Zucker School of Medicine at Hofstra/Northwell Health Fresh Meadows, NY, United States
Karina Fatakhova, MD1, Shmuel Golfeyz, MD2, Meredith E. Pittman, MD2, Christine A. Resta, MD2, Dmitriy O. Khodorskiy, MD2 1Zucker School of Medicine at Hofstra/Northwell Health, Fresh Meadows, NY; 2Maimonides Medical Center, Brooklyn, NY
Introduction: Leiomyomas are the most common benign subepithelial lesions of the esophagus and are slow growing. They are usually incidentally found on upper endoscopy. Herein, we present a case of an enhancing aortopulmonary window (APW) lymph node (LN) on surveillance iodine-131 whole body scan and further localized on fludeoxyglucose positron electron tomography-computed tomography (FDG-PET/CT) scan, ultimately diagnosed as a leiomyoma.
Case Description/Methods: Patient is a 60-year-old woman with past medical history of multifocal papillary thyroid cancer with LN involvement, treated with total thyroidectomy with dissection of the central right compartments of her neck followed by radioactive iodine ablation (RIA) who presented to our endoscopy suite for endoscopic ultrasonography (EUS) with fine needle biopsy (FNB) of APWLN. One year after RIA, the patient underwent a surveillance thyrogen stimulated imaging I-131 whole body scan which demonstrated no uptake in the neck, however, did reveal a subtle focal uptake in the lower chest which was further localized APW on PET-CT scan. EUS-FNB of APWLN was performed, revealing a spindle cell lesion consistent with leiomyoma and was negative for malignancy.
Discussion: I-131 whole body scan should theoretically only pick up thyroid tissue, however, rare case reports have demonstrated uptake by other benign lesions. FDG uptake, is avid in malignant cells and is used on PET-CT scans to detect malignancies or identify recurrence. Post-chemotherapy inflammation, infection and benign tumors can lead to false-positive results. Leiomyomas are composed of smooth muscle cells, they are benign and do not typically enhance on PET-CT scans. This case demonstrates a rare finding and should be considered in the differential diagnosis when working up a LN that is identified adjacent to esophageal lumen. EUS is currently the standard of care for investigating esophageal SELs, and diagnosing and monitoring gastrointestinal leiomyomas. Patients are routinely monitored for interval growth of benign SELs via biennial EUS. Endoscopic or surgical resection is offered if the lesion becomes symptomatic (dysphagia), increases in size or patient wishes to no longer proceed with surveillance endoscopies. This case highlights the importance of thorough evaluation and tissue acquisition of lesions identified during routine or surveillance imaging.
Figure: Figure 1. Bundles of disorganized eosinophilic smooth muscle bundles (A) were present in the lymph node fine needle biopsy. The smooth muscle differentiation of the lesional cells was confirmed by diffuse reactivity for desmin by immunohistochemistry (B). AP window lymph node on EUS. (C)
Karina Fatakhova indicated no relevant financial relationships.
Shmuel Golfeyz indicated no relevant financial relationships.
Meredith Pittman indicated no relevant financial relationships.
Christine Resta indicated no relevant financial relationships.
Dmitriy Khodorskiy indicated no relevant financial relationships.
Karina Fatakhova, MD1, Shmuel Golfeyz, MD2, Meredith E. Pittman, MD2, Christine A. Resta, MD2, Dmitriy O. Khodorskiy, MD2. P0663 - The Curious Case of the Aortopulmonary Window Lymph Node, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.