Impact of magnetic resonance imaging on the surgical management of cystic hygromas

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee

BACKGROUND

Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment.

METHODS

Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question.

RESULTS

The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered.

CONCLUSION

Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

LEVEL OF EVIDENCE: 4

Giant Cervical Lymphangioma Extending from Skull Base to Clavicle- A Rare Case

Lymphangiomas are congenital benign lesions commonly seen in pediatric age group with a rare occurrence in the region of head and neck, commonly presenting as asymptomatic masses. Cervical lymphangioma is a rare entity among adults, and giant sized lymphangiomas in this region have sparse mention in literature. This case report describes the rare presentation of a giant cervical lymphangioma and the challenges involved to treat such masses in the region of head and neck. We encountered a rare case of a 52 year old female who presented with a 10 × 5 cm swelling in the right posterior triangle of neck swelling since 6 months extending from skull base up till clavicle. Pathological and radiological entities confirmed the lesion as a "giant cervical lymphangioma". Head and neck lymphangiomas are congenital lesions of benign origin. Lymphangiomas have been classified as macrocystic if larger than 2 cm, and microcystic if less than 2 cm. Our description of a macrocystic 10 × 6 cm lesion is hence definitely one of the largest cervical lymphangiomas encountered till date. It's a problematic and arduous plan of treatment for such masses in head and neck with a high chance of recurrence if incompletely removed.

Multispecialty Approach to a Very Large Congenital Head and Neck Cystic Lymphatic Malformation in an Infant Born by SARS-CoV-2 Positive Mother—A Case Report

Masses of the head and neck are often diagnosed prenatally and require special care due to the risk of airway obstruction. The EXIT procedure is a preferable mode of delivery. A congenital cystic lymphatic malformation is one of the most common lesions of the cervical region described in neonates. The treatment consists of different strategies and involves the cooperation of multiple specialists. Up to now, no guidelines or protocols are available. We report a case of a congenital cystic lymphatic malformation of the head and neck delivered during the EXIT procedure by a mother who was SARS-CoV-2 positive. We analyzed clinical characteristics, radiologic features, and treatment with injections of sclerotic agents and orally administrated sirolimus. Sirolimus seems a valuable and safe therapeutic option for treating lymphatic malformations, especially with adjunct therapies.

Diagnosis and surgical treatment of cervical macrocystic lymphatic malformations in infants

The treatment of lymphatic malformations (LMs) represents a great clinical challenge. The present study reported on the treatment of 68 infants with cervical macrocystic LMs using surgical resection. The cases were retrospectively analyzed. All patients underwent pre-operative ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) examinations. The surgery was performed under general anesthesia with endotracheal intubation. Ultrasonograms showed that 24 cases were monolocular, 44 were multilocular, 16 had no echo, 20 had a uniform low-level echo and 32 had a non-uniform low-level echo. CT showed non-enhancing low-attenuating cystic lesions and attenuation values of 10–45 HU. The magnetic resonance images of the LMs showed a low signal intensity on T1-weighted imaging (WI) and a high signal intensity on T2-WI. Complete resection was achieved in 56 patients, subtotal resection in eight and partial resection in four. Two complications were noted, including reversible paresis of the marginal mandibular branch of the facial nerve and a surgical-site infection. One patient in whom partial resection was achieved had recurrence at ~2 months after the surgery. Ultrasonography, CT and MRI clearly demonstrated the size, shape, extent and adjacent structures of LMs, which aided in surgical planning and assessment of potential risks. Surgical excision increased the chances of cure and was relatively safe for infants aged <1 year. Location and extent, rather than age, were determined to be the most important factors for successful surgical treatment.

Oral lymphangioma: A rare case report

Lymphangiomas are benign hamartomatous tumors of the lymphatic channels which present as developmental malformations arising from sequestration of lymphatic tissue that do not communicate with the rest of the lymphatic channels. Lymphatic vessels are filled with a clear protein-rich fluid containing few lymph cells. It can also occur in association with hemangioma. The onset of lymphangiomas are either at birth (60% to 70%) or up to two years of age (90%) and rare in adults. Lymphangiomas have marked predilection for the head and neck region (50-70%). The most common location in the mouth is the dorsum of tongue, followed by lips, buccal mucosa, soft palate, and floor of the mouth. On tongue, they may present as a localized or a diffused growth which may enlarge to cause macroglossia, impaired speech and difficulty in mastication. Herewith, we present a rare case of lymphangioma of tongue leading to macroglossia in a 8-year-old boy.

