Massive Localized Lymphedema: Review of an Emerging Problem and Report of a Complex Case in the Mons Pubis

[Massive localized lymphedema of anterior abdominal wall]

Massive localized lymphedema (MLL) is a rare disease observed in people with morbid obesity. MLL is easily confused with soft tissue sarcoma. Therefore, MLL is sometimes called as pseudosarcoma in the literature. MLL was initially described by G. Farshid and S. Weiss in 1998. However, etiology of MLL is still unknown despite certain relationships with injuries, operations and hypothyroidism. Since the term «MLL» was introduced only 20 years ago, there are no reliable statistical data on the prevalence of MLL. According to the World Health Organization data (2016), 13% of the adult world population are obese. Therefore, the risk of MLL is increased in these people. Thigh is the most common site of lesion. Abdominal wall lesion is rare and can cause diagnostic difficulties due to large dimensions and appearance. We report a 50-year-old obese woman with MLL of anterior abdominal wall. She experienced discomfort while walking and sleeping due to giant MLL of anterior abdominal wall that significantly reduced quality of life. Removal of MLL (weight 22160 g) was followed by favorable cosmetic and functional outcome. Analysis of differences between MLL and soft tissue sarcoma in the era of «obesity epidemic» is valuable for correct diagnosis and treatment of this rare complication. This report is the first case of MLL, registered in Russia. In our opinion, this is associated with insufficient awareness of physicians about this complication of obesity. We hope our observation will help clinicians to identify and treat this complication.

Angiosarcoma arising in massive localized lymphedema

We report a case of a 70-year-old woman with a BMI of 58 who developed cellulitis refractory to treatment, within an area of massive localized lymphedema. Biopsy showed angiosarcoma. MRI showed multiple lobulated, low T1, high T2 masses within a background of prominent soft tissue septal stranding, dilated lymphatic channels, and skin thickening. CT also showed the mass well, within the background lymphedema. Massive localized lymphedema is increasing in prevalence due to the worsening obesity epidemic. Radiologists should be aware that the presence of a nodule within an area of massive localized lymphedema is suspicious for sarcoma.

Surgical treatment of a penoscrotal massive localized lymphedema: Case report

INTRODUCTION

Massive localized lymphedema is an aggressive type of lymphedema that causes great functional impairment for the patient, depriving from one's basic life activities. The treatment of this type of lesion is eminently surgical, requiring ablative surgery (complete surgical resection of the lesion), but the possible techniques not always provide a good functional result.

PRESENTATION OF CASE

We reported a case of a penoscrotal massive lymphedema treated by our Body Contour Group/Plastic surgery department of our institute. We performed the resection of the giant penoscrotal lesion, used a posterior scrotal flap for defect's reconstruction and a split-thickness skin graft for penis' body reconstruction, closed with Z-plasty.

DISCUSSION

Contrary to what the literature says, we prefer to use the split-thickness skin graft to reconstruct the penis' body in these cases, against local flaps. According to our experience with some similar cases, this technique provides a better functional result once it allows the penis to a better expansion during erection. The key maneuver to avoid contracture of the graft and retraction of the penis is to perform a broken line suture (Z-plasty) in the topography of the median raphe.

CONCLUSION

In cases of penoscrotal massive lymphedema, the treatment's option with better results is the surgical one. The use of a scrotal flap associated with split-thickness skin graft for penis provides good aesthetic and functional outcomes.

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.

Pseudosarcoma of the thigh: a rare case of massive localized lymphedema

Massive localized lymphedema, also called pseudosarcoma, is a rare condition associated with morbid obesity. Accurate identification of this entity helps the physician make the distinction between this condition and other soft tissue tumors, especially with the increasing rate of obesity worldwide. Obesity and increased caloric intake lead to storage of the excess energy in the form of adipose tissue. The excess adipose tissue disturbs the lymphatic vessels, leading to massive edema localized mostly in the lower extremity, reaching a substantial size and weight that interferes with the quality of life of the individual in question. The mass can cause cosmetic but more importantly functional and structural defects, leading to altered biomechanics with increased risk of deep vein thromboembolism. Below is a presentation of a patient presenting with complaint of a massive medial thigh mass. After much investigation, consultation, and use of diagnostic radiologic modalities it was diagnosed as what is referred to in the literature as massive localized lymphedema, or pseudosarcoma. This mass was managed by surgical excision and the diagnosis was further confirmed by pathologic analysis. After the excision, our patient regained his ability to ambulate on his own, with the help of a rehabilitation program and physical therapy. Massive localized lymphedema needs to be on the differential diagnosis of any morbidly obese patient presenting with mass, especially in the lower extremities. Adequate knowledge about this condition enables the physician to make the distinction between pseudosarcoma and true soft tissue sarcomas.

Gigantic Suprapubic Lymphedema: A Case Study

We present the first case study of idiopathic gigantic suprapubic lymphedema and buried penis treated with puboscrotal reconstruction in a patient with initial extreme obesity after an extensive weight reduction (120 kg). Massive localized lymphedema of the suprapubic region should be differentiated from the scrotal type. Severe lymphedema could not resolve on its own and weight reduction does not seem to be helpful in such cases.

