The treatment has been varied. People have used pulse-dyed laser, especially for the topical component of these. Sclerotherapy has been used for larger cyst cavities. The cavities are aspirated and injected with bleomycin, sodium tetradecyl sulfate or OK432, an inactive strain of group A Strep. Most of the OK432 work has been done in Japan, not much of it has been done in this country. This method of treatment can be very successful. A large series from Columbus Children's Hospital used cyst aspiration and sclerotherapy and had a very low recurrence rate and actually a lower complication rate than that associated with surgery. Radiotherapy has been used commonly and surgery most frequently. All of these treatments are based on the extent of disease.
MRI and ultrasound are the two modalities of evaluation - ultrasound to confirm that it is cystic and MRI to map the extent of disease. MRI is probably better than CT for this purpose. If we do surgery, we like to achieve wide excision with clean margins.
However, the concept of uninvolved surgical margins is somewhat difficult for lymphangioma because the skin can look normal and the margins in the skin can be free of disease but the deep margins where some of the lymphatics penetrate the fascia can be involved. This can lead to recurrence after surgery from the base of the wound rather than from the surgical margin.
So excising it widely may not be enough because some of it may be at a depth. At surgery, you remove skin, subcutaneous tissue and fascia. They can be closed with a skin graft or, if they are small, closed primarily. Recurrence is high, up to 50% depending on the location of the lymphatic malformation.