Retroperitoneal cystic lymphangioma in an adult: A case report and review of the literature

Retroduodenal lymphangiomyoma: A rare cause of abdominal pain - A case report

BACKGROUND

Lymphangiomyomas are rare benign tumors arising from the lymphatic system, most commonly found in the retroperitoneum. Retroduodenal lymphangiomyomas are exceedingly rare and present significant diagnostic challenges due to their nonspecific symptoms and overlapping features with other retroperitoneal and gastrointestinal pathologies.

CASE PRESENTATION

We report a 48-year-old man with persistent abdominal pain lasting several weeks. Clinical examination and laboratory investigations were unremarkable. Gastroscopy revealed no abnormalities. Contrast-enhanced computed tomography (CT) identified a well-demarcated, non-enhancing retroduodenal soft tissue lesion measuring 36 mm × 30 mm with punctate calcifications, suggestive of a benign process. Endosonography confirmed the lesion's location between the aorta and inferior vena cava. A fine-needle biopsy was avoided due to the lesion's vascular nature. Surgical excision was performed, and histopathological analysis revealed anastomosing vascular channels with smooth muscle proliferation, confirming the diagnosis of lymphangiomyoma. Postoperative recovery was uneventful, and follow-up imaging showed no recurrence.

DISCUSSION

This case underscores the importance of a multidisciplinary approach involving radiology, surgery, and pathology in the diagnosis and management of retroduodenal lymphangiomyomas. Contrast-enhanced CT and histopathology are critical in distinguishing lymphangiomyomas from other retroperitoneal masses. Complete surgical excision remains the definitive treatment to prevent recurrence.

CONCLUSION

Although rare, retroduodenal lymphangiomyomas should be considered in the differential diagnosis of retroperitoneal masses with nonspecific symptoms.

Endoscopic submucosal dissection in the treatment of adult cystic lymphangioma: A case report

BACKGROUND

Cystic lymphangioma is a rare hamartoma that is especially found in the adult gastrointestinal tract. In the early stage, most patients are asymptomatic; after the onset of symptoms, there is often no specificity regarding symptoms.

CASE SUMMARY

Here we report the endoscopic diagnosis and treatment of an adult patient with cystic lymphangioma of the ascending colon. One patient who came to our hospital with "dull pain in the left lower abdomen for 2 days" was initially misdiagnosed with a colon cyst according to endoscopy and then underwent endoscopic submucosal dissection. The final pathological results suggested cystic lymphangioma. One year later, no recurrence was found on re-examination via colonoscopy.

CONCLUSION

Cystic lymphangioma in the gastrointestinal tract rarely occurs in adults and is easily misdiagnosed or missed. Endoscopy, imaging, histology, and immunohistochemical staining are useful for diagnosis. Surgical resection is the preferred treatment.

Isolated unilateral ovarian cystic lymphangioma: A case report

Ovarian lymphangiomas are rare benign neoplasms characterized by the proliferation of lymphatic vessels within the ovarian tissue. While lymphangiomas can manifest in various anatomical locations, their occurrence within the ovaries is exceptionally uncommon, posing diagnostic and therapeutic challenges for clinicians. The aetiology of ovarian lymphangiomas remains elusive, with theories suggesting congenital malformations, lymphatic obstruction, or acquired lymphatic proliferation as potential contributing factors. The clinical presentation of ovarian lymphangiomas often includes nonspecific symptoms such as abdominal pain, swelling, or discomfort, leading to difficulties in early detection and diagnosis. Radiological imaging, particularly Ultrasound, CT (computed tomography) and MRI (magnetic resonance imaging), plays a crucial role in identifying these lesions and guiding subsequent management strategies. Despite their generally benign nature, ovarian lymphangiomas can attain significant sizes, causing complications such as torsion, rupture, or compression of adjacent structures. Surgical intervention, typically in cystectomy or oophorectomy, is frequently pursued to alleviate symptoms and prevent potential complications. This paper aims to comprehensively review the existing literature on ovarian lymphangiomas, addressing their clinical presentation, diagnostic challenges, and management strategies. By synthesizing available data, we seek to enhance our understanding of this rare entity, providing valuable insights for clinicians encountering similar cases. Improved awareness and knowledge of ovarian lymphangiomas are essential for timely diagnosis and optimal patient outcomes.

An Unusual Case of Thigh Swelling

Lymphangiomas are benign tumours, almost exclusively found in children. Primary work-up includes imaging. We report a case of lymphangioma in the leg in an adult patient, initially masked as a myxoma. Our patient underwent ultrasound, computerised tomography, and magnetic resonance imaging, which were suggestive of myxoma. Treatment for lymphangioma varies from sclerotherapy to definitive surgical management. In our case, surgical management was selected under consideration of myxoma; however, histopathology confirmed lymphangioma. Lymphangiomas in adult patients can be masked by other conditions and should be considered as a differential in lower leg swellings.

Retroperitoneal lymphangioma as the final diagnosis of a middle-aged woman with abdominal pain: a case report

BACKGROUND

Lymphangiomas are lesions attributed to congenital malformations of the lymphatic system, or acquired chronic obstruction of the lymphatic network due to trauma, radiation, surgical manipulation, inflammation, or infection. Overall, lymaphangiomas are rare, and particularly, retroperitoneal lymphangiomas are far more uncommon per reported cases.

CASE PRESENTATION

A 49-year-old Iranian woman presented with a progressive abdominal pain since approximately 1 month before admission. She was found to have a retroperitoneal lymphangioma after a precise radiological and surgical workup.

