J Gastrointest Surg (2014) 18:2208–2213 DOI 10.1007/s11605-014-2628-8
REVIEW ARTICLE
A Pedunculated Giant Esophageal Liposarcoma: a Case Report and Literature Review A. Dowli & A. Mattar & H. Mashimo & Q. Huang & D. Cohen & P. M. Fisichella & A. Lebenthal
Received: 28 May 2014 / Accepted: 4 August 2014 / Published online: 5 September 2014 # 2014 The Society for Surgery of the Alimentary Tract
Abstract Introduction The majority of esophageal tumors arise from the mucosal layer; only 5 % are of mesenchymal origins. Of the latter, barely 0.5 % are liposarcomas. We present a case of an esophageal liposarcoma with a review of the literature. Case Report A 64-year-old male was referred with 5 years of progressive dysphagia. Preoperative evaluation initially suggested a leiomyoma. The polypoid lesion was then resected through a cervical esophagotomy, once endoscopic resection proved to be not feasible. The definitive pathologic diagnosis confirmed a well-differentiated liposarcoma. Literature Review Esophageal liposarcomas are very rare and only 40 such cases have been reported in the literature. Most patients were male (80 %), the median age was 62 years (range 38–83 years), and the most common symptom was dysphagia (85 %). Only in two cases was a liposarcoma detected on preoperative biopsy. The most common histological subtype was welldifferentiated liposarcoma. Overall, 77.5 % of the patients were successfully treated with surgery, 20 % endoscopically, and 2.5 % were ablated with CO2 laser. Conclusion Esophageal liposarcoma is an extremely rare tumor. The majority of patients are males; dysphagia is the most common initial symptom, and preoperative biopsy is unreliable. Because these tumors are pedunculated, well-circumscribed, and well-differentiated, they can be safely resected locally. All patients need long-term follow-up as this disease can recur many decades after treatment. Keywords Esophagus . Liposarcoma . Mesenchymal tumor
A. Dowli : A. Mattar : D. Cohen : A. Lebenthal (*) Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston VA Health Care System, Harvard Medical School, Boston, MA, USA e-mail:
[email protected] H. Mashimo Division of Gastroenterology, Brigham and Women’s Hospital, Boston VA Health Care System, Harvard Medical School, Boston, MA, USA Q. Huang Department of Pathology, Brigham and Women’s Hospital, Boston VA Health Care System, Harvard Medical School, Boston, MA, USA A. Dowli : A. Mattar : D. Cohen : P. M. Fisichella : A. Lebenthal Department of Surgery, Brigham and Women’s Hospital, Boston VA Health Care System, Harvard Medical School, Boston, MA, USA
Introduction The majority of esophageal tumors arise from the mucosal , layer and less than 5 % have a mesenchymal origin.1 2 Of the latter, only 0.5 % are liposarcomas.3 It is in this context that we present a case of a rare pedunculated esophageal liposarcoma and a review of the literature.
