the most common location in the alimentary tract is the oesophagus , where the tumour is responsible for most diagnoses of benign tumors of the organ .
the frequency of occurrence ranges between 0.005% and 7.9% of the population [ 24 ] .
it is often symptomless and is accidentally diagnosed in tests . if symptoms occur , usually it is dysphagia and pain in the epigastrium and chest [ 5 , 6 ] .
depending on the size and location of the lesion patients are qualified for a particular type of surgery . at present
a wide range of operations are available , from minimally invasive submucosal resections carried out during endoscopy , through surgery involving opening of the thorax , to subtotal oesophageal resection with the transhiatal method or thoracotomy .
although oesophageal leiomyoma is a benign neoplasm , its diagnostics and treatment are often a serious challenge for the whole team of physicians .
below we present a case study of a patient whose considerable oesophageal leiomyoma was both a diagnostic and therapeutic problem .
a patient , aged 54 , was admitted to the department of general surgery and surgical oncology , wielkopolska cancer centre , where she was to be treated for a posterior mediastinal tumour , which filled the left half of her chest .
the lesion was diagnosed in routine periodic examinations at her place of work in march that year ( chest radiograph ) .
the patient had not reported any ailments which may have been related to the presence of the lesion .
the patient was referred to the thoracic surgery outpatient clinic and then admitted to the thoracic surgery department , wielkopolska center of lung disease and thoracosurgery in june that year to undergo diagnostics and treatment .
the patient underwent computed tomography of her thorax , where a pressed left lung lower lobe modelled on an enormous mass was described .
the tumour came out of the stomach and caused concentric thickening of its wall , mainly around the body .
the lesion was adjacent to the pericardium , modelling the left lower pulmonary vein , lifting the left main bronchus and pressing the basal segmental bronchi of the left lung lower lobe .
the maximum size of the infiltration was 12  13  18 cm ( fig .
in the conclusions from the examination the radiologist suggested that the diagnosis should take a lymphoma or myosarcoma into consideration , gist being less likely . in order to obtain a histopathological diagnosis
, no neoplastic cells were found ; the smears had an extremely low cell count .
due to the results a transthoracic core - needle biopsy of the lesion was carried out , which brought no diagnosis , either .
its result only corresponded to relatively numerous very fine fimbriae of low cell connective tissue with individual fine vessels . due to
the lack of histopathological diagnosis and unequivocal image of ct examination the patient was qualified for exploratory thoracotomy with biopsy of the lesion . during the surgery the lesion
was found to be more advanced than the ct examination indicated , because in practice , the tumour occupied the entire thoracic segment of the oesophagus and the gastric cardia , which was moved to the thorax .
part of the tumour seemed to enter the abdominal cavity through the oesophageal hiatus . a specimen collected in the thoracotomy produced the diagnosis of mesenchymal spindle cell carcinoma without distinct traits of malignancy .
later , in august 2012 , the patient was admitted to the surgical department , greates poland cancer centre , pozna , poland .
the patient had diagnostics supplemented with computed tomography of the abdominal cavity , which confirmed the presence of an oesophageal tumour filling the left pleural cavity .
apart from that , the examination did not reveal pathology within the organs and structures beneath the diaphragm .
the patient underwent gastroscopy , which did not reveal any lesions in the oesophageal or gastric mucosa .
the patient was qualified for surgery carried out by a team of surgeons and thoracic surgeons .
next , the thorax was opened on the left , in the scar after the previous thoracic surgery .
the encapsulated tumour was resected by cutting off the oesophagus proximally in the upper thoracic segment and distally within the region of the gastric cardia relocated to the thorax . as was described in the ct examination of the thorax ,
the tumour was adjacent to the pericardium and the lower lung lobe base , which required careful dissection of the lesion .
the resected thoracic segment of the oesophagus passed right through the middle of the tumour .
the alimentary tract was reconstructed by means of a gastric prosthesis , anastomosing it on the left side of the neck to the stump of the cervical segment of the oesophagus .
on the 11 day after the surgery the patient was discharged from hospital with a recommendation of a follow - up examination at the surgical oncology outpatient clinic . the histopathological image based on the results of immunohistochemical examinations ( sma , ki67 , calp , cd 117 , s100 , cd 34 , dog 1 ) corresponded to oesophageal leiomyoma .
the patient remains under control of the surgical oncology outpatient clinic , where she has check - ups .
three months after the surgery no pathological lesions were found in computed tomography of the thorax . , postoperative photograph of the tumour
the analysis of a group of 63 patients with the tumour , who were treated in one centre , revealed that the location in the central part of the oesophagus concerned 47.6% of the patients and the distal location 37.1% of the patients .
similarly , in another study the most frequent location in the distal segment of the oesophagus concerned 46% of the patients . in the case under study the main part of the lesion was also located in the distal segment of the oesophagus . due to the slow growth of these tumours the vast majority of them ( 59% )
some authors report a correlation between the size of the lesion and the occurrence of clinical symptoms .
the average size of the tumour in patients with symptoms was 5.2 cm ( 0.8 - 14 cm ) , whereas in patients without symptoms the average size of the lesion was much smaller  0.4 cm ( 0.1 - 1.0 cm ) .
the literature describes different diameters of resected tumours , ranging from 0.1 cm up to the maximum size of 29 cm [ 1 , 9 , 10 ] . in the case under study ,
in the final histopathological examination the lesion was 22 cm . in spite of this size
the tumour did not cause any clinical ailments and was diagnosed during routine periodic examinations at work , where the patient had her chest x - rayed .
the diagnosis of leiomyoma is based on imaging examinations and biopsy in order to obtain a histopathological diagnosis . by choice endoscopy and endoscopic ultrasound
are the examinations where the lesions can be seen as submucosal movable masses with untouched mucosa , which enables exclusion of the malignant process . in most cases
the tumours did not cause lesions in the oesophageal mucosa , which also did not occur in the case under discussion .
unfortunately , the centre treating the patient does not have a possibility to carry out endoscopic ultrasound ( eus ) .
