Acute pulmonary toxicity following intralesional administration of bleomycin for a lymphovenous malformation

Congenital Vascular Malformations in Children: From Historical Perspective to a Multidisciplinary Approach in the Modern Era-A Comprehensive Review

Congenital vascular malformations (CVMs) are the result of an aberrant development during embryogenesis. Although these lesions are present at birth, they are not always visible yet. Once symptomatic, patients suffer from pain, bleeding, ulcers, infections or lymphatic leakage, depending on the subtype of vessels involved. Treatment includes conservative management, surgery, sclerotherapy, embolization and pharmacological therapy. The clinical presentation varies widely and treatment can be challenging due to the rarity of the disease and potential difficulties of treatment. This review gives an overview of the historical developments in diagnosis and classification and exposes the key elements of innovations in the past decades on the identification of genetic mutations and personalized treatment. These advances in the field and a multidisciplinary approach are highly valuable in the optimization of clinical care aimed at both curing or stabilizing the CVM and pursuing physical and psychosocial wellbeing.

Percutaneous Sclerotherapy of Large Venous Malformations Using Consecutive Polidocanol and Bleomycin Foam: MR Imaging Volumetric and Quality-of-Life Assessment

PURPOSE

To retrospectively evaluate sclerotherapy using consecutive polidocanol and bleomycin foam (CPBF) for large untreated venous malformations (VMs) and/or those resistant to prior treatment.

MATERIALS AND METHODS

This retrospective study included all patients treated with CPBF for untreated VMs larger than 10 mL and/or refractory to treatment between May 2016 and October 2019. Baseline and follow-up VM volumes were measured on fat-suppressed T2-weighted magnetic resonance (MR) imaging. Outcome was evaluated on postprocedural MR imaging volumetry and by a retrospective survey assessing clinical response and adverse events. Imaging response was considered good for volume reduction from 50% to 70% and excellent for volume reduction ≥70%. Symptoms and quality-of-life (QoL) scores were compared before and after CPBF sclerotherapy.

RESULTS

Forty-five patients (mean age, 16 years; range, 1-63 years; 25 males) with 57 VMs were analyzed and treated by 80 sclerotherapy. Sixty percent (27 of 45) of patients had undergone prior treatment for VM. Median VM volume was 36.7 mL (interquartile range, 84 mL) on pretherapy MR imaging. Good and excellent results after the last sclerotherapy were achieved in 36% (16 of 45) and 29% (13 of 45) of patients, respectively, corresponding to a decrease of >50% in 60% (34 of 57) of VMs. QoL score increased by at least 3 points, regardless of initial symptoms. Most patients did not desire additional sclerotherapy owing to near complete symptomatic relief, even for patients who did not achieve a good response. Swelling, pain, and motor impairment scores significantly improved after CPBF. Adverse events included fever (44%, 15 of 34) and nausea/vomiting (29%, 10 of 34).

CONCLUSIONS

CPBF sclerotherapy represents an effective therapy for large and/or refractory VMs with minimal adverse events.

Contemporary management of extracranial vascular malformations

Vascular malformations are congenital vascular anomalies that originate because of disorganized angiogenesis, most commonly from spontaneous somatic genetic mutations. The modern management of vascular malformations requires a multidisciplinary team that offers patients the gamut of medical, surgical, and percutaneous treatment options with supportive care. This manuscript discusses the standard and contemporary management strategies surrounding extracranial vascular malformations and overgrowth syndromes.

[Diagnosis and treatment of benign eyelid tumors]

BACKGROUND

Benign tumors of the eyelids are frequent entities. They are often cause for cosmetic concern or can lead to irritation of the ocular surface. The differentiation from premalignant or malignant eyelid tumors is particularly important. In most cases this can be done clinically; however, in some cases histological evaluation is warranted.

OBJECTIVE

The aim of this article is to characterize the most important benign tumors of the eyelid and to ascertain when a histological examination is necessary. Furthermore, fundamental treatment procedures are discussed.

METHODS

This narrative review was prepared based on a selective literature search. The characteristics of some eyelid tumors are underlined with illustrations from clinical cases.

RESULTS

Most benign eyelid tumors are treated because of cosmetic or functional concerns. Some of them, including actinic keratosis, keratoacanthoma, cutaneous horn, trichofolliculoma, resemble malignant lid tumors or precancerous lesions and are thus excised in oder to obtain a diagnosis. Dermoid cysts can cause complications and congenital melanocytic naevi can exhibit malignant transformation and may need treatment. Inflammatory tumors can be treated conservatively in most cases but might require surgery in certain cases. Systemic associations exist with some of the benign lid tumors and should not be overlooked as they can be crucial for overall patient morbidity.

CONCLUSION

Benign tumors of the eyelids are frequent and can be found at any age depending on the diagnosis. This article describes the lesions most commonly encountered in the clinical routine and helps at making a plan for further management.

