Use of propranolol for parotid hemangioma

Distribution of problematic localized facial infantile haemangiomas and their response to propranolol: a retrospective cohort study

BACKGROUND

The distribution and response to propranolol of problematic facial infantile haemangiomas (IHs) has rarely been described in the literature.

AIM

To map problematic facial IHs and observe their response to propranolol.

METHODS

Eligible patients were categorized according to focal location and cohorts corresponding to these (buccal, medial, zygomatic, lateral and multiregional) were created. The primary efficacy variable was regression score ranging from 1 to 4, calculated using results of colour Doppler ultrasonography.

RESULTS

In total, 104 patients met the inclusion criteria. There were 32 (30·8%) IHs located in the buccal area, 12 (11·5%) in the medial area, 49 (47·1%) in the lateral area and 1 (1·0%) in the zygomatic area, with 10 (9·6%) IH cases having multiregional lesions. We found that the distribution pattern of most IHs matched the surface projection of the trunk of the external carotid and the facial arteries. Further analysis showed that the median regression score in the buccal and medial groups were significantly lower than those in the lateral and multiregional groups.

CONCLUSION

Treatment of buccal and medial haemangiomas tends to be more challenging and their distribution pattern mainly reflects the direction of the facial vessels.

A Large Parotid Hemangioma Managed Successfully with Propranolol

The treatment of parotid hemangiomas has posed a challenge. A male infant presented with large hemangioma of the right parotid gland diagnosed at the age of 3 months. Starting at the age of 4 months, he was treated with oral propranolol for 10 months, which led to a marked reduction in tumor size and strawberry hemangioma. Our case shows that propranolol is effective and safe in treating large parotid infantile hemangioma.

Oral propranolol therapy in parotid hemangiomas: A retrospective comparison with other infantile hemangiomas

BACKGROUND

The outcomes of propranolol treatment remain controversial for parotid hemangiomas, which may be inferior to outcomes for infantile hemangiomas (IHs) at other sites.

METHODS

Patients with IHs treated with oral propranolol were retrospectively reviewed. Outcomes of propranolol therapy for parotid hemangiomas and other IHs were examined. Regression models were conducted to analyze the factors associated with the outcomes for parotid hemangiomas.

RESULTS

Longer treatment duration was needed for parotid hemangiomas (p = 0.012) at a comparable efficacy and relapse rate as those of IHs at other sites. The higher efficacy was associated with early intervention before 4 months of age (OR = 5.2, p = 0.011), while, the lower relapse rate was associated with adequate treatment duration over 6 months (OR = 9.2, p = 0.010).

CONCLUSIONS

With a longer propranolol treatment duration, parotid hemangiomas could achieve a comparable efficacy and relapse rate as other IHs. Early treatment initiation and adequate treatment duration benefited the outcomes.

Color Doppler Evaluation of Arterial Resistive Index in Infantile Hemangioma: A Useful Parameter to Monitor the Response to Oral Propranolol?

Infantile hemangioma (IH) is the most common benign vascular tumor in childhood. In more than 85% of all cases, IHs undergo spontaneous involution, but nearly 10-12% of IHs develop complications and require immediate therapy. Oral propranolol is currently the first-line treatment for IHs. Color Doppler ultrasound is the gold standard in the diagnosis of deep IH, and it is used to evaluate the morphological change and the modification of vascularization that occur during its evolution and treatment. To date, only few data in the literature described the changes of intralesional arterial resistive index (RI) during treatment with propranolol; particularly, some authors have shown an increase of intralesional arterial RI in IHs with clinical regression during treatment with propranolol. The objective of this paper is to evaluate the changes of RI of the intralesional arteries of the IHs during the treatment with oral propranolol. We retrospectively analyzed a total of 64 IHs in 60 patients treated with oral propranolol with a good clinical response. Gray-scale ultrasonography and color Doppler imaging were performed before and during the therapy. The intralesional RIs were measured before and during the treatment. For each lesion, we recorded the RI values, and then we calculated the mean RI value for any single lesion. We compared the mean RI value observed at the baseline with the mean RI value of the last detectable sampling at color Doppler. We also compared between them the mean RI values observed during intermediate ultrasound. The RI values were compared in 44 lesions, with at least two significant samplings of RI. In the 44 lesions compared, we did not find statistically significant variations in the mean RI values between the baseline control and the values recorded at the last post-treatment control. The time trend of mean RI values of the intermediate color Doppler analysis performed between the first pre-treatment control and the last measurable control did not show any statistically significant variation in the trend of mean RI values. Contrarily to what has been described by some authors, in our experience, we have not observed an increase of RI in IHs treated with oral propranolol.

