Current Knowledge of the Pathogenesis of Infantile Hemangiomas

Hemangioma of the Tongue: A Case Report

Vascular anomalies include a wide range of tumors and malformations. Hemangioma is the most frequent vascular defect. Hemangiomas are benign endothelial cell tumors most frequently detected in children but uncommon in adults. Most of them affect the neck and head regions but rarely involve the palate, lips, tongue, and buccal mucosa. Treatment for oral hemangiomas should begin as soon as possible because they are clinically significant. Patients are at an increased risk of developing tongue hemangiomas due to the tongue's high flexibility and muscular structure, which makes it more vulnerable to trauma and its effects. They grow and proliferate within a few weeks of birth, with the majority of their components undergoing involution. Females are more likely than males to develop hemangiomas. Hemangiomas are treated with surgery, laser therapy, radiofrequency, sclerosing agents, radiation treatment, cryosurgery, corticosteroids, embolization, electrocauterization, and interferon. When assessing treatment options for hemangiomas, it is crucial to consider various criteria, such as the lesion's hemodynamics, the patient's age, and the location, size, and feasibility of the planned procedure. This report describes a case of a 19-year-old female diagnosed with a hemangioma located on the middle third of the dorsal aspect of the right lateral border of the tongue.

The Application of Color Doppler Ultrasound in the Evaluation of the Efficacy of 595-nm Pulsed Dye Laser Combined with 755-nm Long-Pulse Alexandrite Laser in the Treatment of Hybrid Infantile Hemangiomas

Purpose

We used color Doppler ultrasound to conduct an objective evaluation of the 595-nm Pulsed Dye Laser (PDL) combined with 755-nm long-pulse alexandrite sequential laser treatment for hybrid IH.

Patients and Methods

A total of 116 cases of hybrid IH were selected for this study. The interval between laser treatments was around 4 weeks, and 6 laser treatments or complete removal of the tumor was the end point. All children underwent color Doppler ultrasonography at the 0th, 1st, 6th months of treatment. Children were grouped by gender, age (<6 months, ≥6 months), thickness (<8 mm, ≥8 mm), and location (face and neck, trunk, and extremities). Calculate the volume of IHs according to color Doppler ultrasound. The volume ratio before and after treatment was defined as the A-value. Treatment outcomes were defined as effective when the A-value <75%.

Results

In total, 74 cases (63.79%) had effective outcomes. Overall, the samples showed a statistically significant difference in the reduction of IH volume after 6 months of laser treatment (P < 0.001). The treatment of <6 months group had better efficacy than the ≥6 months group (P < 0.001), the treatment of thickness <8 mm group had better efficacy than the thickness ≥8 mm group (P < 0.001) and there was no significant difference in efficacy between the three different location groups (P > 0.05). Greater reduction in blood flow in the group with the effective outcome than in the group with the ineffective outcome (P < 0.001).

Conclusion

Color Doppler ultrasound can be applied to the diagnosis of hybrid IH and to the evaluation of treatment time and outcomes, and it can help clinicians recognize hybrid IH with greater accuracy. The earlier intervention for hybrid IH we perform, the better outcomes will be.

Pattern and management outcomes of head and neck hemangiomas: a prospective study from Tanzania

