[Verrucous hemangioma versus microcystic lymphatic malformation].

To the Editor: We read with interest the article titled “A Histopathologic and Imaging Study of Verrucous Hemangioma” by Dr. Garrido-Ríos et al1 published in the November 2008 issue of Actas Dermosif iliográficas.1 It is difficult to establish retrospective diagnoses without clinical (and not just histologic) images of the primary lesion. The appearance and change in these images would provide key information. As indicated in the discussion of the case, in verrucous hemangioma, the endothelium shows focal positivity for type 1 glucose transporter (GLUT-1) and low-level reactivity for mindbomb homolog 1 (MIB-1) in the immunohistochemical study. In contrast, D2-40 staining is not observed. Paradoxically, the authors have not applied these techniques to their case. Verrucous hemangioma usually presents at birth, but the lesions are generally large and extensive and found on the legs, and quickly become hyperkeratotic, often with accompanying bleeding and secondary superinfection2 (Figure). We have operated on 6 patients with verrucous hemangiomas in the last 10 years and in none of them did we encounter the radiologic features of the present case, which are, however, characteristic of lymphatic malformations. The patient described had very small lesions on the abdomen and subsequently on the thigh. In the magnetic resonance imaging study, the lesion appears much more extensive in the subcutaneous tissue. We believe that a microcystic lymphatic malformation was not ruled out with sufficient certainty. These lesions are usually D2-40 positive and GLUT-1 negative.3,4 They present clinically as lesions similar to angiokeratoma or verrucous hemangioma—like the ones described—and represent the tip of the iceberg with respect to involvement of deeper tissue. In fact, we believe the case reported is not actually a verrucous hemangioma but rather, as demonstrated by magnetic resonance imaging, a microcystic lymphatic malformation whose cutaneous manifestations are in the form of angiokeratoma-like lesions.