Segmental haemangiomas of infancy: A review of 14 cases

Haemangiomas of infancy are the commonest benign tumour in childhood, with the majority being a localized subtype, only requiring therapy in specific locations. The segmental subtype, however, confers a higher complication rate, an association with the PHACE syndrome and poorer prognosis. This retrospective case series of 14 infants with segmental haemangiomas aimed to further define the variety of clinical presentations, complication rates, and response to treatment in this subset of patients. We found in our series that 71% of infants with segmental haemangiomas develop at least one complication related to the lesion. Systemic corticosteroids prevented the further growth as well as reduced the pain and ulceration of the segmental haemangiomas in all of those treated. Early recognition and early treatment to arrest the growth of segmental haemangiomas will reduce morbidity and complications associated with these haemangiomas. Corticosteroid use, however, needs to be considered against the high incidence of side-effects such as secondary hypertension (40%), cushingoid features (40%) and growth suppression (67%). In our experience, these infants benefit from multidisciplinary team involvement for the assessment of associated syndromes, and to follow up and avoid complications associated with systemic therapy.

[Pathogenesis and genetics of vascular anomalies]

Vascular anomalies, divided into vascular tumors and vascular malformations, are localized defects of angiogenesis. Hemangiomas appear soon after birth, grow quickly, and then spontaneously, but slowly, disappear. In contrast, vascular malformations are congenital defects of vascular development that grow proportionately with the child. Most vascular anomalies are considered non-hereditary. However, due to detailed analysis inherited forms have been observed, which has led to identify mutations in three genes causing familial vascular malformations: in the angiopoietin receptor TIE2 in mucocutaneous venous malformations (VMCM), in glomulin in glomuvenous malformations (GVM) and in RASA1 in the newly recognized phenotype capillary malformation-arteriovenous malformation (CM-AVM). Identification of the causative genes has permitted more precise diagnosis and differential diagnosis, evaluation of phenotypic variability among patients with a proven mutation, study of used treatments in more homogeneous patient groups, and elucidation of the etiopathogenic mechanisms behind vascular malformations. Further studies are needed to unravel the role of genetic variations in the various vascular malformations and to unravel the precise molecular mechanisms that lead to development of these vascular lesions. This should provide development of new-targeted therapies.

No evidence for maternal-fetal microchimerism in infantile hemangioma: a molecular genetic investigation

In this study, using the placental origin theory as a basis, we set out to explore whether hemangioma endothelial cells (HEC) were maternal in origin. We rigorously addressed this hypothesis using several molecular genetic techniques. Fluorescent in situ hybridization on surgical specimens of proliferating hemangiomas (n=8) demonstrated no XX-labeled HEC from resected tumors of male infants. This analysis was followed by PCR genotyping of HEC (n=11) using microsatellite markers where cellular components were genotyped and compared to genomic DNA of corresponding mother-child pairs. In the seven informative mother-child pairs, HEC matched the genotype of the child and not the maternal genotype. Concerned that HEC represented a mixed population of cells, we subsequently enriched for cells using the placental-specific endothelial cell (EC) marker, Fc gammaRII. Three informative mother-child pairs exhibited only the genotype of the child in our enriched cell population. Using sequence analysis, we identified an informative single nucleotide polymorphism in an exon of the placental-EC-specific protein, GLUT1. When comparing GLUT1 complementary DNA (cDNA) with mother-child DNA, the genotype of the cDNA matched the constitutional DNA of the child. Our results indicate that hemangiomas are not microchimeric in origin. This study provides further insight into the origin of a tumor whose pathogenesis remains elusive.

Renal involvement in multicentric Castleman disease with glomeruloid hemangioma of skin and plasmacytoma

A 47-year-old man presented with fever of unknown origin, generalized weakness, edema, and renal failure. He had left-sided pleural effusion, generalized lymphadenopathy, multiple nontender cutaneous nodules, hepatomegaly, renal failure, and hypergammaglobulinemia. Axillary lymph node biopsy showed findings consistent with Castleman disease of the hyaline vascular type associated with interfollicular plasmacytosis. A renal biopsy performed in view of proteinuria and acute renal failure showed hypercellular glomeruli with capillary loop thickening and double contours consistent with membranoproliferative glomerulonephritis. Skin nodule biopsy showed a glomeruloid hemangioma characterized by dermal proliferation of capillary loops in a nodular manner resembling a glomerulus. He experienced clinical and biochemical remission with steroids. Discontinuation of steroid therapy was associated with recurrence of renal failure, reappearance of nodules, lymphadenopathy, and appearance of bony lytic lesions. Biopsy of bony lytic lesions showed plasmacytoma. The patient achieved complete remission on treatment with steroids and cyclophosphamide and is free of symptoms at the end of 40 months of follow-up. To our knowledge, this is the first case report of the occurrence of membranoproliferative glomerulonephritis, glomeruloid hemangioma of the skin, and plasmacytoma in a patient with multicentric Castleman disease without human immunodeficiency virus infection.