Case Report A 64-year-old male was referred for evaluation of progressive dysphagia for 5 years. On initial evaluation, the patient recalled an episode of vomiting a number of years earlier in which he felt a large beefy mass protruding out through his mouth, which he was not able to pull out from his mouth. He eventually swallowed it and his dysphagia progressed until he sought medical attention. Upper endoscopy at an outside hospital demonstrated a “leiomyoma” of the mid-esophagus and the patient was referred for surgical evaluation. As true
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Fig. 1 Sagittal and coronal CAT scans of the chest revealed a large pedunculated esophageal lesion (arrows) extending from the cervical esophagus down beyond the level of the inferior pulmonary vein. Axial,
coronal, and sagittal images suggested a pedunculated tumor arising from the proximal cervical esophagus
leiomyomas of the esophagus are submucosal tumors that originate from the circular muscle layer, they are rarely pedunculated. Given the clinical presentation, we were skeptical that the patient had a leiomyoma, so we ordered a chest CT scan and a barium swallow, which confirmed a giant tumor within the lumen of the esophagus (Figs. 1 and 2) that was more suggestive of a myxoma or fibrolipomatous polyp. Because of his severe dysphagia, the patient was taken to the operating room with the goal of first attempting endoscopic resection under general endotracheal anesthesia, or a left transcervical resection in the event that endoscopic resection was not possible. On endoscopy, a large, pedunculated, broadbased polypoid mass was seen starting at 16 cm and extending down to 33 from the incisors. With the exception of a mildly dilated esophagus, which we attributed to the mass effect onto the esophagus causing it to appear more patulous, the
remainder of the endoscopy was within normal limits. The barium swallow did not suggest other diseases such as achalasia. We made multiple attempts to lasso the mass. Specifically, we were able to get around the tip of the tumor, but because of its size, we could not pull the lasso proximally towards the stalk. For the same reasons, inversion proved to be impossible. As the large size of the polyp precluded its resection by any endoscopic means, we elected to resect it through a left transcervical incision and an esophagotomy. The stalk of the polypoid was encircled with a Penrose drain, inverted out through the esophagostomy, and resected at its base. The esophagostomy was closed in two layers: the mucosa with polyglactin 3/0 and the muscle with 3/0 silk. A single JP was placed near the esophagostomy. The resected pedunculated mass measured 15×7×3 cm (Fig. 2). The frozen
Fig. 2 Operative specimen showing the large size of the polyp
Fig. 3 Optical microscopy at low power shows a well-differentiated adipocytic liposarcoma with a hyalinized fibrous area in the left upper corner and areas of myxoid changes
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Results
Fig. 4 Optical microscopy shows neoplastic lipoblasts with variable sizes, shapes, and hyperchromatic nuclei. Among these cells are scattered bizarre, often multinucleated cells and plump spindle cells in a myxoid stroma
section of the mass demonstrated a neoplastic fibrolipomatous lesion and a negative proximal resection margin. On postoperative day 1, a swallow test ruled out a leak and a diet was started. The patient experienced immediate resolution of the dysphagia. The Jackson-Pratt drain was removed a week later in the clinic. Definitive pathology of the resected specimen demonstrated submucosal lobulated neoplastic adipose tissue with large areas of dissecting collagenous fibrosis. In addition, pathology showed several nodules of myxoid lesions with frequent multinucleated giant cells (florette-like) with prominent nuclear pleomorphism, hyperchromasia, and mono- and multivacuolated lipoblasts. However, mitotic figures were rare and no necrosis was found. The final findings were consistent with a diagnosis of a well-differentiated liposarcoma (Figs. 3 and 4). Three months following surgery, the patient underwent surveillance endoscopy with biopsies showing no recurrence. He remains asymptomatic at the 6-month follow-up.
Literature Review Materials and Methods A search in PubMed was conducted using the search string: ((esophagus or esophageal or oesophageal or oesophagus) and liposarcoma) or ((“Esophagus”[Mesh] and “Esophageal Neoplasms”[Mesh]) and (“Liposarcoma, Myxoid”[Mesh] and “Liposarcoma”[Mesh])). Google Scholar was also used. We did not enforce any time limits in our scoping searches; however, only English language articles have been reviewed and included.
