Retroperitoneal lymphangioma

194 1994; Vol. 61. No. 2 THE INDIAN JOURNAL OF PEDIATRICS (partial + complete) 8 in children have led to suggestions that childhood melanoma is potentially more responsive and amenable to therapy than it is in adults. Dacarbazine failures m a y respond to cisplatiia and teniposide. Interleukin-2 and interferon are undergoing extensive trials as a d j u v a n t therapy for stage III disease. R~ERENC~ 1. Avril MF, Sancho Gamier H. Skin tumours. In : Voute PA, Bassett A, ed. Cancer in Children. Frankfurt : Springer Verlag, 1992; 332-339. 2. Boddie AW, McBride CM. Melanoma in childhood and adolescence. In : Black C, ed. Cutaneous Melanoma. Philadelphia : Lippincott, 1985; pp 63-69. 3. Rao BN, Hayes FA, Pratt CB et al. Malignant melanoma in children. Its management and prognosis. J Pediatr Surg 1990; 25 (2) : 198-203. 4. Jussawalla DJ, Yeole BB. An epidemiological study of malignant melanoma in greater Bombay. Indian J Cancer 1988; 25 : 70-76. 5. Trozak D, Rowland W, Hu F. Metastatic malignant melanoma in prepubertal children. Pediatrics 1975; 55 : 191-204. 6. Roth ME, Grant-Kels JM, Kuhn K et al. Melanoma in children. J Am Acad Dermatol 1990; 22 : 265-274. 7. Ho VC, Sober AJ. Therapy for cutaneous melanoma : An update. J Am Acad Dermatol 1990; 22 : 159-176. 8. Hayes FA, Green AA. Malignant melanoma in childhood : Clinical course and response to chemotherapy ] Clin Oncol 1984; 2 : 1229-1234. RetroperitonealLymphangioma A.P. Patel, J.M. Kothari*, K.M. Patel, S.N. Shukla, R.B. Shah**, A. Anand, B.J. Parikh, D.D. Girl** and P.M. Shah Departments of Medicine, *Surgery and **Pathology, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad R e t r o p e r i t o n e a l and mesenteric cysts are rare intra-abdominai tumours. ~ Histologically a b d o m i n a l cyst is l y m p h a n g i o m a , non-pancreatic pseudocyst, enteric duplication cyst. Mesothelial cyst or enteric cyst. 2 Mesenteric cysts are more c o m m o n than retroperitoneal cysts. Lymphangiomas in the pediatric age group are still rare) Due to rarity, pre-operative diagnosis was suspected in only 25% of the reported cases? Complete enucleation is the treatment of choice. The next best alternative is marsupialisation. Retroperitoneal cysts are difficult to excise completely due to their proximity to the major vessels and other structures. We present a case of l y m p h a n g i o m a in a two year and nine months old girl. CASE REPORT A two year and nine m o n t h old girl presented in August, 1992 with complaints of abdominal distention, on and off fever, anorexia and weight loss of twelve months duration. She was treated elsewhere with 1994; Vol. 61. No. 2 THE INDIAN JOURNAL OF PEDIATRICS 195 Fi8. 1. Computerised axial tomography of the abdomen showing a multiloculated cyst. emperical anti-tubercular therapy. Examination revealed malnutrition grade III and a huge abdominal lump. Hemogram, urine, liver and renal function tests were normal. Aspiration and study of the cystic fluid showed sugar 61 mg%, protein 2.41 gm% and no malignant cells. X-ray film of abdomen showed a soft tissue opacity with upward displacement of the bowel. CT scan of the abdomen had reported the lesion as a multiloculated ascites (Figure 1). She underwent exploratory laparotomy and a large cyst was completely excised. The cyst of 13 x 9.5 × 6 cm in size was adherent to the peritoneum in the left iliac fossa, pelvic structure, colon, mesocolon, d u o d e n u m and pancreas. The cyst had a nodular surface with haemorrhagic fluid, and was multiloculated. There were no ascites. The patient had an uneventful post-operative period and she is well after six months of the operation. DIscussioN There are no pathognomonic signs and symptoms of abdominal cysts. Diagnosis of an abdominal cyst should be Considered when a patient has a long standing history as in this case. Due to the common occurrence of tuberculosis in India, this case was misdiagnosed as tuberculous abdomen, and was referred to our hospital when she failed to improve on anti-tubercular treatment. Although sonography and CT scan should lead to the diagnosis in almost all the cases, 1 due to rarity of the cysts, they were correctly diagnosed by CT scan and sonography pre-operatively