Lymphatic Channels Research Articles

Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus.

Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Small Bowel Cystic Lymphangioma: An Uncommon Finding During Single-Balloon Enteroscopy

CASE REPORT Cystic lymphangiomas are rare, congenital, nonmalignant lesions, extremely rare in the gastrointestinal tract.1 We report the case of a 76-year-old man referred to our unit for abdominal pain and anemia. Colonoscopy showed hepatic flexure adenocarcinoma confirmed by a contrast-enhanced computed tomography scan, which also revealed a hypodense and intraluminal mass located in the distal jejunum. Therefore, single-balloon-assisted enteroscopy with an antegrade approach was performed. In the distal jejunum, a yellow, glossy, and polylobate polypoid lesion of 30 mm in diameter was found. The lesion showed a tender, smooth, and squeezable surface: Bite-on-bite biopsies were performed, and a large amount of chylous/purulent fluid leaked from the lesion, which gradually deflated (Video 1). Histopathological report was consistent with cystic lymphangioma. Afterward, the patient underwent right hemicolectomy and jejunal resection. Cystic lymphangiomas result from the failure of lymphatic channels to communicate with the main lymphatic system.1 Cysts may contain serous, chylous, bloody, or purulent fluid. Intra-abdominal lymphangiomas mostly occur in the mesentery, followed by the omentum, mesocolon, and retroperitoneum.2 Involvement of solid or cave organs is extremely rare.3 Lymphangiomas are generally asymptomatic or responsible for nonspecific symptoms, including abdominal pain, diarrhea, and bleeding; volvulus typically occurs in mesenteric small bowel lymphangiomas, requiring urgent surgery.2 Enteroscopy, colonoscopy, and endoscopic ultrasonography are useful tools for the diagnosis and management of abdominal lymphangiomas. For symptomatic cystic lesions or tumors larger than 20 mm, surgical resection is the treatment of choice.4 In selected patients, endoscopic resection is a feasible option.4 Lymphangiomas comprise 3% of benign small bowel tumors5; however, it is expected that the frequency of their detection will increase in the coming years given the augmented diffusion of both video capsule and enteroscopy. Therefore, it is important for small bowel endoscopists to be able to recognize these lesions to offer the best therapeutic options to their patients. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Jejunal cystic lympangioma finding during single-balloon enteroscopy.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_4vtc2xhf"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: S. Cocca, G. Pontillo and G. Grande involved in drafting of the manuscript. G. Grande and G. Pontillo performed enteroscopy. S. Cocca, H. Bertani, S. Russo, A. Mussetto and R. Conigliaro performed critical revision of the manuscript. S. Cocca is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

A Review on Angiosarcoma of the Breast: Case Studies

An uncommon kind of cancer called angiosarcoma originates in the lining of lymph and blood arteries. The immune system includes the lymphatic vessels. The lymph vessels remove waste materials, viruses, and germs from the body. Any region of the body can develop cancer of this kind. Angiosarcoma is an aggressive tumour, It is a form of soft tissue sarcoma. The treatment of angiosarcoma is very difficult. Breast cancer arises in the breast's lymphatic or blood vessel networks eventually migrating to the breast and the skin of the arms. Most angiosarcomas have unknown origins. Researchers have found a number of variables that could raise the disease's risk. Angiosarcoma develops when the DNA of cells lining a blood artery or lymph channel changes. The instructions that inform a cell what to do are encoded in its DNA. The adjustment which scientists refer to as mutations, instruct the cells to divide quickly. When healthy cells would perish, the alterations prevent the cells from dying. As a result, cancer cells can accumulate and spread outside of the blood vessel or lymph channel. Cancerous cells are able to infiltrate and obliterate healthy body tissue. Cancer cells could eventually separate and travel to different parts of the body. Angiosarcomas have a rapid development rate and body-wide dissemination. Breast angiosarcomas come in two varieties, primary and secondary, and they are both treated surgically by removing the tumour. Angiosarcoma can be spread in other part of body from breast. Primary breast angiosarcoma is an uncommon kind of breast cancer that only affects women, typically developing in the third to fourth decade. For diagnosis, biopsy, mammogram, breast MRI, PET Scan, ultrasound were performed and for the treatment of breast cancer surgery, chemotherapy, radiotherapy were performed. Only 0.04% of malignant breast tumours are primary breast angiosarcomas, making it a rare form of breast cancer. Secondary malignant tumour growth is one of the dangers of therapeutic radiation. In this paper, various cases are reported of angiosarcoma of the breast.