Massive localized lymphedema: a clinicopathologic study of 46 patients with an enrichment for multiplicity

Massive localized lymphedema is a monstrous tumefactive pseudosarcoma seen in middle-aged morbidly obese adults. Since its initial description in 1998, the etiology remains unknown, although associations with trauma, surgeries, and hypothyroidism have been reported. Herein, we report the largest study of massive localized lymphedema and expand upon its clinicopathologic features. Fifty-four cases from 46 patients were retrospectively identified from the institutional archives of The Ohio State University Wexner Medical Center between 2002 and 2015. Forty-six patients (21 males and 25 females, mean age 50 years) presented with large masses developing over a 5-60-month period. The majority of patients were Caucasian (n=39). All patients were obese with a mean weight of 384.7 lb and a mean body mass index of 59.6 kg/m(2). Thirty-six patients had a history of atherosclerotic cardiovascular disease and diabetes mellitus type 2 was present in 22 patients. Eight patients had multifocal massive localized lymphedema. The sites included thigh (n=33), abdomen (n=17), suprapubic region (n=1), mons pubis (n=6), scrotum (n=2), perianal region (n=1), and right flank (n=1). Mostly, the clinical impression was benign processes, including pannus or lymphedema pseudotumor. Grossly, the mean weight was 8237 g and the mean size was 53.2 cm. Histologically, eight cases showed a unique pattern of dystrophic calcifications mimicking hyperchromatic, atypical nuclei that might lead to misdiagnosis of liposarcoma, four cases showed focal metaplastic ossification, and three cases showed multinucleated cells in addition to prototypic features of massive localized lymphedema. We report that this is the largest series of massive localized lymphedema. This is a lesion mostly seen in morbidly obese patients and the thigh is the most common site of involvement. We note a marked racial predilection for Caucasians and a tendency towards multiplicity. We suggest that obesity itself and the related metabolic syndrome have an important role in its pathogenesis.

Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae

Whether primary or secondary, lymphedema is caused by failure to drain protein-rich interstitial fluid. Typically affecting a whole limb, it has become apparent that lymphedema can also affect localized regions of the skin, or it can be clinically silent but histologically evident, denoted by dilated lymphangiectases (latent lymphedema). Chronic lymph stasis has numerous consequences, including lipogenesis, fibrosis, inflammation, lymphangiogenesis, and immunosuppression. For example, lymphedema's disruption of immune cell trafficking leads to localized immune suppression, predisposing the area affected to chronic inflammation, infection (cellulitis and verrucosis), and malignancy (angiosarcoma and nonmelanoma skin cancer). The pathogenesis of lymphedema is reviewed and exemplified by describing how a combination of lymph stasis-promoting factors such as trauma, obesity, infection, and inflammatory disorders produces localized elephantiasis; furthermore, the finding of lymphangiectases is found to be common in numerous dermatologic disorders and argued to play a role in their pathogenesis. Lastly, it is discussed how antigen burden, which is controlled by lymphatic clearance, affects the immune response, resulting in immune tolerance, immunopathology, or normal adaptive immunity.

[Massive localized lymphoedema (MLL) in the mons pubis]

Massive localized lymphoedema (MLL) is a relatively frequent complication in obesity. MLL is present as a giant swelling and associated with characteristic skin changes. Due to the pathologic and morphologic similarity to sarcoma, MLL is also called "pseudosarcoma". MLL can degenerate into angiosarcoma without surgery. We present a case of MLL of the mons pubis in a 54-year-old man with a BMI of 48.6.

Lesions of the mons pubis: a review

The mons pubis may become involved in dermatologic conditions or gynecologic lesions affecting the vulva. There are also unusual lesions that have been reported arising from the mons specifically. A familiarity with these lesions will be helpful if a patient with a lesion of the mons is encountered.

Massive localised lymphoedema: a rare vascular malformation

Lymphatic malformations are a subset of congenital vascular malformations, and are caused by a defect in lymphatic development during embryogenesis. When lymphatic mesoderm development is prematurely arrested, it retains it proliferative potential. Stimulus in the future can cause the lesion to proliferate locally without coordination or regulation, resulting in the rare condition known as massive localised lymphoedema (MLL). We present a case report of MLL, a rare and ill-defined soft tissue mass reported in the morbidly obese, with reference to the existing literature.

Reconstruction of massive localised lymphoedema of the scrotum with a novel fasciocutaneous flap: A rare case presentation and a review of the literature

Massive localised lymphoedema (MLL) is a benign lymphoproliferative soft-tissue overgrowth in the morbidly obese patient. The diagnosis may be challenging, and is a form of secondary lymphoedema, often described as idiopathic scrotal elephantiasis. The lesion presents as a large mass in the morbidly obese, and patients seek treatment late in the disease course due to limitation of daily living or excoriation and wound breakdown. Resection, followed by reconstruction, is indicated in these cases. We present a unique case of a morbidly obese 52-year-old male with massive enlargement of the scrotum present for several years duration, despite massive weight loss (88.85 kg) from gastric bypass surgery and no other identifiable cause of lymphoedema. Scrotal lymphoedematous tissue was resected and scrotal reconstruction with a novel posterior fasciocutaneous flap from the scrotum was performed in addition to penile reconstruction with a skin graft and local fasciocutaneous flaps as well as a panniculectomy. Histologically, the tissue was characterised by marked oedema with dermal fibrosis and patchy mild perivascular chronic inflammation. Postoperative follow-up revealed wound integrity and patient satisfaction with the outcome. MLL is an important disease process with distinct clinical and histopathologic characteristics that often requires complex reconstruction. Although there are several opposing classification schema, we propose the incorporation of idiopathic scrotal elephantiasis into the diagnostic category of MLL.