CONCLUSION

Retroperitoneal lymphangiomas are rare lesions, sometimes indistinguishable from malignant lesions originating from pancreas and adjacent organs. Complete surgical removal and histologic evaluation of the lesion is the gold standard of treatment and diagnosis.

A case of cystic lymphangioma arising from the parauterine tissue

A 57-year-old woman, gravida 3, para 3, with no complaints visited our hospital for right-sided adnexal tumor found incidentally in cancer screening. She had no medical history, surgical history, or gynecological disease. Imaging studies showed a 5-cm lobular cystic tumor on the right side of uterus. We suspected right hydrosalpinx and decided to perform diagnostic laparoscopy. During laparoscopy, the right adnexa was found to be atrophic, and the tumor was located in the broad ligament. The tumor was observed to be a multilocular cyst containing yellow fluid that developed from the right parauterine tissue. The tumor was resected from the surrounding tissue. Histological examination revealed that the multilocular cyst contained a vascular component surrounding the lymphatic endothelium and was decided to be a cystic lymphangioma. The patient was followed up and there was no evidence of recurrence at postoperative 7 months. We experienced a very rare case of lymphangioma arising from the parauterine tissue. The laparoscopic approach can assist with both diagnosis and treatment.

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.

A rare occurrence of an incidental primary intra-abdominal Cystic Lymphangioma in a Middle Eastern adult female: A case report

Cystic Lymphangiomas (CLs) are rare vascular anomalies of benign nature. The etiology remains a subject of controversy, but they are considered to arise due to anomalies that occur during the normal embryogenic developmental process of lymphatic vessels. They have an estimated incidence rate of merely 1 in every 20,000-250,000 individuals. Since they are mainly known as a disease of the pediatric population, accurate epidemiological rates of CLs, especially in adults, are still unidentified due to the scarcity of published data. Documentation is pivotal to collect further information about them to establish timely diagnoses and minimize the potentially high patient morbidity.

Case Presentation

The authors hereby demonstrate the case of a 46-year-old lady who presented to the outpatient general surgery clinic at our university hospital complaining of chronic right hypochondriac abdominal pain. Investigative radiological imaging marked a cystic formation with well-defined borders and homogenous content extending from the lower pole of the right kidney to the lower hepatic border.

Clinical Discussion

Surgical intervention was performed by completely resecting the lesion in question. Directly afterward, histopathological analysis was achieved and established the diagnosis of a CL.Conclusion:CL is a rare neoplasm with ill-defined symptoms and ambiguous clinical presentations. They remain poorly studied due to their rarity and lack of sufficient data in the published literature. This magnifies the importance of clinical awareness and time-efficient surgical intervention. Documenting these cases aids in identifying their subsequent etiological origins, disease-specific risk factors, clinical course, and yields proposals of novel therapeutic approaches.

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.

Cystic retroperitoneal metastasis from testicular seminoma, radiologically mimicking as lymphangioma

Background

Retroperitoneal nodal metastasis in a primary testicular tumor is not uncommon and usually presents as solid or solid-cystic nodal masses. A completely cystic appearance with fluid attenuation or fluid signal intensity on computed tomography (CT) and magnetic resonance imaging (MRI), respectively, is an uncommon presentation. There are many case reports of different types of cystic retroperitoneal masses; however, to our knowledge, metastatic retroperitoneal cystic masses showing fluid attenuation/fluid signal intensity on CT/ MRI secondary to primary testicular seminoma masquerading as cystic lymphangioma has been rarely reported in the medical literature. Our case report reports a case of a metastatic retroperitoneal cystic mass in a known case of testicular seminoma patient, which was misdiagnosed as cystic lymphangioma initially based on imaging.

Case presentation

A 55-year-old—patient presented to our hospital with abdominal pain, which was on and off in character. The patient underwent routine ultrasound abdomen, CT and MRI, which revealed multiple cystic lesions in the retroperitoneum. Initially, a provisional diagnosis of cystic lymphangioma was made based on the utterly cystic nature of the lesion and the presence of calcification. However, fine-needle aspiration cytology (FNAC) confirmed the metastatic origin of the lesion and was strengthened by the previous clinical history of orchidectomy.

Conclusion

The treatment strategy for cystic retroperitoneal masses varies depending on the cause and its nature, so differentiation between the cystic masses is essential. Metastasis should also be kept in the differentials in all cystic retroperitoneal masses. Moreover, clinical history and FNAC can assist in making the correct diagnosis.

Rapidly enlarging axillary cystic hygroma in a 6-year-old male patient: A case report and literature review

INTRODUCTION

Cystic hygromas are relatively uncommon tumors of lymphatic origin, it appears most of the time, approximately 90 % before age of 2 years, and it is caused by abnormal development of lymphatic vessels.

CASE PRESENTATION

Here we report a case of axillary cystic hygroma in a 6-year-old healthy boy, which presented with the rapid development of a right axillary mass during 3 days, without any predisposing factor.

DISCUSSION

Cystic hygromas occur due to complete or partial obstruction of lymphatic vessels, which leads to lack of communication with the venous system, this results in the accumulation of lymphatic fluid and swelling, it occurs in the cervicofacial region most of the time 75 %, but it can arise anywhere in the body, it classically presents as painless, soft mass, diagnosis can be done using ultrasound, CT, MRI, each of which has its advantages, surgical treatment is routinely favored, but other options are also available.

CONCLUSION

Axillary cystic hygromas are quite rare, few cases have been reported in fetuses and adults, but only one case in the pediatric age group, thus, in light of these cases, cystic hygromas should be considered in the differential diagnosis of any cystic axillary swelling.