Introduction: Hemangiomas arise from the proliferation of endothelial cells surrounding blood-filled cavities. They have a slightly higher female predilection and about 60–70% of them occur in the head and neck region. Various medical and surgical options are available for the treatment of hemangiomas. Aim: To determine the pattern and management outcomes of head and neck hemangiomas in Tanzania. Material and methods: This was a one-year prospective, cross-sectional study that involved all consecutive patients with head and neck hemangiomas treated in Muhimbili National Hospital. A structured questionnaire was used to collect information including age and sex of the patient, chief complaint and, duration, size and site of the lesion. The treatment modalities were surgery and/or intralesional bleomycin injection (IL-Bleo). A standard dose of bleomycin was 0.3 to 0.6 mg/kg per injection not exceeding 15 units per cycle with a maximum of 6 cycles. Frequency distribution and cross-tabulation were performed and association between variables was assessed by the Chi-square test, whereby the p-value was set at p < 0.05. Results: A total of 58 patients were included in the study. The male to female ratio was 1:1.4 and the median age was 6.15 years. Majority (74%) of the patients had infantile hemangioma. The most common presenting complaint of patients/guardians of the patients were facial disfigurement (94.8%), pain (32.8%) and ulceration (22.4%). The most frequently involved sites were the lips (55.2%) followed by the cheeks (37.9%). In patient who were managed surgically, there was a 100% reduction in size of the lesion. Of those who were treated with bleomycin, the percentage reduction in the area of the lesion ranged from 8.33% to 100% with mean of 72.6%. Only 6% of the patient had post IL-Bleo complications. Conclusion: Head and Neck hemangiomas are more common in females and majority are infantile hemangioma. Facial disfigurement is the commonest presenting complication of these lesions, and the lips and the cheeks are mostly affected areas. Intralesional bleomycin is an effective treatment modality which has low complication rates.

P2Y Purinergic Receptors, Endothelial Dysfunction, and Cardiovascular Diseases

Purinergic G-protein-coupled receptors are ancient and the most abundant group of G-protein-coupled receptors (GPCRs). The wide distribution of purinergic receptors in the cardiovascular system, together with the expression of multiple receptor subtypes in endothelial cells (ECs) and other vascular cells demonstrates the physiological importance of the purinergic signaling system in the regulation of the cardiovascular system. This review discusses the contribution of purinergic P2Y receptors to endothelial dysfunction (ED) in numerous cardiovascular diseases (CVDs). Endothelial dysfunction can be defined as a shift from a “calm” or non-activated state, characterized by low permeability, anti-thrombotic, and anti-inflammatory properties, to a “activated” state, characterized by vasoconstriction and increased permeability, pro-thrombotic, and pro-inflammatory properties. This state of ED is observed in many diseases, including atherosclerosis, diabetes, hypertension, metabolic syndrome, sepsis, and pulmonary hypertension. Herein, we review the recent advances in P2Y receptor physiology and emphasize some of their unique signaling features in pulmonary endothelial cells.

The PHACES syndrome: Multiple episodes of reproliferation of subglottic hemangioma

Subglottic hemangioma is a potentially life-threatening manifestation of the PHACES syndrome. The disease process has been treated with corticosteroids, oral chemotherapeutic agents, endoscopic airway interventions, tracheostomy, and even laryngotracheal reconstruction. Oral propranolol has emerged as an effective therapy and in many cases has led to complete regression of hemangioma during the proliferative phase. There have been several reports of patients showing signs of reproliferation after discontinuing propranolol therapy. This article illustrates a patient who has had multiple episodes of reproliferation of subglottic hemangioma after weaning from propranolol therapy.

The use of propranolol in the treatment of subglottic hemangiomas: A literature review and meta-analysis

OBJECTIVES

1) Describe the origins of the use of propranolol in the treatment of subglottic hemangiomas, 2) Perform meta-analysis of all case reports and series in which propranolol was used to treat subglottic hemangiomas.

STUDY DESIGN

Literature review and meta-analysis.

METHODS

A total of 61 cases were identified from 19 scholarly articles. Cases were assessed by parameters including age at diagnosis, presence of other hemangiomas, percent airway obstructed, dose of propranolol, treatment duration, age at therapy termination, use of steroids, and treatment failure. Treatment failure was defined as: 1) Need for surgery after initiation of propranolol, 2) Return of symptoms, or 3) Endoscopic worsening/recurrence of hemangioma. All data was subjected to comprehensive statistical analysis.

RESULTS

Though not statistically significant, a trend was noted towards a decreased treatment failure rate with increasing doses of propranolol (p = 0.0563). The use of concurrent steroids was associated with a higher failure rate (p = 0.0487). Notably, no associations were observed between the presence of additional hemangiomas, prior surgery, or increased initial percent airway obstruction with treatment failure.

