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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 6  |  Page : 1132-1134
Cystic lymphangioma scroti: A common tumor at a rare location


1 Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Moradabad (UP), India
2 Govt. Medical College, Kota (Rajasthan), India

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Date of Web Publication4-Nov-2010
 

   Abstract 

Cystic lymphangioma is a common benign tumor caused by lymphatic malformation. The scrotum is a very rare site for this tumor and only few cases have been reported in the literature. We herewith present a rare case of cystic lymphangioma of the scrotum in an ado­lescent who presented with an incidental scrotal swelling with no other abnormality, where the diagnosis was suspected on scrotal ultrasonography.

How to cite this article:
Rastogi R, Meena G L, Kumar R, Rastogi V. Cystic lymphangioma scroti: A common tumor at a rare location. Saudi J Kidney Dis Transpl 2010;21:1132-4

How to cite this URL:
Rastogi R, Meena G L, Kumar R, Rastogi V. Cystic lymphangioma scroti: A common tumor at a rare location. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Dec 8];21:1132-4. Available from: http://www.sjkdt.org/text.asp?2010/21/6/1132/72306

   Introduction Top


Lymphangioma is a congenital lymphatic tu­mor usually recognized at birth or in early childhood with the commonest location being head, neck and axilla. [1] Lymphangioma occur­ring in the scrotum is very rare. [1],[2] It may pre­sent at birth, in childhood or in adolescence, as seen in our case. [3] Symptomatology is non-spe­cific with resultant diagnostic difficulties. In­accurate diagnosis with improper management is associated with high rates of recurrence. [4]


   Case Report Top


An 18-year-old male with incidentally noted, painless, soft swelling of 2-3 months duration lo­cated on the riht side of scrotum with no other complaints came for ultrasonography. History of trauma was not present. Clinical examination revealed a nontender, extratesticular, soft swe­lling with slight compressibility. Laboratory tests were unremarkable.

High resolution ultrasonography of the scro­tum revealed a well defined, compressible, cys­tic mass with multiple septae and locules lo­cated inferolaterally in the right scrotal sac, separate from the normal appearing testis and epididymis [Figure 1],[Figure 2]. There was apprecia­ble posterior acoustic enhancement. The lesion measured approximately 37.2 × 20.3 × 16.5 mm (6.5 mL in volume). The septae were thin and complete and revealed low velocity and high re­sistance flow on color doppler imaging [Figure 3]. Presence of low level internal echoes with few mobile echogenic foci was also noted. However, no evidence of any calcification was noted. Minimal free fluid was also noted in the right scrotal sac. Ultrasound of the left scrotal sac and the abdomen was unremarkable. No evidence of any extrascrotal extension in to the abdomen was noted even on computed tomo­graphy of the lower abdomen.
Figure 1 :Longitudinal US image of lymphangioma scroti showing a multiseptate, cystic mass with posterior acoustic enhancement.

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Figure 2 :Longitudinal and transverse US image of lymphangioma scroti showing a multiseptate, cystic mass with posterior acoustic enhancement and internal debris separate from the testis.

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Figure 3 :Transverse US image of lymphangioma scroti showing the presence of vascularity in the septae.

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Based on the clinico-radiological findings, a provisional diagnosis of cystic lymphangioma of scrotum was suggested.

Surgery revealed a cystic mass with multiple septae located in the right scrotal sac, densely adherent to the tunica but separate from the right testis and epididymis. Complete excision of the mass including the adjacent skin was performed with uneventful postoperative pe­riod. Histopathology of the excised tissue re­vealed multiple lymphatic channels lined by endothelium while cytology of the contained fluid confirmed lymph like fluid. No evidence of inflammatory infiltrate or cellular atypia was seen. Six months follow-up period was unre­markable.


   Discussion Top


Lymphangioma occurs as a result of the fai­lure of lymph to drain from sequestered lym­phatic vessels with consequent dilatation of the ducts and formation of a cystic, multiseptate mass. Majority of the lesions are congenital but may also occur secondary to infection, in­flammation or degeneration. Out of the three forms, capillary, cavernous and cystic varieties, the cystic type is the commonest. [2]

Trauma or aspiration of lymphangioma can result in internal hemorrhage, making it difficult to differentiate it from hemangioma on micros­copy. However, presence of benign lymphoid aggregates is highly specific for lymphangioma. [5]

Clinical diagnosis of lymphangioma is easier if it is present in usual locations but imaging is crucial in diagnosis at uncommon and rare lo­cations, especially in the scrotum. All the ca­ses reported in the study by Hurwitz et al, were misdiagnosed pre-operatively, [4] further empha­sizing the role of imaging.

