Cystic hygroma in the fetus and newborn

Exploring Complexity: A Case Report of a Cystic Hygroma With Complex Congenital Heart Defects and Annular Pancreas in a One-Year-Old Child

Lymphatic malformations frequently present as benign masses in the neck and clavicle region among infants and young children. Cystic hygroma represents an often-encountered form of lymphatic malformation. This case report details the medical history of a one-year-old girl characterized by a multifaceted medical background, initially exhibiting symptoms of persistent cough, cold, and neck swelling. Further investigations revealed more severe conditions: complex congenital heart defects, including large atrial septal defect (ASD), large ventricular septal defect (VSD), and aorta arising from the right ventricle with cystic hygroma and annular pancreas. The patient underwent various diagnostic tests, including chest X-rays, ultrasound, magnetic resonance imaging (MRI), and computed tomography pulmonary angiogram (CTPA), leading to multidisciplinary treatment involving sclerotherapy for cystic hygroma and supportive therapies. The case underscores the challenges in diagnosing and managing pediatric patients with overlapping conditions and the critical need for continuous follow-up.

Airway Management of an Infant With Giant Neck Macro-Cystic Hygroma Utilizing a High-Flow Nasal Cannula

BACKGROUND

 Cystic hygroma is a congenital lymphatic malformation. It may present as a huge mass in the neck, jeopardizing airway patency and prolonging intubation time, resulting in hypoventilation and hypoxemia. We used a high-flow nasal cannula to decrease the risk of hypoxemia and provide anesthesiologists sufficient time to perform tracheal intubation in young infants.

CASE PRESENTATION

A 33-day-old infant (height, 55 cm; weight, 5.05 kg) was diagnosed with macro-cystic hygroma of the right neck. Considering the progressive enlargement of the macrocystic hygroma and its impact on the airway, urgent intervention becomes imperative. Among the available treatment modalities, percutaneous cyst aspiration and sclerotherapy performed under ultrasound guidance represent the most commonly chosen approach. During the induction of general anesthesia, the otolaryngologists were on standby and prepared for emergency tracheotomy. The anesthesiologists chose total intravenous anesthesia induction while maintaining spontaneous breathing. A high-flow nasal cannula was used to keep the infant oxygenated, and endotracheal intubation was successfully performed using a C-MAC video laryngoscope and fiber-optic bronchoscope.

CONCLUSIONS

Airway management is the biggest challenge for anesthesiologists when delivering general anesthesia to infants with neck macro-cystic hygroma. Total intravenous anesthesia could be a choice for induction without considering compromised respiration and the side effects of inhalational anesthetics. A high-flow nasal cannula can be used in young infants to maintain oxygenation and allow anesthesiologists a longer time to perform intubation.

The efficacy of bleomycin sclerotherapy in the treatment of lymphatic malformations: a review and meta-analysis

OBJECTIVE

At present, bleomycin has been widely used in the treatment of Lymphatic Malformations (LMs). This study aims to perform a meta-analysis to investigate the effectiveness and influencing factors of bleomycin in the treatment of LMs.

METHODS

We conducted a systematic review and meta-analysis to clarify the relationship between bleomycin and LMs. PubMed, ISI Web of Science and MEDLINE were searched.

RESULTS

A total of 21 studies (including 428 cases) about bleomycin sclerotherapy for LMs were included in the current meta-analyses. We calculated pooled effective rate and 95% Confidence Interval (95% CI) using random effects model to evaluate the relations between bleomycin and LMs. The results suggested that the effective rate of bleomycin was the combined effective rate was 84.0% (95% CI 0.81‒0.87) and ranged from 39% (95% CI 0.22‒0.56) to 94% (95% CI 0.87-1.02). The heterogeneity among the studies was substantial (I2=61.7%, p= 0.000). In subgroup analyses, it was observed that among retrospective study and prospective study, the estimated effective rate was 80.0% (95% CI 0.76‒0.84) and 91.0% (95% CI 0.85‒0.97), respectively. In terms of the dosage, the combined effective rates of weight-based group and fixed-dose group were 86% (95% CI 0.83‒0.90) and 74.0% (95% CI 0.66‒0.82), respectively. There was no significant publication bias in Egger's test (p=0.059, 95% CI -3.81 to 0.082), but Begg's test did (p=0.023), and the funnel plot is asymmetric.

CONCLUSION

Our study suggested that bleomycin was safe and effective in the treatment of LMs and was primarily dose dependent.

Sudden Appearance of a Palpable Chest Wall Mass Secondary to Macrocystic Lymphatic Malformation: A Case Report

Chest wall lymphatic malformations are rare and can pose a diagnostic dilemma, particularly if they present abruptly. This case report describes a 15-month-old male toddler presenting with a left lateral chest mass. Histopathology of the surgically excised mass confirmed the diagnosis of a macrocystic lymphatic malformation. Furthermore, there was no recurrence of the lesion in the two-year follow-up period.

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series

Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

Long-term outcome of fetus with ameliorated cystic hygroma

OBJECTIVE

Cystic hygroma often ameliorates or disappears with pregnancy progression. Fetuses/neonates with amelioration, when without chromosomal or major structural abnormality, generally show a favorable outcome at birth. The present study was aimed to clarify the short/long-term outcomes of fetuses/neonates with the amelioration of cystic hygroma during pregnancy.

MATERIAL AND METHODS

This was a retrospective observational study. We focused on fetuses with cystic hygroma managed in our institute between January 2006 and June 2019. The infants were followed by pediatricians (neonatologist, pediatric cardiologist, and pediatric neurologist) and pediatric outcomes were retrieved from the medical records up to 3 years old.