Rare instance of gingival enlargement in Klippel-Trenaunay syndrome: a case report

Klippel-Trenaunay Syndrome is a rare congenital malformation that may include port-wine stain, soft tissue and bony hypertrophy, and venous malformations and lymphatic abnormalities. Although it usually involves the limbs, it may also rarely involve the head, neck, and orofacial regions. Despite its rarity, Klippel-Trenaunay Syndrome should be considered in the differential diagnosis of gingival enlargement. The condition can be easily recognized clinically, but further investigations including imaging studies have to be carried out in order to better understand the nature of the lesion. This report describes a case of gingival enlargement in Klippel-Trenaunay Syndrome in a 16-year-old female patient. The diagnosis of the condition was made based on the patient history, clinical and radiographic examination, computed tomography (CT), and angiogram.

Glomeruloid hemangioma leading to a diagnosis of POEMS syndrome

POEMS is an acronym for polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes. It is a poorly understood paraneoplastic syndrome that stems from an underlying plasma cell dyscrasia. Of the skin changes, the glomeruloid hemangioma is considered to be a specific marker of POEMS syndrome. We describe a 68-year-old man who presented to his dermatologist with multiple hemangiomas, whose biopsy diagnosis of glomeruloid hemangioma resulted in further evaluation and an eventual diagnosis of POEMS.

A new gastrointestinal finding in Proteus syndrome: report of a case of multiple colonic hemangiomas

A patient with Proteus syndrome presented with lower gastrointestinal bleeding due to multiple colonic hemangiomas, a finding which has not been described previously in this syndrome. The patient was a 20-year-old man with features fulfilling the diagnostic criteria for Proteus syndrome. He fulfilled both general criteria (mosaic distribution of the lesions, progressive course and sporadic occurrence) and specific criteria (including epidermal nevus, disproportionate overgrowth of limbs and vascular malformations). Fiberoptic colonoscopy revealed multiple hemangiomas, 0.5-1 cm in diameter, on the left side of the colon. Some gastrointestinal complications have been reported in patients with Proteus syndrome, including rectal polyps, colonic lipomatosis, atrophy of the intestinal villi and intestinal affection with fatty wall thickening but, as far as we are aware, colonic hemangiomas have not previously been reported in this syndrome.

Pharmacologic blockade of angiopoietin-2 is efficacious against model hemangiomas in mice

Hemangioma of infancy is the most common neoplasm of childhood. While hemangiomas are classic examples of angiogenesis, the angiogenic factors responsible for hemangiomas are not fully understood. Previously, we demonstrated that malignant endothelial tumors arise in the setting of autocrine loops involving vascular endothelial growth factor (VEGF) and its major mitogenic receptor vascular endothelial growth factor receptor 2. Hemangiomas of infancy differ from malignant endothelial tumors in that they usually regress, or can be induced to regress by pharmacologic means, suggesting that angiogenesis in hemangiomas differs fundamentally from that of malignant endothelial tumors. Here, we demonstrate constitutive activation of the endothelial tie-2 receptor in human hemangioma of infancy and, using a murine model of hemangioma, bEnd.3 cells; we show that bEnd.3 hemangiomas produce both angiopoietin-2 (ang-2) and its receptor, tie-2, in vivo. We also demonstrate that inhibition of tie-2 signaling with a soluble tie-2 receptor decreases bEnd.3 hemangioma growth in vivo. The efficacy of tie-2 blockade suggests that either tie-2 activation or ang-2 may be required for in vivo growth. To address this issue, we used tie-2-deficient bEnd.3 hemangioma cells, which, surprisingly, were fully proficient in in vivo growth. Previous studies from our laboratory and others have implicated reactive oxygen-generating nox enzymes in the angiogenic switch, so we examined the effect of nox inhibitors on ang-2 production in vitro and on bEnd.3 tumor growth in vivo. We then inhibited ang-2 production pharmacologically using novel inhibitors of nox enzymes and found that this treatment nearly abolished bEnd.3 hemangioma growth in vivo. Signal-transduction blockade targeting ang-2 production may be useful in the treatment of human hemangiomas in vivo.

Epithelioid hemangioma in the oral mucosa: A clinicopathological study of seven cases and review of the literature

To investigate the clinicopathological characteristics and biologic behavior of epithelioid hemangioma in oral mucosa, the clinical features and pathological findings of seven cases of epithelioid hemangioma were reviewed, and all sections were examined by immunohistochemistry. There were 4 males and 3 females ranged from 8 to 65 years (mean 39.7 years). Sites of origin included the tongue (n = 4), lips (n = 2), and palates (n = 1). Five lesions presented as a solitary mass. Three patients had history of minimal trauma. Histopathologically, well-formed but often immature vessels lined by plump epitholid endothelial cells with prominent inflammatory components were observed. Immunohistochemical staining revealed that tumour cells were positive for Vimentin, FVIIIRAg and CD34. All the cases were negative to S-100 protein and EMA. One case recurred after surgical excision, while none of them metastasized. Epithelioid hemangioma is a benign vascular anomaly, and has close relationship with local trauma. The differential diagnosis is usually based upon histopathological findings.