CONCLUSION

Propranolol is rapidly becoming the standard of care in the treatment of subglottic hemangiomas. Despite widespread adoption, the rarity of this condition has limited previous studies to case reports and small series. No evidence-based guidelines exist for proper dosing of propranolol. The results of this meta-analysis suggest a benefit to higher doses of propranolol (3 mg/kg/day), though further investigation is needed.

Evaluation of the efficacy and safety of topical timolol maleate combined with oral propranolol treatment for parotid mixed infantile hemangiomas

The aim of the present study was to assess the efficacy and safety of topical timolol maleate combined with oral propranolol for parotid infantile hemangiomas. Between October 2012 and April 2014, propranolol was administered orally at a dose of 1.0-1.5 mg/kg/day to 22 infants with proliferating hemangiomas in the Department of Oral and Maxillofacial Surgery (Hospital of Stomatology, China Medical University, Shenyang, Liaoning, China). A small amount of 0.5% timolol maleate eye drop solution was topically applied with medical cotton swabs to the area of the lesion twice a day, every 12 h. The study group consisted of 9 males and 13 females, aged 2-9 months, with a median age of 4.7 months. The lesions were all located in the parotid region, and measured between 3.5×4×0.5 and 7×8×3 cm in volume. The planned duration of therapy was 6-8 months, or the two drugs were stopped when complete regression of the lesions was obtained. The therapeutic outcomes and safety were assessed by the change in the size and color of the tumor, and the presence of adverse effects throughout the course of treatment. The mean duration of therapy was 21.1 weeks and ranged from 3 to 8 months. Of the 22 patients, 16 demonstrated an excellent response, 6 showed a good response and 2 displayed a moderate response. No major collateral effects were observed. Overall, oral propranolol combined with topical timolol maleate may be used as the first-line therapeutic choice in the treatment of infantile parotid mixed hemangioma.

Expression of p16 protein in infantile hemangioma

The present study aimed to investigate the expression and significance of p16 in the occurrence, development and regression of infantile hemangioma (IH). The expression of p16 was examined in proliferating, involuting hemangioma and normal tissues using immunohistochemical techniques. The expression of p16 was significantly lower in proliferating hemangioma than in involuting hemangioma, and was significantly lower in the involuting hemangioma than in normal tissues. Significant differences were found between the three groups (P<0.05). The results indicate that p16 may be important in the regression of IH endothelial cells and in anti-angiogenesis. There is a certain association between p16 expression and the regression of hemangioma. This provides a theoretical basis for the further study of the pathological mechanisms of p16 in hemangioma and potential gene therapies that may treat this disease.

Evaluation of the efficacy and safety of propranolol, timolol maleate, and the combination of the two, in the treatment of superficial infantile haemangiomas

Our aim was to compare in a prospective study the clinical effects and safety of propranolol given orally, timolol maleate applied locally, and the combination of the two, in the management of superficial infantile haemangiomas. Thirty-nine patients with superficial infantile haemangiomas were randomised into three equal groups of 13 each: the first given timolol maleate applied topically together with propranolol given orally, the second given only propranolol orally, and the third given only timolol maleate topically. Photographs were taken before, and periodically after, starting treatment. A minimum of 50% improvement was considered to be effective. The maximum duration of treatment was planned for 6 months, and the patients were followed up for 3-12 months. The overall rate of clinical effectiveness for the three groups was 11/13, 9/13, and 8/13, respectively. The two drugs together had a shorter effective response time than when they were given separately. There were no serious adverse effects. We therefore conclude that timolol maleate given topically together with propranolol given orally is safe and effective in the treatment of superficial infantile haemangiomas. Compared with simple medication, this method is more rapid, has an appreciable effect, takes a shorter time, and has fewer adverse reactions. It could be used as a first-line treatment, particularly if the lesion is potentially disfiguring or functionally threatening such as large periocular superficial haemangiomas.

