GENERAL THORACIC
Esophageal Leiomyoma: A 40-Year Experience
Christopher J. Mutrie, MD, Dean M. Donahue, MD, John C. Wain, MD,
Cameron D. Wright, MD, Henning A. Gaissert, MD, Hermes C. Grillo, MD,
Douglas J. Mathisen, MD, and James S. Allan, MD
Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts
Background. Esophageal leiomyomas, although infre-
quent, are the most common benign intramural tumors of
the esophagus. They represent 10% of all gastrointestinal
leiomyomas and frequently cause symptoms, necessitat-
ing resection.
Methods. The Massachusetts General Hospital Patho-
logic Database was reviewed over a 40-year period for
patients who underwent surgical resection of esophageal
leiomyomas. Data analyzed included demographic infor-
mation, presenting symptoms, tumor location, tumor
characteristics and histology, diagnostic procedures, and
treatment modalities/outcomes. Fifty-three patients were
identified; 31 patients were symptomatic from their
leiomyomas.
Results. Symptomatic patients presented at a mean age
of 44 years old and exhibited a twofold male predomi-
nance. Mean tumor diameter among symptomatic pa-
tients was 5.3 cm, as compared to 1.5 cm in asymptomatic
patients (p < 0.0001). Thirty of the symptomatic patients
had solitary leiomyomas, and 1 patient had five separate
E sophageal leiomyomas are the most common benign
intramural tumors of the esophagus. Still, these
tumors are relatively rare, with autopsy series data show-
ing an incidence of 0.006 to 0.1% [1]. By comparison,
esophageal carcinoma is approximately 50 times more
common than leiomyoma [2]. Esophageal leiomyomas
are typically found in patients between 20 and 50 years
old, and represent 10% of all gastrointestinal leiomyo-
mas. They are multiple in 3% to 10% of patients and are
found more often in men by a ratio of 2:1 [3–5]. Eighty
percent occur in the middle to lower third of the esoph-
agus [6]. Historically, dysphagia and odynophagia are the
most common complaints of those patients who are
symptomatic [7].
Leiomyomas are most commonly diagnosed on con-
trast esophagography, where they appear as a smooth
concave filling defect within the esophageal lumen [1].
They can also be seen on chest radiography, computed
tomography, and magnetic resonance imaging.
Pathologically, leiomyomas consist of interlacing
bundles of smooth muscle cells and occasionally can
grow as large as 20 cm in diameter. Generally, tumors
Accepted for publication Aug 13, 2004.
Address reprint requests to Dr Allan, Massachusetts General Hospital, Blake
1570, 55 Fruit St, Boston, MA 02114; e-mail: jallan@partners.org.
© 2005 by The Society of Thoracic Surgeons
Published by Elsevier Inc
leiomyomas. Eighty-four percent of the lesions in symp-
tomatic patients occurred in the lower two-thirds of the
esophagus, with epigastric discomfort being the most
common presenting symptom. Among patients operated
on solely for leiomyoma, 97% were enucleated without
an esophageal resection. None of the leiomyomas
showed malignant transformation or recurrence. All
symptomatic patients had relief of symptoms, with no
perioperative morbidity or mortality.
Conclusions. In a large pathologic series, over half of all
patients with esophageal leiomyomas were symptomatic.
Larger tumors were significantly more likely to be symp-
tomatic. Local enucleation by a variety of surgical ap-
proaches was accomplished in most patients. All symptom-
atic patients had relief of symptoms, with no perioperative
morbidity or mortality. There was no observed tendency for
malignant transformation or recurrence.
(Ann Thorac Surg 2005;79:1122–5)
© 2005 by The Society of Thoracic Surgeons
less than 5 cm in diameter are asymptomatic [1]. In a
comprehensive review of more than 800 cases reported
in the world literature, only two (0.2%) were docu-
mented to show malignant transformation from
leiomyoma to leiomyosarcoma [2].
Patients and Methods
A search of the Massachusetts General Hospital Patho-
logic Database was performed to identify all cases of
esophageal leiomyoma that were surgically resected be-
tween January 1962 and January 2002. Office records,
hospital records, or both from all identified patients were
also reviewed. The data extracted from the medical
records included demographic information, the present-
ing symptoms, the location of the tumor in the esopha-
gus, the size and shape of the tumor, the diagnostic
procedure, the treatment modality, the incidence of re-
currence, surgical complications and deaths. Information
was cataloged and analyzed.
