Surgical excision of giant axillary cystic lymphangioma: a case report

Abstract

Background

Cystic lymphangiomas are rare benign congenital malformations of the lymphatic system, usually diagnosed in childhood and rarely encountered in adults. Axillary involvement in adults is particularly uncommon and presents diagnostic and surgical challenges owing to proximity to neurovascular structures.

Case presentation

This report describes a case of a 22-year-old Yemeni female patient presenting with localized pain in the left breast and a progressively enlarging tender axillary swelling. Imaging revealed a unilocular, thin-walled cystic lesion measuring 13 × 8 cm, extending into the subpectoral space and closely abutting the axillary vessels without invasion. Complete excision was performed via a curvilinear axillary incision, requiring meticulous adhesiolysis to preserve neurovascular integrity. Histopathology confirmed cystic lymphangioma. The postoperative course was uneventful, and no recurrence was noted at 5 month follow-up.

Conclusion

Although predominantly a pediatric entity, cystic lymphangioma should be considered in the differential diagnosis of adult axillary masses. Preoperative imaging is crucial for surgical planning, and complete surgical excision offers excellent outcomes with minimal functional impairment.

Introduction

Cystic lymphangiomas (CLs) are rare tumors originating from the lymphatic system [1]. They develop owing to complete or partial obstruction of lymphatic vessels, which disrupts communication between the lymphatic and venous systems, leading to cyst formation. These cysts may be unilocular but are more commonly multilocular. Swelling occurs because the cysts are isolated from the venous system, allowing lymphatic fluid to accumulate [2].

The most frequent site of cystic lymphangiomas is the neck, accounting for approximately 75% of cases, particularly in the posterior triangle and the cervical region. They are also observed in the axillary region (20%) and, less commonly, in locations such as the retroperitoneum, mesentery, omentum, colon, pelvis, groin, bone, skin, scrotum, and spleen [3]. CLs are predominantly pediatric tumors, with nearly 90% of cases diagnosed before the age of 2 years [4]. Occurrence in adults may result from a delayed proliferation of embryonic cell rests or secondary factors, including infection, trauma, or iatrogenic stimuli [5].

Cystic lymphangiomas typically present as painless masses, often causing concern for the patient. Other clinical manifestations are usually related to complications or the effects of the lesion, such as rapid enlargement or infection accompanied by fever, despite its benign nature. On physical examination, these lesions are generally soft, compressible, nontender, transilluminant, and devoid of bruits [6]. The differential diagnosis includes hematoma, abscess, lymphocele, and soft tissue sarcomas [1].

The diagnosis of cystic lymphangioma is primarily established through ultrasonography, which is particularly useful in distinguishing between solid and cystic lesions. Additional imaging modalities include computed tomography (CT) and magnetic resonance imaging (MRI), each offering specific advantages. CT is valuable in differentiating CL from other masses, such as soft tissue sarcomas, and in assessing the lesion’s extent preoperatively, although it may occasionally be nondiagnostic if a defined cyst wall is absent [7]. MRI provides detailed preoperative staging, allowing the precise identification of individual cystic components and evaluating the involvement of adjacent structures, particularly nerves and vessels [8].

Various treatment modalities have been described for cystic lymphangiomas, including sclerotherapy, laser therapy, cryotherapy, embolization, electrocautery, steroid injection, and radiation therapy. However, given the benign nature of CL, complete surgical excision remains the treatment of choice [9]. This report describes a rare case of a large cystic lymphangioma of the axilla in a young adult female, emphasizing the diagnostic process, surgical challenges due to the lesion’s proximity to vital neurovascular structures, and the favorable outcome following complete excision. This case report has been reported in line with the CARE guidelines [10].

Case presentation

A 22-year-old Yemeni female individual presented to our surgical department with a progressively enlarging, painful swelling in the left axilla radiating to the shoulder and upper arm, which was ongoing for several weeks. The pain was described as dull and intermittent, with gradual worsening over time, and was associated with functional discomfort during shoulder movement. She denied systemic symptoms such as fever, weight loss, or night sweats. Her medical history was unremarkable apart from two prior cesarean sections. She had no history of previous axillary surgery, trauma, radiation exposure, or family history of breast or axillary disease.

On physical examination, a large, firm, tender, well-circumscribed swelling occupied the left axilla. The overlying skin was intact without erythema, ulceration, or dilated veins. The mass was nonpulsatile and noncompressible and showed no transillumination. Neurological and vascular assessments of the left upper limb were normal, with intact motor function, sensation, and peripheral pulses. No supraclavicular or cervical lymphadenopathy was detected.

Routine laboratory investigations, including complete blood count, liver function tests, renal function tests, and inflammatory markers, were within normal limits. High-resolution ultrasonography of the left axilla revealed a well-defined, unilocular, thin-walled cystic lesion measuring 13 × 8 cm, without internal septations or solid components, and no abnormal vascularity on Doppler assessment. Breast ultrasonography showed no abnormalities. Further evaluation with contrast-enhanced computed tomography (CT) of the chest demonstrated a unilocular, thin-walled cystic mass extending into the subpectoral space, closely abutting the axillary vessels but without evidence of infiltration, thrombosis, or features suggestive of malignancy (Figs. 1, 2 and 3). Based on the clinical and radiological findings, a provisional diagnosis of cystic lymphangioma was made.