A total of 40 cases were identified, the earliest being in 1983 (Table 1).20 Most patients were male (80 %), the median age was 62 years (range 38–83 years), and the most common symptom was dysphagia (85 %). Of those who presented with early dysphagia, 73 % had the tumor in the proximal esophagus. Weight loss was seen in about a quarter of patients although the severity was not consistently reported. Only two other cases were reported to have regurgitated a fleshy mass. Two patients presented with acute gastrointestinal bleeding that required fluid resuscitation and blood transfusion. Finally, two patients presented with achalasia-like symptoms (dysphagia and regurgitation) and they both had a , tumor arising in the distal esophagus.10 17 The majority of reported esophageal liposarcomas (78 %) were polypoid in nature, whereas 22 % were sessile. The location of the stalk was cervical in most cases. On preoperative esophagogram, the lesions were located in the proximal esophagus in 76 % of the cases, in the mid-esophagus in 8 %, and in the distal esophagus in 16 %. In our review, we found that most preoperative tests could not diagnose a liposarcoma. Biopsies of the lesions were inconclusive and mostly showed adipose tissue or benign squamous epithelium, sometimes with components of fibrosis. Only two case reports (5 %) reported detecting a liposarcoma on preoperative biopsy. In addition, lymph node metastasis was not reported, as most of these lesions were thought to be benign. This observation makes it difficult to justify a more radical surgery for this lesion. However, one could choose to do a segmental resection to obtain better margins. Along these lines, we found that 25.8 % of the cases reviewed had even a more extensive resection by esophagectomy. Our literature review also demonstrated that the majority of the patients with esophageal liposarcoma had the well-differentiated variant (Fig. 5), as five pathological subtypes of liposarcoma are described (well-differentiated, myxoid, round cell, dedifferentiated, and pleomorphic liposarcoma41). Open surgery was the mainstay of treatment (77.5 %). The remaining cases underwent endoscopic resection, with one case being treated by debulking CO 2 laser after three failed transoral resections.15 We found two cases in which endoscopic resection was attempted and then converted to open surgery due to the size of the tumor (Table 2). , , , Ten percent of the tumors recurred,5 8 15 39 one of them 25 years after initial resection.8 The reasons of recurrence are unclear: One patient was found to have Li-Fraumeni syndrome.33 Recurrences occurred regardless of treatment modality.
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Table 1 Demographics, clinical presentation, pathology, and treatment in 40 cases described in the literature since 1983 Author
Age
Gender
Presenting symptom
Histology
Treatment
Aloraini4 Arteaga-González5 Bacca6 Bak7 Beaudoin8 Boggi9 Bréhant10 Chung11 Cooper12 Czekajska-Chehab2 Di Mascio13 Garcia14 Ginai15 Hasanabadi16 Jakowski17 Liakakos18 Mandell19
63 72 66 49 68 50 70 56 68 56 44 42 53 68 68 72 62
M M W F F M M M M F M M M M M M F
D D D D, WL D, vomiting, extrusion of mass D, GI bleed D, achalasia presentation D, hoarseness, vomiting D Dyspnea D, GI bleed D, WL, vomiting D, extrusion of mass D, hoarseness, vomiting D, achalasia presentation D, chest discomfort vomiting D
Liposarcoma Well-differentiated Myxoid Well-differentiated Well-differentiated Myxoid Well-differentiated Liposarcoma Myxoid Well-differentiated Well-differentiated Pleomorphic Liposarcoma Myxoid Well-differentiated Well-differentiated Liposarcoma
Endoscopic resection Esophagotomy Esophagotomy Esophagectomy Endoscopic resection Longitudinal gastrotomy Esophagotomy Esophagectomy Thoraco-laparotomy Esophagectomy Esophagectomy Esophagectomy CO2 laser Surgery—not specified Thoracotomy Thoracotomy Esophagotomy
Mansour20 Maruyama21 Masumori22 Mica23 Moretti24 Myung25 Nagahama26 Nakazawa27 Pezzatini28 Ramacciato29 Ruppert-Kohlmayr30 Saleh31 Salis32 Smith1 Sui33 Temes3 Torres-Mora34 Watkin35 Will36
53 50 46 73 62 67 68 83 65 65 72 62 73 38 49 69 81 50 60
M M F M F M M M M M F M M M F M M M M
D Cough Protruding tumor Chest discomfort, vomiting, WL D, vomiting D, vomiting, WL D Chest discomfort, vomiting D, WL D D, WL D, WL D, dyspnea, vomiting D, SOB, hoarseness, cough D D Polyp on screening endoscopy D, WL, dyspnea, night sweats D
Myxoid Well-differentiated Well-differentiated Well-differentiated Liposarcoma Well-differentiated Myxoid Liposarcoma Liposarcoma Liposarcoma Well-differentiated Liposarcoma Well-differentiated Well-differentiated Well-differentiated Well-differentiated Dedifferentiated Dedifferentiated Dedifferentiated
