A 58-year-old woman with a longstanding history of panhypopituitarism necessitating
hydrocortisone and levothyroxine supplementation underwent upper endoscopy because
of heartburn, and an esophageal submucosal lesion was detected. Surface biopsies were
normal.
Upper endoscopy was repeated at our institution and a 1-cm red-hued submucosal polypoid
lesion was noted at 28 cm from the incisors ([Fig. 1]).
Fig. 1 Endoscopic view of polypoid lesion seen at 28 cm from the incisors.
Endoscopic ultrasonography (EUS) was performed with an Olympus 3R 20-MHz ultrasound
probe (Olympus, Melville, New York, USA) ([Fig. 2]).
Fig. 2 Endoscopic ultrasound image of the lesion limited to the mucosa.
The lesion was demarcated in the deep mucosa and submucosa as a homogenous hypoechoic
entity without definite muscularis propria invasion. Endoscopic mucosal resection
(EMR) was performed utilizing a small submucosal cushion of saline injected by a sclerotherapy
needle and a 13-mm snare. The lesion was removed via snare electrocautery. Pathological
analysis demonstrated a submucosal neoplasm composed of tumor cells arranged in sheets,
glands, and trabeculae without mitoses ([Fig. 3]).
Fig. 3 Submucosal neoplasm composed of tumor cells arranged in sheets, glands, and trabeculae
without mitoses.
Immunohistochemical studies demonstrated positivity for synaptophysin and chromogranin,
suggestive of an esophageal carcinoid ([Figs. 4],[5]).
Fig. 4 Synaptophysin immunostain.
Fig. 5 Chromogranin immunostain.
Two weeks after the procedure the patient was contacted and reported no complaints.
Endoscopy 2 months later demonstrated mucosal scarring without residual lesion and
surface and “tunnel” biopsies did not reveal any abnormalities. CT imaging of the
thorax and octreotide nuclear scan were also within normal limits.
Esophageal carcinoids typically arise from the mucosal lamina propria or the submucosa
[1]
[2]. EUS has proven utility in staging and interventional planning (endoscopy or surgery)
for gastrointestinal neuroendocrine tumors, and EMR has a solid track record in removal
of superficial lesions of the gastrointestinal tract [3]
[4]. Conceivably, use of a ligation band at the lesion base would increase the ease
and safety of EMR, and this has been utilized for Barrett’s dysplasia and rectal carcinoid
resections [5]. Esophageal carcinoid among other esophageal submucosal lesions will be identified
because of utilization of esophagogastroduodenoscopy and perhaps EUS for gastroesophageal
reflux disease and other common entities.
Competing interests: None
Endoscopy_UCTN_Code_TTT_1AO_2AG
