Surg Today (2010) 40:883–889DOI 10.1007/s00595-010-4255-7

Reprint requests to: H. OjimaReceived: September 16, 2009 / Accepted: January 12, 2010

Case Report

Solitary Hepatic Lymphangioma: Report of a Case

Takuya MATSUMOTO1,4, HIDENORI OJIMA

2, YURI AKISHIMA-FUKASAWA2, NOBUYOSHI HIRAOKA

2, HIROAKI ONAYA3,

KAZUAKI SHIMADA4, YASUNORI MIZUGUCHI

3, SHINTARO SAKURAI5, TOSHIHARU ISHII

6, TOMOO KOSUGE4,

and YAE KANAI2

1 Pathology Division, 3 Diagnostic Radiology Division, and 4 Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan2 Pathology Division, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan5 Department of Surgery, St. Luke’s International Hospital, Tokyo, Japan6 Department of Pathology, Toho University School of Medicine, Tokyo, Japan

AbstractA 52-year-old woman presented with upper abdominal pain. Abdominal ultrasonography showed a 4-cm well-defi ned mass containing solid and cystic components in segment IV of the liver, and contrast-enhanced T1-weighted magnetic resonance imaging revealed het-erogeneous enhancement within the tumor, indicating a solid or fi brous component. There were no cystic lesions in any other organs. A partial hepatectomy was per-formed, based on a preoperative diagnosis of sclerosing hemangioma and biliary cystadenoma or cystadenocar-cinoma. Pathologically, the tumor appeared to be a multilocular and cystic lesion lined by attenuated endo-thelial-like cells with no atypia. Immunohistochemistry demonstrated the endothelial-like cells to be positive for the lymphatic-specifi c markers D2-40, LYVE-1, and Prox-1, which proved helpful for confi rming the diagno-sis as solitary hepatic lymphangioma. This case is pre-sented with details of the pathologic and radiologic fi ndings, because solitary hepatic lymphangioma is an extremely rare tumor and no previous reports have provided details of the immunohistochemical characteristics.

Key words Solitary hepatic lymphangioma · D2-40 · LYVE-1 · Prox-1 · Hemangioma

Introduction

Lymphangiomas are benign neoplasms regarded as mal-formations that arise from sequestrations of lymphatic

tissue that fail to communicate with the normal lym-phatic system during embryogenesis. However, second-ary occlusion of the lymphatic fl ow can also cause lymphangioma.1–3 Lymphangiomas are frequently found in the neonatal period and childhood, but rarely in adulthood.2 Approximately 70%–90% of lymphangio-mas occur in the head, neck, and axilla, whereas intra-abdominal cases account for less than 5% (mesentery 70%, omentum 15%, mesocolon 10%, retroperitoneum 5%).2,4–6 Occasionally, lymphangioma affects soft tissues or parenchymal organs in a diffuse or multifocal fashion, a condition that is termed lymphangiomatosis, which can affect bone, spleen, lung, or liver, and usually has a poor prognosis because complete excision is diffi cult.2 The occurrence of solitary lymphangioma in the liver is extremely rare, and only 7 reports have appeared in the English literature.7–12 Unfortunately, none of these reports provided details of the clinicopathological fi nd-ings and immunohistochemical characteristics.

This report presents a rare case of solitary hepatic lymphangioma, which was investigated in detail with regard to radiologic–pathologic correlations and immu-nohistochemical staining for D2-40,13,14 LYVE-1,15–17 and Prox-1.3

Case Report

A 52-year-old woman with upper abdominal pain was referred to the National Cancer Center Hospital, Tokyo, Japan. The results of a laboratory analysis were within normal limits, and all tumor markers related to the liver were negative. Abdominal ultrasonography (US) showed a 4-cm well-defi ned mass containing solid and cystic components in segment IV of the liver (Fig. 1a). The administration of a contrast agent (Levovist;

884 T. Matsumoto et al.: Solitary Hepatic Lymphangioma

presence of hemorrhagic areas. However, a defi nitive diagnosis could not be established. A partial hepatec-tomy (segment IV) and cholecystectomy were per-formed because the patient’s upper abdominal pain persisted. Surgery revealed several of the cysts detected by preoperative imaging to be simple cysts.

