A case report of giant esophageal neurofibroma

Surgical treatment for esophageal neurofibroma: report of two cases and review of literature

BACKGROUND

Neurofibroma of the esophagus, originated from the nerve sheath cells and fibroblasts of the esophageal submucosal plexus or the intestinal intermuscular plexus, is a very rare mesenchymal tumor. Most of the cases are treated by surgical methods. Due to the technical complexity of video-assisted thoracoscopic surgery (VATS), there are few reports in the literature of VATS for esophageal neurofibroma in recent years.

CASE PRESENTATION

We report on two rare cases of esophageal neurofibroma, one of which is a 52-year-old male patient diagnosed with a 4.6 × 5.7 cm upper esophageal submucosal tumor in physical examination. He was admitted to our hospital and the tumor was enucleated by VATS combined with intraoperative endoscopy. There were no complications after operation, and the patients was discharged on the 16th postoperative day. The other patient was a 76-year-old man, with the main clinical manifestation of dysphagia for over 1 year, diagnosed with an 8.0 × 6.0 × 8.0 cm giant subepithelial mass in the lower esophagus. As the intraoperative exploration revealed the tumor connected tightly with the wall of the esophagus, this patient treated by transthoracic partial esophagectomy. The patient was discharged on the 14th postoperative day, and no signs of post-operative complication during the 53-month follow-up. The diagnosis of esophageal neurofibroma was based on these patients' postoperative pathological examination. In the latest follow-up, these two patients had no evidence of long-term postoperative complication and recurrence.

CONCLUSION

This is the first reported case of 5 cm in diameter esophageal neurofibroma treated by VATS. This technique can be a commendable treatment option for esophageal neurofibroma, and the tumor diameter is not an absolute contraindication for thoracoscopy. To reduce the unnecessary damage, surgical method for complete tumor resection needs to be determined according to preoperative imaging and intraoperative conditions, partial esophagectomy can be performed via thoracotomy or thoracoscopy for removing neurofibroma when necessary.

Understanding esophageal neurofibroma: A case series and systematic review

INTRODUCTION

Esophageal neurofibroma is a rare benign esophageal neoplasm. With very few cases documented in the literature, not much is known about the demographics and clinicopathologic features of this tumor. This study was aimed at presenting a case report of an esophageal neurofibroma, and to conduct a systematic review of published cases.

METHOD

This review was performed according to the PRISMA guidelines. Literature search was conducted through PubMed, SCOPUS, and Cochrane Databases from inception until May 2020 for all histologically confirmed cases of esophageal neurofibroma.

RESULTS

28 cases, including the newly reported case, were included in the review. The mean age at diagnosis was 53.3 years ±12.1. 53.6% were male. Dysphagia was the most common presenting symptom (53.6%). Most of the reported cases involved the upper esophagus (39.3%). The most utilized diagnostic test was esophagogastroduodenoscopy (57.1%). The mean tumor size was 6.1 cm ± 5.1. Preoperative biopsy was done for 9 cases, out of which seven were negative or inconclusive. In 17 cases (60.7%), immunohistochemical (IHC) staining of the resected tumor was not performed. S100 was the most utilized IHC stain. Enucleation (39.3%) was the most common treatment, followed by esophagectomy (28.6%).

CONCLUSION

Esophageal neurofibroma should be considered in the setting of dysphagia caused by a subepithelial tumor. Accurate preoperative histologic diagnosis by using a well-defined biopsy algorithm, in conjunction with IHC analysis, will favor less aggressive surgical treatment and surveillance of asymptomatic lesions. Minimally invasive surgical treatment is feasible and should be considered when the expertise is available.

Life-threatening giant esophageal neurofibroma with severe tracheal stenosis: a case report

BACKGROUND

Benign esophageal tumors are relatively rare, and a neurofibroma in the esophagus is extremely rare. Dysphagia is the most common clinical manifestation in patients with esophageal neurofibroma, and no cases of giant esophageal neurofibroma with severe tracheal stenosis have been reported.

CASE PRESENTATION

A 73-year-old woman presented with shortness of breath, and computed tomography scan exhibited a giant mediastinal tumor causing severe tracheal stenosis. An upper gastrointestinal endoscopy revealed a giant submucosal lesion without mucosal changes located 18-23 cm from the incisor teeth. ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography image revealed an upper mediastinal homogeneous mass and left supraclavicular lymph node with increased FDG accumulation. We performed endoscopic ultrasound-guided fine-needle aspiration biopsy; however, a definitive diagnosis could not be determined. During further investigation, her shortness of breath suddenly worsened and she suffered from wheezing. Because of risk of smothering, we decided to perform quasi-urgent lifesaving surgery. Under the preparation of extracorporeal membrane oxygenation (ECMO) when tracheal intubation fails, bronchial blocker was inserted over the tracheal stenosis and the left-lung ventilation was performed via intubation alone. Under general anesthesia, the patient was placed in the left lateral position and we performed right thoracotomy. The tumor strongly adhered to the trachea; however, the trachea or recurrent laryngeal nerves were not damaged in the surgery. Following esophagectomy, we performed gastric conduit reconstruction through the posterior mediastinum, and hand-sewn anastomosis was performed in the left neck. Immunohistochemical staining was positive for S-100 but negative for c-KIT, CD34, α-SMA, and desmin; these morphological and immunohistochemical characteristics were consistent with the diagnosis of neurofibroma.

CONCLUSIONS

It is often difficult to diagnose esophageal neurofibroma preoperatively. The preparation of ECMO could be considered in patients with severe airway obstruction for safe tracheal intubation. This is the first case of life-threatening giant esophageal neurofibroma with severe tracheal stenosis.