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Kharroubi A, Benzmane K, Lakhal O, Kaddouri L. Elephantiasis Nostras Verrucosa of the Lower Limb: A Case Report and Literature Review. Ann Vasc Dis 2024; 17:43-49. [PMID: 38628934 PMCID: PMC11018103 DOI: 10.3400/avd.cr.22-00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 07/30/2023] [Indexed: 04/19/2024] Open
Abstract
Elephantiasis nostras verrucosa (ENV) is a rare complication of chronic lymphedema, leading to progressive cutaneous hypertrophy and disfigured lower extremities. We present an unusual case of a 79-year-old man with ENV, who had an episode of erysipelas treated and cured with antibiotics. The patient presented with progressive painless lymphedema of the lower limb years ago, complicated with skin changes. The biology and radiology test does not objective any causes. The compression therapy was proposed to the patient. ENV is characterized by lymphedema and skin anomaly. Management of ENV is often challenging, but a variety of successful medical and surgical treatment strategies have been reported.
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Affiliation(s)
- Abdelkarim Kharroubi
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Kenza Benzmane
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Oumaima Lakhal
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
| | - Lahcen Kaddouri
- Vascular Surgery Department, Faculty of Medicine and Pharmacy of Agadir, Sous Massa, University Hospital Center, University Ibn Zohr, Agadir, Morocco
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Duong A, Balfour A, Kraus CN. Acquired vulvar lymphangioma: risk factors, disease associations, and management considerations: a systematic review. Int J Womens Dermatol 2023; 9:e087. [PMID: 37234958 PMCID: PMC10208695 DOI: 10.1097/jw9.0000000000000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/08/2023] [Indexed: 05/28/2023] Open
Abstract
Acquired vulvar lymphangioma (AVL) is not well-characterized. Diagnosis is delayed and the condition is often refractory to therapy. Objective The objective of this study was to provide a systematic review of AVL including risk factors, disease associations, and management options. Methods A primary literature search was conducted using 3 databases: PubMed, CINAHL, and OVID, from all years to 2022. Results In total, 78 publications with 133 patients (48 ± 17 years) were included. Most studies were case reports/series. The most common disease association was prior malignancy (70 patients, 53% of cases) and inflammatory bowel disease (6 patients, 5% of cases). The most common malignancy was cervical cancer (57 patients, 43% of cases). Most patients had prior radiation or surgery, with 36% (n = 48) treated with radiation, 30% (n = 40) with lymph node dissection, and 27% (n = 36) with surgical resection. Common presenting symptoms included discharge/oozing, pain, and pruritus. Most patients underwent surgical treatment for AVL with 39% treated with excision, 12% with laser therapy (the majority used CO2), and 11% with medical therapies. Most patients had failed prior therapies and there was a diagnostic delay. Limitations Retrospective nature. Most studies were limited to case reports and case series, with interstudy variability and result heterogeneity. Conclusion AVL is an underrecognized entity and should be considered in patients with a history of malignancy or radiation to the urogenital area. Treatment should include multidisciplinary care and address underlying lymphatic changes, manage any existing inflammatory conditions, and utilize skin-directed therapies and barrier agents while addressing symptoms of pruritus and pain. Prospective studies are needed to further characterize AVL and develop treatment guidelines.
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Affiliation(s)
- Amber Duong
- School of Medicine, University of California, Irvine, California
| | - Alex Balfour
- School of Medicine, University of California, Irvine, California
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Forte AJ, Khan N, Huayllani MT, Boczar D, Saleem HY, Lu X, Manrique OJ, Ciudad P, McLaughlin SA. Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review. Indian J Plast Surg 2020; 53:17-24. [PMID: 32367914 PMCID: PMC7192660 DOI: 10.1055/s-0040-1709372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background
Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes.
Methods
PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included “lymphovenous” OR “lymphaticovenous” AND “bypass” OR “anastomosis” OR “shunt” AND “lower extremity lymphedema.”
Results
A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%.
Conclusion
LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.