Fifty-three patients were identified. Of these, 31 pa-
tients (58%) underwent surgery solely for the resection of
symptomatic leiomyomas. One patient (2%) underwent
resection of an asymptomatic leiomyoma. The remaining
21 patients (41%) had thoracic procedures for other
indications (eg, lung cancer, esophageal cancer, hiatal
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Ann Thorac Surg
2005;79:1122–5
Fig 1. Anatomical location of leiomyoma.  ⫽ upper third; o ⫽
middle third; s ⫽ lower third.
hernias, etc.), and resection of an incidentally discovered
leiomyoma was concurrently performed. Follow-up data
that adequately described the patient’s health status was
available on 27 of 53 patients in this series, with a mean
follow-up interval of 6.3 years.
Results
Gender
Sixty-four percent (n ⫽ 34) of all patients studied were
male; 36% (n ⫽ 19) were female, yielding a male predom-
inance of 1.8:1. Among symptomatic patients operated on
solely for leiomyoma (n ⫽ 31), 66% (n ⫽ 21) were male,
and 34% (n ⫽ 10) were female, yielding a male predom-
inance of 2.1:1.
Age
The mean age of all patients studied was 51.7 years old
(range, 19 to 81 years old). Among symptomatic patients
Fig 2. Horseshoe leiomyoma.
MUTRIE ET AL 1123
GENERAL THORACIC
ESOPHAGEAL LEIOMYOMA
Table 1. Presenting Complaint(s) Among Symptomatic
Patients (n ⫽ 31)
Symptom Percentage
Epigastric discomfort 68
Dysphagia 52
Regurgitation 23
GI bleed 10
Diarrhea 3
Weight loss 3
GI ⫽ gastrointestinal.
operated on solely for leiomyoma (n ⫽ 31), the mean age
was 43.8 years old (range, 19 to 76 years old).
Size
The mean tumor diameter of all patients studied was 3.7
cm (range, 0.2 to 17.0 cm). Among symptomatic patients
operated on solely for leiomyoma (n ⫽ 31), the mean
tumor diameter was 5.3 cm (range, 0.8 to 17.0 cm).
Asymptomatic patients had a significantly lower mean
tumor diameter (1.5 cm [range, 0.2 to 6.0 cm]; p ⬍ 0.00001,
Student’s t test).
Location
Among all patients studied, the majority of the tumors
arose in the lower (53%) and middle (43%) thirds of the
esophagus (Fig 1). Only 4% were in the upper third of the
esophagus. Among symptomatic patients operated on
solely for leiomyoma (n ⫽ 31), the tumors were distrib-
uted as follows: lower third (39%), middle third (55%),
and upper third (6%).
Tumor Characteristics
Among all patients studied, 48 patients (91%) had solitary
tumors and 5 (9%) had multiple tumors. Three leiomyo-
mas (6%) were calcified. Fourteen (26%) patients had
lobulated masses. Three other patients (6%) had serpig-
enous leiomyomas. One leiomyoma (2%) was horseshoe-
shaped (Fig 2). Among symptomatic patients operated on
solely for leiomyoma (n ⫽ 31), 30 patients (97%) had
solitary tumors and 1 patient (3%) had multiple tumors.
Three leiomyomas (9%) were calcified. Thirteen patients
(41%) had lobulated masses. Three other patients (9%)
had serpigenous leiomyomas. One leiomyoma (3%)
was horseshoe-shaped. None of the lesions showed any
foci of leiomyosarcoma, suggestive of malignant
degeneration.
Symptoms and Associated Disorders
Among symptomatic patients operated on solely for
leiomyoma (n ⫽ 31), 21 patients (68%) reported epigas-
tric distress (including heartburn and other epigastric
symptoms commonly attributed to gastroesophageal
reflux). Sixteen patients (52%) reported dysphagia.
Other symptoms were reported less frequently (see
Table 1).
 1124 MUTRIE ET AL
GENERAL THORACIC
ESOPHAGEAL LEIOMYOMA
Table 2. Surgical Approach in Patients Operated on Solely
for Leiomyoma (n ⫽ 32)
Approach Number
Right thoracotomy 21
Left thoracotomy 6 the esophageal wall. These benign tumors tend to
Thoracoabdominal 1 present as solitary round masses without calcification.
Midline laparotomy 1 A slight majority of our patients were symptomatic and
Right VATS 1 presented with complaints of epigastric distress, dyspha-
Transverse cervical 1 gia, or both. Seremetis and coworkers [5] reported similar
VATS ⫽ video-assisted thoracic surgery.
Diagnostic Evaluation
All symptomatic patients underwent barium esophagog-
raphy. The majority of patients treated within the last
decade also received chest computed tomographic scan.
Esophageal ultrasounds and endoscopic biopsies were
used occasionally by referring physicians, although the
ultimate management of those patients so examined was
not significantly impacted. We do not routinely perform
endoscopic biopsies ourselves unless there is some diag-
nostic uncertainty that would make resection unwar-
ranted. There is also some anecdotal experience suggest-
ing that a preoperative biopsy (and consequent mucosal
adhesions) may impede easy enucleation of the tumor.