Multiple cutaneous angiomas and Poems syndrome

INTRODUCTION

Poems syndrome is characterized by polyneuropathy, organomegaly, endocrinopathy, M-proteins, and skin lesions.

CASE

We describe here a case in which the eruption of diffuse cutaneous angiomas in a woman with a history of bone plasmocytoma and progressive polyneuropathy helped physicians to diagnose Poems syndrome.

DISCUSSION

Other manifestations of Poems syndrome in this patient included endocrine dysfunction (hypothyroidism, adrenal insufficiency, and hypogonadism), sclerotic bone lesions of the femoral shaft, ribs, and vertebral body, monoclonal gammopathy, and anasarca. Steroid treatment led to dramatic improvement of polyserositis and a generally good outcome, despite persistence of the cutaneous lesions. This case points out this unusual cutaneous manifestation associated with Poems syndrome.

The pathogenesis of hemangiomas: a review

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Differentiate between hemangiomas and vascular malformations. 2. Describe arguments for the trophoblast origin of hemangiomas. 3. Give arguments for the angioblast theory for the origin of hemangiomas. 4. Identify key genes involved in the origin of hemangiomas.

BACKGROUND

Hemangiomas of infancy are common endothelial tumors. They differ from vascular malformations in their tissue architecture and biological properties. To date, there is no universally accepted theory that explains the pathogenesis and pathophysiology of hemangiomas.

METHODS

Theories from the medical literature from 1981 to 2004 were gathered, categorized, and reviewed.

RESULTS

Current research is mostly on the cellular and genetic levels. The most authoritative theories focus on angioblast origins, trophoblast origins, mutations in cytokine regulatory pathways, and field defects as the cause of the deranged angiogenesis of hemangiomas.

CONCLUSIONS

To date, no single theory can easily explain all the characteristics of hemangiomas, such as predilection for the female sex, usual occurrence after birth, spontaneous involution, abnormal tissue architecture, and distribution within a developmental field. Hemangiomas are probably the final common expression of several pathophysiological mechanisms taking effect alone or in combination.

Retinal neovascularization and an angioma-like lesion after demarcation photocoagulation for rhegmatogenous retinal detachment

Laser photocoagulation might aggravate the ischemia of an area of retinal detachment and predispose the retina to formation of neovascularization and an angioma-like lesion. We present a case of retinal neovascularization (RNV) and an angioma-like lesion occurring after demarcation photocoagulation for rhegmatogenous retinal detachment (RRD). A 20-year-old woman suffered from a retinal atrophic hole with localized shallow retinal detachment in the right eye. Laser photocoagulation was performed to wall off the area of detachment. Fifteen months later, RNV and an angioma-like lesion had developed in the previously detached retina. Treatment with demarcation photocoagulation for RRD may run a risk of formation of RNV and angioma-like lesion if the retina is not reattached.

Complete recovery after the removal of an ectopic testicle in a case of primary reninism and retroperitoneal hemangioma

A 32-year-old man recovered completely from hypokalemic hypertension that had been caused by primary reninism after the ablation of an ectopic left testis, epididymis and ductus deferens. For several years, severe hypertension has been resistant to treatment, even the concurrent administration of up to seven antihypertensive agents. In this case, cryptorchidism was associated with an indirect inguinal hernia and an open peritoneo-vaginal process on both sides, aplasia of the posterior wall of the inguinal canal on the right side, an umbilical hernia, and a retroperitoneal tendrillar hemangioma.

[Inverted papilloma of the nose in patient after skin face transplantation]

INTRODUCTION

We discuss a case of 65 year old men with inverted papilloma of the right nose cavity. During childhood he had an operation of skin face transplantation prior to face haemangioma. He has no medical documentation from that time. For several months prior to hospitalisation he complained of right nasal cavity obstruction.

METHOD

In endoscopic examination we found red, fragile tumor filing posterior part of right nasal cavity and nasopharynx. Because of skin transplantation and residual haemangioma we choose sublabial and transplant technique of operation to avoid external facial incision.

RESULTS

We observed one recovery of the tumor after 3 months of observation which was sucessfully operated. Follow up for 10 months determine no recurrence in our patient.

CONCLUSIONS

Authors discuss various operation methods of inverted papilloma of the nose.

Prevention or reversal of deep venous insufficiency by aggressive treatment of superficial venous disease

BACKGROUND

This study of patients who received either aggressive or less-aggressive treatment for superficial venous disease was undertaken to determine its effects on deep venous insufficiency (DVI).

