What is the recommended management for a 1.5 cm gastric (stomach) leiomyoma?

Management of a 1.5 cm Gastric Leiomyoma

For a 1.5 cm gastric leiomyoma, observation is the recommended management approach, as most gastric leiomyomas are benign and rarely increase in size or become symptomatic. 1

Diagnostic Considerations

Gastric leiomyomas are benign subepithelial lesions that must be differentiated from gastrointestinal stromal tumors (GISTs), which have malignant potential 2, 3. Key characteristics include:

• Appearance on EUS: Hypoechoic, well-circumscribed masses arising from either the muscularis mucosae or muscularis propria 2
• Immunohistochemistry: Positive staining for smooth muscle actin and desmin, negative staining for CD117, CD34, and S100 protein 2

Management Algorithm for Gastric Leiomyomas

For 1.5 cm Asymptomatic Leiomyoma:

• Observation is appropriate 3, 1
• Recent evidence shows only 2.4% of histologically proven gastric leiomyomas increase in size during follow-up (median 50.8 months) 1

Indications for Intervention:

1. Symptomatic presentation (bleeding, pain, obstruction)
2. Increase in size during surveillance (>25% growth)
3. Presence of ulceration
4. Uncertainty about diagnosis (to differentiate from GIST)

Size-Based Management:

• <2 cm: Observation if asymptomatic and confirmed leiomyoma 3

• 2 cm: Consider resection, especially for GISTs, though this threshold is less strict for confirmed leiomyomas 3

Resection Options (if needed)

If intervention becomes necessary, options include:

1. Endoscopic Resection:

   • Suitable for smaller lesions in submucosa or muscularis mucosae
   • Techniques include endoscopic submucosal resection or enucleation 2

2. Wedge Resection:

   • Appropriate for larger lesions or those in the muscularis propria
   • Can be performed laparoscopically for most locations 4

3. Enucleation:

   • Can be performed endoscopically or laparoscopically
   • Particularly useful for preserving gastric function 5

4. Total Gastrectomy:

   • Rarely indicated for benign leiomyomas
   • May be considered only for very large lesions or those in difficult locations that cannot be managed by other approaches 6

Follow-up Recommendations

For observed leiomyomas:

• Periodic endoscopic surveillance
• Consider repeat EUS if any changes in appearance
• Immediate evaluation if symptoms develop

Caveats and Pitfalls

• Accurate histological diagnosis is crucial - misclassification of GISTs as leiomyomas was common in older literature 2
• Location matters - lesions near the gastroesophageal junction may require specialized approaches if intervention becomes necessary 6, 7
• Always confirm diagnosis with appropriate immunohistochemical staining to differentiate from GISTs, which require more aggressive management 2, 3

Given the small size (1.5 cm) and benign nature of gastric leiomyomas, observation (option D) is the most appropriate initial management strategy, with intervention reserved for symptomatic lesions or those that demonstrate growth during surveillance.