Surgical excision of a large retroperitoneal lymphangioma: A case report

BACKGROUND

Lymphangiomas are rare benign tumors most commonly found in children under 2 years of age; adult cases are extremely rare. Retroperitoneal lymphangiomas represent less than 1% of all lymphangiomas. Because of their benign nature and possibility of spontaneous resolution, lymphangiomas are sometimes left untreated for long periods of time. However, if they grow large enough to compress surrounding structures, retroperitoneal lymphangiomas may cause symptoms such as abdominal pain, nausea or vomiting. We report a case of a rapidly growing retroperitoneal lymphangioma in an adult, treated with complete surgical excision.

CASE SUMMARY

A 60-year-old female who was diagnosed with an intra-abdominal cystic mass (11 cm × 9.5 cm) seven years ago presented to our hospital with symptoms of early satiety, nausea, and intermittent abdominal pain. Computed tomography (CT) scan confirmed interval enlargement to a 24 cm × 22 cm-sized huge left retroperitoneal mass, causing left hydronephrosis by external compression. Laparotomy was done via long midline incision. Due to severe adhesion between the aorta and the medial border of the mass, the cyst was intentionally opened for fluid aspiration and size reduction. After suture closure of the opening, we proceeded carefully with dissection. Aspiration showed light yellowish serous fluid. The mass was excised completely, and the pathology was consistent with cystic lymphangioma. The post-operative period was uneventful, and the patient was discharged without complications. Follow-up CT scan one month after surgery confirmed complete removal of the mass and decreased left hydronephrosis.

CONCLUSION

Excision of the huge retroperitoneal cystic mass resulted in relief of the patient’s symptoms, originally caused by external compression, and also ruled out the possibility of malignancy.

Recurrent Retroperitoneal Lymphatic Malformation in a Pediatric Patient: A Case Report

Retroperitoneal lymphatic malformations are rare, benign, cystic tumors of the lymphatic system, accounting for 1% of all lymphatic malformation manifestations. Lymphatic malformations are often asymptomatic, but may clinically present with abdominal pain and a palpable mass. Initial diagnostic workup is challenging due to the difficulty of differentiating from masses that may arise from the pancreas, liver, and kidney. This report describes a recurrent retroperitoneal lymphatic malformation in a 15-year-old male. The patient presented with abdominal pain and radiological imaging demonstrated abdominal fluid collection. Following conservative management using aspiration, the patient presented three months later with recurrent abdominal pain. Radiological imaging identified a large thin-walled cystic lesion in the right hemiabdomen containing minimal thin internal septations. Histological analysis confirmed the lymphatic malformation following computed tomography-guided biopsy. The patient underwent aspiration and was referred for outpatient sclerotherapy to prevent future abdominal fluid collection. This case highlights conservative management of recurrent retroperitoneal lymphatic malformation, both on the initial and subsequent presentation.

A rare incidence of retroperitoneal Cystic Lymphangioma in a 45-year-old female - A Case Report

Introduction and importance

Cystic lymphangioma is an extremely rare benign vascular neoplasm of mesodermal origin, arising from lymphatic vessels and occurring principally in male children. The retroperitoneum is the rarest site, accounting for <1 % of all types of lymphangioma. The incidence of cystic lymphangioma is unknown due to the scarcity of published data.

Case presentation

A 45-year-old female presented to our hospital complaining of vague abdominal pain and intermittent episodes of vomiting over four months. Preoperative imaging via ultrasound and Computed Tomography revealed a well-demarcated retroperitoneal cystic mass between the right kidney and the liver.

Clinical discussion

The mass was excised laparoscopically. Histopathological examination confirmed a cystic hygroma (a subtype of cystic lymphangioma).

Conclusion

Cystic lymphangioma is rare, often misdiagnosed and may present with vague symptoms. Complete resection may be feasible and can be curative.

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Cystic lymphangioma is a rare benign lymphatic neoplasm presenting almost exclusively in children.

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Retroperitoneal lymphangiomas comprise <1 % of all lymphangiomas.

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Presenting symptoms may be non-specific, as in our case.

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The mass could become infected, bleed or rupture.

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Complete surgical resection is the treatment of choice for such lesions.

Retroperitoneal lymphangioma mimicking malignant tumor treated by pancreaticoduodenectomy

Lymphangiomas are classified as lymphatic malformations, which are more common in children and rare in adults. It frequently occurs in the cervical and axillary regions and uncommonly in the retroperitoneum. A 39-year-old woman presented to our department for the investigation for a 55 mm asymptomatic mass in the right anterior adrenal cavity. Abdominal ultrasound showed a tumor containing cysts in the right anterior adrenal cavity. Contrast-enhanced computed tomography showed that the tumor was poorly contrasted and ill-defined. Magnetic resonance imaging suggested that the tumor contained a small amount of fat. The tumor tended to grow, and the possibility of malignant diseases such as liposarcoma could not be excluded. Therefore, surgical resection was performed. Since intraoperative findings showed that the tumor tightly invaded to the duodenum and pancreatic head, a pancreaticoduodenectomy was selected. The entire tumor was removed without exposing the tumor. Macroscopic findings indicated that the specimen was 55 mm in size, indistinctly demarcated, yellow-white in color, and polycystic. Histologically, lymphovascular proliferation was observed with infiltration of the pancreatic head and the duodenal muscle layer. The diagnosis of lymphangioma was finally made. There was no recurrence 2 years after surgery.