Efficacy and safety of transarterial bleomycin sclerotherapy of early-stage facial arteriovenous malformation: Single-center multidisciplinary team experience

BACKGROUND

To evaluate the efficacy and safety of transarterial bleomycin sclerotherapy of early-stage facial arteriovenous malformation (AVM).

METHODS

A retrospective review was performed of patients who underwent bleomycin sclerotherapy for early-stage AVM (Schobinger stage I or II) in a single-referral vascular anomalies center. Bleomycin was slowly infused transarterially with flow control techniques to prolong the effects of bleomycin. Procedure details, AVM characteristics, and previous treatments were reviewed. Initial therapeutic outcomes were determined by 5 categories using both radiological and clinical findings in a 6-month follow-up. Further follow-up outcomes were reviewed to evaluate the long-term efficacy and safety of the treatment. Procedure-related complications were also analyzed.

RESULTS

Nineteen patients (mean age 22.4 ± 14.0 years, 14 females) with 31 sessions of sclerotherapies were enrolled. All AVMs were Cho-Do classification type III (type IIIa [n = 13], type IIIb [n = 2], and type IIIa+b [n = 4]). Patients received a mean of 1.6 (range, 1-4) sessions of treatment. The mean cumulative bleomycin dose was 23,600 IU ± 14,500 (range, 8000 - 60,000 IU). The results showed that 14 patients (74%) were responsive to transarterial bleomycin sclerotherapy, including complete response (n = 3), marked improvement (n = 1), and partial improvement (n = 10). The remaining 5 (26%) showed no response. During a mean follow-up of 32.6 months, 5 (26%) showed slight progression compared with 6-month outcomes and 14 (74%) were stable. There were only 2 minor complications [hyperpigmentation (n = 1) and cellulitis (n = 1)].

CONCLUSIONS

Transarterial bleomycin sclerotherapy using flow control techniques can be a safe and feasible alternative treatment option for facial early-stage AVM.

Treatment of lymphangiomas by means of sclerotherapy with OK-432 (Picibanil®) is safe and effective - A retrospective case series

Introduction

Congenital cystic lymphangiomas (CCL) or lymphatic malformations (LMs) are benign malformations due to a developmental disorder of lymphatic vessels. Besides surgical excision, sclerosant therapy of these lesions by intracavitary injection of OK-432 (Picibanil®), a lyophilized mixture of group A Streptococcus pyogenes, is a common therapeutical option.

Methods

In a single center retrospective study we analyzed 37 consecutive patients (30 children, 3 adolescents and 4 adults) who were diagnosed with lymphangioma and subsequently treated with OK-432 (Picibanil®) in a general hospital between October 2000 and November 2021.

Results

The median follow-up period was 2.5 months (range 0.7-56.7 months). The lymphangiomas were localized in the head and neck region (n = 25), the thorax/abdomen (n = 6) and extremities (n = 6). The majority of patients had 1 injection with OK-432 (n = 28), five patients had 2 injections, three patients had 3 injections and one patient had more than 3 injections. The most common complications were swelling (89%), fever (81%), redness at the injection site (81%) and pain (73%). The response to therapy was excellent or good in 32 patients (86.4%), 2 patients had a medium response and 3 patients did not show any response. The clinical reaction after the instillation of OK-432 is not predictive for the quality of outcome.

Conclusion

The application of Picibanil is safe and without serious side effects. Parents and patients prefer local sclerotherapy versus surgery as it has less complications. We therefore suggest that Picibanil sclerotherapy should be the first-line treatment for macrocystic and mixed type lymphangiomas.

Management of Venous Malformations

Venous malformations (VMs) are slow-flow, congenital vascular anomalies that are a result of vascular dysgenesis. Clinical presentation and morbidity depend on size, location, and association with other syndromes. VMs are the most common symptomatic vascular anomaly referred for intervention, usually due to thrombosis, swelling, mass effect, functional compromise, or cosmetic concerns. Treatment for larger lesions can be challenging and a multidisciplinary approach involving medical, interventional, and surgical input is critical for comprehensive care. This article will assist the interventional radiologist in patient assessment and will discuss current techniques for treatment, means to minimize adverse events, and expected outcomes.

Bleomycin sclerotherapy for large diffuse microcystic lymphatic malformations

Background

Microcystic lymphatic malformations (LMs) are congenital lesions with the diameter of the majority of cysts <1 cm. Bleomycin sclerotherapy has been shown to yield beneficial results for macrocystic LMs. This study aims to evaluate the safety and efficacy of consecutive bleomycin sclerotherapy for large diffuse microcystic LMs.

Methods

The location and size of the lesions were detected by ultrasound for the 46 patients included in this study. Bleomycin lavage was performed in larger cysts and intradermal injection for the superficial lesion. The outcome and complications were assessed for its efficacy and safety.

