CASE REPORT Massive Localized Lymphoedema Jonathan Hutt, BA, MBBS, Wayne Sturley, MBBS, and Barbara Jemec, MD, FRCS Abstract: A case report of massive localized lymphoedema in a morbidly obese 50-year-old woman and review of the literature. Key Words: obesity, lymphoedema (Ann Plast Surg 2009;63: 000 – 000) A 50-year-old diabetic obese woman weighing 29 st presented with an 18-month history of a large mass on her left thigh. Other surgeons had refused operating as they thought it was a hematoma after Warfarin treatment for a DVT (Fig. 1). A biopsy demonstrated vascular, fatty subcutaneous tissue with mild chronic inflammation with no features of neoplasia or infection. Magnetic resonance imaging showed edematous changes of the cutaneous and subcutaneous tissues within the mass, but no collection, lying superficial to the long saphenous vein. At excision the lesion weighed 4.5 kg. Postoperatively, she developed 2 abscesses in the region of excision which were treated with incision, drainage, and intravenous antibiotics. The patient is now well and to date there is no recurrence of the lesion. DISCUSSION Localized lesions affecting the morbidly obese 1–5 have been called massive localized lymphoedema or even pseudosarcoma. The tumors are usually longstanding and cause a functional problem or infection. They are often massive, with the overlying skin showing the typical features of chronic lymphatic obstruction: brawny, nonpitting edema with hyperkeratosis and lymphangiact- esia. They are diffuse, with no discrete margins and imaging shows they are confined to the superficial epifascial space of the skin and subcutaneous tissue, without extension into the muscles. Histologi- cally (Fig. 2), these lesions have prominent interlobular septae extending though the adipose tissue with a thick epidermis and dermal expansion. Reactive vessels are present at the border of the adipose and fibrous tissues and there may be localized areas of hemorrhage, fat necrosis, and neural edema. The precise mechanism of development remains undefined; the consistent clinical and histopathalogical descriptions of these lesions suggest the following etiology: initial mechanical lymphatic obstruction gives rise to a cycle of lymphostasis and lymphotension, leading to further obstruction and the development of lymphoedema. The leak of protein-rich fluid in the interstitial space stimulates a localized inflammatory response and this further impedes the lym- phatic drainage, and chronic lymphoedema results. 6 The normal transport of lymph relies on the intrinsic contrac- tility of the lymphatic system, with unidirectional flow ensured by the presence of valves. Extrinsic factors such as exercise, activity, and external compression also play a part, and become more impor- tant in the presence of lymphostasis and lymphotension. In the obese patient, it is likely that the pathophysiology develops both from an increase in tissue mass and its mechanical consequences. Obese breast cancer patients undergoing axillary clearance show increased postoperative axillary drainage. 6 In pa- tients with a high BMI, the greater level of interstitial fluid resulting from a higher adipose tissue volume will lead to pressure on the draining capacity of the lymphatics. In the obese patientThe body habitus of these patients causes a significant mechanical impediment to lymphatic drainage. Without surgery or radiotherapy, all cases of massive localized lymphoedema reported have been in dependant areas of the abdomen and the lower limbs. The decreased mobility Received February 5, 2008 and accepted for publication, after revision, September 9, 2008. From the Department of Plastic and Reconstructive Surgery, Chelsea and West- minster Hospital, London, United Kingdom. Reprints: J. Hutt, BA MBBS, 2B Swift St, Fulham, London SW6 5AG, UK. E-mail: drhutt@hotmail.com. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0148-7043/09/6303-0001 DOI: 10.1097/SAP.0b013e31818d4544 FIGURE 1. A 50-year-old diabetic obese woman with a large mass on her left thigh. FIGURE 2. Thickened epidermis with underlying oedema and small lymphatic proliferation. balt5/zps-aps/zps-aps/zps01209/zps5014-09a saliyark S3 6/18/09 21:44 Art: SAP201291 Annals of Plastic Surgery • Volume 63, Number 3, September 2009 www.annalsplasticsurgery.com | 1 AQ:1 F1 AQ:2 AQ:3 F2 AQ:4