Acquired lymphangioma circumscriptum of the vulva in a middle aged woman with chronic hidradenitis suppurativa – A case report

Lymphangioma circumscriptum (LC) is a distention of lymphatic channels present in skin and subcutaneous tissues. LC is either primary (usually present at birth or develops in early childhood) or secondary due to diminished lymphatic outflow. It is commonly prone to develop in oral cavity, tongue, proximal regions of arms and legs, groin, axilla, and trunk. Primary vulvar involvement is unusual. Vulvar LC is a rare untoward outcome of hidradenitis suppurativa (HS), which causes significant physical and emotional discomfort. We report a case of acquired LC of vulva as a sequlae of HS in a 42 years old female who presented with painful papules, edema and thickening of the vulva with history of foul-smelling discharging sinuses. The patient was managed surgically by wide excision and reconstructive surgery by Plastic surgery unit.

Extracellular vesicles from adipose-derived stem cells relieve extremity lymphedema in mouse models.

Transplantation of adipose-derived mesenchymal stem cells (ADSCs) has been reported to improve the severity of chronic lymphedema. Extracellular vesicles (EVs) derived from mesenchymal stem cells have been reported to exert effects such as the promotion of angiogenesis, suppression of inflammation, and regeneration of damaged organs. In this study, we showed that lymphangiogenesis was induced by EVs derived from ADSCs and revealed the therapeutic potential of these EVs for the treatment of lymphedema. We examined in vitro effects of ADSC-EVs to lymphatic endothelial cells (LECs). Next, we conducted in vivo analysis of ADSC-EVs to mouse lymphedema models. Furthermore, Bioinformatics analysis was also performed to evaluate the implications of the altered miRNA expression. We showed that ADSC-EVs promoted the proliferation, migration, and tube formation of LECs, and the gene expression of lymphatic markers was elevated in the ADSC-EV-treated group. Notably, a mouse lymphedema model revealed that legs treated with ADSC-EVs had markedly improved edema with increased numbers of capillary vessels and lymphatic channels. Bioinformatics analysis revealed that ADSC-EV-associated microRNAs, such as miR-199a-3p, miR-145-5p, miR-143-3p, miR-377-3p, miR-100-3p, miR-29a-3p, miR-495-3p, and miR-29c-3p, targeted MDM2, which contributed to the stability of HIF1 and resulted in angiogenesis and lymphangiogenesis in LECs. The present study showed lymphangiogenic effects of ADSC-EVs, which will lead to new treatment options for chronic lymphedema. Cell-free therapy with EVs has fewer potential risks, such as poor engraftment efficiency and potential tumor formation, than stem cell transplantation and could be a promising tool for patients suffering from lymphedema.

The Effectiveness of Fluoroscopy-Guided Manual Lymph Drainage as Part of Decongestive Lymphatic Therapy on the Superficial Lymphatic Architecture in Patients with Breast Cancer-Related Lymphoedema: A Randomised Controlled Trial

The objective of this trial was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD), as part of decongestive lymphatic therapy (DLT), on the superficial lymphatic architecture in patients with chronic mild to moderate breast cancer-related lymphoedema (BCRL). This trial was a multicentre, double-blind, randomised controlled trial involving 194 participants with BCRL. Participants were randomised into (1) DLT with fluoroscopy-guided MLD (intervention group), (2) DLT with traditional MLD (control group), or (3) DLT with placebo MLD (placebo group). Superficial lymphatic architecture was evaluated as a secondary outcome, visualised by ICG lymphofluoroscopy at the baseline (B0), post-intensive (P), and post-maintenance phases (P6). Variables were (1) number of efferent superficial lymphatic vessels leaving the dermal backflow region, (2) total dermal backflow score, and (3) number of superficial lymph nodes. The traditional MLD group showed a significant decrease in the number of efferent superficial lymphatic vessels at P (p = 0.026), and of the total dermal backflow score at P6 (p = 0.042). The fluoroscopy-guided MLD and placebo group showed significant decreases in the total dermal backflow score at P (p < 0.001 and p = 0.044, respectively) and at P6 (p < 0.001 and p = 0.007, respectively); the placebo MLD group showed a significant decrease in the total number of lymph nodes at P (p = 0.008). However, there were no significant between-group differences for the changes in these variables. In conclusion, based on lymphatic architecture outcomes, the added value of MLD, in addition to the other parts of DLT, could not be demonstrated in patients with chronic mild to moderate BCRL.

Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome.

Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.

Fluid Distribution Patterns in Early-Stage Upper Extremity Lymphedema.

Magnetic resonance imaging (MRI) stage 1 (early stage) upper extremity lymphedema is characterized by fluid infiltration in the subcutaneous tissues that does not exceed 50% of the extremity circumference at any level. The spatial fluid distribution in these cases has not been detailed and may be important to help determine the presence and location of compensatory lymphatic channels. The aim of this study is to determine whether there was a pattern of distribution of fluid infiltration in patients with early-stage lymphedema that could correspond to known lymphatic pathways in the upper extremity. A retrospective review identified all patients with MRI stage 1 upper extremity lymphedema who were evaluated at a single lymphatic center. Using a standardized scoring system, a radiologist graded the severity of fluid infiltration at 18 anatomical locations. A cumulative spatial histogram was then created to map out regions where fluid accumulation occurred most and least frequently. Eleven patients with MRI stage 1 upper extremity lymphedema were identified between January 2017 and January 2022. The mean age was 58 years and the mean BMI was 30 m/kg2. One patient had primary lymphedema and the remaining 10 had secondary lymphedema. The forearm was affected in nine cases, and fluid infiltration was predominantly concentrated along the ulnar aspect, followed by the volar aspect, while the radial aspect was completely spared. Within the upper arm, fluid was primarily concentrated distally and posteriorly, and occasionally medially. In patients with early-stage lymphedema, fluid infiltration is concentrated along the ulnar forearm and the posterior distal upper arm, which aligns with the tricipital lymphatic pathway. There is also sparing of fluid accumulation along the radial forearm in these patients, suggesting a more robust lymphatic drainage along this region, possibly due to a connection to the lateral upper arm pathway.

Isolation of lymph shows dysregulation of STAT3 and CREB pathways in the spleen and liver during leukemia development in a rat model.

Acute myeloid leukemia (AML) is a heterogeneous malignant condition characterized by massive infiltration of poorly differentiated white blood cells in the blood stream, bone marrow, and extramedullary sites. During leukemic development, hepatosplenomegaly is expected to occur because large blood volumes are continuously filtered through these organs. We asked whether infiltration of leukemic blasts initiated a response that could be detected in the interstitial fluid phase of the spleen and liver. We used a rat model known to mimic human AML in growth characteristics and behavior. By cannulating efferent lymphatic vessels from the spleen and liver, we were able to monitor the response of the microenvironment during AML development. Flow cytometric analysis of lymphocytes showed increased STAT3 and CREB signaling in spleen and depressed signaling in liver, and proteins related to these pathways were identified with a different profile in lymph and plasma in AML compared with control. Additionally, several proteins were differently regulated in the microenvironment of spleen and liver in AML when compared with control. Interstitial fluid, and its surrogate efferent lymph, can be used to provide unique information about responses in AML-infiltered organs and substances released to the general circulation during leukemia development.

High-frequency ultrasound imaging for monitoring the function of meningeal lymphatic system in mice

The meningeal lymphatic system drains the cerebrospinal fluid from the subarachnoid space to the cervical lymphatic system, primarily to the deep cervical lymph nodes. Perturbations of the meningeal lymphatic system have been linked to various neurologic disorders. A method to specifically monitor the flow of meningeal lymphatic system in real time is unavailable. In the present study, we adopted the high-frequency ultrasound (HFUS) with 1,1′diocatadecyl-3,3,3′,3′-tetramethylindocarbocyanine perchlorate (DiI)-loaded microbubble and FePt@PLGA nanoparticle contrast agents to evaluate the flow of the meningeal lymphatic system in 2-month-old mice. Statistical analysis was performed to identify changes of HFUS signals among the microbubbles, FePt@PLGA nanoparticles, and saline control groups. Approximately 15 min from the start of intracerebroventricular injection of contrast agents, their signals were evident at the deep cervical lymph nodes and lasted for at least 60 min. These signals were validated on the basis of the presence of DiI and Fe signals in the deep cervical lymph nodes. Ligation of afferent lymphatic vessels to the deep cervical lymph nodes eliminated the HFUS signals. Moreover, ablation of lymphatic vessels near the confluence of sinuses decreased the HFUS signals in the deep cervical lymph nodes. Glioma-bearing mice that exhibited reduced lymphatic vessel immunostaining signals near the confluence of sinuses had lowered HFUS signals in the deep cervical lymph nodes within 60 min. The proposed method provides a minimally invasive approach to monitor the qualities of the meningeal lymphatic system in real time as well as the progression of the meningeal lymphatic system in various brain disease animal models.