Sturge-Weber syndrome with pyogenic granuloma

Vascular lesions represent one of the rare disorders affecting overall quality of life of a child. A wide variety of these conditions are known, ranging from a simple nevus to life-threatening hemangiomas. These conditions make the treatment options more complex due to the fear of uncontrollable bleeding. The present case is one of the rare combinations of Sturge-Weber syndrome and pyogenic granuloma. Conditions of importance and treatment options keeping hemangioma in mind are discussed.

Complex vascular anomalies

The classification system for vascular anomalies now used by experts worldwide comprises two distinct disease entities that differ in their biologic and pathologic features: vascular tumors and vascular malformations. Vascular tumors include infantile and congenital hemangiomas, tufted angiomas, and kaposiform hemangioendotheliomas. Infantile hemangiomas, the most common vascular anomaly, generally have a predetermined life cycle (proliferation and subsequent involution). GLUT-1, a glucose transporter, is a marker for these specific lesions during all phases of development. Vascular malformations are classified according to their vascular tissue of origin and include capillary, venous, arteriovenous, lymphatic, and mixed malformations. Complex lymphatic malformations and complex mixed malformations, which may have most vascular components, are the most difficult vascular malformations to successfully treat. These lesions are present at birth and often expand or grow in response to trauma, infection, or hormonal changes. Imaging advancements have enabled more accurate assessments and improved management of vascular anomalies. In addition, many lesions are now being managed with targeted pharmacologic therapy. Propranolol and steroids are used for complex or disfiguring tumors, and new anti-angiogenesis inhibitors such as sirolimus are selectively used to treat lymphatic and venous lymphatic malformations that are poorly responsive to sclerotherapy, embolization, and surgical excision. Multimodal therapies are often essential for complex lesions and require the combined expertise of an interdisciplinary team.

Role of connexins in infantile hemangiomas

The circulatory system is one of the first systems that develops during embryogenesis. Angiogenesis describes the formation of blood vessels as a part of the circulatory system and is essential for organ growth in embryogenesis as well as repair in adulthood. A dysregulation of vessel growth contributes to the pathogenesis of many disorders. Thus, an imbalance between pro- and antiangiogenic factors could be observed in infantile hemangioma (IH). IH is the most common benign tumor during infancy, which appears during the first month of life. These vascular tumors are characterized by rapid proliferation and subsequently slower involution. Most IHs regress spontaneously, but in some cases they cause disfigurement and systemic complications, which requires immediate treatment. Recently, a therapeutic effect of propranolol on IH has been demonstrated. Hence, this non-selective β-blocker became the first-line therapy for IH. Over the last years, our understanding of the underlying mechanisms of IH has been improved and possible mechanisms of action of propranolol in IH have postulated. Previous studies revealed that gap junction proteins, the connexins (Cx), might also play a role in the pathogenesis of IH. Therefore, affecting gap junctional intercellular communication is suggested as a novel therapeutic target of propranolol in IH. In this review we summarize the current knowledge of the molecular processes, leading to IH and provide new insights of how Cxs might be involved in the development of these vascular tumors.

Continuous low-dose-rate radiation of radionuclide phosphorus-32 for hemangiomas

The study goal was to clarify the therapeutic effect and the absorbed dose of radionuclide phosphorus-32 for skin hemangiomas and the consequent risk of side effects in these patients. Phosphorus-32 is an β emitter and is used for skin hemangioma treatment. In comparison with the few Gy per minute of the linear accelerators, the dose rate of phosphorus-32 for hemangiomas is much <1 Gy/hour; so, the latter is called low-dose-rate radiation. To achieve the therapeutic dose, continuous hours or days of radiation is necessary. For strawberry hemangiomas, the phosphorus-32 applicator was tightly placed on the lesion site for several hours until reaching therapeutic dose. The absorbed dose was estimated by radiochromic films. The absorbed dose of phosphorus-32 irradiation declined exponentially with a depth from 0 to 2.5 mm. Of the 316 patients with strawberry hemangiomas, the lesion disappeared completely within 3 months after one-time treatment in 259 cases (82%). For cavernous hemangiomas, 370KBq phosphorus-32 colloid was injected into the hemangioma each square centimeter, and the absorbed radiation was estimated by theoretical calculation. Forty-two of the 58 patients with cavernous hemangiomas (72%) had lesions that completely disappeared within 3 months after receiving one to six treatments. Thus, the phosphorus-32 for strawberry hemangiomas and the chromium phosphate-32 colloid for cavernous hemangiomas were clearly efficacious.

