Laparoscopic resection of retroperitoneal lymphangioma around the pancreas: a case report and review of the literature

Large retroperitoneal lymphangioma

Abnormal cystic lymphangioma is a rare, benign tumour of lymphatic origin that often presents with subtle clinical symptoms. A man in his 20s sought medical attention for a progressively tender mass located in the right lower quadrant. Following ultrasound and CT imaging, surgical pathology confirmed the presence of abnormal cystic lymphangioma. This case is noteworthy because of the patient's young age and the retroperitoneal location. An exploratory laparotomy was performed, mitigating the risk of recurrence. In the future, if imaging identifies a cystic mass, consideration of abnormal cystic lymphangioma within the differential diagnosis is imperative. Despite its predominantly subtle symptoms and non-malignant nature, the mass effect by the abnormal cystic lymphangioma can compromise surrounding structures. Overall, clinicians confronted with a cystic mass should adopt a comprehensive diagnostic approach, encompassing abnormal cystic lymphangioma in the differential diagnosis due to its unknown and complex nature.

Adult Primary Retroperitoneal Lymphangioma: Updated Facts

Lymphangioma is a rare, benign tumor of the lymphatic system. It is believed to be a congenital malformation, when part of the lymphatic channels fail to connect to the main lymphatic system. Lymphangioma is a tumor of the pediatric age, with 50% of patients presenting at birth. The head and neck are the main affected sites (75%), while the retroperitoneal cavity is the least affected area, and comprises less than 1% of cases. Adult lymphangioma is an extremely rare tumor, and adult retroperitoneal lymphangioma (ARL) is even a rarer tumor. Over the last two decades, we have experienced a significant increase in reports published in the English literature discussing ARL. As reports have increased, several questions about previously known facts regarding this tumor arose: For years, it was known that ARL is usually an asymptomatic tumor which is incidentally found - is it a true claim? Is abdominal magnetic resonance imaging the radiological test of choice for diagnosis? What is the best therapeutic option? The main aim for this article is to review the current and old English literature concerning ARL, in order to collect data regarding demographic features, clinical presentation, imaging tests used for diagnosis, therapeutic options and follow-up. This in turn will give precise updated answers for the previous questions. In addition, it will raise awareness for the treating physician regarding the most effective approach for early diagnosis and best therapeutic option to be selected.

Case report and literature review: Giant retroperitoneal cystic lymphangioma

Background

Cystic lymphangioma is a rare benign tumor of the lymphatic system, which is most commonly observed in the neck, head and armpit.Less than 5% of lymphangiomas occur in the abdominal cavity and even less in the retroperitoneum.

Case description

A 65-year-old male patient was diagnosed with an "abdominal mass that had persisted for 1 year, accompanied by abdominal pain, abdominal distension and dyspnea for 7 days". After abdominal computerd tomography, a giant multilobed abdominal lymphangioma was suspected, which squeezed the intestinal canal and was closely related to the inferior vena cava. The patient underwent an exploratory laparotomy, during which, it was found that the tumor formed extensive adhesions to the transverse colon, small intestine and pelvic wall, and enveloped the abdominal aorta, superior mesenteric artery, inferior mesenteric artery and inferior vena cava to varying degrees. It was diffcult to remove the cyst completely. Postoperative pathology confirmed the diagnosis of retroperitoneal cystic lymphangioma. The patient recovered well after the operation, was eating normally by 5 days postoperatively,and was discharged 10 days postoperatively.The patient was followed up 1 month after postoperatively and no evidence of recurrence was observed.

Conclusion

In this case, we report a patient with giant retroperitoneal cystic lymphangioma who underwent exploratory laparotomy combined with preoperative abdominal computerd tomography and acute abdominal pain, abdominal distension and dyspnea. Because of the large volume of the tumor and its close relationship with the superior mesenteric artery and other blood vessels, the surgeon used scissors to separate the tumor sharply and removed the whole tumor completely.

Characteristics of adult abdominal cystic Lymphangioma: a single-center Chinese cohort of 12 cases

Background

Cystic lymphangioma is a rare, benign developmental disease, mostly affecting the cervical and axial regions. The clinical features of abdominal cystic lymphangioma (ACL) are reported among pediatric patients but are less well known in adults. The purpose of this study was to demonstrate the clinical characteristics of ACL in Chinese adults and describe our experience in treating this disease.