Transcatheter Arterial Sclerosing Embolization for the Treatment of Giant Propranolol-Resistant Infantile Hemangiomas in the Parotid Region

PURPOSE

To report the effectiveness and safety of transcatheter arterial sclerosing embolization (TASE) for the treatment of parotid infantile hemangiomas that did not respond appreciably to propranolol.

MATERIALS AND METHODS

A total of 21 infants (12 male and 9 female) with large propranolol-resistant infantile hemangiomas in the parotid region were enrolled in this study. During TASE, the feeding arteries of the lesions were embolized using pingyangmycin-lipiodol emulsion and polyvinyl alcohol particles (300-500 μm) to reduce the blood flow rate. All children were followed up as outpatients at 2 weeks and monthly thereafter. The curative effect was evaluated at the 1- and 3-month follow-up visits.

RESULTS

Nine lesions were located on the right side of the parotid gland, whereas 12 were located on the left side. The feeding arteries in all patients originated from branches of the external carotid artery. TASE was technically successful in all patients. The mean (± SD) maximal diameter of the hemangiomas significantly decreased from 6.50 cm ± 2.28 before treatment to 3.56 cm ± 1.84 at 1 month after TASE (P <. 05). Three months after TASE, the mean maximal diameter further significantly decreased to 1.94 cm ± 1.58 (P <. 05). During the follow-up period, 16 cases were rated as excellent and 5 as good; no recurrence or serious complications were noted. Minor side effects, such as slight pain, mild fever, and tissue swelling, were observed.

CONCLUSIONS

TASE significantly decreased the size of the parotid hemangiomas with minor side effects during a short follow-up period.

Propranolol inhibits proliferation and induces apoptosis of hemangioma-derived endothelial cells via Akt pathway by down-regulating Ang-2 expression

Hemangioma is one of the commonest benign vascular tumors among children. Propranolol is the first-line therapeutic drug for hemangioma. However, the effects and mechanisms of propranolol in hemangioma have not been thoroughly elaborated. In this study, the effects and mechanisms of propranolol were explored using hemangioma-derived endothelial cells (HemECs). The expression of GLUT1 were determined by immunofluorescence staining. qRT-PCR assay was conducted to detect the mRNA expressions of angiopoietin-2 (Ang-2) and Tie-2. Western blot assay was carried out to measure the protein levels of Ang-2, Tie-2, protein kinase-B (Akt) and phospholyrated-Akt (p-Akt). Cell proliferation was assessed by Cell Counting Kit-8 (CCK-8) assay and Western blot of Ki67 protein level. Cell apoptosis was measured by flow cytometry analysis and Western blot of Bax and Bcl-2 levels. We found that propranolol inhibited proliferation and induced apoptosis in human umbilical vein endothelial cells (HUVECs) and HemECs. Moreover, propranolol inhibited the expressions of Ang-2 and Tie-2 in HUVECs and HemECs. Functional analysis revealed that Ang-2 attenuated the effects of propranolol on HemEC proliferation and apoptosis. Mechanistical analysis showed that propranolol inhibited the Akt pathway by regulating Ang-2 expression in HemECs. Futhermore, inhibition of the Akt pathway attenuated the effects of Ang-2 on proliferation and apoptosis in HemECs. In conclusion, propranolol inhibited proliferation and induced apoptosis of HemECs via Akt pathway by down-regulating Ang-2 expression, which contributes to our understanding on the pathogenesis of hemangioma and promotes the development of therapeutic approaches for hemangioma.

Intralesional Bleomycin Injection for Propranolol-Resistant Hemangiomas

Propranolol has been the first-line treatment for alarming hemangiomas. However, some hemangiomas are propranolol-resistant. The authors reported 1 propranolol-resistant hemangioma which was treated with intralesional bleomycin injections. Sixteen months after 3 injections, the lesion still remained stable. Its potential mechanism was clarified by ultrasonic monitoring. Intralesional bleomycin injection can be considered an ideal option in treating propranolol-resistant hemangiomas.