Obscure Gastrointestinal Bleeding Caused by a Small Intestinal Lymphatic-venous Malformation: A Case Report with a Literature Review

A 44-year-old woman presented with severe anemia. We strongly suspected gastrointestinal bleeding; however, esophagogastroduodenoscopy, colonoscopy, and computed tomography showed no bleeding sources. Video capsule endoscopy revealed an actively bleeding submucosal lesion within the jejunum. Double-balloon enteroscopy revealed a 20-mm continuously bleeding submucosal lesion in the distal jejunum. We suspected small intestinal vascular malformation and performed surgical resection. The resected specimen pathologically comprised dilated, thin-walled lymphatic channels and blood vessels involving the small intestinal submucosa. Therefore, the patient was diagnosed with small intestinal lymphatic-venous malformation. Postoperatively, the patient recovered well, and recurrence was not observed.

Adult Primary Retroperitoneal Lymphangioma: Updated Facts.

Lymphangioma is a rare, benign tumor of the lymphatic system. It is believed to be a congenital malformation, when part of the lymphatic channels fail to connect to the main lymphatic system. Lymphangioma is a tumor of the pediatric age, with 50% of patients presenting at birth. The head and neck are the main affected sites (75%), while the retroperitoneal cavity is the least affected area, and comprises less than 1% of cases. Adult lymphangioma is an extremely rare tumor, and adult retroperitoneal lymphangioma (ARL) is even a rarer tumor. Over the last two decades, we have experienced a significant increase in reports published in the English literature discussing ARL. As reports have increased, several questions about previously known facts regarding this tumor arose: For years, it was known that ARL is usually an asymptomatic tumor which is incidentally found - is it a true claim? Is abdominal magnetic resonance imaging the radiological test of choice for diagnosis? What is the best therapeutic option? The main aim for this article is to review the current and old English literature concerning ARL, in order to collect data regarding demographic features, clinical presentation, imaging tests used for diagnosis, therapeutic options and follow-up. This in turn will give precise updated answers for the previous questions. In addition, it will raise awareness for the treating physician regarding the most effective approach for early diagnosis and best therapeutic option to be selected.

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer-Related Lymphedema.

The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo. Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data. Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant. Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema. Risk, V.

Reappraisal of the Lymphatic Drainage System of the Distal Rectum: Functional Lymphatic Flow into the Presacral Space and Its Clinical Implication in Rectal Cancer Treatment

Understanding the source and route of pelvic metastasis is essential to developing an optimal strategy for controlling local and systemic diseases of rectal cancer. This study aims to delineate the distribution of lymphatic channels and flow from the distal rectum. In fresh-frozen cadaveric hemipelvis specimens, the ligamentous attachment of the distal rectum to the pelvic floor muscles and the presacral fascia were evaluated. Using indocyanine green (ICG) fluorescence imaging, we simultaneously evaluated the gross anatomy of the lymphatic communication of the distal rectum. We also investigated the lymphatic flow in the pelvic cavity intraoperatively in rectal cancer patients who underwent radical rectal resection with total mesorectal excision (TME). In fresh cadavers, multiple small perforating lymphovascular branches exist in the retrorectal space, posteriorly connecting the mesorectum to the presacral fascia. The lymphatic flow from the distal rectum drains directly into the presacral space through the branches. In patients who underwent TME for rectal cancer, intraoperative ICG fluorescence signals were seen in the pelvic sidewalls and the presacral space. This anatomical study demonstrated that the lymphatic flow from the distal rectum runs directly to the pelvic lateral sidewalls and the presacral space, suggesting a possible route of metastasis in distal rectal cancer.

Is advanced bipolar v anced bipolar vessel sealing de essel sealing device really eff eally effective in decreasing the pelvic lymphocele ratio in open surgery for endometrial cancer?