Esophagotomy Esophagotomy Endoscopic resection Esophagotomy Thoracotomy Esophagotomy Esophagotomy Esophagectomy Esophagotomy and thoracotomy Thoracotomy Endoscopic resection Esophagotomy Esophagotomy Esophagotomy Thoracotomy Endoscopic resection Endoscopic resection Esophagectomy Endoscopic resection
Xu37 Yang38 Yates39 Yo40
50 49 49 44
M M M M
D D, WL D D
Well-differentiated Well-differentiated Myxoid Well-differentiated
Esophagotomy Esophagotomy, thoracotomy and laparotomy Esophagectomy Endoscopic resection
D dysphagia, WL weight loss
Discussion Esophageal adenocarcinoma and squamous cell carcinoma account for the majority of esophageal cancers,42 while sarcomas account for 0.5 % of esophageal malignancies.1 The
majority of patients with esophageal liposarcoma are middleaged individuals. The wide range of age distribution of this disease may be attributed to the slow growth of this lesion. The diseases have a preponderance to arise from the upper esophagus.21 This finding may explain why the majority of
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Fig. 5 The distribution of esophageal liposarcoma subtypes found in the literature
patients presented with early dysphagia. In fact, of the patients who presented with dysphagia, 73 % had a proximal lesion. The diagnosis of esophageal liposarcoma often requires more tissue than that attained by conventional biopsy forceps. Therefore, it is not surprising that most biopsies of esophageal liposarcomas have not been diagnostic.3 Nevertheless, we highlight the fact that this diagnosis should remain in the differential when encountering polypoid lesions with benign-appearing atypical adipose cells with cytolastic vacuolation, hyperchromatia, and lobulated myxoid changes, even without conspicuous mitosis and necrosis. Regardless, in the majority of cases, the pathological diagnosis of esophageal liposarcoma can be straightforward with routine hematoxylin and eosin staining, and in some cases, immunohistochemical and genetic markers could be helpful in establishing a diagnosis. In fact, S100 is immunoreactive in lipomatous lesions and MDM2, CDK4, and P53 markers are absent in , benign lipomatous lesions.23 43 For instance, Myung et al.25 found that a series of 29 amplified genes (among which are CDK4 and MDM2) were characteristic of well-differentiated
liposarcoma, which is the most common subtype. Immunostains are now available commercially for the detection of CDK4 and MDM2 genes on chromosome 12q13-15, and this could help in identifying well-differentiated liposarcomas.4 Our review demonstrates that 10 % of esophageal liposarcomas recur, with a latency period of up to 25 years after resection.8 The reasons of this recurrence are unknown. We speculate that the recurrence may have been due to genetic susceptibility, incomplete resection, or a new primary rather than a local recurrence. To minimize the incidence of recurrences, some authors have employed adjuvant radiation therapy in one of the reviewed cases.35 However, mediastinal radiation can be complicated by significant morbidity such as radiation pneumonitis or constrictive pericarditis44 and one may argue that the role of adjuvant radiation therapy may be limited in such cases. Based on our review, it is impossible to determine which methodology could best identify recurrences, whether it is long-term annual upper endoscopy surveillance with biopsies or stringent clinical follow-up with new onset dysphagia as trigger for endoscopy. However, the results of our review suggest that all patients need some sort of long-term follow-up, as this disease can recur many decades after treatment.
Conclusion Esophageal liposarcoma is an extremely rare tumor. The majority of patients are males, dysphagia is the most common initial symptom, and preoperative biopsy is unreliable. Because these tumors are pedunculated, well-circumscribed, and well-differentiated, they can be safely resected locally. All patients need long-term follow-up, as this disease can recur many decades after treatment.
Conflict of Interest The authors have no conflicts of interest to declare. Table 2 Surgical approach in 40 cases described in the literature since 1983 Surgery Esophagotomy Esophagectomy Thoracotomy Esophagotomy and thoracotomy Longitudinal gastrotomy Esophagotomy, thoracotomy, and laparotomy Thoraco-laparotomy Surgery—not specified Endoscopic resection Debulking CO2 laser
77.5 41.9 25.8 16.1 3.2 3.2 3.2 3.2 3.2 20 % 2.5
% % % % % % % % % %
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