METHODS

From 1998 to 2004, we treated 1,500 consecutive patients with superficial venous disease at our outpatient care center. A total of 100 patients were available for the study; the remaining patients were not available for the complete follow-up duplex scans 6 months after therapy, irrespective of the therapeutic results. Sixty-four patients underwent aggressive therapy, which included high ligation with partial selective perforation-invagination (PIN) axial stripping of the greater saphenous vein, ambulatory stab phlebectomy of the varicose veins, and transdermal treatment of the spider veins. Thirty-six patients underwent less-aggressive treatment, which included high ligation with selective partial PIN axial stripping of the greater saphenous vein and ambulatory phlebectomy of varicose vein clusters but no spider vein treatment.

RESULTS

Follow-up duplex scanning after aggressive treatment of superficial venous disease showed improvement or complete reversal of DVI in the majority of patients. This improvement was defined as a marked decrease in the size of the deep veins in 80% of patients and a decrease of the reflux closure time of the deep venous valves in 83% of patients. Only 28% of patients receiving less-aggressive treatment without transdermal laser therapy of the spider veins showed improvement in their reflux valve closure time; the remaining 72% were unchanged or deteriorated.

CONCLUSIONS

Aggressive treatment of superficial venous disease can prevent or even eliminate deep vein insufficiency (DVI).

A possible hypoxia-induced endothelial proliferation in the pathogenesis of epithelioid hemangioma

Epithelioid hemangioma is an uncommon benign vascular lesion with distinct clinicopathological characteristics. Histologically, this entity mainly composed of well-formed but often immature vessels lined by epithelioid endothelial cells with prominent chronic inflammatory component. There is considerable controversy whether epithelioid hemangioma is a reactive lesion or a true neoplasm. We postulated that the local hypoxia may play a role in the pathogenesis of this vascular tumor. This local hypoxic condition may caused by many incidences such as congenital vascular malformation or trauma. The hypoxia will lead to the proliferation of endothelial cells and the formation of this vascular tumor, which may lead by putative stimulators VEGF and HIF-1. Hypoxia may also promote endothelial cell proliferation through the renin-angiotensin-aldosterone system. Additionally, the inflammatory cells including eosinophils and mast cells may contribute to the endothelial cell proliferation in EH. Further study investigating the associated factors of hypoxia may lead to new, potentially important insights into epithelioid hemangioma, and might also contribute to novel strategies for the management of this entity.

[A case of Klippel-Trenaunay-Weber syndrome of the hand: description and review of the literature]

We report the first malagasy case of a 10 years-old child with a Klippel-Trenaunay-Weber syndrome. The patient presented with cutaneous hemangioma, varicosities and unilateral hypertrophy of soft tissues of the left hand. Arteriovenous fistula was findings by the echo-doppler. Ligature of the fistula was performed.

Reactive Angioendotheliomatosis in Association with a Well-Differentiated Angiosarcoma

A 55-year-old white female with a complex medical history including mixed connective tissue disease and peripheral vascular disease developed a group of red-purple papules on her proximal medial thigh that was followed, five months later, by the development of a large violaceous patch. She reported a history of radiation to this site (for melanoma) during her childhood. She was admitted to the hospital with a presumptive diagnosis of cellulitis, but failed to respond to antibiotics. A biopsy was performed and demonstrated a well-differentiated angiosarcoma arising in conjunction with reactive angioendotheliomatosis. Excision of the lesion was performed, and fifteen months of follow-up have shown no recurrence or metastasis.

Epithelioid haemangioma in association with a deep arteriovenous malformation

Epithelioid haemangiomas are benign, vascular tumours characterized by the proliferation of epithelioid endothelial cells with abundant eosinophilic hyaline cytoplasm. We report a case of epithelioid haemangioma in association with a deep arteriovenous malformation of the subclavian artery. The association of reactive vascular proliferations with arteriovenous malformations is uncommonly reported.

[Clinical analysis of 13 cases of hemangioma and vascular malformation associated with thrombopenia]

PURPOSE

To explore the diagnosis and treatment of hemangioma and vascular malformation associated with thrombopenia (Kasabach-Merritt syndrome, KMS).

METHODS

From October 1997 to December 2003, 13 cases of KMS were treated in our hospital. Among the 13 patients, 4 were located in the maxillofacial region, 3 were located in the trunk, 6 were located in the lower limb. The size of the lesion of all patients exceeded 8 cm; 10 were hemangioma, 1 was arteriovenous malformation (AVM), 1 was venous malformation (VM), 1 was Klippel-Trenaunay Syndrome (KTS). The platelet count was all lower than 70 x 10(9)/L, the lowest was 10 x 10(9)/L, the average was 41 x 10(9)/L. The clinical characteristics and course of treatment were analyzed.

RESULTS

9 patients were cured, 1 improved, 1 had no response, and 2 died. The treatment of choice for KMS was steroids, but the response rate was not high (23.08% in this series). If patients had no response to steroids, they also had no response to interferon.

CONCLUSIONS

If a proper treatment was taken in early stage, most patients could get a good result, but for patients with an extensive vascular malformation that can't be removed, the prognosis was poor. For lesions in the limbs and trunk, pneumatic compression therapy has certain curative effect, fewer side effects, therefore worthy of popularization.

