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Hu LJ, Fang HM, Lin HM, Kang X, Lin Y, Xiao J. Case report: Staged tension-reducing excision of giant acquired vulvar lymphangioma secondary to cervical cancer surgery. Front Oncol 2024; 14:1418829. [PMID: 39309744 PMCID: PMC11412948 DOI: 10.3389/fonc.2024.1418829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/22/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction Acquired vulvar lymphangioma (AVL), a rare disease caused by the dilation of superficial lymphatic vessels secondary to deep lymphatic vessel injury, is characterized by a wide range of morphological diversity and massive exudate. This morphological heterogeneity has often led to misdiagnosis or non-diagnosis. The management of AVL presents a therapeutic challenge due to the absence of a standardized treatment protocol. Case presentation A 53-year-old female patient, previously received surgical treatments for stage IIb cervical squamous cell carcinoma, presented with vulvar enlargement and copious amount of yellow exudate seven years post-treatment. Clinically, the patient exhibited chronic vulvar swelling, with easily-exudated nodules. The vulvar biopsy revealed lymphatic vessel dilation with lymphocyte infiltration, consistent with AVL. Due to the extensive lesions and severe exudate, staged excisions of bilateral vulvar lesions were performed at one-month intervals. Follow-up examinations of this patient for one-year post-surgery showed no evidence of recurrence. Conclusion In this instance, AVL manifest secondary to cervical cancer surgery, as a result of damage to the deep lymphatic vessels of the vulva, with characteristic symptoms of copious amounts of exudate and vulvar lesions with diverse morphologies, which provides a cautionary note for physicians. Besides, the staged resection strategy in this case may offer insights into surgical treatment protocol for extensive AVL.
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Affiliation(s)
- Ling-Juan Hu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Department of Gynecology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Hao-Ming Fang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
- Clinical Division, School of Chinese Medicine, Hong Kong Baptist University, Kowloon, Hong Kong SAR, China
| | - Huan-Mei Lin
- Department of Gynecology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xu Kang
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ying Lin
- Department of Dermatology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jing Xiao
- State Key Laboratory of Traditional Chinese Medicine Syndrome/Department of Gynecology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Calhau A, Salgueiro Neto R, Leiria Gomes R, Freitas T, Oliveira I. Unusual Presentation of Lymphangioma Circumscriptum of the Vulva: In Association With Crohn Disease. J Low Genit Tract Dis 2024; 28:113-115. [PMID: 38117567 DOI: 10.1097/lgt.0000000000000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
ABSTRACT Lymphangioma circumscriptum (LC) is a rare benign condition, with marked dilation of surface lymphatic vessels in the deep and subcutaneous layers. Vulvar LC can become a highly disabling condition with vulvar discomfort, itching, burning and lymph seeping being the dominant symptoms. Biopsy is mandatory for the diagnosis. There is no consensus on the standard treatment for vulvar LC and recurrence is frequent. In complex cases with wide disease location, combination of different treatment options, such as abrasive methods and surgery, may lead to the best clinical and aesthetical result, with extended disease-free periods. We present a patient with a long history of Crohn disease with multiple pelvic surgeries who developed an extensive vulvar LC.
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Affiliation(s)
- Ana Calhau
- Gynecology and Obstetrics Unit of Hospital Dr. Nélio Mendonça, SESARAM EPERAM, Funchal, Madeira Island, Portugal
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Luu YT, Kimmis BD, Bodine JS, Gloyeske NC, Dai H. Malignancy-associated acquired vulvar lymphangioma circumscriptum: A clinicopathologic study of 71 cases. J Cutan Pathol 2021; 49:426-433. [PMID: 34877687 DOI: 10.1111/cup.14181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/14/2021] [Accepted: 11/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acquired lymphangioma circumscriptum of the vulva is rare and can occur subsequent to malignancies of the anogenital and pelvic region. We sought to investigate the clinicopathologic characteristics of malignancy-associated acquired vulvar lymphangioma circumscriptum (AVLC). METHODS We identified all cases of AVLC within our institution with history of prior malignancy between 2005 and 2021. A similar search was performed in the PubMed database to identify published cases to date. The clinical and histopathologic information was recorded. RESULTS A total of 71 cases were identified. The most common preceding malignancy was cervical carcinoma (71.8%, 51/71). Radiation therapy was given to 91.4% (64/70) of the patients and lymph node dissection was made on 70.2% (40/57). Median interval between the diagnosis of malignancy and the AVLC was 10 years (range 0-32 years). AVLC frequently presented as vesicular (31.6%, 18/57) or verrucous (28.1%, 16/57) lesions clinically. Common treatments for AVLC included excision (53.1%, 26/49) and laser therapy (16.3%, 8/49), with an overall recurrence rate of 42.9% (24/56) at a median follow-up interval of 1.8 years (range 0.04-32.3 years). CONCLUSION AVLC is a rare, late complication of anogenital and pelvic malignancies causing debilitating physical symptoms and psychological stress. Further studies are warranted to determine the most effective treatment modalities to mitigate recurrence.
