors\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u003cstrong\u003eComorbid diseases\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cstrong\u003eUpper GI Endoscopy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u003cstrong\u003eEUS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u003cstrong\u003eOther diagnostic modalities (1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u003cstrong\u003eOther diagnostic modalities (2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003ePathology\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u003cstrong\u003eLocation\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 1984\u003c/strong\u003e (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/ 75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eStenotic sensation in the pharyngeal region\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eHeavy smoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAn elevated\u0026nbsp; erosive\u0026nbsp;\u0026nbsp; lesion in the posterior wall of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eBarium esophagogram: a tumorous\u003c/p\u003e\n\u003cp\u003eshadow,5cm, middle thoracic esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle\u0026nbsp; third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eSurgery: blunt dissection of\u003c/p\u003e\n\u003cp\u003ethe esophagus without thoracotomy, esophagogastroanastomosis\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 1995\u003c/strong\u003e (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eDysphagia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle\u0026nbsp; third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEsophageal resection and reconstruction\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 1995\u003c/strong\u003e (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNot mentioned, referred for treatment of\u003c/p\u003e\n\u003cp\u003ean esophageal tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA mucosal irregularity on the surface of the submucosal tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle\u0026nbsp; third of esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEsophageal resection and\u003c/p\u003e\n\u003cp\u003ereconstruction\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 1995\u003c/strong\u003e (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eAsymptomatic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eHeavy smoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eSessile polypoid lesion at abdominal\u0026nbsp; esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA 9mm submucosal tumor with smooth contour, leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eBarium swallow: as health checkup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eDouble contrast barium esophagogram: semispherical tumor, 1.5 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying poorly\u003c/p\u003e\n\u003cp\u003edifferentiated SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eDistal third\u0026nbsp; of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eSurgical Resection\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 1997\u003c/strong\u003e (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eSessile polypoid lesion with a smooth surface at the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA hypoechoic tumor just below the epithelial layer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eModerately differentiated SCC on leiomyoma originating from muscularis mucosa\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eProximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic resection by aspiration lumpectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2002\u003c/strong\u003e (12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNot mentioned, referred for treatment of\u003c/p\u003e\n\u003cp\u003ean esophageal tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA protruding lesion, resembling a submucosal tumor, in the proximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA hypoechoic tumor confined to the submucosa with a well demarcated, smooth outline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy: non-staining\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eModerately differentiated SCC overlying the leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eProximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic submucosal dissection\u0026nbsp; (ESD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2004\u003c/strong\u003e (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA sessile polypoid lesion with a smooth surface in the proximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA hypoechoic tumor, 13 mm in diameter,\u003c/p\u003e\n\u003cp\u003elocated in the submucosa, with clear margins and a smooth\u003c/p\u003e\n\u003cp\u003econtour, with the muscularis propria layer intact\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy: non-staining\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying poorly differentiated SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eProximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic\u0026nbsp; submucosal\u0026nbsp; dissection\u0026nbsp; (ESD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2006\u003c/strong\u003e (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003emalignant lymphoma of the thyroid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA superficial ulcerative tumor (24 mm in diameter) in the\u003c/p\u003e\n\u003cp\u003elower\u0026nbsp; third\u0026nbsp; of\u0026nbsp; the esophagus,\u0026nbsp; overlying\u0026nbsp; the smaller\u0026nbsp; leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eCancer\u0026nbsp;\u0026nbsp; overlaid\u0026nbsp; the smaller\u003c/p\u003e\n\u003cp\u003eleiomyoma and invaded\u0026nbsp; the\u003c/p\u003e\n\u003cp\u003esubmucosal layer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eBarium\u0026nbsp; swallow\u003c/p\u003e\n\u003cp\u003eEsophagogram: two\u0026nbsp; smoothly rounded\u0026nbsp; defects\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy: non-staining\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eSquamous cell carcinoma in situ overlying a leiomyoma, separated multiple leiomyomas\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eDistal third\u0026nbsp; of\u0026nbsp; the\u003c/p\u003e\n\u003cp\u003eesophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eSurgery: esophagectomy, gastric pull-up\u0026nbsp; reconstruction, cervical anastomosis via abdominal, left cervical and right\u003c/p\u003e\n\u003cp\u003ethoracotomy incisions\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2008\u003c/strong\u003e (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eMild epigastralgia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA submucosal tumor with a smooth and mildly\u003c/p\u003e\n\u003cp\u003ered surface mucosa in the proximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA hypoechoic lesion\u003c/p\u003e\n\u003cp\u003eoriginating from the muscularis mucosae with\u003c/p\u003e\n\u003cp\u003ea clear margin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy with iodine staining: non-staining area\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eProximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic submucosal dissection\u0026nbsp; (ESD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eIran, 2009\u003c/strong\u003e (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eProgressive dysphagia and epigastric pain and about 20 kg weight loss.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA depressed area with\u003c/p\u003e\n\u003cp\u003euneven and irregular border\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eSeveral leiomyomas, the largest of which was covered by malignant SCC.