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Affiliation(s)
- Antonio J Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | | | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Humza Y Saleem
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Oscar J Manrique
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Sarah A McLaughlin
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, United States
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Hara H, Mihara M. Lymphaticovenous anastomosis and resection for genital acquired lymphangiectasia (GAL). J Plast Reconstr Aesthet Surg 2018; 71:1625-1630. [DOI: 10.1016/j.bjps.2018.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 04/08/2018] [Accepted: 05/26/2018] [Indexed: 10/14/2022]
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Robinson CG, Lee KR, Thomas VD. The Successful Treatment of Elephantiasis Nostras Verrucosa With Ablative Carbon Dioxide Laser. J Cutan Med Surg 2018. [PMID: 29519146 DOI: 10.1177/1203475418763548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Elephantiasis nostras verrucosa (ENV) is a disfiguring skin condition that is difficult to treat. Existing treatment modalities serve to improve cosmesis or treat symptoms. Herein, we report a case of ENV with lymphocutaneous fistula successfully treated with ablative carbon dioxide laser. STUDY DESIGN/PATIENTS AND METHODS A 57-year-old woman with biopsy-proven ENV with lymphocutaneous fistula was treated with ablative carbon dioxide laser to the symptomatic area of her right thigh in 3 treatment sessions over 6 months. RESULTS The patient had resolution of lymphocutaneous drainage as well as 90% improvement in the appearance of ENV lesions at the 1-month follow-up visit. CONCLUSION Ablative carbon dioxide laser may provide cosmetic, symptomatic, and medical benefit for patients with localized ENV.
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Affiliation(s)
| | - Kory R Lee
- 2 University of Texas at Houston McGovern Medical School, Houston, TX, USA
| | - Valencia D Thomas
- 3 Department of Dermatology, MD Anderson Cancer Center, Houston, TX, USA
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Lymphedema: Diagnostic workup and management. J Am Acad Dermatol 2017; 77:995-1006. [PMID: 29132859 DOI: 10.1016/j.jaad.2017.03.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 12/19/2022]
Abstract
Lymphedema is a localized form of tissue swelling resulting from excessive retention of lymphatic fluid in the interstitial compartment. It is caused by impaired lymphatic drainage. Lymphedema is a chronic progressive disease with serious physical and psychosocial implications. It can be challenging to diagnose, especially in obese patients and in those with coexisting venous disease. We performed PubMed and Google Scholar searches of the English-language literature (1966-2017) using the terms lymphedema, lymphedema management, and lymphatic complications. Relevant publications were manually reviewed for additional resources. There are currently no standard guidelines for the diagnosis of lymphedema. There is no cure yet for lymphedema, and the objective for management is to limit disease progression and prevent complications.
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Beta Human Papillomavirus Infection Is Prevalent in Elephantiasis and Exhibits a Productive Phenotype: A Case-Control Study. Am J Dermatopathol 2017; 39:445-456. [PMID: 28253203 DOI: 10.1097/dad.0000000000000681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Elephantiasis is considered a cutaneous region of immune deficiency with cobblestone-like surface caused by a wart-like eruption. Verrucosis is a diffuse human papillomavirus (HPV) infection linked to immunodeficiency disorders. The objective of this study was to examine the prevalence of HPV infection in lymphedema and its pathogenic role in elephantiasis. A retrospective case-control study was performed examining lymphedematous skin and controls of peritumoral normal skin. HPV infection was evaluated at the DNA, protein, and histopathologic levels by polymerase chain reaction, immunohistochemistry, and light microscopy, respectively. Overall, 540 HPV DNAs were detected in 120 of 122 cutaneous samples (median 4 HPV DNAs per sample, range 0-9). Compared with controls, no differences existed in type or number of HPVs identified. Instead, a diverse spectrum of HPV-related histopathologies were evident, likely reflecting the multiplicity of HPV genotypes detected. Most notably, increasing histopathologic lymphedema stage significantly correlated with markers of productive HPV infection such as altered keratohyaline granules and HPV L1 capsid expression. Limitations of this study are the absence of normal skin controls not associated with neoplasia or subclinical lymphedema, and lack of assessment of HPV copy number per keratinocyte infected. In conclusion, productive HPV infection, not HPV type or numbers detected, distinguished lymphedematous skin from controls. These findings support the theory that lymphedema creates a region of depressed immunity that permits productive HPV infection, manifested clinically by diffuse papillomatosis, characteristic of elephantiasis.