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Affiliation(s)
- Yen T Luu
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Brooks D Kimmis
- Division of Dermatology, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Jared S Bodine
- Kansas City University of Medicine and Biosciences, Kansas City, Missouri, USA
| | - Nika C Gloyeske
- Department of Pathology and Laboratory Medicine, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Hongyan Dai
- Department of Pathology and Laboratory Medicine, University of Kansas Hospital, Kansas City, Kansas, USA
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Petit KN, Petit DM, Bridges AG. Vulvar Lymphangioma Circumscriptum Secondary to Crohn Disease. Mayo Clin Proc 2021; 96:2923-2924. [PMID: 34736616 DOI: 10.1016/j.mayocp.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kristin N Petit
- Wright State University Boonshoft School of Medicine, Fairborn, OH
| | - Danielle M Petit
- The Christ Hospital Physicians - Dermatology, Liberty Township, OH
| | - Alina G Bridges
- Dermpath Diagnostics Richfield Laboratory of Dermatopathology, Cincinnati, OH.
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5
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Hara H, Mihara M. Genital lymphaticovenous anastomosis (LVA) and leg LVA to prevent the recurrence of genital acquired lymphangiectasia. Microsurgery 2021; 41:412-420. [PMID: 34107100 DOI: 10.1002/micr.30733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 03/03/2021] [Accepted: 03/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Genital acquired lymphangiectasia (GAL) commonly recurs after simple resection. This study aimed to elucidate the efficacy of lymphaticovenous anastomosis (LVA) in the genital region or legs for preventing GAL recurrence after resection. METHODS We retrospectively investigated 25 female patients who underwent GAL resection and LVA, lymphoscintigraphy, and indocyanine green (ICG) lymphography. Isotope or ICG was injected into the leg. Medicine accumulating in the genitals indicates lymphatic flow from the legs to the genitals (type 1). In some cases, we injected ICG into the anus to detect lymphatic flow from the anus to the genitals (type 2). Based on the findings, we selected LVA site (genital or leg). RESULTS The mean patient age was 61.4 (range, 42-81) years. Seventeen patients underwent leg LVA only, while eight patients underwent genital LVA. The mean follow-up period was 285 (range, 87-365) days. GAL recurrence was observed in 10 patients (40.0%): three of eight (37.5%) who underwent genital LVA versus seven of 17 (41.2%) who underwent leg LVA. Among patients with type 2 lymphatic vessels, GAL recurrence was observed in two of six (33.3%) who underwent genital LVA versus five of nine (55.6%) who underwent leg LVA. CONCLUSION Genital LVA prevented GAL recurrence in patients with type 2 lymphatic flow. Detecting the direction of lymphatic flow around GAL is essential to its successful treatment.
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Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery, JR Tokyo General Hospital, Tokyo, Japan
| | - Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery, JR Tokyo General Hospital, Tokyo, Japan
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A Verrucous Plaque With Linear Fissures in a Patient With Crohn's Disease: Answer. Am J Dermatopathol 2021; 43:461-463. [PMID: 34006733 DOI: 10.1097/dad.0000000000001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shields BE, Richardson C, Arkin L, Kornik R. Vulvar Crohn disease: Diagnostic challenges and approach to therapy. Int J Womens Dermatol 2020; 6:390-394. [PMID: 33898705 PMCID: PMC8060678 DOI: 10.1016/j.ijwd.2020.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 12/16/2022] Open
Abstract
Crohn disease (CD) may be complicated by contiguous, metastatic, or associated inflammatory cutaneous lesions. Vulvar CD is a rare phenomenon characterized by granulomatous genital inflammation that occurs independently from fistulizing CD. Left untreated, vulvar CD can result in debilitating lymphedema, disfiguring anatomic changes, secondary abscesses, cellulitis, and squamous cell carcinoma. We present a series of cases to highlight the clinical presentation of vulvar CD, the diagnostic testing required to distinguish complicating conditions, the asynchronous courses of skin and intestinal disease, and the complexities in the management of this disease and associated conditions. We review our multidisciplinary approach to care, aimed at reducing morbidity and improving patient quality of life.