The tumor measured 3 cm in diameter, was well delineated, and contained a mixture of small cystic com-ponents and gray-white solid components with calcifi ed spots; several of the cysts in the tumor contained trans-parent and colorless viscous liquid (Fig. 3a,b). There was no indication of either any fresh hemorrhage or clots that would have suggested hemangioma.

The surgically resected specimen was fi xed in 10% formalin for 3 days at room temperature. The entire tumor was then cut into slices at intervals of 0.7–1.0 cm, and all the tumor-containing sections were routinely processed and embedded in paraffi n to examine their histological characteristics. Immunohistochemical studies were carried out on formalin-fi xed, paraffi n-embedded tissues. The antibodies included those against Ki-67 antigen (clone MIB-1; Dako, Glostrup, Denmark; dilution 1 : 100), pankeratin (clone AE1/AE3; Dako; dilution 1 : 100), cytokeratin 7 (clone OV-TL12/30; Dako; dilution 1 : 500), von Willebrand factor (vWF; polyclonal; dilution 1 : 200), CD31 (clone JC/70A; Dako; dilution 1 : 50), CD34 (clone MY10; Becton Dickinson, Franklin Lakes, NJ, USA; dilution 1 : 100), D2-40 (clone D2-40; Signet, Dedham, MA, USA; dilution 1 : 100), LYVE-1 (polyclonal; dilution 1 : 100),15 and Prox-1 (polyclonal; AngioBio, Del Mar, CA, USA; dilution

galactose-palmitic acid; Bayer, Germany) revealed a spotty blood fl ow signal in the tumor in the early phase and a fi lling defect in the late phase (Fig. 1b,c). Unen-hanced computed tomography (CT) depicted the lesion as a heterogeneously hypoattenuated area with several tiny calcifi cations in the periphery. The central part of the lesion demonstrated a subtle, irregular enhance-ment in the portal-venous dominant phase of contrast-enhanced CT, thus suggesting the presence of solid components (Fig. 2a–c). T1-weighted magnetic reso-nance (MR) imaging showed a well-defi ned mass with almost homogeneous hypointensity. T2-weighted imaging demonstrated a multilocular hyperintense mass with septa, indicating that the lesion was cystic. Con-trast-enhanced T1-weighted imaging revealed heteroge-neous, mild to moderate enhancement within the tumor, which was more marked than that shown by enhanced CT. This made the tumor appear to consist of a larger central sponge-like well-enhanced component sur-rounded by peripheral small cysts divided by septa showing weak enhancement (Fig. 2d–f). Several simple cysts were also detected in the liver, but no extrahepatic cystic lesions were evident.

The preoperative differential diagnosis eventually included biliary cystadenoma or cystadenocarcinoma, and sclerosing hemangioma. Biliary cystadenoma or cystadenocarcinoma was highly suspected because of the presence of both solid components and cystic com-ponents within the tumor. Sclerosing hemangioma, which shows less enhancement than a common heman-gioma, could not be ruled out due to the occasional

Fig. 1. a Liver ultrasonography depicts a well-defi ned round mass (arrowheads) with a mixture of solid and small cystic components in segment IV. Very high-echo spots considered to be calcifi cation are evident (arrow). GB, gallbladder; PV, portal vein. b Spotty blood fl ow signals are seen in the tumor during the early phase after the injection of Levovist. c In the late phase, a fi lling defect is demonstrated

T. Matsumoto et al.: Solitary Hepatic Lymphangioma 885

1 : 100). The sections were deparaffi nized and dehy-drated, and then were developed using the labeled streptavidin-biotinylated antibody technique and fi nally were visualized in diaminobenzidine using conventional methods, except for LYVE-1 immunohistochemistry, which was performed using a CSAII kit (Dako).