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Hernández-Godoy J, Casado Sánchez C, Iglesias Urraca C, Landín Jarillo L, Casado Pérez C. Opciones quirúrgicas actuales en el tratamiento del linfedema crónico. ANGIOLOGIA 2013. [DOI: 10.1016/j.angio.2012.10.004] [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]
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Dean SM, Zirwas MJ, Horst AV. Elephantiasis nostras verrucosa: An institutional analysis of 21 cases. J Am Acad Dermatol 2011; 64:1104-10. [DOI: 10.1016/j.jaad.2010.04.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 04/21/2010] [Accepted: 04/29/2010] [Indexed: 11/24/2022]
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Vignes S, Arrault M, Trévidic P. Surgical resection of vulva lymphoedema circumscriptum. J Plast Reconstr Aesthet Surg 2009; 63:1883-5. [PMID: 20004630 DOI: 10.1016/j.bjps.2009.11.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 11/06/2009] [Accepted: 11/10/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lymphangioma circumscriptum, a rare, benign disease that can be either congenital or acquired, involves the deep dermis and subcutaneous lymphatics. OBJECTIVE This study aims to analyse the efficacy of surgical resection of vulva lymphangioma circumscriptum (VLC). MATERIALS AND METHODS Between January 2000 and December 2008, eight consecutive women referred to our centre and treated surgically for VLC were included in the study. VLC was responsible for recurrent lymph oozing in seven cases. All women were treated by the same plastic surgeon specialising in lymphatic diseases. RESULTS The first surgery was performed after a median interval of 5.4 years since VLC onset. The first cutaneous resection included the labia majora of all women and labia minora of five and clitoral hood of four. Five women experienced rapidly recurrent vesicles associated with lymph oozing and underwent resection again (once: two women, twice: three women). The second resection was performed 4-6 months after the first, whereas the third took place 1-6 years after the second. Five women had moderate and transitory post-surgical lymph oozing. After a median follow-up of 53 months after the last surgery, seven of the eight women were free from symptom. CONCLUSION Surgical resection is an effective and well-tolerated therapy for VLC in most women. Lesion recurrence is frequent but resection can be repeated several times with no adverse effects.
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Affiliation(s)
- Stéphane Vignes
- Department of Lymphology, Hôpital Cognacq-Jay, 15, rue Eugène Millon, 75015 Paris, France.
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Yap YL, Lim J, Shim TWH, Naidu S, Ong WC, Lim TC. Patent Blue Dye in Lymphaticovenular Anastomosis. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n8p704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Introduction: Lymphaticovenular anastomosis (LVA) has been described as a treatment of chronic lymphoedema. This microsurgical technique is new and technically difficult. The small caliber and thin wall lymphatic vessels are difficult to identify and easily destroyed during the dissection.
Materials and Methods: We describe a technique of performing lymphaticovenular anastomosis with patent blue dye enhancement. Our patient is a 50-year-old lady who suffers from chronic lymphoedema of the upper limb after mastectomy and axillary clearance for breast cancer 8 years ago.
Results: Patent blue dye is injected subdermally and is taken up readily by the draining lymphatic channels. This allows for easy identification of their course. The visualisation of the lumen of the lymphatic vessel facilitates microsurgical anastomosis. The patency of the anastomosis is also demonstrated by the dynamic pumping action of the lymphatic within the vessels.
Conclusion: Patent blue dye staining during lymphaticovenular anastomosis is a simple, effective and safe method for mapping suitable subdermal lymphatics, allowing for speedier dissection of the lymphatic vessels intraoperatively. This technique also helps in the confirmation of the success of the lymphaticovenular anastomosis.
Key words: Lymphaticovenular anastomosis, Lymphoedema, Patent blue dye, Supermicrosurgery
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Affiliation(s)
| | - Jane Lim
- National University Hospital, Singapore
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