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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 12  |  Page : 1778-1780

Generalized cystic lymphangiomatosis incidentally recognized in an asymptomatic adult: Peroperative, CT, MRI, and histopathological findings of a very rare case


1 Department of Radiology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
2 Department of Gastrointestinal Surgery, ZTB Women's Health Research and Education Hospital, Ankara, Turkey

Date of Submission18-Nov-2018
Date of Acceptance18-Jul-2019
Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. S Akay
Department of Radiology, University of Health Sciences, Gulhane Training and Research Hospital, Etlik - 06018, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_582_18

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   Abstract 


Generalized cystic lymphangiomatosis is an uncommon congenital lymphatic malformation that may affect soft and hard tissues as well as organs. It is rarely seen in adult patients. Osseous lesions appear as well-defined cystic lesions with a sclerotic rim without periosteal reaction or a soft tissue component. A nonenhancing lesion in fluid density appears to be one of the most common characteristics of abdominal diseases, and clinical features are directly related to the extent of the disease. In this report, we present peroperative, computed tomography (CT), magnetic resonance imaging (MRI), and histopathological findings of a very rare case of generalized cystic lymphangiomatosis recognized in adulthood.

Keywords: Computed tomography, congenital, generalized cystic lymphangiomatosis, lymphatic malformation, magnetic resonance imaging


How to cite this article:
Arda K N, Akay S, Kizilkanat K. Generalized cystic lymphangiomatosis incidentally recognized in an asymptomatic adult: Peroperative, CT, MRI, and histopathological findings of a very rare case. Niger J Clin Pract 2019;22:1778-80

How to cite this URL:
Arda K N, Akay S, Kizilkanat K. Generalized cystic lymphangiomatosis incidentally recognized in an asymptomatic adult: Peroperative, CT, MRI, and histopathological findings of a very rare case. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 12];22:1778-80. Available from: http://www.njcponline.com/text.asp?2019/22/12/1778/272211




   Introduction Top


Generalized cystic lymphangiomatosis (GLA) is an uncommon congenital disorder of the lymphatic ducts that may involve soft tissues, bone structures, and various organs in the body.[1] Well-defined cystic lesions with a sclerotic rim without periosteal reaction or associated soft tissue mass are the most common presentation of osseous involvement.[1] The condition may involve mediastinum, lungs, liver, and spleen. Abdominal lymphangiomatosis is very rarely seen in adult patients.[1] Clinical features are directly related to the severity and the number of sites affected by the disease.[2]

In the current report, we present an extremely rare case of GLA in the abdomen recognized incidentally during a cesarean section and its peroperative, computed tomography (CT), and magnetic resonance imaging (MRI) results as well as histopathological findings.


   Case Report Top


A 29-year old pregnant female (gravida 2, para 1) was admitted to the obstetrics and gynecology department of a different hospital at term. The patient was accepted for a cesarean section because she had an uncomplicated cesarean section for her birth three years before. Before surgery, laboratory results were within normal limits. During the operation, white opaque liquid was seen at the incision and in the abdomen, and there were multiple white, cystic structures on the intestine walls [Figure 1]. A gastrointestinal surgeon was asked to join the operation.
Figure 1: Peroperative photo shows white, round structures located on the walls of the intestines (black arrows). The cysts contain a white fluid called chyle

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Frozen section biopsy revealed that the structures were all benign. A surgical drain was placed and the operation was terminated upon successful delivery of the baby. Lymphangiectasis was reported in histopathology results, and the patient was referred to our hospital for further evaluation.

Radiologic examinations were performed for further assessment. CT results revealed an enlarged spleen containing multiple well-circumscribed cystic lesions, which usually show no contrast enhancement. Perihepatic, paraaortic, and pelvic free fluid were seen. Multiple thin-walled cystic lesions were detected in the right iliac bone, sacrum, one of the ribs in the left cage, the T12 vertebral body, and some lumbar vertebrae. Extensive free fluid collections were observed in the perihepatic region and pelvic area [Figure 2]. Upon enhanced MRI examination, cystic lesions similar to those seen on CT were seen at thoracic and lumbar vertebral bodies and on the spleen. All of the lesions were hypointense on T1-weighted images and hyperintense on T2-weighted images and showed no enhancement after contrast administration [Figure 3].
Figure 2: Axial-enhanced CT image in abdomen window (a) demonstrates a well-defined, thin-walled, hypodense cyst in the spleen (white arrow) and a large lesion with fluid density without mass effect in the paraaortic region (black arrow). In addition, a lytic lesion is readily seen at the left side of the lumbar vertebral body (black arrowhead). Axial CT image in the bone window (b) shows a lytic lesion with a sclerotic border at the right iliac bone (white arrow)

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Figure 3: Coronal fat-saturated T2-weighted MRI demonstrates multiple, hyperintense lesions in the vertebral bodies, spleen, and uterus

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Cytologic examination revealed many mature lymphocytes, a few histiocytes, eosinophils, and two centrally localized mesothelial cells in the cystic fluid. The findings were consistent with indicators for lymphangioma [Figure 4].
Figure 4: Cytologic examination taken from abdominal cystic lesions demonstrates many mature lymphocytes, a few histiocytes, eosinophils, and two centrally located mesothelial cells in the cyst fluid that is consistent with lymphangioma (May–Grunwald–Giemsa stain × 100)

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Based on these findings, the patient was diagnosed with GLA both clinically and histopathologically and was referred to the oncology department of our hospital for further treatment.