Methods

We conducted a single-center, non-interventional, retrospective study of 12 adult patients with ACL admitted to Peking Union Medical College Hospital in Beijing, China from November 1984 through August 2017. The demographic, clinical, laboratory, imaging, histopathologic, and therapeutic data were collected.

Results

Detailed information on seven males and five females was available. The mean age at diagnosis was 39.1 (SD 17.3) years. The mean duration of follow-up was 6.9 years. Six (50%) patients were asymptomatic, and abdominal pain was the leading symptom for three (25%) patients. The cysts were evaluated by ultrasound (n = 8, 67%), CT (n = 10, 83%), and MRI (n = 4, 33%). Therapeutic modalities include laparotomy (n = 6, 50%), laparoscopy (n = 4, 33%), and aspiration (n = 2, 17%), with variable outcomes. The mean postsurgical hospital stay was 6.8 days. Complete excision was accomplished in eight patients, and one recurrence was observed during follow-up. Of patients who underwent partial resection, one experienced disease relapse.

Conclusions

This is the first report on an Asian cohort of adult patients with ACL. Typical imaging features could lead to timely diagnosis and treatment of ACL. Radical resection is recommended with a longer period of follow-up. The analysis of this cohort deepens our understanding of adult ACL.

Robotic versus open resection of benign nonadrenal retroperitoneal tumors: A propensity score-matched study

BACKGROUND

Robotic resection of benign nonadrenal retroperitoneal tumors (BNRTs) is considered safety and feasibility. However, whether robotic BNRT resection (RBR) is superior to open BNRT resection (OBR) has not been reported. The comparative study was designed to analyze the short outcomes of RBR versus OBR on patients with BNRTs.

METHODS

Demographics and perioperative outcomes among patients who underwent RBR (n = 30) versus OBR (n = 30) for BNRTs between January 2015 and September 2018 were reviewed. A 1:1 propensity score matched analysis was performed between both groups.

RESULTS

There were no significant differences in the operative time, blood transfusion rate, and morbidity rate between the RBR and OBR groups. No patients underwent RBR required conversion to laparotomy. Robotic approach reduced estimated blood loss (EBL) (50 vs. 100 ml, p = 0.00) and postoperative hospital stay (PHS) significantly (4.6 vs. 7.9 d, p = 0.00) when compared with OBR. In patients with tumors adherent to major vessels, RBR also reduced EBL and PHS significantly (50 vs. 250 ml, p = 0.02; 4.4 vs. 9.3 d, p = 0.00), which were similar to the results of the patients with tumors larger than 5 cm (50 vs. 200 ml, p = 0.00; 4.9 vs. 7.5 d, p = 0.01).

CONCLUSIONS

When compared with OBR, RBR was associated with less EBL, and shorter PHS in selected patients even for tumors which are large or adherent to major vessels.

Cystic lymphangioma of the pancreas: a hard diagnostic challenge between pancreatic cystic lesions-review of recent literature

Lymphangiomas are rare congenital benign tumors arising from the lymphatic system. The incidence of this disease in the pancreas is extremely rare, accounting for less than 1% of these tumors. Before introducing the review we reported a case of a 67-year-old woman with cystic lymphangioma of the pancreas. We reported the radiological investigations carried out preoperatively and the treatment performed. The review tries to identify the features described in literature of the pancreatic lymphangioma. We have performed a PubMed research of the world literature between January 1^st 2000, to November 31^st 2017, using the keywords [Lymphangioma pancreas], [diagnosis], [CT lymphangioma] and [MRI lymphangioma]. We have found 158 articles, of which about 100 were case reports. Based on our search criteria, we have identified 31 pancreatic lymphangioma in literature reporting their imaging characteristics. According to our report and to several authors in literature the diagnosis of cystic pancreatic lymphangioma should be considered as a differential diagnosis of pancreatic cystic lesions (PCLs). The role of imaging exams (CT and MRI) can help to identify and suspect this possibility of diagnosis. The endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can have a potential role to reach the correct diagnosis.