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Affiliation(s)
- Bridget E Shields
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Catherine Richardson
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States
| | - Lisa Arkin
- Department of Dermatology, University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States
| | - Rachel Kornik
- Department of Dermatology, University of Wisconsin, School of Medicine and Public Health, Madison, WI, United States
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Galvin S, Flint SR, Toner ME, Healy CM, Ekanayake K. Oral lymphangiectasias and Crohn's disease: two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 126:e31-e34. [DOI: 10.1016/j.oooo.2017.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
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Bae GE, Yoon G, Song YJ, Kim HS. High-grade squamous intraepithelial lesion arising adjacent to vulvar lymphangioma circumscriptum: a tertiary institutional experience. Oncotarget 2018; 7:48120-48129. [PMID: 27329721 PMCID: PMC5217005 DOI: 10.18632/oncotarget.10158] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/06/2016] [Indexed: 11/25/2022] Open
Abstract
Lymphangioma circumscriptum of the vulva occurs in patients who have undergone radical hysterectomy, lymph node dissection, or radiation therapy for management of advanced uterine cancer. Since vulvar lymphangioma circumscriptum typically presents as multiple, grossly verrucous vesicles of various sizes, it may be impossible to clinically distinguish vulvar lymphangioma circumscriptum from other vulvoperineal cutaneous diseases. In the present study, 16 (1.6%) out of the 1,024 vulvar biopsy or excision specimens were diagnosed as lymphangioma circumscriptum. In two (12.5%) out of the 16 cases, unusual histopathological findings were observed. Both patients had previously undergone radical hysterectomy with lymph node dissection and postoperative radiation therapy or concurrent chemoradiation therapy for advanced cervical cancer. Microscopic examination revealed high-grade squamous intraepithelial lesions, which were located immediately adjacent to the normal squamous epithelium covering the dilated subepithelial lymphatic vessels. Further, human papillomavirus genotyping confirmed that both patients were infected with high-risk human papillomavirus. High-grade squamous intraepithelial lesion cannot be grossly distinguished from vulvar lymphangioma circumscriptum because the multiple, verrucous vesicles that constitute the characteristic gross appearance of vulvar lymphangioma circumscriptum hinder its distinction. In this regard, our cases of high-grade squamous intraepithelial lesion, located adjacent to vulvar lymphangioma circumscriptum, support the notion that active surgical excision is necessary for the treatment of vulvar lymphangioma circumscriptum.
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Affiliation(s)
- Go Eun Bae
- Department of Pathology, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - Gun Yoon
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Yong Jung Song
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Hyun-Soo Kim
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Akhavan S, Agah J, Nili F. Congenital lymphangioma circumscriptum of vulva presenting as multiple giant mass lesions: a case report and literature review. J Obstet Gynaecol Res 2018; 44:978-982. [DOI: 10.1111/jog.13609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Setareh Akhavan
- Department of Gynecology Oncology; Vali-Asr Hospital, Tehran University of Medical Sciences; Tehran Iran
| | - Jila Agah
- Department of Obstetrics and Gynecology Oncology; Sabzevar University of Medical Sciences; Sabzevar Iran
| | - Fatemeh Nili
- Department of Pathology; Cancer Institute, Imam Khomeini Hospital Complex; Tehran Iran
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11
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Padilla-España L, Bosco Repiso-Jiménez J, Abitei C. Pseudoverrucous Lesions of Recent Appearance on the Vulva. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2017.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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12
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Pseudoverrucous Lesions of Recent Appearance on the Vulva. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:65-66. [PMID: 28283172 DOI: 10.1016/j.ad.2016.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/04/2016] [Accepted: 07/24/2016] [Indexed: 11/21/2022] Open
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13
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Hara H, Mihara M, Anan T, Fukumoto T, Narushima M, Iida T, Koshima I. Pathological Investigation of Acquired Lymphangiectasia Accompanied by Lower Limb Lymphedema: Lymphocyte Infiltration in the Dermis and Epidermis. Lymphat Res Biol 2016; 14:172-80. [DOI: 10.1089/lrb.2016.0016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
| | - Takashi Anan
- Sapporo Dermatopathology Institute, Hokkaido, Japan
| | | | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takuya Iida
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Abstract
Awareness of the extraintestinal manifestations of Crohn disease is increasing in dermatology and gastroenterology, with enhanced identification of entities that range from granulomatous diseases recapitulating the underlying inflammatory bowel disease to reactive conditions and associated dermatoses. In this review, the underlying etiopathology of Crohn disease is discussed, and how this mirrors certain skin manifestations that present in a subset of patients is explored. The array of extraintestinal manifestations that do not share a similar pathology, but which are often seen in association with inflammatory bowel disease, is also discussed. Treatment and pathogenetic mechanisms, where available, are discussed.