The tumor was composed of various-sized cysts with thin septa, partially including calcifi ed granules: the cysts were lined by attenuated endothelial-like cells without atypia, and had colloid-like contents (Fig. 3b). Elastica van Gieson staining revealed no evidence of invasive proliferation or vessel invasion that could be regarded as malignancy anywhere in the specimen. However, we found that some small cysts showed con-tinuous extension from a destroyed portal area (Fig. 3c). Accordingly, biliary cystadenoma, hemangioma, and lymphangioma were considered as possible histopatho-logical diagnoses.

Immunohistochemically, the endothelial-like cells were almost all positive for CD31, CD34, and Prox-1 (Fig. 3e–g), and partially positive for D2-40 and LYVE-1 (Fig. 3h,i). Pankeratin AE1/3, cytokeratin 7, and vWF were all negative. In addition, the small cysts contained more D2-40- and LYVE-1-positive endothelial-like cells than the large ones.

The lesion was fi nally diagnosed to be a solitary hepatic lymphangioma, because grossly the tumor was multilocular without any clots, and microscopically it was multicystic and lined by endothelial-like cells without atypia, which were positive for the lymphatic-specifi c immunohistochemical markers D2-40, LYVE-1,

and Prox-1, and negative for pankeratin, cytokeratin 7, and vWF. The patient remains well without any evi-dence of tumor recurrence 6 months after surgery.

Discussion

Solitary hepatic lymphangioma is an extremely rare tumor, and only 8 cases, including the one presented here, have so far been reported in the English litera-ture7–12 (Table 1). Four cases in children were accompa-nied by acute symptoms, and each tumor was very large (average diameter about 17 cm). In contrast, one of the three adult cases showed intermittent upper abdominal pain and the other two had either no symp-toms or the symptoms were not described. Each of these tumors was small, ranging from about 1 to 4 cm in diameter. The present case caused abdominal pain in an adult female, and the lesion measured 3 cm in diameter, similar to the other three reported adult cases. However, the fi ndings in the other seven reported cases were insuffi cient to allow a pathological diagnosis of lymphangioma, because the immunohisto-chemical examination was performed using only ves-sel-specifi c markers such as vWF, and lymphatic-specifi c markers such as D2-40, LYVE-1, and Prox-1 were not employed. It is diffi cult to determine whether a tumor is derived from a lymph duct or blood vessel only on the basis of histology with hematoxylin–eosin staining or immunohistochemical examinations with vessel- specifi c markers. Furthermore, antibodies against

Fig. 2. a Unenhanced computed tomog-raphy (CT) depicts the lesion as an area of heterogeneous hypoattenuation (arrowheads) with several tiny calcifi ca-tions in the periphery (arrow). b The lesion shows almost no enhancement during the arterial dominant phase of contrast-enhanced dynamic CT. c The central part of the lesion shows subtle, irregular enhancement suggesting the presence of solid components in the late phase. d T1-weighted magnetic resonance (MR) image shows a well-defi ned, almost homogeneous hypointense mass. e T2-weighted MR image demonstrates a multilobulated hyperintense mass with septa, indicating a cystic lesion. f Con-trast-enhanced T1-weighted MR image demonstrates mild to moderate heteroge-neous enhancement within the tumor, the degree being more marked than that evident by enhanced CT

886 T. Matsumoto et al.: Solitary Hepatic Lymphangioma

vessel-specifi c immunohistochemical markers react with both blood vessels and lymph duct endothelial cells. In fact, some previous cases of lymphangiohe-mangioma in various organs were diagnosed at a time when no antibodies against lymphatic-specifi c markers were available.17,18

The novel antibodies D2-40, LYVE-1, and Prox-1 were introduced to help reliably differentiate lymphatic from vascular endothelium. All of the antigens they rec-ognize are expressed on endothelial cells of normal or neoplastic lymph ducts, and not blood vessels. Some previous reports have indicated that almost all lymph-angiomas, wherever they are located, are positive for D2-40, LYVE-1, and Prox-1.3,13–16,19 Blood vessel endo-thelial cells of hemangioma are positive for CD31,