Surgical Approach and Outcomes
Among symptomatic patients operated on solely for
leiomyoma (n ⫽ 31), 21 patients (66%) were approached
through a right thoracotomy (limited or posterolateral).
The remaining 10 patients (34%) were approached in
accordance with Table 2. In all patients except one, the
leiomyoma was enucleated by dissection within the mus-
cular wall of the esophagus. In all patient the muscular
layer was reapproximated with interrupted silk sutures.
One patient sustained a full-thickness injury to the
esophageal wall during enucleation, which was directly
repaired and buttressed with a pedicled intercostal mus-
cle flap at the time of surgery without sequelae. One
patient required an esophagogastrectomy for removal of
a giant (⬎ 10 cm) leiomyoma. All symptomatic patients
had relief of symptoms. There were no postoperative
complications or perioperative deaths in this group. No
patients represented to our care with recurrence.
Comment
We report here a large single-institution case series of
esophageal leiomyoma. Our data first point to the rarity
of this entity. Despite being a tertiary referral center for
surgical esophageal disease, our hospital performed less
than one operation per year solely for the treatment of a
symptomatic esophageal leiomyoma. These data are in
concordance with reported autopsy series suggesting an
overall incidence of 0.006% to 0.1% for esophageal
leiomyoma [1]. Our data also show that leiomyoma have
a twofold male sex predominance. This finding is in
agreement with the 1.9:1 ratio found in a compilation of
Ann Thorac Surg
2005;79:1122–5
838 patients from the world literature, reported by Ser-
emetis and colleagues in 1971 [5]. Our data also show that
leiomyoma are preferentially found in the lower two-
thirds of the esophagus, which is consistent with the
normal anatomical distribution of smooth muscle within
symptomology in their review, noting that dysphagia and
pyrosis (heartburn) were the most common presenting
symptoms. However, Seremetis noted in his own series
of 19 patients that only those with concomitant hiatal
hernias presented with pyrosis. Our data also show the
intuitive finding that large leiomyomas are significantly
more likely to be symptomatic. The mean diameter of
tumors in symptomatic patients was 5.3 cm, as opposed
to 1.5 cm for patients with incidentally found leiomyomas
(p ⬍ 0.001; Student’s t test).
The majority of leiomyomas in this series were re-
sected by open thoracotomy by enucleating the lesion
from within the muscular wall of the esophagus, without
entering the mucosal lumen. It has been our practice to
routinely reapproximate the muscular layer of the esoph-
agus with interrupted silk suture following enucleation,
which may be significant in the prevention of postoper-
ative complications such as diverticula. We have found
this approach to be both safe and efficacious, and report
no morbidity or mortality using these techniques. In
particular, we have not observed an increased incidence
of heartburn or epigastric pain following resection. This
is most likely due to our efforts to minimize hiatal
dissection and mobilization during the operation.
In this series, we are reporting only 1 patient whose
leiomyoma was removed by a video thoracoscopic ap-
proach. We recognize that thoracoscopic removal of
these benign tumors is currently an excellent approach to
the management of most simple leiomyomas. The low
frequency of minimally invasive resections in this series
is due both to its historical nature and due to individual
surgeon preferences. Bardini and colleagues [8] first
described video thoracoscopic enucleation of esophageal
leiomyomas in 1992, and several investigators have re-
ported favorable results using combined thoracoscopic
and endoscopic approaches [9, 10]. We believe that
minimally invasive procedures are certainly acceptable,
particularly for smaller rounded solitary lesions, where
the submucosal plane can be easily identified and
developed.
We have described a pathologic series of esophageal
leiomyomas in which slightly over half of the patients
were symptomatic. Larger tumors were significantly
more likely to be symptomatic. Local enucleation by a
variety of surgical approaches was accomplished in the
vast majority of patients. One patient with a giant leiomy-
oma required esophagogastrectomy. None of the
leiomyomas showed malignant degeneration or re-
curred. All symptomatic patients had relief of symptoms,
with no perioperative morbidity or mortality.
Ann Thorac Surg
2005;79:1122–5
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MUTRIE ET AL 1125
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ESOPHAGEAL LEIOMYOMA
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esophagus. In: Sabiston DC, ed. Textbook of surgery: the
biological basis of modern surgical practice. Philadelphia:
W.B. Saunders Company, 1991:689 –700.
8. Bardini R, Segalin A, Ruol A, Pavanello M, Peracchia A.
Videothoracoscopic enucleation of esophageal leiomyoma.
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9. Bonavina L, Segalin A, Rosati R, Pavanello M, Peracchia A.
Surgical therapy of esophageal leiomyoma. J Am Coll Surg
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10. Izumi Y, Inoue H, Endo M. Combined endoluminal-
intracavitary thoracoscopic enucleation of leiomyoma of the
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