Giant idiopathic benign retroperitoneal cyst: a case report

BACKGROUND

Primary retroperitoneal cyst formation without connection to adjacent anatomical structures is a rare and benign entity with the majority of these cysts being discovered incidentally. If symptoms develop, they are generally non-specific and related to compression of the adjacent retro-/or intraperitoneal structures. Complete resection of the cyst is curative and therefore the preferred treatment option. We report a case of giant retroperitoneal cyst for which a total surgical removal was performed.

CASE REPORT

A 79-year-old female consulted our department with complaints of long lasting abdominal pain and progressive abdominal distension. CT abdomen revealed a giant retroperitoneal cyst (35 cm × 25 cm × 21 cm) without radiological features of malignancy but with severe mass effect on the surrounding intra-abdominal structures. A median laparotomy was performed with a complete excision of cyst. No signs of malignancy or atypia were observed on histological examination.

CONCLUSION

Idiopathic retroperitoneal cysts can slowly grow to giant proportions and subsequently lead to chronic vague abdominal symptoms. Complete surgical excision is curative and should be pursued.

A rare case of a retroperitoneal lymphangioma causing chronic flank pain in an adult

Retroperitoneal lymphangiomas are exceedingly rare and typically asymptomatic. We present a case of a 27 year-old female with chronic right flank pain and cross-sectional imaging showing a large multi-cystic mass located medial and inferior to the right kidney. The patient underwent an uncomplicated robotic-assisted, laparoscopic resection of the mass with final pathology showing a benign lymphangioma. This case highlights the importance of recognizing retroperitoneal lymphangiomas as atypical causes of chronic flank pain and demonstrates that these benign tumors can be successfully resected robotically. Given today's urology residency training, urologists are likely uniquely positioned to best manage these peri-renal lymphatic malformations.

Pediatric cystic lymphangioma of the retroperitoneum: A case report and review of the literature

RATIONALE

Cystic lymphangioma (CL) is a rare benign tumor resulting from a failure of the lymphatic system development. It may occur at any age but it is more frequent during childhood. Its clinical presentation and location are various but abdominal CL are uncommon. Among those, mesenteric presentation is the most frequent form whereas CL of the retroperitoneum are particularly rare.

PATIENT CONCERNS

Herein, we report the case of a 17-years-old patient with no medical history who presented with right-upper quadrant (RUQ) pain, but no other symptom. Physical examination showed tenderness of the RUQ without distension. Lab tests were unremarkable.

DIAGNOSIS

Abdominal computed tomography (CT) highlighted a retroperitoneal cystic mass potentially infiltrating the mesenterium, raising suspicion of a CL of the retroperitoneum. Diagnosis of CL was confirmed by histological analyses.

INTERVENTION

Patient underwent an exploratory laparoscopy that infirmed infiltration of the mesenterium and allowed for resection.

OUTCOMES

Postoperative course was uneventful and there is no evidence of recurrence after 14 months of follow-up.

LESSONS

Although CL essentially occur in children, pediatric retroperitoneal CL is a rare finding, with only 21 cases identified in the literature.In summary, CL are benign tumors rarely located in the retroperitoneum. Despite performant imaging technologies, preoperative diagnosis is challenging. Whenever possible, laparoscopic resection should be the treatment of choice. Herein, we report the largest CL pediatric case laparoscopically resected, and the first review of the literature on the topic.

Cystic lymphangioma of the stomach with marked reactive changes: a rare cause of gastric outlet obstruction in adult

Cystic lymphangiomas are benign lymphatic tumours which usually affect the paediatric population and are predominantly located in the head and neck region. Its occurrence during adulthood and an intra-abdominal location are both extremely uncommon. Clinically and radiologically, these lesions often mimic malignancy. Infrequently, these tumours can undergo degenerative and reactive changes obscuring the diagnostic features. We describe hereby an anecdote of cystic lymphangioma with marked reactive changes presenting with the features of gastric outlet obstruction in an adult patient.

Benign multicystic peritoneal mesothelioma: literature review and update

Benign multicystic peritoneal mesothelioma (BMPM) is a rare peritoneal tumor diagnosed predominantly in pre-menopausal women. Associated risk factors include endometriosis and pelvic inflammatory disease in women, and prior abdominal surgery in both genders. To date, the pathogenesis of this disease remains controversial with possible etiologies, including a neoplastic versus a reactive process. Given the risk factors, some authors believe that this disease is secondary to a reactive process. However, because some studies describe cases where there is no prior surgical history or inflammatory milieu present, and because of this entity’s predilection for recurrence, some authors believe the origin to be neoplastic. Some genetic and familial associations have also been reported. Malignant transformation is extremely rare, with only two cases reported in the literature, despite the recurrence potential. Like the etiology, the name of this entity is also controversial. Some authors prefer the term “peritoneal inclusion cyst (PCM)” instead of “benign cystic mesothelioma” and argue that the term mesothelioma should only be used when there is evidence of atypia. Most cases of BMPM are discovered incidentally. Others reflect sequela of tumor mass effect. It appears intra-operatively as large, multi-focal, cystic lesions in the peritoneal and pelvic cavity. Diagnosis is achieved through surgical sampling with histopathological examination. Immunobiologically, BMPM exhibits multiple small cystic spaces with flattened lining containing calretinin positive cells without atypical features, mitotic figures, or tissue invasion. Treatment includes cytoreductive surgery. Here we present a case of BMPM in a 60-year-old male – a rare disease in an uncommon patient population.

Retroperitoneal lymphatic malformation in a dog

Background

Lymphatic vascular malformations are rare findings in canine patients with six reports available in veterinary literature. Retroperitoneal cystic lymphatic malformations have not been described previously in canine patients and neither has the use of immunohistochemistry to determine their origin, i.e. vascular versus lymphatic.