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Affiliation(s)
- Joshua W Hagen
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA
| | - Jason M Swoger
- Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop street, C-Wing, Mezzanine, Pittsburgh, PA 15213, USA
| | - Lisa M Grandinetti
- Department of Dermatology, University of Pittsburgh Medical Center, Medical Arts Building, 3708 Fifth Avenue, 5th Floor, Pittsburgh, PA 15213, USA.
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Chang MB, Newman CC, Davis MDP, Lehman JS. Acquired lymphangiectasia (lymphangioma circumscriptum) of the vulva: Clinicopathologic study of 11 patients from a single institution and 67 from the literature. Int J Dermatol 2016; 55:e482-7. [DOI: 10.1111/ijd.13264] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 10/05/2015] [Accepted: 11/18/2015] [Indexed: 11/27/2022]
Affiliation(s)
| | | | | | - Julia S. Lehman
- Department of Dermatology; Mayo Clinic; Rochester MN USA
- Division of Anatomic Pathology; Mayo Clinic; Rochester MN USA
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Hoffmann J, Hadaschik EN, Schäkel K, Wacker J, Enk AH, Hartschuh W. Multiple perianale Papeln bei einer 37-jährigen Frau. J Dtsch Dermatol Ges 2014. [DOI: 10.1111/ddg.12367_suppl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jochen Hoffmann
- Department of Dermatology, Heidelberg University Hospital; Heidelberg
| | - Eva N. Hadaschik
- Department of Dermatology, Heidelberg University Hospital; Heidelberg
| | - Knut Schäkel
- Department of Dermatology, Heidelberg University Hospital; Heidelberg
| | | | - Alexander H. Enk
- Department of Dermatology, Heidelberg University Hospital; Heidelberg
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18
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Hoffmann J, Hadaschik EN, Schäkel K, Wacker J, Enk AH, Hartschuh W. Multiple perianal papular lesions in a 37-year-old woman. J Dtsch Dermatol Ges 2014; 12:831-2. [PMID: 24902968 DOI: 10.1111/ddg.12367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Jochen Hoffmann
- Department of Dermatology, Heidelberg -University Hospital, Heidelberg, Germany
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Acquired vulvar lymphangioma circumscriptum. Case Rep Dermatol Med 2014; 2013:967890. [PMID: 24396614 PMCID: PMC3876770 DOI: 10.1155/2013/967890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 11/27/2013] [Indexed: 11/17/2022] Open
Abstract
Lymphangioma circumscriptum (LC) is a benign dilation of lymph channels localized to the skin and subcutaneous tissues. It is generally localized in mouth mucosa, tongue, proximal regions of arms and legs, groin, axilla, and trunk. Primary vulvar involvement is very rare. Vulvar involvement occurs in various clinical settings. Here, two uncommon cases with giant lymphangioma circumscriptum mimicking genital warts will be presented: a 55-year-old female patient with extensive lymphangiectasic lesions and genital wart-like papular lesions in the vulva secondary to diffuse scrofuloderma scars and a 60-year-old female patient with verruca-like lesions secondary to chronic inflammation.
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21
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North J, White K, White C, Solomon A. Acquired, verrucous, gluteal lymphangioma in the setting of Crohn's disease. J Am Acad Dermatol 2011; 64:e90-1. [PMID: 21496698 DOI: 10.1016/j.jaad.2010.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 10/25/2010] [Accepted: 10/29/2010] [Indexed: 10/18/2022]
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