RESULTS

One hundred and seven fetuses with cystic hygroma were included. Of the 107, cystic hygromas ameliorated in 31 fetuses (31/107: 29%). Of the 31, there were 26 livebirths. Half (n = 13) of the 26 fetuses had a good outcome, whereas the remaining half (n = 13) had abnormalities. Various abnormalities were detected in their infancies. A nuchal thickness (diameter of hygroma) of ≥5 mm was significantly correlated with abnormalities (P = 0.047).

CONCLUSION

Physicians should pay attention to fetuses/neonates with ameliorated cystic hygroma. Of those, special attention should be paid to fetuses/neonates with a nuchal thickness at diagnosis ≥5 mm.

Chylous content might determine the optimal surgical approach for mesenteric lymphatic malformations in childhood

BACKGROUND

Mesenteric lymphatic malformations (LMs) represent rare congenital anomalies that can include chylous or nonchylous content. The pathologic mechanisms explaining this phenomenon are poorly understood and not yet described. Furthermore, the current management approach does not consider the contents of the mesenteric LMs. In the present study, we have defined the relationship between the lymphatic mesenteric cyst content and the histologic evidence of LMs within the bowel wall.

METHODS

We retrospectively investigated all patients with mesenteric LMs treated surgically at our department from 1999 to 2018.

RESULTS

A total of 11 patients (6 girls and 5 boys) were included in our analysis. Seven patients had presented with LMs located in the jejunal mesentery, three in the ileocecal region, and only one in the mesocolon transversum and omentum. Of the 11 children, 7 had had LMs with nonchylous content and 4 had presented with chylous content LMs. Intestinal resection was performed in all 4 patients with chylous content LMs and 4 patients with nonchylous content LMs. Histopathologic evaluation of the surgical specimens determined that only the LMs with chylous content displayed malformed lymphatic channels throughout the bowel wall. The resected small bowel of four patients with nonchylous content showed no LM extension throughout the intestinal wall.

CONCLUSIONS

LMs with chylous content seem to develop from malformed lymphatic channels within the bowel wall. In such cases, segmental intestinal resection is mandatory. In contrast, mesenteric LMs with nonchylous content can potentially be treated without bowel resection if the blood supply can be preserved. This finding is, to the best of our knowledge, reported in the present study for the first time.

Bleomycin sclerotherapy in lymphangiomas of the head and neck region: a prospective study

Intralesional sclerotherapy for lymphatic malformations (LMs) has become a modality of choice because of the high morbidity and recurrence rates with surgical excision. Traditionally, the macrocystic variant has shown good results with sclerotherapy. This prospective study was performed to evaluate the role of bleomycin sclerotherapy in the management of different radiological variants of LM. A total of 142 patients were included in this study. The lesions were classified as macrocystic, microcystic, or mixed LMs on the basis of ultrasonography. All patients were managed by intralesional injection of bleomycin and were recalled after 4 weeks for evaluation. Colour photographs of the patients were taken before the onset of treatment and at each monthly visit, and were utilized to assess the response. Following the second, third, and fourth doses, the response was better in patients with the macrocystic variant than in those with the other two variants. However, after the completion of six doses, 80.3% of patients with the macrocystic variant, 67.4% with the microcystic variant, and 71.4% with the mixed type had a complete response. There was no difference in the overall response between the three types (P=0.28). Oedema, erythema, and local induration with fever were the most common adverse effects and were more common in younger children.

Cystic Hygroma: A Preliminary Genetic Study and a Short Review from the Literature

BACKGROUND

The objective of this study is to examine the hypothesis that cystic hygroma (CH) with normal karyotype can manifest as a Mendelian inherited trait, and that a genetic similitude with hereditary lymphedema exists. To reach this goal, we investigated the prevalence of genetic variants in angiogenesis and lymphangiogenesis genes in a cohort of euploid fetuses with CH that almost resolved before delivery. A short review of cases from literature is also reported.

METHODS AND RESULTS

Five fetuses were screened using a next-generation sequencing approach by targeting 33 genes known to be associated with vascular and lymphatic malformations. The genetic evaluation revealed two novel variants in KDR and KRIT1 genes.

CONCLUSION

A review of the literature to date revealed that an association exists between CH and hereditary lymphedema and, similar to lymphedema, CH can be inherited in autosomal recessive and autosomal dominant manner, with the latter most likely associated with a better prognosis. About KDR and KRIT1 genes, no other similar associations are reported in the literature and caution is needed in their interpretation. In conclusion, we thought that a genetic test for the outcome of familial CH could be of enormous prognostic value.

Predicting the intrauterine fetal death of fetuses with cystic hygroma in early pregnancy

We investigated whether it was possible to predict the prognosis of fetuses with cystic hygroma in early pregnancy based on the degree of neck thickening. We retrospectively analyzed 57 singleton pregnancies with fetuses with cystic hygroma who were examined before the 22nd week of pregnancy. The fetuses were categorized according to the outcome, structural abnormalities at birth, and chromosomal abnormalities. Here, we proposed a new sonographic predictor with which we assessed neck thickening by dividing the width of the neck thickening by the biparietal diameter, which is expressed as the cystic hygroma width/biparietal diameter ratio. The median cystic hygroma width/biparietal diameter ratio in the intrauterine fetal death group (0.51) was significantly higher than that in the live birth group (0.27). No significant difference in the median cystic hygroma width/biparietal diameter ratio was found between the structural abnormalities group at birth and the no structural abnormalities group, and no significant difference in the median cystic hygroma width/biparietal diameter ratio was found between the chromosomal abnormality group and the no chromosomal abnormality group. We used receiver operating characteristic analysis to evaluate the cystic hygroma width/biparietal diameter ratio to predict intrauterine fetal death. When the cystic hygroma width/biparietal diameter ratio cut-off value was 0.5, intrauterine fetal death could be predicted with a sensitivity of 52.9% and a specificity of 100%. It is possible to predict intrauterine fetal death in fetuses with cystic hygroma in early pregnancy if cystic hygroma width/biparietal diameter ratio is measured. However, even if cystic hygroma width/biparietal diameter ratio is measured, predicting the presence or absence of a structural abnormality at birth or a chromosomal abnormality is difficult.