Ophthalmological manifestations in VHL and NF 1: pathological and diagnostic implications

Von Hippel-Lindau disease (VHL) and neurofibromatosis type 1 (NF 1) are hereditary multitumor syndromes that show associated ocular manifestations. Capillary retinal angioma, a benign vascular tumor, is the classical ocular lesion in VHL. It often appears as the first manifestation of the disease and may thus lead to the diagnosis of VHL. Since small angiomas can be treated easily by laser photocoagulation, a regular ocular screening of VHL patients is recommended. Ocular manifestations of NF 1 are more diverse as compared to VHL. Lisch nodules of the iris are an important diagnostic criteria of NF 1 since they can be found in almost every affected patient. Optic glioma can occur both intraorbitally and intracranially. The intraorbital form causes progressive protrusion of the globe and eventually blindness. Extension of the tumor beyond the chiasm worsens the prognosis quoad vitam. The hallmark of NF 1, namely cutaneous neurofibroma can cause visual impairment when affecting the skin of the eyelids. The rare intraorbital pexiform neurofibroma is associated with abnormal development of the orbital bones and infantile glaucoma. It may result in orbital mass effects and therefore may need surgical excision.

Update on hemangiomas and vascular malformations

PURPOSE OF REVIEW

Our knowledge base in the area of vascular anomalies is growing rapidly. With greater understanding of classification and diagnosis, as well as with the numerous areas of research bringing further awareness on the complexity of these lesions, we are improving our ability to treat them. We will attempt in this article to summarize the developments in the field of vascular anomalies over the last year.

RECENT FINDINGS

Emphasis on correct classification is still a high priority in the literature and yet there remains a great deal of misinformation. Many new developments in the basic science of these lesions are allowing better understanding of why these lesions occur while improving our management in these patients. Advances in laser surgery as well as sclerotherapy techniques have improved our ability to treat extensive lesions and also improve patients' quality of life.

SUMMARY

Many new and exciting areas of discovery occur almost daily in the field of vascular anomalies. Due to the breadth of this topic, it is certain that not all articles can be reviewed however the author has tried to present the most recent and clinically relevant breakthroughs in the field.

Neurokutane Angiomatose

A 54-year-old woman developed epilepsy and gait disorder. The initial CCT showed multiple intracerebral cysts. Histologically these turned out to be cavities from repetitive bleedings out of abnormal vessels in the border region. Regular observation during 7 years showed spontaneous episodes of regression and progression of the cysts. In addition, multiple hemangiomas of the skin were found. The case presented here represents an unusual manifestation of neurocutaneous angiomatosis.

Otolaryngologic manifestations of PHACE syndrome

Two case reports of PHACE syndrome (posterior fossa malformations (P), hemangiomas (H), arterial anomalies (A), coarctation of the aorta and cardiac defects (C), and eye abnormalities (E)) are presented. Clinical characteristics consisted of cutaneous and airway hemangiomas, aortic coarctation, and left superior vena cava in one child and cutaneous and airway hemangiomas, sternal clefting, and supraumbilical raphe in the other child. Treatment modalities included systemic and intralesional steroids for cutaneous and airway hemangiomas, submucosal resection and laryngotracheal reconstruction for airway hemangiomas, repair of aortic coarctation, and laser treatment of cutaneous hemangiomas. PHACE syndrome poses a significant potential for airway compromise from hemangiomas, which may require multimodality treatment.

Clinical characteristics and management of vascular anomalies: findings of a multidisciplinary vascular anomalies clinic

OBJECTIVE

To describe the scope of the University of California, San Francisco (UCSF), Vascular Anomalies Clinic (VAC), including the types of diagnoses, characteristics, and management of patients seen in the clinic.

DESIGN

Case series.

SETTING

Referral, outpatient, multidisciplinary clinic in a university system.

PATIENTS

Consecutive sample of 175 patients seen in the VAC at UCSF from January 2001 to July 2003.

MAIN OUTCOME MEASURES

Diagnosis before and after clinic visit, symptoms, treatment recommendations, age of onset, age at clinic visit, location of lesion, sex, and type of referring physician.

RESULTS

A total of 96% of patients had cutaneous involvement, 71% of patients had vascular malformations, and 14% had infantile hemangiomas. Fifty-eight percent of patients were referred from outside the UCSF system. Of the patients who had not been previously seen by members of the VAC team or UCSF dermatologists, only 22% had been assigned correct specific diagnoses before coming to the VAC, and 13% had incorrect specific diagnoses before coming to the VAC. Fifty-six percent of vascular malformations were first noted at birth and 17% were noted at later than 10 years of age. Eighty-seven percent of patients were symptomatic from their vascular lesion. Sixty-six percent of patients underwent prior magnetic resonance imaging of their lesion. Further diagnostic workup was recommended in 43% of cases, and treatment recommendations were made in 83% of cases.

