Recurrent Cystic Lymphangioma Fig. 4. Pathologic specimen showing multiple cystic spaces containing lymphoid and endothelial cells (hematoxylin- eosin ×100). multi-locular cystic masses. The opacification of the locules during lymphangiography also sup- ports this hypothesis.8 The most common location is the neck (cystic hygroma) in 75% of the cases, followed by the axilla in 20%. In the remaining 5%, other areas of the body are affected. Abdominal lymphangiomas most commonly occur in the intestinal mesentery, retroperitoneum being the second location of choice.9 Multisystem involvement is very rare and has a bad prognosis. Complications include ane- mia, hemorrhage, infection, torsion, volvulus and rupture of the mass and intestinal and ureteric obstructions.10 Lymphangiomas have been classified into three groups: capillary (or simple), cavernous and cystic, depending on the size of the lymphatic spaces. Simple lymphangiomas are composed of small, thin-walled, lymphatic channels with con- siderable connective tissue stroma. Cavernous lymphangiomas consist of dilated lymphatic chan- nels, whereas cystic lymphangiomas contain single or multiple cystic masses.1,5,11 These tumors can recur.12 Recurrence of mass 13 years after the first operation in a 52-year-old female has been reported only once in the litera- ture before.1 The cause of recurrence is unclear but may be due to incomplete resection of the mass. Long term follow-up is needed to determine the exact reason and incidence of recurrence. The differential diagnosis possibilities are lim- ited for large, cystic, intraabdominal masses of childhood. These are ovarian masses such as teratoma, serous cystadenoma and mucinous cystadenoma. The most commonly encountered ones are the teratomas that demonstrate bone and calcific foci on US and radiographs. Pancreatic pseudocysts, multiloculated cystic nephromas, and liver and spleen cysts originate from the cited organs. Smaller lesions such as traumatic hema- tomas and urinomas can be clinically diagnosed. In enteric duplications, US can generally demon- strate the significant muscular and mucosal layers and the hyperechogenicity at the periphery of the mass.7 Abdominal lymphangiomas are often dis- cussed in conjunction with mesenteric cysts, but lymphangioma presents earlier in life.13 Neverthe- less, the presentation age of our case contradicted with this classical information. Our case was different in the sense that it first presented at the age of 7 years, showed a recurrence after 11 years and had a mass in the retroperitoneum, which is a very rare location. The cyst contents of the present case did not show enhancement after postcontrast images, similar to that reported in a study by Bonhomme et al,14 but in contrast we could not obtained fibrous capsula. Though numerous publications have stated that lymphangiomas of the retroperitoneum do not calcify, at least two prior case reports have dem- onstrated calcification.10,15 The series by Davidson et al. includes two examples of unicameral lymphangiomas with a thick layer of mural cal- cium.8 US, CT and MR appear to be complementary in the evaluation of cystic lymphangiomatosis. US is useful in demonstrating the internal structure of lymphangiomas, particularly septations.16 CT may help distinguish retroperitoneal and mesenteric lymphangiomas from adjacent bowel loops. CT may also be able to distinguish parapelvic renal lymphangiomatosis from hydronephrosis. The ability of MR to provide images in multiple planes without loss of resolution may demonstrate addi- tional lesions and further delineate their bound- aries.1 The final diagnosis of lymphangioma is achieved by pathological examination of the specimen after surgical or laparoscopic examination17 and is based on well-established criteria.18 These include a well circumscribed, cystic lesion with or without Yonsei Med J Vol. 46, No. 5, 2005