Picibanil (OK-432) in the treatment of head and neck lymphangiomas in children

BACKGROUND

Picibanil (OK-432) is a lyophilized mixture of group A Streptococcus pyogenes with antineoplastic activity. Because of its capacity to produce a selective fibrosis of lymphangiomas (LMs), it has been approved by Japanese administration in 1995 for the treatment of LMs.

MATERIALS AND METHODS

We treated 15 children (age range: 6-60 months) affected by head and neck macrocystic LMs with intracystic injections (single dose of 0.2 mL) of Picibanil (1-3 injections).

RESULTS

Complete disappearance of the lesion was noticed in eight (53.33%) cases, a marked (>50%) reduction of LMs was found five (33.33%) cases, while a moderate (<50%) response was recorded in two (13.33%) cases. Picibanil side effects included fever, local inflammation, and transitory increase of blood platelets' concentration; a single case of anemia was resolved with concentrated red blood cells transfusion.

CONCLUSIONS

Intracystic injection of Picibanil is an effective and safe treatment for macrocystic LMs in pediatric patients and may represent the treatment of choice in such cases, especially where surgical excision is associated with the risk of functional/cosmetic side effects.

Cystic hygroma

Surgical management of cystic hygroma is very challenging since it has a thin wall consisting of endothelium which can easily be torn during its enucleation leading to recurrence. The other treatment options are intralesional injection of OK-432, triamcinolone followed by surgical excision, if necessary, injection of sclerosing agents, repeated aspiration, radiotherapy and finally spontaneous regression without any form of treatment. This is a case report of cystic hygroma of parotid region where regression occurred without any form of treatment.

Pulmonary lymphangioma in a 14-month-old

Intrapulmonary lymphangiomas are very rare. We report a case of a 14-month-old child found to have a pulmonary lymphangioma on routine chest radiograph in the emergency department and discuss the possible implications and appropriate management of this condition by the emergency physician.

Sclerotherapy for cervical cystic lymphatic malformations in children. Our experience with computed tomography-guided 98% sterile ethanol insertion and a review of the literature

PURPOSE

The treatment of cystic lymphatic malformations of the neck and mediastinum is controversial. Surgical management may be limited by the invasiveness of the procedure, the complex anatomy of this region, and the high recurrence rate. An alternative therapeutic method is sclerotherapy. We report our experience in the treatment of cystic lymphatic malformations of the neck by computed tomography (CT)-guided instillation of 98% sterile ethanol in children.

METHODS

Eight children with clinical suspicion of cervical cystic lymphatic malformation were assessed by ultrasonography (US) and magnetic resonance imaging (MRI) to define the location, size, and number of cystic cavities. The CT-guided instillation of 98% sterile ethanol was performed. Cystic fluid was analyzed by fine-needle aspiration cytology. Clinical and US or MRI follow-up was performed after 1 and 3 months and at 1 and 2 years.

RESULTS

The results were excellent with complete disappearance of the lesion in 7 (87.5%) of 8 patients. One patient (12.5%) with satisfactory results required a second alcohol injection with an excellent outcome. No allergic reactions or complications were observed.

CONCLUSIONS

The CT-guided 98% sterile ethanol sclerotherapy is a good alternative to surgical therapy. This procedure seems accurate, minimally invasive, safe, low cost, and reliable without untoward complications. Moreover, it does not exclude later surgical treatment.

Lymphatic malformation in adult patient: a rare case

Lymphatic malformation is an uncommon anomaly that commonly occurs in the posterior triangles of infants. The case presented here was an adult male patient with swelling in submental region. This site often leads to misdiagnosis of other common pathology including plunging ranula or lipoma. However, USG and MRI were done for diagnosis of the lesion by which final diagnosis of lymphatic malformation was made. Surgical excision was carried out and histopathology confirmed the primary diagnosis. No recurrence is seen in one and half year follow-up period.

Lymphatic malformations: a proposed management algorithm

OBJECTIVE

The aim of this study was to develop a management algorithm for cervicofacial lymphatic malformations, based on the authors' experience in managing these lesions as well as current literature on the subject.

STUDY DESIGN AND METHODS

A retrospective medical record review of all the patients treated for lymphatic malformations at our institution during a 10-year period (1998-2008) was performed.

DATA COLLECTED

age at diagnosis, location and type of lesion, radiologic investigation performed, presenting symptoms, treatment modality used, complications and results achieved.