Case presentation

An 8-year-old neutered female Cocker spaniel was referred for pollakiuria, dysuria and a painful abdomen. Computed tomography scanning of the abdomen showed a fluid filled structure adjacent to the urinary bladder. During surgical exploration, a thin walled cystic structure with sero-haemorrhagic fluid was found, extending from the retroperitoneal space into the abdomen. The mass was excised and submitted for histopathology, revealing a cystic mass lined by a fibrovascular capsule within the retroperitoneal/mesenteric adipose tissue. The inner surface of the cyst was lined by a single layer of bland, flattened spindle cells. Intramural blood vessels were well differentiated, with perivascular haemorrhage. On recurrence 11 months later, the mass was excised for the second time and a PleuralPort (Norfolk Animal products) was placed. Fifteen months after initial presentation, progression occurred with haemorrhagic fluid in the cystic space, pleural- and abdominal cavities and the owners opted for euthanasia. Histopathology and positive immunohistochemistry for lymphatic markers lymphatic vessel endothelial hyaluronic acid receptor-1 (LYVE-1) and prospero homeobox protein-1 (PROX-1) confirmed a lymphatic vascular origin of the cystic structure.

Conclusions

To our experience, a definitive diagnosis of retroperitoneal cystic malformation of lymphatic origin could be done only by combining the clinical presentation, advanced imaging, histopathology and LYVE-1 and PROX-1 immunohistochemistry. This is the first report of a vascular malformation in a dog where immunohistochemistry was used to make a final diagnosis. A lymphatic malformation, even if rare, should be added on the list of the differential diagnosis in a patient with a retroperitoneal cystic structure containing serohaemorrhagic fluid. Results of this case report can aid in diagnosis of future cases, however, further studies on therapy and management are needed to provide additional information about optimal treatment of these patients.

Retroperitoneal cystic masses: magnetic resonance imaging features

The objective of this review is to discuss the clinical and histopathologic features, MRI characteristics, and management options of retroperitoneal cystic masses. Radiologists should be familiar with the MR imaging characteristics of retroperitoneal cystic masses to allow for a refined differential diagnosis, assist with lesion management, and prevent unnecessary invasive procedures.

Αdnexal cystic lymphangiomas in patients with massive leiomyomatous uterus: a not so uncommon finding on pelvic MRI

PURPOSE

To investigate any association between the presence of an adnexal cystic lymphangioma (ACL) and an enlarged leiomyomatous uterus.

METHODS

A retrospective observational study was conducted by two expert radiologists using a 10-year MRI database (2008-2018); 85 patients (mean age: 45.5 years ± 10.9) were considered eligible due to the presence of a single (n = 31) or multiple (n = 54) leiomyomas causing distortion of the uterine contour and uterine enlargement. The association of specific leiomyoma features (longest diameter (Dmax), location, number) and uterine volume with the presence of ACL was statistically tested. Diagnosis of ACL was based on typical imaging features (n = 14) and intraoperative/histological findings (n = 3).

RESULTS

ACL (unilateral = 9, bilateral = 8) was recorded in 17/85 (20%) of patients; it was more frequently observed when the largest leiomyoma was located in the uterine fundus (33.3%). Patients with ACL had significantly more leiomyomas (median: 5 vs. 2, p = 0.043), greater Dmax of largest leiomyoma (median: 13.3 vs. 7.2 cm, p < 0.001), and larger uterine volumes (median: 676.7 vs. 223.1 cm³, p < 0.001) compared to patients without ACL. ROC curve analysis for a number of leiomyomas showed that the optimal cut-off for the prediction of ACL was the presence of 5 leiomyomas with 53.8% sensitivity and 84% specificity (AUC = 0.65, 95% CI 0.51-0.83, p = 0.049), Dmax of largest leiomyoma 9.1 cm with 76.5% sensitivity and 77.9% specificity (AUC = 0.83, 95% CI 0.73-0.94, p < 0.001), and uterine volume 311 cm³ with 71% sensitivity and 75% specificity (AUC = 0.79, 95% CI 0.66-0.92, p < 0.001).

CONCLUSIONS

The presence of ACL is significantly associated with number of leiomyomas, Dmax of largest leiomyoma, and uterine volume; prospective evaluation of our results is needed to investigate its clinical significance.

Giant Primary Retroperitoneal Serous Cystadenoma: A Rare Entity Mimicking Multiple Neoplastic and Nonneoplastic Processes

Serous cystadenoma, often known as ovarian serous cystadenoma, is one of the common benign ovarian neoplasms. On the other hand, primary retroperitoneal serous cystadenoma is an extremely rare benign entity whose pathogenesis has not been well understood. Clinical presentation and symptomatology vary greatly and are highly dependent on the size and location of the lesion. Primary retroperitoneal serous cystadenomas are homogeneous, unilocular, thin-walled cystic masses. If they grow large enough, they tend to compress and deform adjacent organs, giving clinicians a misimpression of malignant pattern of behavior. Therefore, it is crucial to differentiate benign primary retroperitoneal serous cystadenomas from other epithelial and nonepithelial cystic lesions or masses involving retroperitoneal regions. Management-wise, complete cyst excision without rupture or spillage of the cyst contents is the recommended therapeutic method for primary retroperitoneal serous cystadenomas. This review will highlight the current knowledge on its pathogenesis and discuss its histopathologic features and differential diagnoses from the pathologist's point of view.