Analysis of cystic hygroma diagnosed in the prenatal period: 5-years' experience at a tertiary hospital in Southeastern Turkey

PURPOSE

Our aim was to evaluate the association of cystic hygroma (CH) with fetal malformations and also to investigate the outcome of fetuses with CH diagnosed in the prenatal period.

METHODS

We divided the CH patients into two main groups as isolated CH or CH associated with the congenital structural abnormality (CSA) by measuring the thickness of CH and showing other fetal abnormalities. Pregnancy outcomes were recorded as spontaneous abortion, elective termination, intrauterine death, live birth, postnatal death, and lost to follow-up.

RESULTS

There were 74 cases of fetal CH including 19 in CSA-CH group and 55 in isolated-CH group diagnosed between 11 and 21 weeks' gestation. Karyotype analysis of these 28 patients revealed 18 (64.2%) normal karyotypes. Pregnancy outcomes included 54 elective terminations, five postnatal deaths, one spontaneous abortion, six live births, four intrauterine deaths, and four patients were lost to follow-up.

CONCLUSION

In the presence of any CSA concurrent with CH, prognosis may be considered as poor and any additional help of fetal karyotyping is questionable. But fetal karyotyping may be advocated in counseling patients with isolated CH, in which a better prognosis and resolvement of CH may be expected in case of a normal karyotype.

Sudden Onset, Rapidly Expansile, Cervical Cystic Hygroma in an Adult: A Rare Case with Unusual Presentation and Extensive Review of the Literature

Cystic hygroma (CH) is a benign infiltrative malformation of the lymphatic channels. We report a case of a 28-year-old Indian female who presented with rapidly enlarging right sided neck swelling over the posterior triangle since 5 days. Complete resection of CH is sometimes not amenable because of its infiltrative nature and involvement of surrounding vital structures. However, in our patient successful complete surgical resection was undertaken. The MRI findings of our patient were consistent with brachial cleft cyst; this posed a challenge in the diagnosis of CH. The histopathological analysis of the resected mass confirmed CH. CH is rare in adults and such an acute presentation is exceptionally atypical. History of prior trauma and infection are known etiological factors for adult CH; these were conspicuously absent in our patient. CH should be considered in the differentials of rapidly enlarging cystic swelling of posterior region of neck in adults. Optimal and timely management is necessary to achieve a favorable prognosis. Therefore, we report a case of rapidly enlarging cervical CH in an adult along with extensive literature review to have a better understanding regarding epidemiology, etiopathogenesis, clinical presentation, optimal management, and prognosis of such a rare entity in adults.

Advances in Fetal Surgery

Advances in prenatal screening and diagnosis, combined with an understanding of the pathophysiology of congenital anomalies, have brought incredible impetus to the field of fetal surgery. Identification of fetal anomalies can lead to counseling of the affected family so that informed decisions can be made on how to proceed with the pregnancy. Counseling may lead to pregnancy termination, changes in the timing or mode of delivery, and, in select cases, prenatal intervention. Open fetal surgery may be considered in severe cases of congenital diaphragmatic hernia, congenital chest lesions, sacrococcygeal teratoma, urinary tract obstruction, and myelomeningocele. The ex utero intrapartum treatment procedure may be lifesaving for fetuses with giant neck masses. Finally, fetoscopic surgery may be offered for select cases of twin-twin transfusion syndrome and twin reversed arterial perfusion sequence. Fetal intervention in all of these cases depends on a team approach to the patient and on the objective comparison of outcomes with and without fetal therapy. In the future, further understanding of the genetic basis of congenital diseases may enable minimally invasive treatments such as stem cell transplantation or gene therapy.

Giant fetal lymphangioma at chest wall and prognosis: case report and literature review

OBJECTIVE

To report a rare liveborn case with a giant, septated, chest wall lymphangioma that underwent prenatal expectation treatment.

CASE REPORT

A case of giant fetal chest wall cystic lymphangioma was diagnosed prenatally at 19 weeks gestation. Expectation treatment was performed, carefully after prenatal counseling, ruling out other structural abnormalities. At 38 weeks gestation, ultrasound showed a multilocular, subcutaneous cystic mass of 12.3 cm × 9.2 cm × 11.0 cm located on the left chest wall and left upper arm. The tumor was surgically removed 4 days after birth, and no recurrence was observed in the following 18 months.

CONCLUSION

Our experience suggests that a large, septated fetal lymphangioma may still merit prenatal expectation treatment if there is no evidence for chromosomal and structural abnormality.

Successful Treatment of Macroglossia Due to Lymphatic Malformation With Sirolimus

Objective:

To evaluate the effectiveness and safety of sirolimus therapy in a child with macroglossia due to lymphatic malformation.

Methods:

Sirolimus treatment was applied to the patient with an initial dosing of 0.8 mg/m2 per dose, administered orally, twice daily at approximately 12-hour intervals.

Results:

After 9 months of sirolimus therapy, there was a nearly complete resolution of lymphatic malformation. The last evaluation was performed 6 months after withdrawal of treatment, and the lesion had almost completely resolved.

Conclusion:

This article presents a novel approach to the treatment of lymphatic malformation of the tongue using sirolimus, which appears to be safe and effective for the management of complex cases.