Fig. 1.

Coronal computed tomography scan demonstrating a giant axillary cyst occupying the entire left axillary region and exerting mass effect on the adjacent chest wall

Fig. 2.

Axial computed tomography scan demonstrating a giant axillary cyst occupying the entire left axillary region, extending to the subpectoral space

Fig. 3.

Sagittal computed tomography scan demonstrating a giant axillary cyst exerting mass effect on the adjacent chest wall and closely abutting the axillary vessels

Given the lesion’s size, progressive nature, and proximity to neurovascular structures, surgical excision was planned. Under general anesthesia, a curvilinear axillary incision was made. The cyst was found to be well-encapsulated, extending into the subpectoral region with dense adhesions to surrounding soft tissues (Fig. 4). Meticulous sharp and blunt dissection allowed complete excision without rupture, preserving the axillary neurovascular bundle (Figs. 5 and 6). A closed-suction drain was placed, and the incision was closed in layers.

Fig. 4.

Intraoperative image showing a large, well-encapsulated, unilocular cystic mass occupying the entire left axillary region

Fig. 5.

Intraoperative image showing the cystic mass dissected away from the axillary vessels and pectoralis muscles, with its fibrous band clearly visible

Fig. 6.

Intraoperative image showing the completely excised cystic mass measuring 13 cm in diameter

Postoperatively, the patient had an uneventful recovery. The drain was removed on postoperative day two, and she was discharged in stable condition. Histopathology revealed cystic spaces lined by flattened epithelium containing eosinophilic proteinaceous fluid with lymphocytic infiltration, consistent with cystic lymphangioma, with no evidence of malignancy (Fig. 7). At 5 month follow-up, the patient remained asymptomatic with full resolution of pain, no recurrence, and satisfactory cosmetic outcome of the axillary incision.

Fig. 7.

Histopathological examination showing cystic spaces lined by flattened endothelial cells and filled with eosinophilic proteinaceous material, with focal lymphocytic infiltration of the cyst wall, consistent with cystic lymphangioma

Discussion

Cystic lymphangiomas originate during embryonic development when the primary lymphatic sacs fail to connect with the central venous system. These lesions typically present as round or lobulated, compressible masses. The most commonly used classification categorizes them as microcystic, macrocystic, or mixed on the basis of whether the cystic spaces measure less than or greater than 2 cm [11]. Alternatively, several authors classify these lesions as capillary lymphangiomas, cavernous lymphangiomas, or cystic hygromas [12].

On CT imaging, cystic lymphangiomas typically appear as low-density cystic lesions with smooth, well-defined walls, and their homogeneous contents do not enhance with contrast. MRI provides superior characterization of the cyst components, with CL showing low signal intensity on T2-weighted images and high signal intensity on T1-weighted images [13].

The treatment of choice for cystic lymphangioma is complete surgical excision. Alternative approaches, including incision and drainage, sclerotherapy, steroid therapy, radiotherapy, and carbon dioxide laser, have been reported [14], Consequently, total surgical removal remains the preferred approach to minimize the risk of recurrence, as spontaneous resolution is uncommon [15]. The primary challenge in managing cystic lymphangioma is preventing recurrence. While simple aspiration and sclerotherapy are linked to higher recurrence rates, they are generally associated with fewer complications. By contrast, surgical excision offers the lowest recurrence rate but carries potential risks, including injury to adjacent neurovascular structures and postoperative seroma formation [16].

Adult-onset cystic lymphangioma of the axilla is a rare clinical entity that should be considered in the differential diagnosis of large, painless, or painful axillary cystic swellings. Preoperative imaging is essential for accurate diagnosis and surgical planning, particularly when lesions are adjacent to major neurovascular structures. Complete surgical excision is the definitive treatment, with meticulous dissection required to prevent neurovascular injury and reduce recurrence risk. Early recognition and appropriate management can lead to excellent functional and cosmetic outcomes.

Conclusion

Cystic lymphangioma of the axilla in adults is an exceptionally rare condition that can mimic other benign or malignant cystic lesions. Comprehensive imaging plays a pivotal role in diagnosis and operative planning. Complete surgical excision remains the gold standard of treatment, ensuring both symptom resolution and prevention of recurrence. Careful dissection is particularly important in the axilla to preserve adjacent neurovascular structures. With timely diagnosis and meticulous surgery, excellent functional and cosmetic outcomes can be achieved.

CARE guidelines

This case report has been reported in line with the CARE guidelines.

Abbreviations

CL

Cystic lymphangioma

CT

Computed tomography

MRI

Magnetic resonance imaging

Author contributions

The author contributed to the conceptualization, literature review, case management, data collection, manuscript writing, and final approval of the version to be submitted.

Funding

There are no funding sources.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Ethical approval for the publication of this case report was obtained from the Institutional Ethics Review Committee of Ibn Sina Hospital, Sanaa, Yemen, in accordance with local regulations (approval number: 2025-12). Written informed consent for participation and publication was obtained from the patient.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interest

The author declares that he has no competing interests.