As previously mentioned, the patient remained asymptomatic until adulthood, and no complication or white opaque liquid leakage from the incision site was observed during the cesarean section. We attributed this to the fact that there had not been much free fluid in the pelvic area at that time and it may have increased in the intervening three years.


   Discussion Top


Lymphangiomas are cystic malformations that constitute one of the rarest benign pathologies of the lymphatic system. This condition is commonly seen in children and adults are rarely affected.[3] When this malformation is identified in multiple locations and organs, it is considered “generalized lymphangiomatosis.”

The diffuse or multicentric proliferation of dilated lymphatic vessels resembling common lymphatic malformations is the main characteristic of GLA. Complex lymphatic anomaly is another term that has recently been suggested for intractable lymphatic disorders such as GLA and Gorham–Stout disease (GSD).[4] In 1955, Gorham and Stout[5] reported the main pathological characteristics of this disease. While GLA presents with lytic areas confined to the medullary cavity of the bones, GSD patients have cortical bone loss due to progressive osteolysis.[6].

Pelvic bones, femur, rib, vertebra, and skull are the most affected bones in GLA.[3],[6] Although osseous involvement occurs mostly as lytic lesions, a rare sclerotic variant has also been described.[7] Typical bone involvement is in the form of well-defined, round lytic lesions with sclerotic margins without periosteal reaction or a soft tissue component.[8]

GLA commonly presents at birth or in childhood. This condition has a wide range of presentations and may affect various sites, including bone, liver, spleen, mediastinum, lungs, and soft tissues. The number of affected sites and severity determines the disease's clinical course.[2]

Abdominal pain, gastrointestinal bleeding, and protein-losing enteropathy are typical clinical features of abdominal lymphangiomatosis, but it can be asymptomatic.[1] Cystic abdominal lesions such as pancreatic pseudocyst, abdominal tuberculosis, hydatid disease, or cystic malignancies are the main differential diagnoses of the lymphatic system.[9]

The current imaging modalities for evaluating lymphangiomatosis are CT and MRI. Lymphangiomas are seen as nonenhancing lesions in fluid density with thin, indistinct walls and septa on CT.[10] Typical lesions appear as well-defined, nonenhancing cystic structures.

MRI is widely used as a tool for the diagnosis of GLA and possesses several advantages. It offers a better characterization of lesion morphology and is able to specify lesion origin.[9] Existing studies show that lytic lesions of lymphangiomatosis typically appear hypointense on T1-weighted magnetic resonance images and hyperintense on T2-weighted images, while the rare sclerotic variant is seen as hypointense on both T1- and T2-weighted images.[7]

In conclusion, GLA is a disease that should not be disregarded in any pathology findings characterized by multiple cystic lesions involving bones and/or abdomen. Although it is generally seen in children, it can also be diagnosed in adult patients. Familiarity with the CT and MRI characteristics of these lesions enables more accurate diagnosis and can provide valuable guidance for the treatment plan.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lin RY, Zou H, Chen TZ, Wu W, Wang JH, Chen XL, et al. Abdominal lymphangiomatosis in a 38-year-old female: case report and literature review. World J Gastroenterol 2014;7;20:8320-4. doi: 10.3748/wjg.v20.i25.8320.  Back to cited text no. 1
    
2.
Blei F. Lymphangiomatosis: clinical overview. Lymphat Res Biol 2011;9:185-90. doi: 10.1089/lrb.2011.0020.  Back to cited text no. 2
    
3.
Alqahtani A, Nguyen LT, Flageole H, Shaw K, Laberge JM. 25 years' experience with lymphangiomas in children. J Pediatr Surg 1999;34:1164-8.  Back to cited text no. 3
    
4.
Trenor CC 3rd, Chaudry G. Complex lymphatic anomalies. Semin Pediatr Surg. 2014;23:186-90. doi: 10.1053/j.sempedsurg.2014.07.006.  Back to cited text no. 4
    
5.
Gorham LW, Stout AP. Massive osteolysis (acute spontaneous absorption of bone, phantom bone, disappearing bone); its relation to hemangiomatosis. J Bone Joint Surg Am 1955;37-A:985-1004.  Back to cited text no. 5
    
6.
Michael TD, Nupur G, Bjorn RO. Viewpoints on vessels and vanishing bones in Gorham–Stout disease. Bone 2014;63:47-52. doi: 10.1016/j.bone.2014.02.011.  Back to cited text no. 6
    
7.
Forstner R, Datz C, Dietze O, Rettenbacher L. Sclerotic variant of lymphangiomatosis of bone: imaging findings at diagnosis and long-term follow-up. Skeletal Radiol 1998;27:445-8.  Back to cited text no. 7
    
8.
Maki DD, Nesbit ME, Griffiths HJ. Diffuse lymphangiomatosis of bone. Australas Radiol 1999;43:535-8.  Back to cited text no. 8
    
9.
Ozeki M, Fujino A, Matsuoka K, Nosaka S, Kuroda T, Fukao T. Clinical Features and Prognosis of Generalized Lymphatic Anomaly, Kaposiform Lymphangiomatosis, and Gorham-Stout Disease. Pediatr Blood Cancer. 2016;63:832-8. doi: 10.1002/pbc.25914.  Back to cited text no. 9
    
10.
Patil AR, Nandikoor S, De Marco J, Bhat R, Shivakumar S, Mallrajapatna G. Disorders of the lymphatic system of the abdomen. Clin Radiol. 2016;71:941-52. doi: 10.1016/j.crad.2016.06.116.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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