Mesenteric lymphatic hygroma in adults: A case report with a review of the literature

Mesenteric lymphatic hygroma is a benign tumor of lymphatic origin that is rarely observed in adult patients. Congenital and developed non-specific symptoms, including abdominal distension, pain and ileus, develop at an early age in patients. This type of disease is usually reported by pediatric doctors, as referred to in the literature. The current study presents the case of a 23-year-old male in whom a polycystic mass in the mesentery was identified by computed tomography. The size of the tumor was measured to be 30×20×15 cm during surgery. The mass was excised completely with preservation of the intestine, duodenum, pancreas and other neighboring organs. Histopathological examination confirmed the diagnosis of lymphatic hygroma. The post-operative recovery was uneventful, with the exception of chylous leakage for one week, which was relieved spontaneously. In addition, the present study presents a review of the previous literature concerning mesenteric lymphatic hygroma.

All that wheezes: A young infant with a mediastinal mass

Wheezing infants are frequently encountered in the emergency department. Bronchiolitis is the most commonly seen cause. Radiographs are not recommended in the routine management of bronchiolitis. We present the case of a young wheezing infant with a mildly abnormal chest x-ray whose cystic hygroma caused life-threatening respiratory distress soon after he was admitted to the hospital.

A rare case of lymphangioma in the gluteal region: surgical treatment combined with sclerotherapy and laser therapy

BACKGROUND

Lymphangioma, a rare benign malformation of lymphatic channels, is among the surgically treatable diseases of the lymphatic vessels. However, damage to surrounding structures together with incomplete resection due to adjacent organ infiltration and a high recurrence rate have encouraged the search for alternative treatments. This study aimed to identify the best therapeutic management for this difficult-to-treat disease.

METHODS

This report describes a case of congenital lymphangioma in the gluteal region in a young woman. First, sclerotherapy of the lymphangioma was performed and then surgical excision of residual lesions. Finally, as a third therapeutic step, the patient also was subjected to a cycle of laser therapy with the aim of further improving the appearance of the gluteal region. Pulsed dye laser was used to remove cutaneous dyschromias, and an erbium:yttrium-aluminum-garnet laser was used to remove surface irregularities and obtain better skin smoothness. The outcome assessments included standardized photography, the physician's global assessment, the patient's satisfaction scores, and magnetic resonance imaging of the gluteal region.

RESULTS

All the lesions of lymphangioma were removed. After the last laser treatment, the skin of the entire treated region was eutrophic and uniform in color, and it appeared to be smooth and soft when palpated. The patient was satisfied with the clinical and aesthetic results achieved.

CONCLUSIONS

The combination of sclerotherapy with surgery can be a good solution for the treatment of lymphangioma. The authors also propose laser therapy as an additional therapeutic approach that may follow surgery or sclerotherapy with the aim of improving the skin trophism and the appearance of the affected region.

Fetal axillary cystic hygroma: a case report and review

Cystic hygroma (CH) is a lymphatic malformation occurring different parts of fetal body, typically in the region of the fetal neck and axillary, abdominal wall, mediastinal, inguinal and retroperitoneal areas. CH has been associated with fetal aneuploidy, hydrops fetalis, structural malformations and intrauterine fetal death.

A 24-year-old gravida 1, para 1 was admitted to our hospital at 28 weeks of gestation. Ultrasonographic examination determined 28 weeks of gestation, singleton, alive fetus who had a mass derived from the right axillary region which was extending to the anterior and posterior thoracic wall with fluid-filled cavities about 12 cm in size. There was no evidence of intrathorasic or intraabdominal extension of mass. Cordocentesis was performed and karyotype examination was normal 46 XY. The fetal demise was found after the first visit. The patient was delivered vaginally after labor induction with oxytocin infusion. The fetal autopsy confirmed the diagnosis of CH.

The fetal CH carries high risk of aneuploidy and fetal malformations. Patients that have been diagnosed with CH in antenatal follow-ups should be assessed in terms of other anomalies. Fetal karyotyping should be done and the patient should be monitored for fetal hydrops. The birth should be planned in a multidisciplinary hospital and as neonatal resuscitation could be needed, pediatricians should be consulted.

Spontaneous resolution of multiple lymphangiomas of the colon: A case report

Lymphangioma of the colon is a relatively rare non-epithelial tumor and usually presents as a submucosal polypoid lesion. Many cases incidentally discovered are usually asymptomatic. However, they may present as abdominal pain or bleeding, and their resection is normally required. Lymphangioma itself is generally recognized as a benign tumor and no cases of malignant transformation have yet been reported, although its natural history is currently unknown. To the best of our knowledge, this study is the first to describe a case of spontaneous resolution in multiple colonic lymphangiomas without any specific treatment.

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.

Multidisciplinary approach in cystic hygroma: prenatal diagnosis, outcome, and postnatal follow up

BACKGROUND

The aim of the present study was to determine prenatal follow up and clinical outcome in fetuses born with cystic hygroma.

METHODS

A series of 64 cystic hygroma patients, who were diagnosed in the first and the second trimester of pregnancy, was enrolled. Associated structural abnormalities, karyotype analysis and pregnancy outcome were studied. Survivors were followed for their fetal outcome and prognosis.

RESULTS

There were 64 new cases of cystic hygroma in 8524 subjects screened (0.75%). Thirty-nine (60.9%) were of non-septated and 25 (39.1%) were of septated cystic hygroma. Chromosomal abnormalities were present in 25 (39.1%). The most common abnormality in non-septated cystic hygroma was trisomy 21 (10, 27.8%), and that in septated cystic hygroma was Turner syndrome (5, 23.8%). Associated structural malformations are common in cystic hygroma and overall survival was poor. Nine of the present infants were live-born and were subsequently followed up. Two had cardiac pathology and died after cardiac operation, two others were diagnosed with axillary cystic hygroma, had an excellent prognosis and responded well to treatment, and another two had cranial findings with mild neurological sequel. Only three cases had, at birth and in the follow-up period, no complications.

CONCLUSION

Cystic hygroma is highly correlated with adverse perinatal outcome. Prenatal diagnosis and invasive procedures are vital for counselling with close follow-up after delivery for appropriate medical support. A multidisciplinary approach is strictly recommended in live-born children.

