Combination conventional endoscopy and endoscopic ultrasound can differentiate between esophageal granular cell tumors and leiomyomas

Abstract

Esophageal leiomyomas and granular cell tumors (GCTs) are the 2 most common subepithelial tumors found in the esophagus. We attempted to differentiate the 2 tumors using endoscopic findings and endoscopic ultrasound (EUS) features. Between December 2008 and June 2021, a total of 38 esophageal GCTs and 11 esophageal leiomyomas originating from the muscularis mucosa were selected. Clinical characteristics and endoscopic features were retrospectively reviewed. Although esophageal GCTs are mainly located in the lower third of the esophagus (81.6%), esophageal leiomyomas are mainly located in the upper third of the esophagus (45.5%). Broad-based (84.2%, P = .002) and whitish-to-yellowish color changes (97.4%, P < .001) are significant endoscopic features of esophageal GCTs. The echogenicity of esophageal leiomyoma was similar to that of proper muscle echogenicity. However, the echogenicity of esophageal GCTs was hyperechoic compared to that of the proper muscle layer (90.0% vs 9.1%, respectively, P < .001). EUS revealed a clearer hyperechoic epithelial lining in the esophageal leiomyoma than in esophageal GCTs (100% vs 26.7%, respectively, P < .001). The 5 endoscopic factors (location of the lower third, broad base, whitish-to-yellowish color, hyper-echogenic, and unclear demarcated hyperechoic epithelial line) were counted to differentiate esophageal GCTs from esophageal leiomyomas. Tumors with 3 or more endoscopic factors were all esophageal GCTs. The characteristic endoscopic and EUS features of esophageal GCTs were broad-based, whitish-to-yellowish colored subepithelial tumors located in the lower third of the esophagus and hyperechoic tumor with an unclear demarcated hyperechoic epithelial line. A combination of these features can predict esophageal GCTs before endoscopic resection.

Figure 1.

Histologic findings of endoscopically resected esophageal leiomyoma and granular cell tumor. (a) and (b) show relatively well-demarcated subepithelial tumor mass composed of spindle cells positive for smooth muscle actin (SMA). (c) and (d) show relatively unclear demarcated subepithelial tumor composed of polygonal cells positive for S100.

Figure 2.

Endoscopic and EUS findings of esophageal granular cell tumors and leiomyoma originated from muscularis mucosa. (a) Shows esophageal GCT with normal overlying mucosa with narrow base, (c) shows broad-based yellowish surface GCT, (e) shows broad based yellowish molar tooth appearance GCT. (b), (d), (f) show hyperechoic with unclear overlying hyperechoic epithelial line during EUS. (g) Shows leiomyoma with normal overlying mucosa with narrow base, (i) showed leiomyoma with reddish surface change with narrow base. (k) Shows leiomyoma with whitish-to-yellowish surface change with narrow base. (h), (j), (l) show hypoechoic mass similar to proper muscle layer with clear hyperechoic epithelial line. EUS = endoscopic ultrasonography, GCT = granular cell tumor.

Figure 3.

Combination conventional endoscopy and endoscopic ultrasound can differentiate esophageal granular cell tumor and leiomyoma.