CONCLUSIONS

Significant confusion still exists regarding the appropriate terminology, diagnosis, and management of vascular anomalies. Multidisciplinary clinics effectively address these complicated and troubling disorders by providing accurate diagnoses, clear treatment recommendations, and counseling from a team of specialists.

Hepatic haemangiomas: possible association with female sex hormones

BACKGROUND AND AIMS

The association of hepatic haemangiomas with female sex hormones is not entirely clear. We prospectively evaluated the impact of female sex hormones on the natural history of liver haemangiomas.

METHODS

We followed 94 women with 181 haemangiomas diagnosed by ultrasound for a period of1-17 years (mean 7.3 (5.5) years). The location, number, size, and ultrasonographic pattern of the lesions were evaluated. Patients were also evaluated by questionnaire for gynaecological and reproductive history. We compared the change in number and size of haemangiomas in patients who received or did not receive exogenous hormonal treatment.

RESULTS

Age at first period was inversely associated with the size of haemangiomas (r = 0.181, p = 0.015) while age at menopause was positively correlated with the number of haemangiomas detected at first ultrasound (r = 0.542, p<0.0001). During follow up, no change in the ultrasonographic pattern or number of haemangiomas was observed. An increase in the size of the lesions was demonstrated in 5/22 (22.7%) hormone therapy exposed patients compared with 7/72 (9.7%) controls. Three variables (ultrasonographic pattern, number of haemangiomas, and hormone therapy) predicted whether or not a given haemangioma would increase in size. A hypoechoic pattern increased the risk of progression while a hyperechoic pattern decreases that risk (p = 0.003). The number of haemangiomas was inversely associated with the likelihood of progression (p = 0.006) and hormone therapy increased the risk of haemangioma enlargement (p = 0.05).

CONCLUSIONS

Hepatic haemangiomas seem to be influenced by both endogenous and exogenous female sex hormones although significant enlargement occurs only in a minority of patients. Consequently, routine liver ultrasound follow up in women with hepatic haemangiomas receiving hormone therapy appears appropriate.

von Hippel-Lindau disease with bilateral multiple renal cell carcinoma managed by right radical nephrectomy and left repeat partial nephrectomy

von Hippel-Lindau (VHL) disease is an autosomal dominant disorder characterized by cysts and cystadenoma in the kidney, pancreas and epididymis and angiomas of the central nervous system and retina as well as renal cell carcinoma (RCC), phaeochromocytoma, islet tumors of the pancreas, and endolympatic sac tumors. VHL for its multicentric-characteristic and bilateralism often puts the surgeon in challenging situation. We present a case of VHL with bilateral RCC and retinal angiomas managed with right radical nephrectomy and left repeat partial nephrectomy.

Intramuscular haemangioma of the thigh in a basketball player

Haemangioma is a common benign soft tissue tumour. Intramuscular haemangiomas may present as a perceived sporting injury. Magnetic resonance imaging is the investigation of choice. Intramuscular haemangioma should be considered in the differential diagnosis of unexplained pain and swelling in a muscle.

Erfahrungen aus der interdisziplinären Basler Mundhöhlensprechstunde

Wozu eine Spezialsprechstunde interdisziplinären Charakters? Das Interesse an der Untersuchung der Mundhöhle und Interpretation der Befunde verbindet den Allgemeinpraktiker und den Dermatologen, den Internisten und den HNO-Arzt, den Kieferchirurgen und den Gastroenterologen, den Zahnarzt und den Rheumatologen, womit die Liste betroffener Fächer keineswegs erschöpft ist. Jede Fachrichtung hat hier typische Referenzbefunde zum klinischen Bild: Der Gastroenterologe wird den Aspekt des Zungenbelages, der Pädiater den Koplik’schen Fleck und der Kieferorthopäde die Zahnfehlstellung mit Leichtigkeit sehen, im Kontext des Beschwerdebildes interpretieren und auch behandeln können. Die Erfahrung zeigt jedoch, dass bei Begegnung mit ungewöhnlichen Veränderungen an der mobilen und fixierten Schleimhaut, der Zungen- und Kaumuskulatur und dem Zahnhalteapparat die Patientenkarriere nicht selten einen längeren Weg einschlägt. Oft schildern die enttäuschten Patienten vorwurfsvoll lange Behandlungen mit desinfizierenden Spüllösungen bei quälenden Schleimhauterosionen, hinter welchen sich ursächlich blasenbildende Dermatosen, Krankheiten blutbildender Organe, paraneoplastische Exantheme oder unerkannte Parafunktionen – mechanische Schäden der Schleimhaut vorwiegend nächtlich auftretender unterbewusster Muskelaktivität in der Mundhöhle wie Kau-, Saug- und Pressbewegungen – verborgen hatten.