Prox-1 and VEGFR3 antibodies are superior to D2-40 in identifying endothelial cells of lymphatic malformations--a proposal of a new immunohistochemical panel to differentiate lymphatic from other vascular malformations

We previously reported that D2-40 antibody identifies lymphatic endothelial cells (LECs) of lymphatic malformations (LM) with high specificity but only moderate sensitivity. The aim of this study was to compare the sensitivity and specificity of the markers Prospero-related homeobox gene-1 (Prox-1) and VEGFR3 to those of D2-40 for LECs in LM. Seventeen LM and 6 other vascular malformations with venous component (VM) were stained with D2-40, Prox-1, VEGFR3, CD31, and CD34 antibodies. The staining characteristics of vessels by each marker were assessed. Prox-1 and VEGFR3 specificity for LECs was examined by endothelial staining of VMs. Prox-1 and VEGFR3 stained substantially more large vessels than did D2-40 (15 of 17 cases). Small vessel staining was uniformly positive with all vascular markers except CD34, which did not stain lymphatic vessels. Eight cases had no or minimal D2-40 staining of large vessels, but the selected D2-40-vessels stained positive with VEGFR3, and 7 of 8 vessels were Prox-1 positive. Nine cases had variable D2-40 staining of large vessels; the selected D2-40 channels were all Prox-1 positive, and 8 of 9 were VEGFR3 positive. Two had rare vascular channels with no lymphatic marker stain but were positive for CD31 and CD34. Endothelial cells of VM had no Prox-1 but were VEGFR3/CD31/CD34 positive. VEGFR3 and Prox-1 antibodies have greater sensitivity for large lymphatic vessels than does D2-40. All lymphatic markers have high sensitivity for LECs of small lymphatic channels. Prox-1 has superior sensitivity and specificity to LECs. We recommend utilizing an immunohistochemical panel consisting of Prox-1, VEGFR3, CD31, and CD34 antibodies to differentiate lymphatic from venous malformations in pathologic practice.

Prenatal diagnosis of posterior mediastinal lymphangioma by two- and three-dimensional ultrasonography

Lymphangioma is a rare benign tumor characterized by proliferating lymph vessels and composed of large cyst spaces with endothelium-lined channels of varying dimensions. The incidence of lymphangioma is approximately one in 6000 pregnancies. Less than 1% of lymphangiomas are purely mediastinal. The great majority of cases are of cystic lymphangioma, but very rarely there is a mixed lesion consisting of multiple cysts of dilated capillary and lymph vessels. We report a case of posterior mediastinal lymphangioma diagnosed at 28 weeks' gestation, in which three-dimensional ultrasonography was helpful in determining the precise location of the tumor. A Cesarean section was performed at 39 weeks and the tumor was resected on the 5(th) day postdelivery; histological examination revealed a mixed cystic lymphangioma.

Cystic hygroma: characterization by computerized tomography

Lymphangiomas are benign nonencapsulated lesions composed of sequestered noncommunicating lymphoid tissue lined by lymphatic endothelium and are thought to be caused by congenital obstruction of lymphatic drainage. They are subclassified by vessel size, such as the capillary, which is rare and located in subcutaneous tissue, cavernous (located about the mouth and tongue), and cystic (cystic hygromas). The cystic hygromas show a predilection for the neck (75%) and maxilla (20%), and the remaining 5% arise in rare locations such as the mediastinum, retroperitoneum, bone, kidney, colon, liver, spleen and scrotum. Only 3%-10% of neck lesions extend into the mediastinum. In this paper, we report a rare case of cystic hygroma with a huge dimension discussing the use of computed tomography scanning for diagnosis.

Noninterventional treatment of selected head and neck lymphatic malformations

BACKGROUND

Indications for treatment of lymphatic malformations include disfigurement, symptoms, and infection. Patients with lymphatic malformations often undergo resection or sclerotherapy to prevent possible complications, as it has been thought that lymphatic lesions do not regress.

METHODS

A retrospective analysis of all head and neck lymphatic malformations for the past 5 years was performed.

RESULTS

Twenty-five patients with lymphatic malformations of the head and neck were treated, all underwent computed tomography or magnetic resonance imaging for evaluation. Fourteen patients had macrocystic lesions; others were considered mixed or microcystic. Seventeen patients underwent intervention. Ten patients underwent surgical resection alone, 4 patients underwent sclerotherapy, and 3 patients had both sclerotherapy and surgical resection. Of 17, 15 patients who underwent intervention had complications, including recurrence and nerve damage. Eight patients with predominantly macrocystic lesions were managed with close observation and were asymptomatic other than a mass. With follow-up of 33.4 months, in 4 of 8 patients, the lesion significantly decreased; 4 of 8 patients continue to be asymptomatic.

CONCLUSIONS

Patients who undergo intervention have a high complication and recurrence rate. Selected patients with asymptomatic macrocystic lymphatic malformations of the head and neck can often be managed by observation alone. These patients should be followed closely in a multidiscliplinary clinical setting.

Cystic hygroma and lymphangioma: associated findings, perinatal outcome and prognostic factors in live-born infants

OBJECTIVES

We aimed to determine associated ultrasonographic findings, chromosome abnormalities and the prognostic factors of cystic hygromas in live-born infants.

METHODS

We reported a series of 57 cystic hygroma cases, who were diagnosed in the first and the second trimester of pregnancy by means of the ultrasonographic morphology of cystic hygroma, associated structural abnormalities, karyotype analysis and the autopsy findings. Survivors were followed for their fetal outcome and prognosis.

