eMedicine Specialties > Dermatology > Diseases of the Vessels

Lymphangioma

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Geover Fernandez, MD, FAAD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry New Jersey, New Jersey Medical School

Updated: Nov 13, 2009

Introduction

Background

Lymphangiomas are uncommon, hamartomatous, congenital malformations of the lymphatic system that involve the skin and subcutaneous tissues. The classification of lymphangiomas lacks a standard clear definition and universal application, in part because of the nature of lymphangiomas, which represent a clinicopathologic continuum. The classification most frequently used divides these lesions into 2 major groups based on the depth and the size of these abnormal lymph vessels. The superficial vesicles are called lymphangioma circumscriptum. The more deep-seated group includes cavernous lymphangioma and cystic hygroma. Many categorize cystic hygroma as a variant of cavernous lymphangioma.

16-year-old obese boy with large unilateral verrucous lymphangioma

Pathophysiology

In 1976, Whimster² studied the pathogenesis of lymphangioma circumscriptum. According to Whimster, the basic pathologic process is the collection of lymphatic cisterns in the deep subcutaneous plane. These cisterns are separated from the normal network of lymph vessels, but they communicate with the superficial lymph vesicles through vertical, dilated lymph channels.

Whimster postulated that these cisterns might arise from a primitive lymph sac that fails to connect with the rest of the lymphatic system during its embryonic development. A thick coat of muscle fibers that cause rhythmic contractions line these sequestered primitive sacs. Rhythmic contractions increase the intramural pressure, causing dilated channels to protrude from the walls of the cisterns toward the skin. He suggested that the vesicles seen in lymphangioma circumscriptum are outpouchings of these dilated projecting vessels.

Whimster's observations are supported by those of lymphangiographic and radiographic studies. These studies revealed that large multilobulated cisterns extend deep in the dermis and laterally beyond the obvious clinical lesions. These deep lymphangiomas show no evidence of communication with the adjacent normal lymphatics. The cause for the failure of these primitive lymph sacs to connect to the rest of the lymphatic system is not known.

Some lymphangiomas may represent vascular malformations during embryonic development rather than as true neoplasms.³ Vascular endothelial growth factor (VEGF)–C and VEGF receptor-3 are active in the formation of lymphangiomas. Based upon their expression, superficial lymphangiomas more likely result from peripheral lymphatic dilatation than from a growth factor.

Frequency

United States

Lymphangiomas are rare. They account for 4% of all vascular tumors and approximately 25% of all benign vascular tumors in children.

Mortality/Morbidity

Rarely do cutaneous lymphangiomas interfere with the well-being of patients. Patients are expected to live a full healthy life, and they usually seek medical intervention because of cosmetic reason.

• Lymphangiomas represent hamartomatous malformations with no risk of malignant transformation.
• In the case of cystic hygroma, total surgical excision is appropriate to prevent complications such as respiratory compromise, aspiration, and infections in critical areas, such as the neck.
• Lymphangiomas have a strong tendency for local recurrence unless they are completely excised. Recurrent episodes of cellulitis and minor bleeding are not uncommon.

Race

No racial predominance is reported for lymphangiomas.

Sex

Equal sex incidences are reported for lymphangiomas in most studies. Some groups have reported that lymphangioma circumscriptum is more common in females than in males, while others report a 3:1 male-to-female ratio.

Age

Lymphangioma can become evident at any age, but the greatest incidence occurs at birth or early in life. About 50% of lymphangiomas are seen at birth, and most lymphangiomas are evident by the time the patient is aged 5 years.

Clinical

History

• Lymphangioma circumscriptum
  • The typical history involves a small number of vesicles on the skin at birth or shortly after. In subsequent years, they tend to increase in number, and the area of skin involved continues to expand. Vesicles or other skin abnormalities may not be noticed until several years after birth.
  • Usually, lesions are asymptomatic, but, occasionally, patients may have spontaneous episodes of minor bleeding and copious drainage of clear fluid from ruptured vesicles.
• Cavernous lymphangioma
  • Typically, during infancy, a solitary rubbery nodule with no skin changes becomes evident in a single location, such as the face, trunk, or extremity. These lesions often have a fast growth phase similar to that of raised hemangiomas.
  • No family history of prior lymphangiomas is described.
• Cystic hygroma
  • Soon after birth, the infant is noted to have a deep subcutaneous cystic swelling, usually in the axilla, base of the neck, or groin. If these lesions are drained, they tend to fill up rapidly with lymph fluid.
  • The lesions tend to grow and increase to a large size if they are not completely excised at surgery.