Neonatal liver tumours

Primary liver tumours are very rare during the neonatal period, but increasing numbers of them are now diagnosed prenatally by routine ultrasound scan. A precise diagnosis is sometimes problematic because of non-specific clinical symptoms, misleading imaging and difficulties with histological interpretation. Benign infantile haemangioendothelioma usually undergoes spontaneous regression, but may be life-threatening due to congestive heart failure and/or consumptive coagulopathy when treatment with resection, embolization or arterial ligation is necessary. Malignant hepatoblastoma may occur in the newborn, and often has to be treated with chemotherapy to achieve resectability. Symptoms are less specific and the prognosis is worse than in older children. Mesenchymal hamartoma is a benign cystic lesion that should be resected whenever possible. Rarely, germ cell tumours occur in the neonatal liver. Benign teratomas have to be resected, while malignant choriocarcinomas may respond to chemotherapy and can be cured in some cases.

[MRI findings of orbital hemangiomas]

PURPOSE

To evaluate the MR imaging findings of orbital hemangiomas in pediatric and adult groups.

MATERIALS AND METHODS

MR imaging findings of seven orbital hemangiomas were reviewed. All patients had axial and coronal T1 and T2 weighted images. Axial and coronal fat suppressed (STIR) images and postcontrast T1 weighted images in three planes were obtained in order to evaluate the relation with surrounding structures. Localization, size, margins and signal characteristics of the lesions were analyzed.

RESULTS

Four of the cavernous hemangiomas were intraconal, one was extraconal. The location of the lesions was superomedial in two, middle medial, inferomedial and inferolateral in one lesion. The lesions were iso-hypointense to muscle on T1W, hyperintense on T2W and markedly hyperintense on STIR images. All cases had a capsule. In four cases a chemical shift artifact was seen. Contrast enhancement was patchy in early images and homogenous in late images. Cavernous hemangiomas were well circumscribed. All cases underwent operation and had a histopathologic diagnosis. The capillary hemangioma seen in a ten-year-old case was superomedial in localization and had irregular contours. The other case was a one year old. The lesion surrounded the superolateral margin of the bulbus and involved the lateral rectus, the eyelid and neighboring skin. The lesions were hypointense on T1W and hyperintense on T2W images, with diffuse homogenous contrast enhancement.

CONCLUSION

With MRI, orbital hemangiomas, the most common cause of chemosis and proptosis are easily detected. MR findings are not only helpful for diagnosing the lesion but also for choosing the appropriate surgical approach.

Mast Cells and Hemangioma

Hemangioma is a primary tumor of the microvasculature in which angiogenesis is initially excessive, followed by spontaneous regression of the newly formed vessels, with the cellular parenchyma gradually being replaced with fibrofatty tissue. Mast cells, which are highly heterogenous in terms of their morphology, function, and metabolic products, have been implicated in the pathophysiology of hemangioma. Csaba stain shows that mast cells are predominantly of the biogenic amine phenotype throughout the development of hemangioma. The predominance of this phenotype remains unaltered following successful steroid therapy, although their number increases fourfold. Mast cells, all of which stain positive for tryptase, and those that stain positive for chymase as well, have been identified in hemangioma biopsy specimens throughout the three developmental phases. The total number of mast cells is highest during the involuting phase, less in the involuted phase, and least in the proliferative phase. The proportion of mast cells that contain both tryptase and chymase decreases from the proliferative through involuting to the involuted phase. This decreasing proportion of mast cells that contain both tryptase and chymase with ongoing involution parallels that of progressive deposition of the extracellular matrix as indicated by increasing fibrosis and fatty deposition. The short-chain type VIII collagen, thought to play a key role in angiogenesis, has been detected throughout the developmental phases of hemangioma. It has been postulated that this collagen, which is produced early in new vessel development, provides a substratum to facilitate the migration of endothelial cells. It may also facilitate the deposition of other extracellular constituents and influence cell movement and the maintenance of cell phenotypes. The intracellular localization of type VIII collagen in mast cells only in the early proliferative phase suggests that there is an active synthesis by mast cells during this phase. The increasing extracellular localization during hemangioma development may be caused by an increased secretion of protein from intracellular stores. The increased number of mast cells during the involuting phase indicates that these cells may play a role in the regression of hemangioma. This is in contrast to the large body of evidence showing the proangiogenic role of mast cells. The proportion of proliferating mast cells decreases, whereas the proportion of mast cells positive for clusterin/apolipoprotein J increases with ongoing involution of hemangioma. Clusterin/apolipoprotein J expression has been considered as a prominent marker of apoptotic cell loss. The presence of clusterin/apolipoprotein J granules both in the adjacent endothelial cells and in capillary lumens suggests that mast cells may be secreting this apoptotic modulator to promote the regression of hemangioma. Certain effectors produced by mast cells may participate in the development of hemangioma. It has been proposed that one of the functions of mast cells is to release factors leading to the regression of hemangioma. The evidence suggests that although mast cells may have a function in the endothelial proliferation in hemangioma, they also play a crucial role in the regression of this tumor. However, the roles of mast cells in the life cycle of hemangioma are likely to be complex and may involve stimulators of angiogenesis in the proliferative phase but inhibitors in later phases.