Fistula between the Thoracic Duct and an Unusual Vessel Aneurysm Branching Off the Abdominal Aorta Revealed by Aneurysm Rupture: A Case Report

Fistulas between an aneurysm branching off the abdominal aorta and the thoracic duct are rare. We report a case of aneurysmal-thoracic duct fistula diagnosed by angiography when aneurysm ruptured, and we successfully treated by catheter embolization. A 42-year-old man was referred to our hospital with a chief complaint of sudden back and chest pain. Computed tomography showed both post-mediastinal and retroperitoneal hematomas, with the aneurysm from the aorta being connected to the thoracic duct. After confirming the aneurysmal-thoracic duct fistula by angiography, we performed embolization of the aneurysm. The patient has remained well for 3 postoperative months, to date.

Giant Ovarian Lymphangioma: Case Report and Review of the Literature

INTRODUCTION

Lymphangiomas are benign tumors/malformations, characterized by proliferation of the lymphatic vessels. They may arise anywhere, although the most common localizations are the head-neck region and the axilla. To date, only 21 cases of lymphangioma of the ovary in a 60-year literature survey have been reported.

CASE REPORT

A 16-year-old female patient with long standing abdominal distension had 40 cm × 15 cm × 29 cm ovarian lymphangioma.

CONCLUSIONS

Our case highlights that lymphangiomas can occur in the adolescent population and should be added to the differential diagnosis of ovarian masses in this age group.

Detection and management of retroperitoneal cystic lesions: A case report and review of the literature

The identification of cystic lesions within the retroperitoneal space is a rare event that poses clinicians the challenge of a difficult diagnosis and disease management. Retroperitoneal cystic lesions account for a group of lesions that range from common benign lesions (e.g., lymphoceles developing as a surgical complication) to rare aggressive malignant neoplasms. Currently, in the majority of cases, image-guided procedures allow for a pathological diagnosis to be achieved in these challenging lesions, thus offering the chance of an appropriate treatment; however, the overall clinical assessment of retroperitoneal cysts is highly demanding. The present study reports the management of a representative clinical case, presenting with a voluminous cystic mass able to dislocate cave vein, whose diagnosis was preceded by a deep vein thrombosis. Computed tomography-scan and ultrasound guided percutaneous drainage were performed to achieve the diagnosis. Following the discussion of the current case report, a review of the pathological and radiological characteristics of retroperitoneal cystic lesions is presented.

An unresectable retroperitoneal malignant fibrous histiocytoma: A case report

Malignant fibrous histiocytoma (MFH) is most commonly observed in the extremities and the trunk but rarely in retroperitoneum. The present case report documents a 64-year-old man who was admitted with an abdominal palpable mass for 6 months. After a thorough investigation, a tumor of the retroperitoneum was identified adhered to adjacent organs and vessels. The patient experienced mild hydronephrosis and hydroureter as a result of the tumor compression. A number of previous surgeons considered the tumor unresectable and suggested palliative treatment. En bloc resection of the tumor was attempted but incomplete surgery was performed initially as the tumor was friable and prone to bleeding. Therefore, a biopsy of the tumor was performed and a double J ureteral stent was set for hydronephrosis. Histopathological examination confirmed the tumor was an MFH. The patient received neo-adjuvant chemotherapy with 4 cycles of mesna, doxorubicin, ifosfamide, and dacarbazine (MAID). A computed tomography scan demonstrated that the tumor had reduced in size following chemotherapy. En bloc resection of the tumor was arranged again 6 months later. The tumor exhibited a complete response to neo-adjuvant chemotherapy after the formal pathological evaluation. The patient survives without tumor recurrence >5 years without recurrence.

Retroperitoneal lymphangioma: A report of 2 cases and a review of the literature regarding the differential diagnoses of retroperitoneal cystic masses

Cystic lymphangioma is a type of benign tumor originating from the lymph vessels. The tumor commonly occurs in childhood, in the head or neck regions, and retroperitoneal localization and presentations in adulthood are rare. Determining a pre-operative diagnosis is often challenging, and in the majority of cases, a diagnosis is only possible subsequent to the histological examination of the surgical specimen. A radical resection is the recommended treatment for cystic lymphangioma, and recurrence is usually due to an incomplete excision of the mass. The present study reports 2 cases of cystic lymphangioma, localized in the pancreatic gland and duodenal wall respectively, which were treated with surgical resection. The study also briefly reviews the literature regarding the differential diagnosis of retroperitoneal cystic masses.

Primary retroperitoneal masses: what is the differential diagnosis?

Primary retroperitoneal masses include a diverse, and often rare, group of neoplastic and non-neoplastic entities that arise within the retroperitoneum but do not originate from any retroperitoneal organ. Their overlapping appearances on cross-sectional imaging may pose a diagnostic challenge to the radiologist; familiarity with characteristic imaging features, together with relevant clinical information, helps to narrow the differential diagnosis. In this article, a systematic approach to identifying and classifying primary retroperitoneal masses is described. The normal anatomy of the retroperitoneum is reviewed with an emphasis on fascial planes, retroperitoneal compartments, and their contents using cross-sectional imaging. Specific radiologic signs to accurately identify an intra-abdominal mass as primary retroperitoneal are presented, first by confirming the location as retroperitoneal and secondly by excluding an organ of origin. A differential diagnosis based on a predominantly solid or cystic appearance, including neoplastic and non-neoplastic entities, is elaborated. Finally, key diagnostic clues based on characteristic imaging findings are described, which help to narrow the differential diagnosis. This article provides a comprehensive overview of the cross-sectional imaging features of primary retroperitoneal masses, including normal retroperitoneal anatomy, radiologic signs of retroperitoneal masses and the differential diagnosis of solid and cystic, neoplastic and non-neoplastic retroperitoneal masses, with a view to assist the radiologist in narrowing the differential diagnosis.

