Esophageal leiomyoma is the most common benign esophageal tumor, originating from the muscularis propria layer, and accounts for 60-70% of all esophageal neoplasms. Usually located in the distal 2/3 of the esophagus (smooth muscle zone); rare in the upper 1/3 (striated muscle). Most common between ages 20-50, more frequent in males. Most patients are asymptomatic and detected incidentally. Large lesions may cause dysphagia. Appears as a smooth, submucosal mass on CT and barium — the 'right angle sign' is pathognomonic. Malignant transformation (leiomyosarcoma) is extremely rare (<1%).
Age Range
20-60
Peak Age
40
Gender
Equal
Prevalence
Uncommon
Leiomyoma is a benign proliferation of smooth muscle cells in the esophageal muscularis propria layer. The tumor is well-circumscribed and pushes but does not invade surrounding tissues. Histologically composed of intersecting fascicles of smooth muscle cells. Because the tumor grows in the submucosal space, the mucosa remains intact — reflected on barium as smooth filling defect with preserved mucosal relief. The submucosal origin causes the tumor to form a 'right angle' (90 degrees) with the esophageal wall when growing intraluminally — this angle is pathognomonic of intramural lesions. The homogeneous soft tissue density and smooth borders on CT reflect the uniform packing of smooth muscle cells. Calcification is rare but when present may be nodular or peripheral.
Sharp 90-degree angle between the submucosal mass and normal esophageal wall on barium. This angle is pathognomonic of intramural (submucosal) origin lesions. Seen in submucosal lesions like leiomyoma, GIST, duplication cyst. This angle is lost in mucosal origin (carcinoma) or extrinsic compressions.
Smooth filling defect protruding into the lumen on barium. A sharp 90-degree angle (right angle sign) forms between the mass and normal esophageal wall. The overlying mucosa is intact with smooth barium coating. Mucosal folds are stretched over the mass but not destroyed.
Report Sentence
A smooth submucosal filling defect with right angle sign between the mass and wall is observed in the esophagus; the mucosa is intact, consistent with leiomyoma.
Well-circumscribed, smooth-contoured mass of homogeneous soft tissue density (30-50 HU) in the esophageal wall on CT. Shows homogeneous and mild-to-moderate enhancement on contrast CT. Internal necrosis, ulceration, or calcification is usually absent. The mass shows continuity with the esophageal muscularis propria.
Report Sentence
A homogeneously enhancing, well-circumscribed intramural mass measuring approximately ___ cm in the esophageal wall; consistent with leiomyoma.
Rarely (1-2%), calcification may be seen within leiomyoma. Calcification is usually nodular or peripheral in distribution. Calcified leiomyoma is important in differential diagnosis because calcification is very rare in GIST.
Report Sentence
Calcification areas within the esophageal intramural mass; consistent with calcified leiomyoma.
Homogeneous mass with intermediate-to-low signal intensity on T2-weighted sequences. Smooth muscle tissue shows low signal due to short T2 relaxation time. Isointense to hypointense on T1. Homogeneous enhancement after gadolinium. Areas of myxoid degeneration may show high signal on T2.
Report Sentence
The esophageal intramural mass shows intermediate-to-low signal on T2 with homogeneous enhancement; consistent with leiomyoma.
Exophytic growth pattern may be seen in large leiomyomas — the mass extends from the esophageal wall into the mediastinum. The intraluminal component remains small while the exophytic component may be dominant. In this pattern, the mass shows clear borders with periesophageal fat (no invasion).
Report Sentence
A well-circumscribed mass showing exophytic extension from the esophageal wall into the mediastinum with preserved periesophageal fat plane; consistent with large leiomyoma.
Rare annular (ring-shaped) growth pattern — leiomyoma circumferentially encases the esophageal wall. Lumen narrows concentrically. Wall thickness is homogeneously and symmetrically increased. CT shows smooth, symmetric wall thickening — may be challenging to differentiate from achalasia or carcinoma.
Report Sentence
Circumferential, homogeneous, symmetric wall thickening in a short segment of the esophagus; consistent with annular leiomyoma.
Criteria
Single mass protruding into the lumen. Most common type (90%).
Distinct Features
Typical right angle sign and smooth filling defect. Size usually 2-5 cm.
Criteria
Size >10 cm. Rare.
Distinct Features
Appears as mediastinal mass. Exophytic growth dominant. May have cystic degeneration. Difficult to differentiate from GIST and leiomyosarcoma.
Criteria
Multiple leiomyomas, diffuse esophageal leiomyomatosis. May be associated with Alport syndrome.
Distinct Features
Diffuse wall thickening. Obstructive symptoms earlier. Alport syndrome screening recommended.
Distinguishing Feature
GIST is hyperintense and more heterogeneous on T2; leiomyoma shows intermediate-low signal and homogeneous on T2. Necrosis more common in GIST
Distinguishing Feature
Schwannoma is markedly hyperintense on T2 (Antoni B areas); leiomyoma shows low signal on T2
Distinguishing Feature
Duplication cyst is fluid density (0-20 HU) and non-enhancing; leiomyoma is solid density (30-50 HU) and enhances
Distinguishing Feature
SCC shows mucosal destruction and irregular borders; leiomyoma has intact mucosa, right angle sign, and smooth borders
Urgency
routineManagement
conservativeBiopsy
Not NeededFollow-up
annualAsymptomatic small leiomyomas (<5 cm) do not require treatment; annual CT or endoscopic US follow-up is sufficient. For symptomatic or growing lesions, surgical enucleation (video-assisted thoracoscopic surgery — VATS) is preferred. Endoscopic biopsy is NOT RECOMMENDED because the mucosa is intact and post-biopsy fibrosis complicates surgery. EUS (endoscopic ultrasound) is valuable for GIST differentiation — leiomyoma arises from muscularis propria, GIST may also originate from muscularis mucosae.
Esophageal leiomyomas generally require no treatment. Enucleation (submucosal resection) is performed for symptomatic or rapidly growing lesions. Risk of malignant transformation is extremely low. Biopsy is generally not recommended (insufficient material since mucosa is intact).