CD34, and vWF, and negative for D2-40, LYVE-1, and Prox-1 (Table 2). The extent of endothelial cells positive for Prox-1 was very high in the present case, but unex-pectedly few cells were positive for D2-40 and LYVE-1. The radiologic–pathologic correlation between lymph-angioma and hemangioma is summarized in Table 2.2,13,19–27 Ultrasonography fi ndings, contrast enhance-ment patterns on multiphasic CT and MR images, gross fi ndings, and immunohistochemical examination are very important for distinguishing lymphangioma from hemangioma. In particular, Prox-1 was found to be very helpful for making a defi nitive diagnosis in the present case.

No defi nite preoperative diagnosis was obtained in the current patient because both cystic components and

Fig. 3. a Gross appearance, showing a well-delineated tumor (arrowheads) with a mixture of various-sized cystic compo-nents (white arrow) and a gray-white solid component con-taining spotty calcifi cations (yellow arrow). b Cysts are lined by attenuated endothelial-like cells with no atypia and includ-ing a colloid-like content. Spotty calcifi cation is evident (black arrow) (H&E stain, ×200). c Elastic fi bers (arrowheads) sur-rounding portal area are partly destroyed, but some remain. Various cystic components seem to extend from this area

(Elastica van Gieson staining, ×40). d High-magnifi cation view (H&E stain, ×200). Immunohistochemical expression of CD31 (e), CD34 (f), Prox-1 (g), D2-40 (h), and LYVE-1 (i) (×200). High immunohistochemical expression of CD31 (e) and Prox-1 (g), and low immunohistochemical expression of D2-40 (h) and LYVE-1 (i) are demonstrated. Expression of both D2-40 and LYVE-1 is higher in the small cysts than in the large ones

T. Matsumoto et al.: Solitary Hepatic Lymphangioma 887

solid components were radiologically evident in the lesion. A detailed review of the imaging fi ndings of this case revealed an obvious correlation with the pathologi-cal fi ndings, i.e., the slow enhancement of part of the tumor on CT and MR was consistent with the fi brous part evident on microscopy. This corresponded exactly to the part that appeared to represent a solid compo-nent on preoperative imaging, and appeared grayish-white and solid on gross cross- sectional examination. In addition, fi ne vascular proliferation was evident around the cysts and within the fi brous areas, and this was immunohistochemically positive for CD31 and CD34. This might have con tributed to the enhancement seen within the tumor on multiphasic CT and MR imaging with contrast medium. The presence of such features as the solid (fi brous) component and heterogeneous enhancement made a preoperative diagnosis of lymph-angioma diffi cult.

The pathogenesis of adult-type hepatic lymphangi-oma is unknown. There are two hypotheses for the origin of the present tumor. It may have been congenital and present in the patient’s liver for a long time, becom-ing manifest only when it began to cause upper abdomi-nal pain, possibly as a result of infl ammation. However, there is no clear explanation for the relationship between the upper abdominal pain and the tumor. Although the patient was a middle-aged woman, this hypothesis is still compatible with the epidemiology of lymphangioma, which is found most commonly as a congenital lesion in children. The observed calcifi cations may indicate that the tumor had existed for a long period of time. The second possibility is that the lesion may have been a very slow-growing benign tumor derived from prolifer-ating lymph ducts. The lymph ducts of the liver are found within the portal area and around some hepatic vein branches, but not within the hepatic parenchyma.28 The proliferated lymph ducts might have originated through natural lymphatic dilatation in the portal area, due to lymphatic stasis resulting from localized infl am-mation or some other cause. In fact, microscopic obser-vations demonstrated a transitional zone between the proliferated or dilated lymph ducts in the portal area and the hepatic parenchyma (Fig. 3c). It was diffi cult to think that the present tumor showed active cell prolif-eration, because the Ki-67 index was markedly low.