Physical

• Lymphangioma circumscriptum
  • Lymphangioma circumscriptum involves small clusters of vesicles measuring about 2-4 mm. These clear vesicles can vary from pink to red to black secondary to hemorrhage.
  • The lesions can have a warty appearance on their surface; as a result, these lesions are often confused with warts.
  • Shah et al report a lymphangioma presenting on the penis.⁴
• Cavernous lymphangioma
  • Typically, cavernous lymphangiomas appear as subcutaneous nodules with a rubbery consistency. They may have large dimensions.
  • The overlying skin has no lesions or changes.
  • The area of involvement varies, ranging from lesions smaller than 1 cm in diameter to larger lesions that involve an entire limb.
• Cystic hygroma
  • Cystic hygromas are usually larger than cavernous lymphangiomas, and they more commonly occur in the neck and parotid area.
  • Often, deep cavernous lymphangiomas are not evident on superficial examination, but cystic hygromas are detected with ease because of their size and location. These large cystic lesions are soft and translucent.

A 44-year-old woman with plaque on her forearm since birth that clinically appeared to be typical lymphangioma circumscriptum. Histologically, however, it had features of both hemangioma and lymphangioma.

Close-up of Media File 1 demonstrating the clinical morphology to better advantage.

Lymphangioma on the back.

Causes

The reason that these embryonic lymph sacs remain disconnected from the rest of the lymphatic system is not known.

Differential Diagnoses

Other Problems to Be Considered

Other cysts and soft subcutaneous masses should be considered.

Occasionally, acquired lymphangioma circumscriptum of the vulva may mimic genital warts.^5,6

Workup

Imaging Studies

• MRI can help define the degree of involvement and the entire anatomy of the lymphangioma lesion.
• MRI can help prevent unnecessary extensive, incomplete surgical resection, because of the association with a high recurrence rate.

Other Tests

• Immunohistochemical study is useful in differentiating lymphangiomas from hemangiomas in difficult cases.
  • Test results with factor VIII–related antigen are positive for hemangiomas but negative or weakly positive in the endothelium of lymphangiomas.
  • Immunohistochemical studies for laminin show the typical multilayered basal lamina of normal blood vessels and the discontinuous basal lamina in lymphangiomas.
• Dermoscopic findings may aid in the diagnosis of cutaneous lymphangioma circumscriptum.^7,8 Nodules filled with clear fluid show light brown lacunas surrounded by paler septa. Those tinged with blood may have focal reddish areas inside the lagoons, pink diffuse coloration, and/or reddish to violaceous lacunar structures. Thus, they are characterized by a lacunar pattern and with a marked hematic content may be indistinguishable from a hemangioma.

Procedures

• Biopsy: The diagnosis of lymphangiomas is based mainly on the clinical history and findings from physical examination and conventional light microscopy.

Histologic Findings

Microscopically, the vesicles in lymphangioma circumscriptum are greatly dilated lymph channels that cause the papillary dermis to expand. They may be associated with acanthosis and hyperkeratosis. These channels are numerous in the upper dermis and often extend to the subcutis. These deeper vessels seem to have a large caliber, and they often have a thick wall that contains smooth muscle. The lumen is filled with lymphatic fluid, but it often contains red blood cells, lymphocytes, macrophages, and neutrophils. These channels are lined by flat endothelial cells, which stain positive for Ulex europaeus agglutinin-I. The interstitium often has numerous lymphoid cells and shows evidence of fibroplasia.

Nodules in cavernous lymphangioma are characterized by large, irregular channels in the reticular dermis and subcutaneous tissue that are lined by a single layer of endothelial cells. An incomplete layer of smooth muscle often lines the walls of these malformed channels. The surrounding stroma consists of loose or fibrotic connective tissue with a number of inflammatory cells. These tumors often penetrate muscle.

Cystic hygroma is indistinguishable from cavernous lymphangiomas on histology.

Treatment

Medical Care

No medical care has been proven effective for lymphangiomas. Lymphangioma is not responsive to radiation therapy or steroids. Antibiotics are given for secondary cellulitis.