RESULTS

There were 57 new cases of cystic hygroma among 8,155 screenings (0.7%). 35 of the cases (61.4%) were nonseptated and 22 of the cases (38.6%) were septated cystic hygroma. Chromosomal abnormalities were found in 23 of the cases (40.3%). The most common abnormality in nonseptated cystic hygroma was trisomy 21 (8 cases, 25%) and in septated cystic hygroma was Turner syndrome (4 cases, 21.1%). The most common associated structural malformations were cardiac abnormalities (in 7 cases, 20%) in nonseptated cystic hygroma cases and nonimmune hydrops (in 12 cases, 54.5%) in septated cystic hygroma cases. Overall survival was poor; only one case of septated cystic hygroma with axillary location and seven cases of nonseptated cystic hygroma, of whom two died in the neonatal period, were alive (10.5%). This study had 80% power to detect 0.03% difference in diagnosis cystic hygroma (alpha = 0.05, beta = 0.80).

CONCLUSION

Fetuses with cystic hygroma are at high risk for adverse outcome. Prenatal diagnosis with invasive procedures should be done in order to inform the parents in detail. Axillary location of the hygroma and the depth of invasion had prognostic importance.

Spontaneous resolution of cystic hygroma in 47,XYY fetus

INTRODUCTION

47,XYY karyotype occurs in 1 out of 1,000 male births. Physical phenotype is normal, with tall stature by adolescence. Prenatal diagnosis of the 47,XYY syndrome is usually fortuitous. Some cases are being diagnosed when prenatal karyotyping is done for the detection of Down syndrome and other major aneuploidies. Some cases are diagnosed when prenatal ultrasonographic findings of fetal abnormalities are found. Herein, we report a case of 47,XYY after prenatal finding of fetal cystic hygroma with spontaneous resolution.

CASE REPORT

A 19-year-old primigravid woman presented for antenatal care at the 13th week of pregnancy. She used oral isotretinoin, being unaware of pregnancy, for a treatment of acne during the first 4 weeks of gestation. Ultrasonogram was performed due to first trimester screening and the history of isotretinoin exposure. The result revealed a single viable fetus compatible with a 13-week pregnancy and a posterior cervical cystic hygroma. No other structural anomalies were noted. An amniocentesis was performed for prenatal chromosome analysis and a 47,XYY karyotype was found. Repeated ultrasonogram at 23-week gestation showed that the cystic hygroma had spontaneously disappeared. She delivered a normal appearing male infant by spontaneous vaginal delivery at 40 weeks. The maternal and neonatal outcomes were uneventful.

CONCLUSION

Fetal cystic hygroma can be associated with abnormal karyotype, such as 47,XYY. Without hydrops fetalis, this may be ended with a normal outcome. Therefore, an antenatal karyotype determination should be offered to any woman whose fetus has cystic hygroma, even to those with spontaneous resolution.

Treatment of Cystic Lymphatic Vascular Malformations with OK-432 Sclerotherapy

BACKGROUND

Cystic lymphatic vascular malformations are benign lesions that can cause disfigurement and functional impairment. Complete surgical resection is often difficult, and clinical recurrence is common. Sclerotherapy has been used as an alternative to excision. OK-432 is a lyophilized mixture of Streptococcus pyogenes and benzylpenicillin which, when injected into a lesion, has shown significant ability to reduce its size or obliterate it completely.

METHODS

The authors report a series of 12 patients treated in this fashion at the Vascular Anomalies Clinic, British Columbia Children's Hospital, between 1999 and 2004. All patients underwent imaging of the lesion: 10 had magnetic resonance imaging, one had a computed tomographic scan, and one had ultrasound examination. Six patients had macrocystic malformations (cysts > or = 2 cm) and six had microcystic or combined lymphaticovenous malformations. Patients were treated with intralesional injection of OK-432. The position of the injection was confirmed by angiography and/or ultrasound in 10 cases. Response to treatment was assessed clinically.

RESULTS

All patients with macrocystic malformations had complete resolution or good response to treatment. None required any additional treatment. In contrast, those with microcystic or combined malformations responded poorly. All of these patients underwent subsequent excision without adverse consequences. The size and location of the lesion did not correlate with response to treatment. Seventy-five percent of patients experienced pyrexia. Local swelling is an expected phenomenon and must be anticipated, particularly for lesions near the airway.

CONCLUSIONS

OK-432 is an excellent treatment for patients with macrocystic lymphatic malformations. However, it is ineffective for microcystic lesions.

Alcoholic solution of zein (Ethibloc) sclerotherapy for treatment of lymphangiomas in children

PURPOSE

The aim of this study was to report the experience and efficacy of Ethibloc sclerotherapy as treatment of lymphangiomas.

METHODS

Between 1992 and 2004, 63 patients had Ethibloc sclerotherapy for lymphangiomas at our institution. Computed tomographic scan or magnetic resonance imaging and clinical evaluation determined efficacy of the treatment. Results were classified as excellent (> or =95% decrease in lesion volume), satisfactory (> or =50% decrease and asymptomatic), or poor (<50% decrease or symptomatic).

RESULTS

Sixty-three patients with 67 lesions underwent sclerotherapy with a median of 2 treatments per patient. Thirty-five involved the neck; 10, the head and face; and 22, the thorax or limb. Thirteen were predominantly microcystic; 28, macrocystic; and 26, mixed. Of the 63 patients, 6 underwent sclerotherapy for postsurgical residual lesions. Results were classified by type: of the 54 macrocystic/mixed cases, 26 (49%) had excellent, 19 (35%) had good, and 9 (16%) had poor results; in the 13 predominantly microcystic lesions, 3 (23%) had excellent, 7 (54%) had good, and 3 (23%) poor results. Five patients (7.7%) required surgery for complications; 2, for scar revision; 2, for persistent drainage; and 1, for a salivary fistula. Infection occurred in 4 patients (6.2%) after sclerotherapy. Follow-up averaged 3.5 years (range, 12 months to 12 years).

CONCLUSION

Ethibloc sclerotherapy is a safe and effective alternative to surgical excision of macrocystic lymphangiomas and can be used for postsurgical recurrences.