In summary, this report immunohistochemically dem-onstrated the lymphatic nature of a solitary hepatic lymphangioma, and detailed its pathological features and radiologic–pathologic correlations. This is the fi rst reported study to describe the immunohisto chemical features of hepatic lymphangioma in detail using new selective markers of the lymphatic endothelium.

Acknowledgments. The authors thank Takahiro Hasebe, MD, for his helpful advice and comments.Ta

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888 T. Matsumoto et al.: Solitary Hepatic Lymphangioma

Table 2. Radiologic and pathologic fi ndings of lymphangioma and hemangioma

Lymphangioma2,13,19,20,24–26 Hemangiomaa 2,21–23,25,27

Ultrasonography B mode Hypoechoic with septa (multicystic)

Hyperechoic

Computed tomography Unenhanced Hypoattenuation (multicystic) HypoattenuationContrast-enhanced No enhancement except for septa Dense peripheral enhancement

following centripetal fi ll-inMagnetic resonance imaging T1WI Hypointensityb Hypointensity

T2WI Hyperintensity with septa HyperintensityGross fi ndings Color Gray-white Dark brownc

Sectioned Well-circumscribed various sized cysts

Well-circumscribed various vascular spaces

Contents Proteinaceous fl uid BloodCalcifi cation Sometimes exists Sometimes exists

Microscopic fi ndings Composed of cystic lesions lined by a single layer of attenuated endothelium with no atypia

Composed of blood-fi lled spaces lined by a single layer of fl at endothelial cells

Immunohistochemical staining

vWF Negative PositiveCD31 Positive PositiveCD34 Positived PositiveD2-40 (Podoplanin) Positive NegativeLYVE-1 Positive NegativeProx-1 Positive Negative

a Mainly cavernous hemangiomab Rarely hyperintensity owing to proteinaceous nature of fl uid and hemorrhagec Sometimes gray-white (especially sclerosed hemangioma)d Small subset of cells is positive

References

1. Godart S. Embryological signifi cance of lymphangioma. Arch Dis Child 1966;41:204–6.

2. Weiss SW, Goldblum JR, Enzinger FM. Benign tumors and tumor-like lesions of blood vessels. Tumors of lymph vessels. In: Weiss SW, Goldblum JR, Enzinger FM, editors. Soft tissue tumors. 5th ed. Philadelphia: Elsevier Health Sciences; 2008. p. 636–64, 734–43.

3. Wigle JT, Oliver G. Prox1 function is required for the development of the murine lymphatic system. Cell 1999;98:769–78.

4. Roisman I, Manny J, Fields S, Shiloni E. Intra-abdominal lymph-angioma. Br J Surg 1989;76:485–9.

5. Van Steenbergen W, Joosten E, Marchal G, Baert A, Vanstapel MJ, Desmet V, et al. Hepatic lymphangiomatosis. Report of a case and review of the literature. Gastroenterology 1985;88:1968–72.

6. Muramori K, Zaizen Y, Noguchi S. Abdominal lymphangioma in children: report of three cases. Surg Today 2009;39:414–7.

7. Chan SC, Huang SF, Lee WC, Wan YL. Solitary hepatic lymphan-gioma-a case report. Int J Clin Pract Suppl 2005:100–2.

8. Haratake J, Koide O, Takeshita H. Hepatic lymphangiomatosis: report of two cases, with an immunohistochemical study. Am J Gastroenterol 1992;87:906–9.

9. Koh CC, Sheu JC. Hepatic lymphangioma — a case report. Pediatr Surg Int 2000;16:515–6.

10. Stavropoulos M, Vagianos C, Scopa CD, Dragotis C, Androulakis J. Solitary hepatic lymphangioma. A rare benign tumour: a case report. HPB Surg 1994;8:33–6.

11. Nzegwu MA, Ekenze SO, Okafor OC, Anyanwu PA, Odetunde OA, Olusina DB. Solitary hepatic lymphangioma in an infant. J Perinat Med 2007;35:164–5.