Perinatal outcome after prenatal diagnosis of placental chorioangioma

OBJECTIVE

To review the prenatal complications, management, and perinatal outcome in pregnancies complicated by placental chorioangioma.

METHODS

Cases of placental chorioangioma diagnosed prenatally as part of a prospective, multicentric program for fetal diagnosis and therapy were identified. All cases were evaluated with color flow imaging. In the latter part of the study, three-dimensional power Doppler angiography was also used to study the vascular pattern of the tumor. Information on maternal demographics, prenatal sonographic findings, pregnancy complications, antenatal intervention, and perinatal outcome was obtained by reviewing the medical records or contacting the referring obstetricians.

RESULTS

In the 5-year period from January 1997 to December 2001, 11 cases of placental chorioangioma were diagnosed prenatally. Nine cases were diagnosed in singleton and two in twin pregnancies. Among the nine cases occurring in singletons, five (56%) were associated with pregnancy complications, including polyhydramnios (n = 3), oligohydramnios (n = 2), fetal growth restriction (n = 2), and nonimmune hydrops (n = 1). Amniodrainage was required in one of these cases, allowing prolongation of pregnancy until term. Four (44%) singletons delivered before 35 weeks. Overall, two fetuses died, including one twin due to complications of twin-twin transfusion syndrome and another with hydrops after alcohol injection into the chorioangioma. In four pregnancies, no prenatal complications were detected in spite of continuous growth and vascularity of the placental mass in three of them.

CONCLUSION

Placental chorioangioma is associated with an increased risk of pregnancy complications, the most common being polyhydramnios and preterm delivery. In selected cases, amniodrainage allows continuation of the pregnancy with improving perinatal outcome. Fetuses who develop hydrops are at the highest risk for perinatal death, with limited therapeutic options being available. Close follow-up is advised, even in those cases with no associated findings at the time of the diagnosis.

[Pathology and pathogenesis of haemangiomas]

Haemangiomas are tumours of infancy that are characterised by an initial phase of proliferation followed by an involution that, in the majority of cases, results in complete regression. From the pathological point of view, this is a hyperplasic proliferation of endothelial cells, which in the phase of proliferation form highly cellular masses with scarce vascular lumina, invading the dermis and/or subcutaneous cellular tissue. Cellularity diminishes in the phase of involution, the vascular lumina increases and there is a total, or near total, replacement by residual fibroadipose tissue. Its pathology is not well known and two theories are at present postulated: on the one hand, an intrinsic defect of the precursor endothelial cells that, through somatic mutation in a gene regulating angiogenesis, develop a phenotype that induces clonal proliferation. On the other hand, it might arise from cells originating in the placenta that embolize in foetal tissue during pregnancy or delivery. The similarities in antigen expression between haemangioma cells and placenta tissue support this second hypothesis.

Clinicopathological study of vascular tumors of the breast: a series of ten patients with a long follow-up

Ten cases of vascular tumors of the breast were examined in our laboratory during the last decade (1992-2001). Nine patients were female and one male (ages 31-77, average 52 years). Six patients presented parenchymal vascular lesions (1 angiosarcoma, 1 atypical hemangioma, 3 perilobular hemangiomas, 1 cavernous hemangioma) measuring 0.5-6 cm in the greatest diameter. Two lesions were accidental findings in lumpectomy specimens excised for fibrocystic disease with microcalcifications. Four patients presented non-parenchymal vascular lesions: three cavermous hemangiomas (one in a male patient) and one angiolipoma measuring 1-6 cm in diameter. All tumors were treated by lumpectomy with the exception of the atypical hemangioma which was treated by simple mastectomy. The patient with the angiosarcoma was treated by simple mastectomy, radiotherapy and chemotherapy and died with disseminated disease three years after initial diagnosis. All other patients are well up to date (follow-up 1-9 years).

[Intraocular mass lesion--case report]

The authors present a case of a 27 years old patient, admitted in the Ophthalmological Department, presenting an intraocular mass lesion of the right eye, which consist of 2 different tumours of the eyeball (with different shape and location). The patient presents scleral staphiloma due to the intraocular tumours of the eye ball, the change of the shape and colour of the anterior aspect of the eye, loss of vision for two months. The complementary examinations for the diagnosis, that have been done (A Scan and Bscan, MRI of the eye ball) pointed to a possible choroidal hemangioma of the middle tunic of the eyeball. This diagnosis was confirmed by the histopathologic exam after surgery.

Photodynamic therapy for diffuse choroidal hemangioma associated with Sturge Weber syndrome

PURPOSE

To report successful treatment of a diffuse choroidal hemangioma associated with chronic retinal detachment.

DESIGN

Interventional case report.

METHODS

A patient with bilateral Sturge Weber syndrome and associated retinal detachments failed external beam radiation. He was then treated with single session, multispot photodynamic therapy with verteporfin. There was prompt resolution of the retinal detachment and significant reduction in thickness of the choroidal hemangioma.

CONCLUSION

Verteporfin therapy may be useful in diffuse choroidal hemangiomas.