We aim to show pelvic lymphocele (PL) rates in patients who were operated for endometrial cancer (EC) and underwent systematic paraaortic bilateral pelvic lymph node dissection (PABPLND) with advanced bipolar vessel sealing device (ABVSD). The medical files of all patients who underwent open surgery for EC between January 2017 and December 2021 were retrospectively analyzed. One hundred three patients who operated with the diagnosis of high-intermediate and high-risk endometrial cancer were included. Systematic PABPLND was performed with total abdominal hysterectomy with or without bilateral salpingo-oophorectomy during surgery to all patients. All operations were performed by same three surgeons who were expert in their field. While the lymph packages were removed during surgical dissection, the distal afferent and proximal efferent lymphatic channels were sealed with LigaSure™ blunt tip sealer/divider (Medtronic, Covidien, USA). The patients were scanned with computed tomography (CT) between 8 and 12 weeks postoperatively. Lymphocele diagnosis was confirmed by radiologists and largest diameter was recorded. Clinical-pathological findings of all patients were recorded. Mean age and body mass index (BMI) of all participants were 58.6 ±10.2 years and 28.1± 5.6 kg/m2 . The most histopathological findings were endometrioid type (84.5%) and grade 2 (44.2%) ECs. The pelvic lymphocele (PL) was detected with CT in 24 of 103 patients at 8 to 12 weeks postoperatively. Only two PL patients were symptomatic. The first patient had symptoms of pelvic fullness and compression while the second patient had infected image. PL was located to right pelvic area in first case while the second was located on the vaginal cuff. The dissection and sealing of major lymph vessels were achieved during the removal of all lymph packages with LigaSure™ blunt tip laparoscopic sealer/divider. The use of advanced bipolar systems can reduce the formation of PL in lymph node dissection in endometrial cancer.

Management of large post-crossover inguinal lymphocele

A 73-year-old man with a history of peripheral arterial disease and previous bilateral common femoral artery reconstruction presented with left foot critical limb-threatening ischaemia and underwent right to left femoro-profunda crossover grafting. Postoperatively, he developed a left groin lymph leak that initially dried up but later re-presented as a very large lymphocele. Initial attempts with aspiration on three occasions and then surgical drainage with sac excision and ligation of long saphenous lymphatics did not lead to resolution. Subsequently, a hybrid approach using percutaneous lymphangiography and drainage, sclerotherapy (bleomycin, then absolute alcohol) and eventual identification and ligation of the afferent lymphatic channel resulted in resolution of the lymphocele without untoward side effects, sepsis or compromise of the revascularisation.

Delineating the Boundaries of Superficial Lymphangitis: A Retrospective Study of 11 Cases with a Review of Literature.

Lymphangitis is an inflammation of lymphatic channels caused by infectious or non-infectious agents, presenting with characteristic linear erythematous streaks draining toward regional lymph nodes. To describe the clinical characteristics and etiological factors involved in acute superficial lymphangitis in a retrospective descriptive study. Materials and Methods: Records of patients were analyzed retrospectively who presented with linear erythematous streaks, diagnosed as superficial lymphangitis, in the outpatient department of dermatology during the last 5 years (January 2018-December 2022) in a tertiary care hospital. Patients were evaluated for their demographic profile, detailed history, complete physical examination, and standard blood tests (if necessary). A total of 11 patients were found, out of which 7 (63%) were males and 4 (37%) were females. The mean/median age of these patients was 30 years (range 9-52 years). The minimum duration of development of lymphangitis was within minutes in the case of a mosquito bite reaction and around 72 hours in the case of trauma or infection induced, with a median interval of 48 hours. The site most commonly involved was the upper extremity in 8 (72%) patients, followed by the trunk in 2 (18%) and the lower extremity in 1 (9%). Arthropod bite reactions (63%) were the most common etiological agent. All patients presented with linear erythematous streaks extending towards draining lymph nodes. Lymphangitis is often considered to be a bacterial infection and is mostly treated with antibiotics; however, non-bacterial and non-infectious causes should be kept in mind while treating superficial lymphangitis to make judicious use of systemic antibiotics.