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

INTRODUCTION

Lymphangiomas are rare, benign tumors. An intra-abdominal location of these lesions is rarer still and there are only a few reports describing laparoscopic resection for retroperitoneal lymphangiomas, especially in tumors that mimic pancreatic tumors.

CASE PRESENTATION

We present the case of an asymptomatic 30-year-old Japanese woman in whom a cystic tumor was found incidentally in close approximation to the pancreas. Because the tumor was located in the retroperitoneal space and the body of the pancreas was compressed, we were unable to distinguish a cystic lymphangioma from cystic pancreatic tumors. We started the procedure laparoscopically with five ports. The tumor was in fact separated from the pancreas and was dissected free from the body of the pancreas using scissors and laparoscopic coagulating shears. The left gastric vessels, which were compressed by the tumor, were preserved. As we realized that the tumor was connected to the retroperitoneal lymphatic tissue, we completed the procedure by performing a cystectomy without rupture. The specimen was extracted using a plastic bag. Our patient was discharged on postoperative day 7 without any complications. There is no evidence of recurrence during a >2-year observation period.

CONCLUSIONS

In addition to the therapeutic significance in differentiating between a cystic lymphangioma in close approximation to the body of the pancreas and a pancreatic cystic neoplasm, the laparoscopic approach is feasible and effective.

Retroperitoneal lymphangioma in an adult: a case report of a rare clinical entity

Background. Retroperitoneal lymphangioma is a rare, benign mesodermal tumor arising from the retroperitoneal lymphatics which usually presents in infancy and it is worthy to report a case when it has presented in an adult. After a thorough literature search in English we concluded that less than 200 cases of adult retroperitoneal lymphangioma have been reported so far. Apart from being a rare entity it also presents as a diagnostic dilemma and final diagnosis is often made on surgical exploration. Case Presentation. We report a case of retroperitoneal lymphangioma in a 55-year-old male who presented with abdominal distension and dull aching abdominal pain. Conclusion. Retroperitoneal lymphangiomas are rare tumors of infancy but may also present in adults where they are a diagnostic challenge. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone are often inconclusive and surgery is frequently required for definitive diagnosis and to ameliorate the symptoms.

Clinical and pathological characteristics of adrenal lymphangioma treated by laparoscopy via a retroperitoneal approach: experience and analysis of 7 cases

To describe the clinical and pathological characteristics of adrenal lymphangioma (AL) and share our experiences of the treatment of AL with retroperitoneal laparoscopic surgery. All patients pathologically diagnosed with AL were examined. The clinical and pathological characteristics, process of diagnosis, and preparation and treatment of all patients, especially patients treated with laparoscopic surgery, were summarized and retrospectively analyzed. From January 2008 to May 2014, 8 patients underwent adrenalectomies and were diagnosed with AL in our hospital. The median age was 45.5 years. All of these patients experienced a smooth adrenalectomy: 7 performed by laparoscopy via a retroperitoneal approach and 1 performed by open surgery. Five were female and the other 3 were male. These patients had unilateral adrenal lesions. Four were located on the right which to be same as the contralateral. In addition, 1 specimen was assayed by immunohistochemistry (IHC), which revealed positive results for CD31, CD34, Factor VIII-related antigen and D2-40, and negative results for cytokeratin AE1/AE3. During a brief follow up, all patients exhibited favorable results without discomfort. AL is a benign lesion with mild bio-behavior and patients are generally asymptomatic. The use of computerized tomography (CT) combined with enhanced CT has a superior advantage in diagnosis. Laparoscopic adrenalectomies that are performed via a retroperitoneal approach would be a very safe and efficient choice for AL treatment. D2-40 can be considered as a specific IHC marker in the pathological diagnosis of AL. However, pheochromocytoma and adrenal tuberculosis should be ruled out before and during the operation.

Cases of atypical lymphangiomas in children

Background. Lymphatic malformations or lymphangiomas are rare benign hamartomas that result from maldevelopment of primitive lymphatic sacs. They are most frequently found in the neck and axilla, while intra-abdominal and mediastinal lymphangiomas are uncommon. These are primarily tumours of infancy and childhood and are successfully treated with surgical excision. Summary of Cases. Five cases of lymphangioma comprising three intra-abdominal lymphangiomas and two unilateral axillary lymphangiomas presenting at one institution in Trinidad W.I. between 2005 and 2012 were examined. The presentations, location, workup, treatment, and outcome of these patients were studied. Conclusion. This paper discusses a range of extracervical lymphangioma cases seen at San Fernando General Hospital, Trinidad W.I. We report three intra-abdominal cases and the most common clinical presentations were abdominal pain and distension. Also two axillary cases were reported, which presented as painless axillary masses. The major concerns for excision of axillary lymphangioma by parents and surgeons were cosmesis and feasibility of complete resection without disruption of developing breast tissue and axillary vessels. We believe that ultrasound scan is very good at detection of the lesion, while CT is better at determining tumour content and planning for the operation. It is our opinion that complete surgical excision can be achieved.

Chronic Low Back Pain due to Retroperitoneal Cystic Lymphangioma

Abdominal cystic lymphangioma is a rare benign neoplasm. Less than 1% of lymphangiomas is in the retroperitoneum. Lymphangioma is mostly asymptomatic. Chronic symptoms were reported in retroperitoneal type more than others. Acute symptoms due to complications like infection, cyst rupture or hemorrhage may occur. We report an 18-years-old girl with low back pain from 6 months ago with huge pelvic mass and diagnosis of retroperitoneal cystic lymphangioma.

