Esophageal subepithelial tumors (SETs) are often diagnosed incidentally and the treatment
strategy can be challenging. In asymptomatic lesions without proven histology, endoscopic
surveillance is justified [1]. However, the uncertainty regarding the risk of progression and the need for frequent
surveillance endoscopies have to be balanced against the possibility and the potential
risks associated with minimally invasive endoscopic resection.
A 42-year-old woman without preexisting comorbidities underwent upper gastrointestinal
endoscopy because of recurrent epigastric pain. The patient was otherwise asymptomatic.
In the proximal esophagus, a nodular SET with a bluish-purple appearance and a diameter
of about 20 mm was seen ([Fig. 1]). The lesion was located 1 cm distal to the upper esophageal sphincter. Magnetic
resonance imaging confirmed a lumen-occupying mass in the proximal esophagus, 27 ×
20 × 14 mm in diameter. Endoscopic ultrasound showed an inhomogeneous hypoechoic and
well-demarcated mass in the submucosal layer ([Fig. 2]). According to the lesion’s morphology, cavernous hemangioma was suspected. Biopsies
were not taken because of the bleeding risk and the exact diagnosis of the asymptomatic
mass remained unclear after diagnostic workup.
Fig. 1 Endoscopic appearance of the subepithelial tumor in the proximal esophagus.
Fig. 2 Endoscopic ultrasound confirmed an inhomogeneous hypoechoic and well-demarcated mass
localized in the submucosa.
An endoscopic surveillance strategy versus endoscopic resection to confirm an exact
diagnosis and avoid follow-up examinations were discussed. The patient opted for endoscopic
resection and endoscopic submucosal dissection (ESD) was performed under general anesthesia
([Video 1]). En bloc resection was possible without any bleeding or other complications ([Fig. 3]). The resection specimen showed a multinodular, purple mass 2 cm in diameter and
located in the submucosal layer ([Fig. 4]). The further course was uneventful. Histopathology confirmed a submucosal cavernous
hemangioma, which was resected R0 ([Fig. 5]).
Endoscopic submucosal dissection of a large cavernous hemangioma located in the proximal
esophagus.Video 1
Fig. 3 Resection area after endoscopic submucosal dissection in the proximal esophagus.
Fig. 4 The resection specimen after endoscopic submucosal dissection, showing a multinodular
purple mass in the submucosa (specimen was fixed onto cork with needles; view from
the submucosal direction).
Fig. 5 Histopathology showed a vascular neoplasia with large cystically dilated vessels (partially
filled with blood) and focally fibrotic walls. The lesion was localized in the submucosal
layer and covered by normal squamous epithelium (hematoxylin and eosin).
The diagnosis of esophageal cavernous hemangioma can be suspected macroscopically
but usually cannot be confirmed without resection of the lesion [2]
[3]
[4]
[5]. When performed in experienced hands, ESD offers a minimally invasive and safe treatment
option that confirms the diagnosis and achieves a definitive treatment.
Endoscopy_UCTN_Code_CCL_1AB_2AC
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