Surgical treatment of cervicofacial cystic hygromas in children

AIM

The aim of this study was to evaluate the results of surgical treatment of cervicofacial cystic hygromas in children.

PATIENTS AND METHODS

Medical records of 17 patients who were operated for cervicofacial cystic hygroma between 1985 and 2004 were evaluated in terms of age, gender, symptoms, diagnostic workups, outcomes and complications.

RESULTS

There was a slight male predominance -- 10 (59%) boys and 7 (41%) girls. Nine (53%) out of 17 lesions were located on the left side of the neck, 7 (41%) lesions were located on the right side of the neck and 1 lesion (6%) was located in the middle of the neck. Eleven (65%) lesions were located in the infrahyoid region, 6 (35%) lesions in the suprahyoid region. Following surgical excision of the lesion, we encountered 4 postoperative complications: 1 recurrence (6%), 2 facial paralyses (12%) and 1 collection of fluid (6%) at the resection site. The patient who had a recurring lesion needed to be reoperated, other complications were treated conservatively.

CONCLUSIONS

Cervicofacial cystic hygromas are easy to diagnose. There is no need for expensive and time-consuming imaging studies. Surgery seems the treatment of choice. However, nonsurgical treatment options may be considered for the lesions located over the parotid region in order to avoid complications of surgery.

Massive cystic lymphangiomas of a fetus

We present a fetus with progressive massive subcutaneous lymphangiomas leading to intrauterine death. A 28-year-old woman was referred to our hospital because of a precordial cystic mass of the fetus. An ultrasound revealed lymphangiomas extending from bilateral axillae to the anterior chest wall. At 18 weeks' gestation, amniocentesis was performed and the karyotype of the fetus was found to be normal 46, XY. Thereafter the lesions increased in size gradually and spread over the body. Amniotic fluid decreased, pericardial, and pleural effusion appeared, and cardiomegaly became evident. The fetus died in utero at 25 weeks' gestation. Postmortem examination revealed a male fetus surrounded with multicystic soft masses spreading over the body, and syndactyly (left third and fourth fingers) was present. Histologically, a number of irregularly dilated lymphatics extended through subcutaneous tissues to the skeletal muscles. No communications between the cysts and the thoracic or abdominal cavity existed, and no lymphatic dilations in the viscera were confirmed. As far as we know, such conditions have rarely been reported. Considering that in previous literature, a favorable prognosis of a fetus with an atypically located (lateral cervical or non-cervical) lymphangioma with a normal karyotype has been reported, our case may be included in a distinct pathological entity. When we find a lymphangioma in a fetus, careful follow-up by ultrasound is mandatory.

Dosage-dependent requirement for mouse Vezf1 in vascular system development

Vezf1 is an early development gene that encodes a zinc finger transcription factor. In the developing embryo, Vezf1 is expressed in the yolk sac mesoderm and the endothelium of the developing vasculature and, in addition, in mesodermal and neuronal tissues. Targeted inactivation of Vezf1 in mice reveals that it acts in a closely regulated, dose-dependent fashion on the development of the blood vascular and lymphatic system. Homozygous mutant embryos display vascular remodeling defects and loss of vascular integrity leading to localized hemorrhaging. Ultrastructural analysis shows defective endothelial cell adhesion and tight junction formation in the mutant vessels. Moreover, in heterozygous embryos, haploinsufficiency is observed that is characterized by lymphatic hypervascularization associated with hemorrhaging and edema in the jugular region; a phenotype reminiscent of the human congenital lymphatic malformation syndrome cystic hygroma.

First-Trimester Septated Cystic Hygroma

OBJECTIVE

To estimate prevalence, natural history, and outcome of septated cystic hygroma in the first trimester in the general obstetric population, and to differentiate this finding from simple increased nuchal translucency.

METHODS

Patients at 10.3-13.6 weeks of gestation underwent nuchal translucency sonography as part of a multicenter clinical trial. Septated cystic hygroma cases were offered chorionic villi sampling for karyotype, and targeted fetal anatomical and cardiac evaluations. Survivors were followed up for fetal and long-term pediatric outcome (median 25 months, range 12-50 months). Cases of septated cystic hygroma were also compared with cases of simple increased nuchal translucency.

RESULTS

There were 134 cases of cystic hygroma (2 lost to follow-up) among 38,167 screened patients (1 in 285). Chromosomal abnormalities were diagnosed in 67 (51%), including 25 trisomy-21, 19 Turner syndrome, 13 trisomy-18, and 10 others. Major structural fetal malformations (primarily cardiac and skeletal) were diagnosed in 22 of the remaining 65 cases (34%). There were 5 cases (8%) of fetal death and 15 cases of elective pregnancy termination without evidence of abnormality. One of 23 (4%) normal survivors was diagnosed with cerebral palsy and developmental delay. Overall, survival with normal pediatric outcome was confirmed in 17% of cases (22 of 132). Compared with simple increased nuchal translucency, cystic hygroma has 5-fold, 12-fold, and 6-fold increased risk of aneuploidy, cardiac malformation, and perinatal death, respectively.

CONCLUSION

First-trimester cystic hygroma was a frequent finding in a general obstetric screening program. It has the strongest prenatal association with aneuploidy described to date, with significantly worse outcome compared with simple increased nuchal translucency. Most pregnancies with normal evaluation at the completion of the second trimester resulted in a healthy infant with a normal pediatric outcome.

First and second trimester evaluation of risk for fetal aneuploidy: the secondary outcomes of the FASTER Trial

The FASTER Trial was a multicenter National Institute of Child Health and Human Development sponsored study of Down syndrome screening in a large unselected obstetric population using first and second trimester maternal serum markers and first trimester nuchal translucency sonography. The following paper will describe the FASTER Trial. It will review the outcomes of pregnancies complicated by cystic hygroma and the FASTER Trial's findings regarding first trimester nasal bone ultrasonography and screening for aneuploidy. Although the study's first and foremost goal was to compare various first and second trimester methods of screening for Down syndrome, the FASTER Trial has revealed a wealth of information not only on screening for aneuploidy but also on other obstetric issues.