12. Shahi KS, Geeta B, Rajput P. Solitary hepatic lymphangioma in a 22-day-old infant. J Pediatr Surg 2009;44:E9–11.

13. Fukunaga M. Expression of D2-40 in lymphatic endothelium of normal tissues and in vascular tumours. Histopathology 2005;46:396–402.

14. Galambos C, Nodit L. Identifi cation of lymphatic endothelium in pediatric vascular tumors and malformations. Pediatr Dev Pathol 2005;8:181–9.

15. Akishima Y, Ito K, Zhang L, Ishikawa Y, Orikasa H, Kiguchi H, et al. Immunohistochemical detection of human small lymphatic vessels under normal and pathological conditions using the LYVE-1 antibody. Virchows Arch 2004;444:153–7.

16. Banerji S, Ni J, Wang SX, Clasper S, Su J, Tammi R, et al. LYVE-1, a new homologue of the CD44 glycoprotein, is a lymph-specifi c receptor for hyaluronan. J Cell Biol 1999;144:789–801.

17. Xu M, Luo D, Lei W, Zhang H, Wu N, Zhou C. Mediastinal lymphangiohemangioma communicating with the left innominate vein. J Comput Assist Tomogr 2005;29:650–2.

18. Riquet M, Briere J, Le Pimpec Barthes F, Puyo P. Lymphangiohe-mangioma of the mediastinum. Ann Thorac Surg 1997;64: 1476–8.

19. Xu H, Edwards JR, Espinosa O, Banerji S, Jackson DG, Athana-sou NA. Expression of a lymphatic endothelial cell marker in benign and malignant vascular tumors. Hum Pathol 2004;35: 857–61.

20. Bezzi M, Spinelli A, Pierleoni M, Andreoli G. Cystic lymphangi-oma of the spleen: US-CT-MRI correlation. Eur Radiol 2001; 11:1187–90.

21. Caseiro Alves F, Brito J, Araujo AE, Belo Soares P, Rodrigues H, Cipriano A. Liver haemangioma: common and uncommon fi nd-ings and how to improve the differential diagnosis. Eur Radiol 2007;17:1544–54.

22. Ferrozzi F, Bova D, Campodonico F. Cystic primary neoplasms of the liver of the adult. CT features. Clin Imaging 1993; 17:292–6.

23. Fujii T, Zen Y, Sato Y, Sasaki M, Enomae M, Minato H, et al. Podoplanin is a useful diagnostic marker for epithelioid heman-gioendothelioma of the liver. Mod Pathol 2008;21:125–30.

24. Hornick JL, Fletcher CD. Intraabdominal cystic lymphangiomas obscured by marked superimposed reactive changes: clinicopath-ological analysis of a series. Hum Pathol 2005;36:426–32.

T. Matsumoto et al.: Solitary Hepatic Lymphangioma 889

25. Ishak KG, Goodman ZD, Stocker JT. Benign mesenchymal tumors and pseudotumors. In: Ishak KG, Goodman ZD, Stocker JT, editors. Atlas of tumor pathology: Tumors of the liver and intrahepatic bile ducts. Washington, DC: Armed Forced Institute of Pathology; 2001: p. 87–92, 98–9.

26. Jeung MY, Gasser B, Gangi A, Bogorin A, Charneau D, Wihlm JM. Imaging of cystic masses of the mediastinum. Radiographics 2002;22:S79–93.

27. Nguyen VA, Kutzner H, Furhapter C, Tzankov A, Sepp N. Infan-tile hemangioma is a proliferation of LYVE-1-negative blood

endothelial cells without lymphatic competence. Mod Pathol 2006;19:291–8.

28. MacSween RNM, Desmet VJ, Roskams T. Developmental anatomy and normal structure. In: MacSween RNM, Burt AD, Portmann BC Scheurer KG, Anthony PP, Weisenberg E, editors. Pathology of the liver. 4th ed. London: Churchill Livingstone; 2002: p. 48–9, 69.