Surgical Care

The preferred treatment for lymphangiomas is complete surgical excision.⁹

• Local recurrences are common in lymphangiomas.
• On the basis of the Whimster hypothesis, the large subcutaneous cisterns should be removed to prevent the lesion from resurfacing.
• Adequate excision of lymphangiomas can be difficult and, at times, unfeasible. This problem is the main reason for the high recurrence rate.
• Tumors that are confined to the superficial dermis are more amenable to surgical excision, which is associated with a high rate of success.
• The use of other treatment modalities has been advocated; these include cryotherapy, sclerotherapy, and cautery.
• Vaporization with a carbon dioxide laser has been tried with good results.¹⁰
• A new therapeutic option for lymphangioma circumscriptum is 23.4% hypertonic saline sclerotherapy.¹¹
• The use of intralesional OK432 (Picibanil) is a new and effective treatment for macrocystic lesions,¹² but the response of microcystic or cavernous lesions to OK-432 has been disappointing and surgery remains the most effective treatment for these microcystic and cavernous lesions.¹³

Follow-up

Further Inpatient Care

• In the case of lymphangioma circumscriptum, severe recurrent cellulitis may warrant inpatient care at times, especially in patients who are immunocompromised.

Further Outpatient Care

• Patients with lymphangiomas should be monitored and treated for cellulitis, especially those with ruptured vesicles, which provide a portal of entry for infection.
• Regular skin examination should be included in the follow-up treatment to evaluate recurrence and the response to treatment.

Complications

• Lymphangioma circumscriptum may occur.
  • Lymphangiomas circumscriptum is associated with minor bleeding, recurrent cellulitis, and lymph fluid leakage.
  • Two cases of lymphangiosarcoma arising from lymphangioma circumscriptum have been reported. However, in both of the patients, the preexisting lesion was exposed to extensive x-ray therapy. Therefore, radiation therapy should be avoided in lymphangiomas.
• In cystic hygroma, large cysts can cause dysphagia, respiratory problems, and serious infection if they involve the neck.
• A cystic lymphangioma of the scrotum may present as an acute scrotum, owing to the rare complication of hemorrhage.¹⁴
• A Dabska tumor may rarely arise within lymphangioma circumscriptum.¹⁵

Prognosis

• Lymphangiomas are benign hamartomatous malformations instead of true neoplasms.
• The prognosis for lymphangiomas is excellent.

Patient Education

• Patients should receive reassurance.
• Lymphangiomas represent benign lymphatic malformations and not premalignant lesions.
• Patients should be aware of the risk of recurrence.

Miscellaneous

Medicolegal Pitfalls

• Failure to evaluate for congenital disorders, such as Turner syndrome and Down syndrome, in patients with cystic hygroma

Special Concerns

• Cystic hygroma can be associated with the following congenital disorders:
  • Turner syndrome
  • Chromosomal aneuploidy
  • Hydrops fetalis
  • Down syndrome and other trisomy disorders¹⁶
  • Fetal alcohol syndrome
  • Noonan syndrome
  • Several other congenital syndromes
• Patients with cystic hygroma should undergo cytogenetic analysis for chromosomal aneuploidy.
• Parents should receive genetic counseling because aneuploidic conditions can recur in subsequent pregnancies.¹⁷

Multimedia

Media file 1: A 44-year-old woman with plaque on her forearm since birth that clinically appeared to be typical lymphangioma circumscriptum. Histologically, however, it had features of both hemangioma and lymphangioma.

Media file 2: Close-up of Media File 1 demonstrating the clinical morphology to better advantage.

Media file 3: Lymphangioma on the back.

Media file 4: 16-year-old obese boy with large unilateral verrucous lymphangioma

References

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12. Ahn SJ, Chang SE, Choi JH, Moon KC, Koh JK, Kim DY. A case of unresectable lymphangioma circumscriptum of the vulva successfully treated with OK-432 in childhood. J Am Acad Dermatol. Nov 2006;55(5 Suppl):S106-7. [Medline].

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Keywords

lymphangioma, cutaneous lymphangioma, lymphangioma circumscriptum, cavernous lymphangioma, cystic hygroma, abnormal lymph vessel, lymph vessel

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Geover Fernandez, MD, FAAD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry New Jersey, New Jersey Medical School
Geover Fernandez, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Society for MOHS Surgery
Disclosure: Nothing to disclose.

Medical Editor

Carrie L Kovarik, MD, Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, University of Pennsylvania School of Medicine
Carrie L Kovarik, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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