Lymphangioma CircumscriptaA Diagnostic Dilemma

Lymphangiomas are developmental malformations that present as benign hamartomas of lymphatic channels. They present at birth or before two years of age, with 50-70% predilection for the head and neck region and less frequently reported in the oral cavity. However, affected sites in the oral cavity include the tongue, palate, gingiva, buccal mucosa, lips and alveolar ridge. Lymphangioma of the buccal mucosa is rare, only 27 cases of lymphangioma of buccal mucosa have been reported till date, out of which seven were in children. The prognosis is good for most patients, but recurrence has also been reported in some cases. This present case is of Lymphangioma Circumscriptum in a 13-year-old child involving right buccal mucosa and lip since birth. This lesion was surgically removed under general anaesthesia and there was a recurrence of the lesion after one year of follow-up. In the literature there was no reported case of Lymphangioma Circumscriptum involving the lip of a child, so this present case was the firstreported case of Lymphangioma Circumscripta involving the lip in a child with recurrence.

Lymphatic Alterations Under Tattoos: Preliminary Reports of One Observational Study.

The number of people within the European population having at least one tattoo has increased notably and with it the number of tattoo-associated clinical complications. The injected inks are known to be removed by the lymphatic vessels and can be found in the draining lymph nodes. To report our observations on the lymphatic drainages seen under tattoos using near infrared fluorescence imaging of these lymphatic vessels after the injection of indocyanine green. Indocyanine green was injected intradermally at the basis of the 20 tattooed area(s) in 19 subjects (nine women and ten men; mean age = 28.6). Ten subjects had only black tattoos (six upper limbs and four lower limbs), five (two upper limbs and three lower limbs) black and white tattoos and five multi-colored tattooed limbs (four lower limbs and one upper limb). The imaging exams revealed alterations in eight individuals, seven of whom had tattoos on their lower limbs. Furthermore, the imaging results showed that the abnormalities might be related to the tattooed limb, the tattoo extent and colour. Alterations of the cutaneous lymphatic channels are frequently observed under tattooed territories. Their causal factors should be more precisely studied in future works and these lymphatic alterations should be considered in tattooed patients when using similar imaging techniques for therapeutic and surgical assessments.

Acquired Cutaneous Lymphangiectasia of Vulva: A Novel Dermoscope Finding.

A 61-year-old woman presented with a 1-year history of multiple, oozy, raised pruritic lesions over the genitalia. Four years back, she had undergone radical hysterectomy followed by loco-regional radiotherapy for her stage IIA carcinoma cervix. On physical examination, she had multiple, grouped, translucent, thin-walled vesicles resembling “frogspawn” on the bilateral labia majora [Figure 1]. Histopathological examination showed a hyperkeratotic epidermis with multiple dilated lymphatic channels in the superficial and deep dermis. Dermoscopy (Dermlite 4) revealed clustered, translucent, reddish-white lacunae surrounded by whitish septa. Few lacunae showed radially arranged, hairpin-like vessels [Figure 2]. The features were consistent with acquired cutaneous lymphangiectasia of vulva (ACLV). Radiofrequency ablation of the lesions was performed and she was under regular follow-up.Figure 1: Multiple, grouped, translucent to flesh-colored, fluid-filled vesicles - ”frogspawn appearance” on labia majoraFigure 2: Dermoscopy (Dermlite 4: Polarized view, 10× magnification) showing clustered, translucent, reddish-white lacunae surrounded by whitish septa (yellow circle). Few lacunae showed radially arranged hairpin-like vessels (black circles)ACLV is a rare entity, which occurs secondary to conditions like trauma, surgery, keloids, radiation, scleroderma, pregnancy, malignancies, Crohn’s disease, or infections like erysipelas, tuberculosis, filariasis, and lymphogranuloma venereum. These conditions cause destruction of lymph nodes and impair lymphatic flow thereby resulting in the accumulation of lymph in dermal lymphatics producing vesicles.[1] The differential diagnosis includes lymphangioma circumscriptum, syringoma, condyloma, herpes, warts, molluscum contagiosum, and benign hemangioendothelioma.[12] Errichetti et al.[3] in their dermoscopy of ACLV reported a vascular pattern with well-demarcated, round to oval red lacunae surrounded by white areas/lines with several punctiform and a few irregular vessels. In addition, we have observed radially arranged hairpin-like vessels in our case. In dermoscopy, similar hairpin-like vessels are found in seborrheic keratosis, keratoacanthoma, squamous cell carcinoma, amelanotic melanoma, superficial basal cell carcinoma (BCC), nodular BCC, eccrine poroma, porocarcinoma, and pilomatrixoma.[4] We report this case for the novel dermoscopic finding. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.