Retroperitoneal cystic lymphangioma diagnosed by endoscopic ultrasound-guided fine needle aspiration

Retroperitoneal cystic lymphangiomas are rare tumors of the lymphatic system. These tumors usually present in childhood and are often diagnosed incidentally with imaging procedures. Although benign, they can grow to large sizes and become symptomatic due to their compressive effects. They can cause diagnostic dilemmas with other retroperitoneal cystic tumors including those arising from the liver, kidney, and pancreas. Endoscopic ultrasound (EUS) has become an invaluable tool in the assessment of cystic lesions in the region of the pancreas. This case describes a 66-year-old female who presented with 3 months of abdominal pain. Radiographic imaging was suggestive of a cystic lesion in the region of the pancreas. EUS was performed confirming a cystic lesion adjacent to the tail of the pancreas with subsequent fine needle aspiration fluid analysis consistent with a cystic lymphangioma.

Lymphangioma: surrounding the ovarian vein and ovary

Lymphangiomas are usually benign lesions seen in the head and neck region in children. Intra-abdominal localisation is rare and the majority of these cases are in early childhood. Retroperitoneal lymphangiomas constitute approximately 1% of all lymphangiomas. They are generally diagnosed incidentally, may be asymptomatic or may present with a palpable abdominal mass. A limited number of cases of ovarian lymphangiomas have been reported in women, whereas there are no reported cases of paraovarian localisation. We present a rare case of lymphangioma located in bilateral paraovarian region and along the left ovarian vein with radiological findings.

Dynamics of Elective Case Cancellation for Inpatient and Outpatient in an Academic Center

BACKGROUND

Unexpected surgical cancellation is common and can have significant adverse effects. Cancellation rates vary because of a lack of a standard definition, different patient populations and study methodology. We hypothesized that case cancellation has a different pattern in a dedicated ambulatory surgical center compared to a general operating room (OR) setting in a large academic center without an anesthesia preoperative evaluation center necessitating evaluation by the various surgeons.

METHODS

Elective cases in general OR and in the ambulatory surgical center were included in this study. Elective cases are defined as the non-emergent cases scheduled before 8:00 am on the day of surgery. A cancelled case was defined as a scheduled procedure which is not performed on the scheduled procedure day. Case cancellation was monitored in real time using an electronic patient flow system (Navicare). As soon as the case is cancelled, the reason for the cancellation was obtained from the surgeon, the anesthesiologist, the OR coordinated nurses and/or the floor nurse. In the day surgical center, the cancelled cases were followed to determine whether/when they were rescheduled.

RESULTS

4261 elective cases were included in this investigation, including 2751 cases in the general OR and 1510 cases in the ambulatory surgical center. A total of 283 cases (6.6%) were cancelled which include 206 cases from the general OR and 77 from the ambulatory surgical center. The cancellation rate in the general OR was 7.5%, among which inpatients have the highest cancellation rate of 18.1%, followed by outpatients at 4.6%, and same day admission at the lowest cancellation rate of 2.0%. The top 3 reasons for cancellation in general OR werein adequate preoperative preparation 29.4 ± 4.5%, medical condition change 28.5 ± 10.2%; and scheduling issue 20.2 ± 7.1%. Most (59.2 ± 8.9%) of the cancellations was considered preventable, 12.3 ± 5.9% was considered potentially preventable, and 28.5 ± 10.2% were not preventable (such as patient condition changes). The cancellation rate in the ambulatory surgical center was 5.1%. The major reason for cancellation was patient no show 75.8 ± 5.2 %, 61% of those no show patients were rescheduled and the mean delay in surgery was 18 days (range from 1 day to 84 days).

CONCLUSIONS

Case cancellation is not un-common in a large academic center without a preoperative evaluation clinic. The dynamics of case cancellation are different in an ambulatory surgical center as compared to the general OR. Inpatients have the highest cancellation rate associated with inadequate preoperative preparation and scheduling, this should be preventable via adopting proper systems of evaluation and preparation. Most of the case cancellations in the ambulatory surgical center are from patient no show, suggesting that administrative strategies to reduce this issue should be implemented. The patients admitted on the same day of surgery had the lowest cancellation rate requiring minimal intervention.

Retroperitoneal cystic lymphangioma: a diagnostic and surgical challenge

A lymphangioma is a benign proliferation of lymph vessels, producing fluid-filled cysts that result from a blockage of the lymphatic system. The incidence of abdominal lymphangiomas is unknown; however they account for from 3% to 9.2% of all pediatric lymphangiomas, with retroperitoneal lymphangioma representing less than 1% of abdominal lymphangiomas. Due to rarity, preoperative diagnosis is often difficult.

Cystic pancreatic lymphangioma

Lymphangioma of the pancreas is a rare benign tumor of lymphatic origin. Retroperitoneal lymphangiomas account for 1% of all lymphangiomas. Herein, we report a case of cystic pancreatic lymphangioma diagnosed in 34 year-old female patient who was hospitalized for a slight pain in the epigastrium and vomiting. Radiological imaging revealed a large multiloculated cystic abdominal mass with enhancing septations involving the upper retroperitoneum. During the laparoscopic surgery, a well circumscribed polycystic tumor was completely excised preserving the pancreatic duct. The patient made a complete recovery and is disease-free 12 months postoperatively.