What is the management for a 1 cm gastric leiomyoma?

Management of a 1 cm Gastric Leiomyoma

For a 1 cm gastric leiomyoma, observation is the most appropriate management strategy as these lesions are benign and rarely require intervention at this size.

Understanding Gastric Leiomyomas

Gastric leiomyomas are benign subepithelial lesions (SELs) that:

• Account for approximately 2.5% of gastric neoplasms 1
• Are most commonly found in the esophagus, but can occur in the stomach
• Need to be differentiated from gastrointestinal stromal tumors (GISTs), which have malignant potential 2

Evidence-Based Management Algorithm

For 1 cm Gastric Leiomyoma:

1. Initial Management: Observation

   • Asymptomatic leiomyomas generally do not require surveillance or resection 2
   • Small leiomyomas (especially <1 cm) demonstrate benign behavior with very low risk of progression
   • Recent evidence shows that size increase is infrequent (only 2.4% of cases) even during long-term follow-up 3

2. Surveillance Considerations:

   • If observation is chosen, endoscopic ultrasound (EUS) can be used for periodic assessment
   • The 2022 AGA Clinical Practice Update indicates tissue sampling using FNA or FNB is useful to distinguish leiomyoma from GIST 2

3. Indications for Intervention:

   • Development of symptoms (bleeding, obstruction)
   • Ulceration of the lesion
   • Increase in size during surveillance 3
   • Uncertainty in diagnosis (unable to differentiate from GIST)

When Intervention Is Needed:

If the leiomyoma requires removal due to symptoms, growth, or diagnostic uncertainty:

• For 1 cm lesions:

  • Endoscopic resection techniques are preferred if technically feasible
  • EMR (endoscopic mucosal resection) or ESD (endoscopic submucosal dissection) can be considered for small lesions

• For larger lesions or those with unfavorable location:

  • Laparoscopic wedge resection may be appropriate 4, 5
  • For posterior wall lesions, transgastric or intragastric approaches can be used 6, 5

Key Considerations

• Differentiation from GIST is crucial: GISTs have malignant potential and require different management strategies
• Size matters: The 2022 AGA guidelines emphasize that gastric GISTs >2 cm should be considered for resection, but this threshold does not apply to confirmed leiomyomas 2
• Location impacts surgical approach: Anterior wall lesions are amenable to wedge resection, while posterior lesions may require transgastric approaches 5

Pitfalls to Avoid

1. Overtreatment: Unnecessarily removing small, asymptomatic leiomyomas exposes patients to procedural risks without clear benefit
2. Misdiagnosis: Failing to differentiate leiomyoma from GIST could lead to inappropriate management
3. Inadequate follow-up: If observation is chosen, ensure proper surveillance is established for any changes in size or appearance

Based on the available evidence, the correct answer to the multiple-choice question is D. Observation, as a 1 cm gastric leiomyoma is benign and does not require immediate intervention in the absence of symptoms or concerning features.