Resection of an Axillary Cystic Lymphatic Malformation in a 14-year Old Child using Intraoperative ICG Lymphography

Aim of the study: Lymphangioma is a benign malformation of the lymphatic system. Surgical excision or sclerotherapy are common treatment modalities. Surgical resection is often challenging as the lymphatic malformation may compress and compromise major adjacent structures including nerves, veins, arteries and lymphatic vessels. Intraoperative Indocyanine Green (ICG) lymphography may be used to rule out any connection between the normal lymphatic vessels and the lymphatic malformation, allowing efficient and safe resection.

Case description: A 14-year-old female presented with an asymptomatic left axillary cystic mass. Axillary ultrasound revealed an un-echoic lesion. An axillary MRI showed 12cm*6cm cystic lymphatic malformation. Prior surgery, we carried out an ICG lymphography to analyze the lymphatic flow around the lesion. ICG lymphography revealed three functional main lymphatic vessels draining the left arm and reaching the cystic lesion without connection to lymphatic malformation. A skin incision was performed in the pre-marked axillary region and careful excision of the lymphatic lesion was performed with simultaneous identification and separation of functional lymphatic vessels using intraoperative ICG lymphography. Following lesion excision, ICG imaging was repeated intraoperatively, ruling out damage to lymphatic vessels. Microscopic histopathologic evaluation was consistent with macrocystic lymphatic malformation. The post-operative follow-up was uneventful.

Conclusions: Intraoperative ICG lymphography is very useful to identify any connection and the anatomic relationship between the normal lymphatic vessels and the lymphatic cyst malformation, allowing safe resection of the cystic lesion.