[Propranolol for treatment of subglottic hemangioma]

Subglottic hemangiomas are extremely dangerous due to its location and rapid growth during the proliferative phase. Many different treatments are described but these methods are still not satisfactory. Recently propranolol has been used as a new option in hemangioma therapy. We describe a case of 6-week infant with subglottic hemangioma discovered direct laryngoscopy, presented with dyspnoea and inspiratory stridor. After oral propranolol administration all baseline airway symptoms had resolved and endoscopic examination demonstrated significant regression of the hemangioma. We suggest that the propranolol should be used as a first-line treatment in subglottic hemangiomas in children.

Propranolol for the treatment of airway hemangiomas: a case series and treatment algorithm

OBJECTIVES

(1) To present six patients with symptomatic airway hemangiomas treated with oral propranolol. (2) To review the diagnostic and treatment options for airway hemangiomas and propose a new management protocol.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care children's hospital.

SUBJECTS AND METHODS

Pediatric patients diagnosed with obstructive airway hemangiomas treated with oral propranolol. Patients were followed for symptomatic improvement and relief of airway obstruction on imaging or laryngoscopy.

RESULTS

Seven patients presenting with airway obstruction were treated with propranolol. One patient had a focal hemangioma confined to the subglottis. Four patients had airway hemangiomas that extended beyond the confines of the larynx and trachea. A sixth patient had a bulky supraglottic hemangioma. A seventh patient with an extensive maxillofacial lesion failed propranolol therapy and was found to have a pyogenic granuloma on final pathology after excision. Six patients had failed standard medical therapy and/or surgical interventions and were treated successfully with oral propranolol with improvements in airway symptoms and oral intake, requiring no further surgical intervention. Treatment was initiated as early as 1.5 months of age, and as late as 22 months. No adverse side effects of propranolol were noted.

CONCLUSIONS

Oral propranolol was successfully used to treat airway hemangiomas, resulting in rapid airway stabilization, obviating the need for operative intervention, and reducing the duration of systemic corticosteroid therapy while causing no obvious adverse effects. These outstanding results enable the possibility of use of a standardized diagnostic and treatment algorithm for airway hemangiomas that incorporates systemic propranolol.

Successful treatment of infantile haemangiomas of the orbit with propranolol

BACKGROUND

Propranolol is a novel therapeutic agent in the treatment of cutaneous infantile haemangiomas. We assessed the effect of propranolol therapy in infantile haemangiomas of the orbit.

METHODS

A case series of four patients with orbital infantile haemangiomas were referred for management in our tertiary referral hospitals. Two of the patients had inadequate responses to prior corticosteroid therapy. One of the patients was commenced on propranolol at 2.5 years of age when the lesion was not in the proliferative phase. This represented the first case report of propranolol treatment for infantile haemangioma outside infancy. The other three children were in their infancy when propranolol was commenced. The patients were treated with oral propranolol.

RESULTS

All patients had significant improvement in their physical appearance, ocular examination findings and size of their lesions on radiological evaluation. No side-effects of propranolol treatment were observed.

CONCLUSIONS

Propranolol is a promising treatment against infantile haemangiomas in the orbit, not only in infants but also in an older child with a stable lesion.

Propranolol for the treatment of a life-threatening subglottic and mediastinal infantile hemangioma

An infant with a subglottic hemangioma remained in respiratory distress after multiple treatments failed and was found to have an enlarging mediastinal infantile hemangioma compressing the trachea. Treatment with oral propranolol resulted in resolution of symptoms within 2 days and a 50% reduction in lesion size within 1 week.

