Verrucous localized lymphedema of genital areas: Clinicopathologic report of 18 cases of this rare entity

Genital Lymphedema after Cancer Treatment: A Narrative Review

Genital lymphedema may affect males and females after cancer treatment (gynecological, such as cervical, uterine or ovarian, melanoma, prostate, anus…). It is frequently associated with lower limb lymphedema, and is responsible for discomfort, cosmetic disfigurement and functional disturbances. Impacts on body image, sexual function and quality of life are major, and difficult to explore because cancer treatment itself and lymphedema are so closely interwoven. Local complications, e.g., papillomatosis, warty growth, lymph vesicles with embarrassing lymph oozing and cellulitis, may occur. Usual lymphedema therapies, like bandaging and elastic compression, are poorly adapted to these sites. Surgery, essentially based on cutaneous resection techniques, is the primary symptomatic treatment; it achieves good efficacy, in adults and children, with possible recurrence requiring reintervention.

Massive Localized Lymphedema in an Unreported Location (Retroperitoneum)

Background

Massive localized lymphedema (MLL) is a non-neoplastic benign soft tissue lesion that may be confused with sarcomas or other neoplastic proliferations both clinically and morphologically. Most occur in morbidly obese adults on the lower extremities. The objective of this article is to document a case of MLL in the retroperitoneal cavity which is a previously unreported site for this lesion, and to highlight its unusual clinical features.

Case presentation

The patient was a non-obese male who had undergone major abdominal surgery due to bladder extrophy 17 years ago. Abdominal ultrasonography detected a large incidental mass in the right renal sinus during his investigation for nephrolithiasis. The lesion extending from renal pelvis down to pelvis was resected and its histopathological findings were compatible with massive localized lymphedema.

Conclusions

Retroperitoneum has to be added to the list of locations that MLL can be found. Liposarcoma will be a challenging differential diagnosis when the lesion is encountered in an unusual site.

Penile lymphoedema: approach to investigation and management

BACKGROUND

Penile lymphoedema (with and without cellulitis) is a rare, often chronic, clinically heterogeneous entity with an uncertain pathogenesis and an important differential diagnosis. It creates significant physical and psychosexual morbidity, and presents considerable therapeutic challenges. The existing literature is limited.

AIM

To describe and share our updated cumulative experience of a cohort of patients with penile lymphoedema.

METHODS

This was a retrospective review of the case records of patients with chronic penile lymphoedema seen in two dedicated male genital dermatology clinics between January 2011 and July 2016.

RESULTS

In total, 41 cases were identified. Over a third had Crohn disease (CD) (which was occult in one-third of these), and over a third had serological evidence of streptococcal infection. All patients responded to systemic antibiotics and specialized urological surgery circumcision and excision).

CONCLUSIONS

Penile lymphoedema should be investigated to exclude underlying pathology especially CD and streptococcal infection. Treatment with antibiotics should be considered early and long term to try to preserve the foreskin: most patients are uncircumcised. Some patients may benefit from a course or courses of oral steroids. The development of gross dysfunction of the prepuce usually dictates circumcision and excision of lymphoedematous tissue once the situation is medically stabilized.

Compression therapy in obese patients

Triggered by obesity, venous (obesity-associated dependency syndrome) and lymphatic drainage disorders (obesity-associated lymphoedema) can develop, which in themselves require compression therapy, or other comorbidities with indication for compression therapy may exist. In obese patients, some specific features have to be observed in compression therapy:

- An adequate initial decongestive phase with padding and bandage materials,

- Compression hosiery with a high degree of stiffness (high-strength materials, where appropriate, flat-knitted) and optimal fit (meticulous fitting),

- Garment types that are suitable for daily use, if necessary, multi-part garment,

- Need for aids or auxiliary persons to ensure correct use,

- Concomitant consistent, intensive, lipid-replenishing skin care and optimised hygiene to reduce complications and side effects

- Regular medical check-ups to ensure correct fit of the leg compression garment.

Sometimes, particularly at the initial provision and in patients with a complicated physical shape, the stockings have to be modified several times before an optimal fit is achieved.

Selected Case From the Arkadi M. Rywlin International Pathology Slide: Massive Localized Lymphedema in Morbid Obesity Complicated by a Nonspecific Subcutaneous Abscess

A 59-year-old morbidly obese female developed an ulcerated, slowly growing, 25 cm, subcutaneous, pendulous mass in the right groin which became infected and was excised in January 2014. The excised skin and subcutaneous fat weighed 1901 g. The skin exhibited a cobblestone appearance, the dermis was thickened and edematous, and the subcutaneous fat was traversed by fibrous septae. Histologically, there were dilated, thin-walled vessels, perivascular chronic inflammatory cells, slightly atypical macrophages, and expanded subcutaneous fibrous septae surrounding degenerating adipocytes resembling lipoblasts. Nearly all the Club members agreed with the submitted diagnosis of massive localized lymphedema in morbid obesity. Postoperatively, the wound healed well, there has been no recurrence or further infection as of July 2015, but the patient suffers from diabetes and congestive cardiac, the more common complications of morbid obesity.