What are the management options for leiomyoma (smooth muscle tumor) of the stomach?

Management of Gastric Leiomyoma

For histologically confirmed gastric leiomyomas, asymptomatic lesions require no resection or surveillance, while symptomatic lesions (bleeding, pain, obstruction) warrant surgical or endoscopic resection. 1

Critical First Step: Confirm the Diagnosis

True gastric leiomyomas are extremely rare—most historical "leiomyomas" were actually misclassified GISTs before modern immunohistochemistry became available. 1 This distinction is critical because GISTs require completely different management including potential adjuvant therapy. 1

Diagnostic Workup:

• Obtain tissue sampling via EUS-guided fine needle aspiration (FNA) or fine needle biopsy (FNB) to differentiate leiomyoma from GIST. 1
• Leiomyomas stain positive for smooth muscle actin and desmin, while negative for CD117, CD34, and S100 protein. 1
• GISTs stain positive for CD117 (c-kit protein) and arise from the muscularis propria. 2

Management Algorithm Based on Presentation

Asymptomatic Lesions with Confirmed Leiomyoma Histology:

• No resection or surveillance is recommended. 1
• Recent data shows that most gastric leiomyomas remain stable over time—only 2.4% increased in size during a median follow-up of 50.8 months. 3
• Close monitoring with routine follow-up without resection is sufficient for histologically proven gastric leiomyoma. 3

Symptomatic Lesions:

Resection is indicated for:

• Bleeding 1, 4
• Pain 1
• Obstruction 1
• Ulceration 3
• Size increase during surveillance 3

Surgical Approach Selection

For Small to Moderate Lesions:

• Endoscopic resection techniques (ESD, EMR) are acceptable for select small lesions arising from the muscularis propria with acceptable complication rates. 1
• Laparoscopic wedge resection or enucleation is feasible for benign disease. 5
• Laparoscopic-endoscopic cooperative surgery may be effective when EUS-guided biopsy fails to establish diagnosis, allowing both pathological diagnosis and complete resection. 6

For Large Lesions at the Gastroesophageal Junction:

• Robotic-assisted endoluminal resection is a novel approach that preserves the stomach and avoids high-risk anastomosis. 7
• Avoid extensive resections (total gastrectomy) for benign disease when minimally invasive enucleation or wedge resection is feasible. 1

Critical Pitfalls to Avoid

Never assume all gastric smooth muscle tumors are benign leiomyomas—histologic confirmation distinguishing from GIST is mandatory. 1 GISTs have malignant potential even when small and require different management. 2

Ensure complete histologic evaluation when resection is performed—band ligation techniques that allow tumor sloughing prevent adequate pathologic assessment. 1

Confirm complete resection, as incomplete removal of premalignant lesions is concerning. 1

In cases showing ulceration or size increase during surveillance, resection may be beneficial even if initially asymptomatic. 3 One case in a recent series that increased in size was ultimately found to be leiomyosarcoma. 3

Special Considerations

Most gastric leiomyomas are located at the cardia (77.1%) with a median size of 3 cm. 3 This anatomic distribution should inform surgical planning, particularly for lesions near the gastroesophageal junction where preservation of function is paramount. 7