These lesions usually present as painless, indolent scrotal masses but may sometimes be associated with acute scrotum due to enlarge­ment or pain following infection or hemorrhage. [6],[7] These tumors are frequently infiltra­tive and may extend in to the abdominal wall, perineum or retroperitoneum. [1],[4],[6] It may be asso­ciated with cryptorchidism. [2]

High resolution ultrasonography is highly ac­curate in delineating the type and extent of the lesions in most cases. Color doppler US gives an idea of the pattern and extent of vascular supply. Computed tomography and magnetic resonance imaging are used only as problem solving tools especially to determine the ex­tension in to the pelvis and retroperitoneum.

High resolution ultrasonography of cystic lym­phangioma reveals cystic mass with multiple septations and locules filled with low level in­ternal echoes that may be mobile. The echoes may be due to internal hemorrhage or debris. Septations seen in lymphangioma often shows low velocity and high resistance vascular flow, characteristic of benign lesion. [8]

Complete excision of the lymphangioma in­cluding the scrotal skin is the treatment of choice to prevent recurrences. Injection of scle­rosing agents, fulguration or local cryotherapy for cystic lymphangioma are associated with high recurrence rates. [1],[3]

The important differential diagnoses of the multicystic, extratesticular scrotal mass include loculated hydrocele/pyocele, hematocele, varico­cele, hernia, spermatocele, cystic lymphangio­ma of epididymis and epididymal cyst. Presence of septal flow differentiates cystic lymphangio­ma from hydrocele, pyocele and hematocele. Absence of color flow in the cystic spaces differentiates lymphangioma from varicocele. Hernia will have an intra-abdominal extension.

To summarize, although scrotum is a very rare site for cystic lymphangioma, it should be considered in the list of differential diagnosis of multiloculated, benign appearing extratesti­cular lesions with limited vascular supply in a young male. Ultrasonography is decisive in most cases, accurately identifying and determining the extent of these lesions. Correct diagnosis not only avoids mismanagement but also re­duces recurrences by institution of the specific therapy early in the course of disease.

 
   References Top

1.Alqahtani A, Nguyen LT, Flageole H, Shaw K, Laberge JM. 25 years' experience with lymphangioma in children. J Pediatr Surg 1999;34:1164-8.  Back to cited text no. 1
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2.Vikicevic J, Milobratovic D, Vukadinovic V, Golubovic Z, Krstic Z. Lymphangioma scroti. Pediatr Dermatol 2007;24:654-6.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Morani AK, Asrani A, Maheshwari P. Cystic lymphangioma of the scrotum. Applied Radiology Online AR Online (Case reports)] 2006;35(4).  Back to cited text no. 3
    
4.Hurwitz RS, Shapiro E, Hulbert WC, et al. Scrotal cystic lymphangioma: The misdiag­nosed scrotal mass. J Urol 1997;158:1182-5.  Back to cited text no. 4
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5.Faul JL, Berry GJ, Colby TV, et al. Thoracic lymphangiomas, lymphangiectasis, lymphan­giomatosis, and lymphatic dysplasia syndrome. Am J Respir Crit Care Med 2000;161:1037-46.  Back to cited text no. 5
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6.Weidman ER, Cendron M, Schned AR, Harris RD. Scrotal lymphangioma: an uncommon cause for a scrotal mass. J Ultrasound Med 2002;21:669-72.  Back to cited text no. 6
[PUBMED]    
7.Hacker A, Hatzinger M, Grobholz R, Alken P, Hoang-Bohm J. Scrotal lymphangioma-a rare cause of acute scrotal pain in childhood. Aktuelle Urol 2006;37:445-8.  Back to cited text no. 7
    
8.Loberant N, Chernihovski A, Goldfeld M, et al. Role of Doppler sonography in the diagnosis of cystic lymphangioma of the scrotum. J Clin Ultrasound 2002;30:384-7.  Back to cited text no. 8
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Correspondence Address:
Rajul Rastogi
Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Moradabad (UP)
India
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PMID: 21060188

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