. apart from the eus , computed tomography and magnetic resonance are the examinations that enable diagnosis .
the computed tomography image shows a mass bound to the oesophagus , without traits of lymphadenopathy , which enables the diagnosis of a benign lesion . in the case under discussion
there was a relatively large discrepancy between the computed tomography description and the actual image observed in exploratory thoracotomy .
the collection of specimens for histopathological diagnosis is a subject of discussion [ 6 , 11 ] .
some authors stress that multiple biopsies may cause adhesions in the thorax , which later make minimally invasive resection of the lesion much more difficult and which cause weakening of the mucosa , which is of key importance in an attempt to enucleate the tumour without resection of the oesophagus [ 7 , 12 ] . besides , the collected material is usually insufficient to make a final diagnosis , especially if it is only cytological smear . at present histopathological diagnostics also includes the immunohistochemical examination , but it is necessary to have an appropriate amount of material to make the examination . in the case under study neither the attempt of a fine - needle aspiration biopsy nor core - needle biopsy resulted in diagnosis . even when a specimen was collected during exploratory thoracotomy ,
the final histopathological diagnosis was made when the entire lesion was resected and a panel of immunohistochemical examinations was carried out .
the choice of surgical technique depends on the size and location of the lesion and on the occurrence of clinical symptoms .
usually these lesions are accidentally diagnosed and they do not cause any clinical symptoms . some authors do not recommend resection of the lesions .
larger lesions , over 5 cm in size , which cause clinical symptoms , have a visible growing tendency , cause ulceration and their final histopathological diagnosis is uncertain , need to be radically resected [ 5 , 13 ] . so far four cases of malignant transformation of leiomyoma have been described .
the tumour located in the oesophagus can be resected with a minimally invasive method during thoracoscopy .
patients whose tumours do not exceed 5 cm are qualified for minimally invasive surgery , although some authors suggest that during thoracoscopy it is possible to resect lesions sized even up to 8 cm .
it may be difficult to resect smaller lesions than 1 cm , because precise location of the lesion may cause problems .
jiang et al . described a group of 40 patients with oesophageal leiomyoma , where in two out of five patients whose tumours were smaller than 1 cm in diameter it was impossible to locate the lesions in thoracoscopy and it was necessary to apply conversion .
in as many as 10% of cases with the diagnosis of leiomyoma it is necessary to resect the oesophagus .
usually this concerns larger lesions than 8 cm , which occupy the entire oesophagus and strongly adhere to the mucosa [ 5 , 14 ] . by expanding growth
there is a report of a case of oesophageal leiomyoma pressing the left atrium of the heart and causing symptoms of dyspnoea and fatigue .
the ailments were caused by obstructed flow of blood to the left atrium and the left ventricle .
similarly , in the case under study the tumour closely adhered to the pericardium and the left lobe base , which required careful dissection of the lesion .
resection of the oesophagus with the lesion causes elimination of all ailments and prevents the occurrence of reflux , which is sometimes described in the literature after operations where only the tumour was resected .
besides , many authors note that a long - lasting pressure of the tumour causes thinning and impairment of the muscularis mucosae , which may cause healing difficulties and result in the formation of a fistula .
when large oesophageal leiomyomas are treated , a possible transformation into leiomyosarcoma should always be taken into consideration .
therefore , the best procedure with large lesions is resection of the oesophagus with the lesion .
oesophageal leiomyoma , which is a benign neoplasm , is a serious diagnostic and therapeutic challenge .
smaller lesions sized 5 - 8 cm may be resected with minimally invasive methods , but lesions sized over 8 - 10 cm require precise preparation for the surgery , because resection of the oesophagus may be necessary .
combining the skills of a team of surgeons and thoracic surgeons provides an optimal therapeutic procedure to a patient with a large tumour . a complete resection of the lesion combined with resection of the oesophagus was the optimal therapeutic procedure , which led to the patient 's recovery .
 oesophageal leiomyoma is a rare benign tumour of the oesophagus , which does not cause clinical symptoms in more than half of cases . below 
 we present the case of a symptomless oesophageal tumour . due to the unequivocal result of imaging examinations and no histopathological diagnosis the patient was qualified for thoracotomy . during the operation 
 the oesophageal tumour was suspected of passing through the hiatus into the abdominal cavity . 
 the specimen revealed a neoplasm of mesenchymal origin without distinct traits of malignancy . 
 the patient was admitted to the surgical department , where she was qualified for surgery , which was carried out by a team of surgeons and thoracic surgeons . 
 the encapsulated tumour and oesophagus were resected . 
 the histopathological and immunohistochemical examinations corres ponded to leiomyoma oesophagi . 
 the lesion was radically resected . 
 the size of the lesion was 22  14  13 cm . 
 three months after the surgery no traits of relapse were found . 