Interferon-alpha for alarming hemangiomas in infants: experience of a single institution

BACKGROUND

Hemangioma is the most common tumor in infancy. 'Alarming hemangiomas' refer to the lesions that potentially impair vital structures or cause life-endangering complications, and which warrant vigorous treatment. Interferon-alpha has been used for alarming hemangiomas at Mackay Memorial Hospital, Taipei, Taiwan, since 1994.

METHODS

The records of 21 consecutive infants treated between January 1994 and December 2005 were retrospectively reviewed. The initial dose of interferon-alpha was 50 000 IU/kg per day, which was increased to 100,000 IU/kg per day in the second week of therapy if tolerated. It was tapered depending on response, with total treatment lasting no longer than 12 months. Treatment response was evaluated depending on the size of the lesion and resolution of complications.

RESULTS

The duration of therapy ranged from 6 to 12 months. Six patients (29%) had a reduction in mass of > or =25% after 1 month of therapy. Twenty patients (95%) had achieved a decrease in size of 50% by 12 months, and 15 (71%) had total involution of lesions by a median age of 13.5 months (range 7-50 months). Only mild and transient adverse effects were encountered. No neurologic complications occurred.

CONCLUSIONS

Interferon-alpha appears to be an effective and well-tolerated treatment for alarming hemangiomas in infancy.

Emerging Concepts in Airway Infantile Hemangioma Assessment and Management

OBJECTIVE: The purpose of this study was to evaluate changes in airway infantile hemangioma treatment.

STUDY DESIGN: Retrospective.

SUBJECTS: Airway hemangioma patients, tertiary pediatric hospital.

METHODS: Data collected included age at diagnosis, evaluation methods, hospitalizations, airway size, and interventions. Patients were divided into group A (1981–1993) and group B (1994–2005) and were analyzed using descriptive statistics, the Fisher exact test, and the Student t test.

RESULTS: Thirty-two subjects were identified. Nasopharyngoscopy was used more in group B (11/16 [69%]) than group A (4/16 [25%], P = 0.032). CT angiography (3/16 [19%]) and laryngeal distractors (11/16 [69%]) were only used in group B; these techniques showed airway hemangiomas to be “transglottic,” not just “subglottic.” Intralesional steroids alone (3/16 [19%]) and primary hemangioma excision (2/16 [13%]) were new treatments used in group B. Frequent direct laryngoscopies (>six) correlated with tracheotomy (5/32 [16%], P = 0.015). Presenting age (<2 months) impacted treatment more than airway hemangioma size.

CONCLUSIONS: New methods of airway infantile hemangioma assessment changed our concept of airway hemangiomas and their primary treatment.

Head and neck hemangiomas of infancy

PURPOSE OF REVIEW

Hemangiomas are the most common benign tumor in infancy, affecting approximately 10% of infants. More than half of hemangiomas involve the head and neck. Increased understanding of hemangiomas has come about from identification of immunohistochemical markers, developmental defects associated with certain hemangiomas, and morphologic and classification schemes (focal versus segmental).

RECENT FINDINGS

Immunohistochemical markers have been identified which are specific to hemangiomas in all phases of development and involution. Morphologic subtypes and anatomic locations have been identified that place an infant at higher risk for complications from the hemangioma. Hemangiomas associated with other developmental anomalies have been identified, which help guide the treating physician to tease out which infants will need more complete systemic investigations or imaging. Importantly for surgeons, studies have continued to identify which lesions may benefit from early intervention, either surgical or medical.

SUMMARY

While full understanding of the mechanisms that turn on and turn off hemangiomas of infancy is not complete, progress has been made in identification of markers, subtypes at increased risk for complications, and in treatment. With continued work in these areas, we have increased knowledge of treatment options, optimal timing of surgical intervention, and ultimately, preventive options.