in only 25% of the reported cases. Ultrasonography and CT scan of the cyst showed a 196 THE INDIAN JOURNAL OF PEDIATRICS 1994; Vol. 61. No. 2 Fig. 2. Microphotograph (HematoxyF.n and Eosin x 6.3) of the section of the cyst. Arrows show lymphatic fluid and the lining of the cyst. multiloculated cystic lesion with thin septa. In addition to it, CT scan of abdomen also showed the fluid of variable densit),. Due to the large size of the lesion, the cyst was difficult to differentiate from ascites. These findings are in agreement with the diagnostic features published by P a b l o R. Ros et al. z Lymphangioma is differentiated from other abdominal cysts by the presence of its endothelial lining, z (Figure 2.) Lymphangioma is more common in children and young adults supporting its congenital origin) Adherence of the cyst and the exudative nature of the fluid may be secor.dary to the infection following the tapping elsewhere. Malignant abdominal cyst is extremely rare in the pediatric age group) The retroperitoneal cysts are less corn- mon than the mesenteric cysts: and they have more chances of recurrence due to incomplete removal because of their proximity to the surrounding structures) Although there were adhesions, the cyst of this patient could be r~moved completely without resecting bowel or pancreas. CONCLUSION Any abdominal cystic mass of long standing duration should raise the suspicion of an abdominal cyst. Complete excision is the treatment of choice. ACKNOWLEDGEMENT We would like to thank the Director of our Institute for giving us the permission to 1994; Vol. 61. No. 2 THE INDIANJOURNALOF PEDIATRICS publish this case. We are also thankful to the departments of Radiology and Photography for their invaluable help. R~ERENCES 1. Robert JK, Thomas MH, James H et al. •Mesenteric and retroperitoneal cysts. Ann 197 Surg 1986; 203 : 109-112. 2. Pablo RR, William WO, Richard PM et al. Mesenteric and omentai cysts : Histologic classification with imaging correlation. Radio/ogy1987; 164 : 327-332. 3. Sun CCJ, Tank CK, Hill JL. Mesenteric lymphangioma. Arch Pathol Lab Mcd 1980; 104 : 316-318. Endoscopic Removal of Impacted Foreign Bodies Prabha Sawant, S.A. Nanivadekar, U.R. Dave, R.R. Kanakia, R.P. Satarkar, R.S. Bhatia and H. Devarbhavi Department of Gastroenterology, L.T.M. Medical College and Hospital, 5ion, Bombay Foreign body ingestion is a common clinical problem, most frequently encountered in children, and psychotic patients? Most common in the pediatric group are coins, 2 but marbles, bottle tops, safety pins, button batteries and screws also form an astonishing variety. ~ Radiological Iocalisation is mandatory? However, non radio-opaque objects will not be seen. An aggressive approach is required for chicken bones, blades and open safety pins as these have the reputation of a hazardous passage. 3~ With the advent of endoscopes and their various accessories, foreign bodies can be removed without resorting to surgery. Younger children frequently require general anaesthesia? In case of impacted foreign bodies, an attempt at endoscopic removal must be made at the earliest? A prior rehearsal and planning is useful and advisable. 7 We had four cases of impacted foreign bodies, an open safety pin, a large hair'pin, an earring and a coin. CAsE REPOgT Case 1. A one and a half year old cachexic female child who had ingested a safety pin, 30 hours prior to admission and had a past history of colostomy for Hirshprung's disease. Her plain X-ray film showed an open safety pin in the stomach. A dry run was performed using the rat tooth forceps and was found to be effective. Her endo scopy was carried out under general anaesthesia. The open safety pin was found lodged in the fundus. An inverted latex hood was attached to the tip of the endoscope. The -scope was introduced, the safety ])in was held in the center with the rat tooth forceps, and gently dislodged. On entering the stomach, the hood got everted, but reverted to its original position in the oesophagus covering the open safety pin. The scope was carefully withdrawn with the safety pin. After retrieving the pin, the scope was reintroduced to check that there was no injury, either to the gastric or oesophageal mucosa. The patient was kept