Cystic hygroma in the quadriceps muscle: a sanguine diagnosis for knee pain

Reported here is a 28-year-old female who presented with severe right knee pain and swelling nearby the joint. Ultrasonography, magnetic resonance imaging and eventually surgery were performed. She was diagnosed to have a cystic hygroma in the vastus lateralis muscle. This is the first patient of a cystic hygroma in the quadriceps muscle.

Increased nuchal translucency and distended jugular lymphatic sacs on first-trimester ultrasound

OBJECTIVE

To investigate the presence and volume of jugular lymphatic sacs (JLS) in first-trimester fetuses with normal nuchal translucency thickness (NT) and in those with increased NT.

METHODS

This was a prospective study of 26 fetuses with NT > 95(th) percentile, which were compared with 137 fetuses with normal NT. Following crown-rump length (CRL) and NT measurement the neck region of the fetus was studied by transvaginal ultrasound. The JLS presented as spheroidal translusencies in the anterolateral region of the neck.

RESULTS

The prevalence of JLS differed significantly between fetuses with enlarged NT and the control group (P < 0.0001). In the group of 26 fetuses with increased NT, 22 had clearly visible JLS. Chorionic villus sampling revealed aneuploidy in 10 and euploidy in 16 fetuses. In the control group two fetuses, with NT values of 2.8 mm and 2.9 mm, had JLS; pregnancy outcome was normal in both cases. Logistic regression analysis in the total study group showed that an increase in NT was associated with a greater probability of JLS being present (for NT = 3-3.5 mm, probability = 0.67; for NT > 3.5 mm, probability = 0.93). In fetuses with JLS, an increase in CRL was associated with a significant increase in right JLS volume (r = 0.51; P-value = 0.01) and a non-significant increase in left sac volume (r = 0.40; P-value = 0.09). Increase in NT was not associated with a significant increase in JLS volume.

CONCLUSION

There is a significant association between increased NT and the presence of JLS on first-trimester ultrasound. In our opinion, the pathophysiological explanation for increased NT lies in a disturbance in lymphangiogenesis.

Identification of lymphatic endothelium in pediatric vascular tumors and malformations

The distinction between lymphatic and other vascular vessels on microscopic sections is a challenging task. D2-40, a novel antibody, has been reported to be selective for lymphatic endothelium. We studied the specificity and sensitivity of D2-40 in pediatric vascular tumors and malformations. Fourteen lymphatic and 11 vascular lesions were randomly selected and stained with D2-40 and CD31 antibodies. The lymphatic lesions included 6 lymphatic malformations, 5 cystic hygromas (macrocystic lymphatic malformation), 2 lymphovenous malformations, and 1 lymphangioma, and the vascular lesions comprised 3 infantile hemangiomas, 3 Kaposiform hemangioendotheliomas, 2 tufted angiomas, 1 pyogenic granuloma, 1 arteriovenous, and 1 venulocapillary malformations. The staining patterns of the vascular channels were compared. In all lesions D2-40 labeled only the endothelium of thin-walled vascular channels morphologically consistent with lymphatic vessels (25 of 25). No staining of the vascular lesions (0 of 11) or of arteries and veins (0 of 25) was observed. All lymphatic lesions had D2-40-positive vessels; however, the percentage of vessels that stained varied. Five lymphatic lesions showed more than 75% D2-40-positive channels, 5 lesions had approximately 50%, and 4 cases showed fewer than 25% D2-40-positive channels. There was a tendency of more consistent D2-40 staining of small versus large lymphatic channels. CD31 constantly labeled arteries, veins, capillaries, and lymphatics in all lesions and all endothelial cells in the vascular lesions. D2-40 is a very specific antibody for lymphatic endothelium, with variable sensitivity. CD31 more reliably identifies lymphatic endothelium. Currently, D2-40 appears to be a good marker to identify lymphatic vessels in pediatric vascular tumors and malformations.

Population-based study of the outcome following the prenatal diagnosis of cystic hygroma

OBJECTIVE

To identify the population prevalence, pregnancy outcome, and the pattern of associated anomalies with a prenatal diagnosis of cystic hygroma.

DESIGN

We analysed the pregnancy outcomes from 99 cases of prenatally diagnosed cystic hygroma reported to the Trent Congenital Anomalies Register from 1 January 1997 to 31 December 1999, by means of an outcome reporting form completed by the notifying centre.

RESULTS

We identified a population prevalence of 1 in 1775 livebirths for prenatally diagnosed cystic hygroma. There were 64 terminations of pregnancy, 19 spontaneous pregnancy failures, and 16 livebirths. Of the 87 pregnancies karyotyped, 53 (61%) demonstrated aneuploidy with Turner syndrome being the most common, 29 (33%). There were a large variety of structural malformations identified, however, only 14 out of 83 terminations of pregnancy and spontaneous pregnancy failures had post-mortem examinations. Termination of pregnancy for Turner syndrome not complicated by identified structural malformations was the norm. Of the 16 livebirths, only 6 were normal at birth, 1 other has had successful hygroma surgery. Four of the liveborn infants have since died.

CONCLUSIONS

The 'normal outcome' rate from pregnancies complicated by prenatally diagnosed cystic hygroma is less than 10% in this study (6/99). Prenatal diagnosis of cystic hygroma requires careful assessment of the fetus, with regard to both karyotyping and ultrasound. Post-mortem examination should be encouraged after termination of pregnancy, or spontaneous pregnancy loss. This is important not just to the current pregnancy but also for future pregnancies.