RESULTS

14 patients were identified. Eight (57%) male and six (43%) female. There was an equal distribution between the left and right sides. The majority (71%) of cases were diagnosed within the first year of life. The majority of lesions were located in the suprahyoid region. The predominant reason for referral was an asymptomatic mass in 7 cases (50%) followed by airway compromise (36%) and dysphagia (14%). Management options employed included: observation, OK-432 injection, surgical excision and laser therapy. In 5 cases (36%) a combination of these were used.

CONCLUSION

Historically surgical excision has been the management option of choice for lymphatic malformations. However due to the morbidity and high complication rate associated this is increasingly being questioned. Recent advances in sclerotherapy e.g. OK-432 injection have also shown significant promise. Based on experience in managing these lesions as well as current literature the authors of this paper have developed an algorithm for the management of cervicofacial lymphatic malformations.

[Cystic cervicofacial lymphangioma in children in Gabon]

OBJECTIVES

To review the etiopathogenesis, diagnosis, and the role of surgery in the management of childhood cystic cervicofacial lymphangioma in Gabon.

MATERIAL AND METHODS

Our retrospective study concerned 16 cases of childhood cystic cervicofacial lymphangioma treated surgically between 1990 and 2004.

RESULTS

The sample included ten girls and six boys whose average age was 30.2 months. The cystic lymphangioma was seen at birth in seven cases. It was discovered before 2 years in eight cases and after 2 years in eight cases. Two of these latter eight cases were a recurrence after previous surgery. The tumor was localized in the cervical are in ten cases, the jugal area in three cases, one of which was extended to the parotidis, the submandibular area in two cases, and the lower labial area in one case. The surgical indication was based on the clinical examination in six cases and on imaging in ten cases. The resection was considered complete in 14 cases and incomplete in two cases. In two cases, the resection was difficult, because the lymphangioma adhered to the internal jugular vein and rolled the higher laryngeal nerve and the carotid junction. The early complications were lymphoedema associated with facial paralysis (one case) and respiratory distress (one case), hematoma associated with facial paralysis (one case), lymphorrhea (one case), and a paralysis of the chin branch of the facial nerve (one case). The functional and aesthetic after-effects were marked by the persistence of facial paralysis and the existence of jugal bud flesh. The jugal (one case) and labial (one case) recurrence were discovered within 6 and 9 months after the surgery. In these two cases, there were capillary lymphangiomas. None of the patients died.

CONCLUSION

Cystic cervicofacial lymphangioma is a particular aspect of surgical pathology in children in Africa. Despite the advent of sclerosing products, surgery remains the treatment of choice in this context.

[A gigant cystic lymphangioma of the neck]

The cystic lymphangiomas are congenital pathology of lymphatic system which concern 90% of children population, adults suffer very seldom. The authors present the case of giant cystic lymphangioma of the neck in the 37-year-old man with symptoms of tumor of the neck. The USG, CT and MRI confirm the presence of polycystic tumour with feature of bleeding into one of the cavities. Surgical treatment was performed. The patient is controlled without any relaps. The authors remind this rare pathology that should be considered in case of neck tumours.

New treatment options for lymphangioma in infants and children

Lymphangiomas are congenital malformations of the lymphatic system. These lesions occur most often in the head and neck area, and their treatment continues to be a challenge. Fortunately, a number of advances have occurred in the diagnosis and management of lymphatic malformations in the past decade. The purpose of this article is to clarify the embryology, pathogenesis, histopathology, and classification of these lesions, as well as to describe their various forms of clinical presentation. We provide a complete review of the diagnostic measures available and thoroughly discuss new therapeutic interventions proposed to treat lymphangiomas.

Cystic hygroma in the fetus and newborn

Cystic hygromas are developmental abnormalities of the lymphoid system that occur at sites of lymphatic-venous connection, most commonly in the posterior neck. They are frequently associated with karyotypic abnormalities, various malformation syndromes, and several teratogenic agents. The disease course of an infant with cystic hygroma is unpredictable. When diagnosed prenatally, the overall prognosis is poor. Cystic hygroma diagnosed after birth is usually associated with a good prognosis. This article reviews the embryologic, genetic, and pathologic correlates of these lymphatic system abnormalities, as well as the clinical course and outcome of the fetus and newborn with a cystic hygroma. Management strategies are reviewed, including newer nonsurgical therapies for the neonate with a cystic hygroma.