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eLaparotomy, transhiatal esophagectomy, cervical esophagastrostomy (Orringer), and bilateral\u003c/p\u003e\n\u003cp\u003echest tube insertion\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2009\u003c/strong\u003e (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eAsymptomatic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eHeavy smoking and alcohol consumption\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAn\u0026nbsp; esophageal\u0026nbsp; tumor in the middle\u0026nbsp; thoracic esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eHypoechoic\u003c/p\u003e\n\u003cp\u003etumor in the muscularis\u0026nbsp; mucosae covered with\u003c/p\u003e\n\u003cp\u003eintraepithelial\u0026nbsp; layer indicative of\u0026nbsp; leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy with iodine staining: non-staining area\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eMagnifying endoscopy with narrow band imaging (NBI): dilated and elongated intrapapillary capillary loop\u003c/p\u003e\n\u003cp\u003e(IPCL), indicated intraepithelial\u003c/p\u003e\n\u003cp\u003ecarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eLeiomyoma with overlying SCC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle\u0026nbsp; third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic submucosal dissection\u0026nbsp; (ESD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eTurkey 2012\u003c/strong\u003e (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eWeight\u0026nbsp; loss\u003c/p\u003e\n\u003cp\u003eand\u0026nbsp; dysphagia\u0026nbsp; for\u0026nbsp; two\u0026nbsp; month\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA\u0026nbsp; tumoral\u0026nbsp; mass with a\u0026nbsp; partially\u003c/p\u003e\n\u003cp\u003eirregular surface in the distal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eCT scan of the thorax and abdomen: minimally diffuse esophageal wall enlargement\u003c/p\u003e\n\u003cp\u003ein a 5 cm segment of the distal esophagus with no lymph\u003c/p\u003e\n\u003cp\u003enode involvement or distant metastasis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eSCC infiltrated to the submucosa and two separated leiomyoma along with five reactive and three metastatic lymph nodules.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eDistal third\u0026nbsp; of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eDistal\u0026nbsp; esophagectomy and an esophagogastrostomy together with a laparotomy and\u0026nbsp; thoracotomy (Ivor-Lewis approach)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eJapan, 2013\u003c/strong\u003e (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eFemale/75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eEsophageal tumor at health\u003c/p\u003e\n\u003cp\u003echeckup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003ehyperglycemia and osteoporosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA\u003c/p\u003e\n\u003cp\u003esubmucosal tumor, measuring 5 x 4 mm in\u003c/p\u003e\n\u003cp\u003ediameter, 20 cm from the incisors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eCoexistence of esophageal SCC in situ\u003c/p\u003e\n\u003cp\u003e(high-grade intraepithelial neoplasia) overlying\u003c/p\u003e\n\u003cp\u003eleiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEndoscopic submucosal dissection\u0026nbsp; (ESD)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eSouth Korea, 2014\u003c/strong\u003e (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eEsophageal tumor at health\u003c/p\u003e\n\u003cp\u003echeckup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAn elevated mass, 1.8 cm in diameter, with irregular central small erosion in the upper thoracic esophagus.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy with iodine staining: non-staining area\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eSquamous cell carcinoma in\u003c/p\u003e\n\u003cp\u003esitu overlying submucosal leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eProximal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eSubtotal esophagectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eSouth Korea, 2015\u003c/strong\u003e (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eMale/66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eEsophageal tumor at health\u003c/p\u003e\n\u003cp\u003echeckup\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA protruding mass that measured 1\u0026times;1 cm in diameter and was located 25 cm from the upper incisors.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eA hypoechoic and homogeneous lesion that originated from the muscularis mucosa (MM) below the epithelial layer.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChromoendoscopy with iodine staining: non-staining area\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eSquamous cell carcinoma in\u003c/p\u003e\n\u003cp\u003esitu overlying submucosal leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eEn bloc resection using ESD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e\u003cstrong\u003eIran, 2020\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eFemale/41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eProgressive dysphagia and significant weight loss for the preceding 6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNegative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eA large fungating and ulcerative mass, middle and lower third of esophagus, 25-33 cm from the upper incisors.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003eChest CT scan: a 29*18 mm soft tissue fullness at middle to distal esophagus, suggestive for tumoral lesion.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"98\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003eMultiple leiomyomas, SCC overlying a leiomyoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003eMiddle and distal third of the esophagus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"163\"\u003e\n\u003cp\u003eExtended thoracotomy, esophagectomy, gastric pull-up, pyloroplasty, cervical esophagostomy (Orringer)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esophageal squamous cell carcinoma, Leiomyoma of esophagus, simultaneous occurrence, overlying, esophageal resection","lastPublishedDoi":"10.21203/rs.3.rs-38770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-38770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSquamous cell carcinoma is the most common epithelial tumor of the esophagus. Upper endoscopy with multiple minimally invasive biopsies should be performed to confirm the diagnosis. Leiomyoma of esophagus is rare, but it’s the most common benign submucosal mesenchymal tumor of the esophagus. The simultaneous occurrence of an overlying epithelial lesion and a mesenchymal lesion is very rare. This study aims to show a case operated due to squamous cell carcinoma of esophagus that was postoperatively diagnosed with coexistent esophageal leiomyoma and provide a clear overview of the existing literature on it. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e The patient was a 41-year-old lady who underwent three field esophagectomy (McKeown). In reviewing the pathology slides, the patient had poorly differentiated squamous cell carcinoma and also multiple leiomyomas. A leiomyoma was coexisted with an invading overlying squamous cell carcinoma. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIt is concluded that esophageal carcinomas may coexist with leiomyomas; preexisting benign tumors may have played an important role in the development of carcinoma by inducing constant stimulation of the overlying mucosa; endoscopic ultrasonography is recommended to avoid overestimating the extent of tumor invasion and the resultant aggressive radical surgery; and esophageal resection is still the modality of choice in treatment in developing countries and also countries with limited equipment.\u003c/p\u003e","manuscriptTitle":"Esophageal Leiomyoma and Simultaneous Overlying Squamous Cell Carcinoma: A Case Report and Review of the Literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-07-09 16:56:40","doi":"10.21203/rs.3.rs-38770/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1e92c64-dc69-43d6-8878-6481851bce13","owner":[],"postedDate":"July 9th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":137833,"name":"Oncology"}],"tags":[],"updatedAt":"2020-07-09T16:56:41+00:00","versionOfRecord":[],"versionCreatedAt":"2020-07-09 16:56:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-38770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-38770","identity":"rs-38770","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}