Results

The large diffuse microcystic LMs mainly located in the neck, abdominal wall and axilla/lateral chest wall. The average lesion size was 10.6 cm × 7.2 cm. The mean number of treatment sessions was 4.5 with 7.3 mg bleomycin for per session averagely. Excellent (69.6%) and moderate (23.9%) responses were obtained. There was no recurrence for the 6 patients (13%) who received a long follow-up. Obvious local swelling, slight intralesional hemorrhage and low-grade fever were the most commonly occurred complications. No lung fibrosis was identified for the patients who received more than 6 sessions.

Conclusions

Local lavage combined with intradermal injection of bleomycin is effective and safe for large diffuse microcystic LMs with good therapeutic effect and low complication rates, and can be regarded as the mainstay of therapy for microcystic LMs.

Bleomycin for Percutaneous Sclerotherapy of Venous and Lymphatic Malformations: A Retrospective Study of Safety, Efficacy and Mid-Term Outcomes in 26 Patients

Percutaneous sclerotherapy is used to treat venous and lymphatic vascular malformations, which can cause significant discomfort and/or disfigurement. The purpose of this study is to describe the bleomycin sclerotherapy technique and to evaluate its clinical and radiological efficacy and safety. We retrospectively identified consecutive patients with venous malformations (VMs) and lymphatic malformations (LMs) who underwent bleomycin sclerotherapy in 2011–2020 at our institution. We collected the clinical and radiological success rates, complications and recurrences separately in the VM and LM groups. We identified 26 patients, 15 with VMs and 11 with LMs. The significant volume reductions obtained were 45% in the VM group and 76% in the LM group (p = 0.003 and p = 0.009, respectively). Significant reductions in discomfort/pain and in cosmetic disfigurement were obtained in both groups. An overall improvement was reported by 69% and 82% of patients in the VM and LM groups, respectively. No major complications occurred during the mean follow-up of 51 ± 34 months in the VM group and 29 ± 18 months in the LM group. A recurrence developed within 2 years in 23% of patients. Bleomycin is clinically and radiologically effective for the treatment of venous and lymphatic malformations, with a high level of patient safety.

Bleomycin for orbital and peri-orbital veno-lymphatic malformations - A systematic review

BACKGROUND

Orbital and peri-orbital venolymphatic malformations (VLM) are low flow vascular malformations. Intralesional bleomycin is now commonly being used to treat such malformations.

OBJECTIVE

The purpose of this systematic review is to synthesize evidence on the safety and efficacy of bleomycin/pingyangmycin sclerotherapy for the treatment of orbital and peri-orbital VLM.

METHODS

We searched Medline, Embase, Scopus and Cochrane database for studies reporting outcomes of bleomycin/pingyangmycin sclerotherapy for orbital and peri-orbital VLM between 1974 to April 5th, 2019. Nine retrospective cohort studies enrolling 132 patients were included. Two reviewers independently screened and extracted data and assessed the risk of bias. Predefined outcome measures were subjective and objective reduction of the lesion and associated complications.

RESULTS

Subjective reduction of the lesions was seen in 96.2% of the studies. Objective reduction of the lesion and symptomatic improvement were reported in 91.6 and 95% of the studies respectively. Non responders were 9.0%. Minor adverse events were reported in 18.1% of the studies. Major complications like pulmonary toxicity or pulmonary fibrosis was not encountered in any of the included studies. Quality of evidence was generally low.

CONCLUSION

Bleomycin/pingyangmycin sclerotherapy is very effective and relatively safe for the treatment of orbital and periorbital VLM and is not associated with any major side effects including pulmonary fibrosis.Limitations: The systematic review is limited mainly due to low quality of the included studies with retrospective design.

The Role of Interventional Radiologists in the Treatment of Congenital Lymphatic Malformations

Lymphatic malformations are low-flow vascular malformations that are typically apparent in the pediatric population and can cause significant functional limitations and effects on quality of life. While surgical resection has historically been the mainstay of therapy, percutaneous sclerotherapy has garnered increasing popularity due to its efficacy and low complication rates. The role of interventional radiology in the multidisciplinary management of these often complex malformations requires thorough understanding of the disease process. This article will review the pathophysiology, clinical presentation, imaging workup, and management options of lymphatic malformations. Special attention will be devoted to available sclerosants, the mammalian target of rapamycin inhibitor sirolimus, and complex lymphatic anomalies.

Preliminary experience with promethazine hydrochloride injection in the sclerotherapy of oral mucocele

Mucoceles are common in the minor salivary and sublingual glands. Sclerotherapy is a possible treatment strategy for mucoceles. The purpose of this study was to evaluate the clinical outcomes of sclerotherapy with promethazine hydrochloride injection in treating mucoceles. Thirty-seven patients were enrolled. Sclerotherapy was performed with promethazine hydrochloride injection (25mg/ml) through the mucosa. Patients were followed up at 1, 3, and 6 months after the last sclerotherapy. Clinical data were reviewed. The lesions (range 2-30mm in diameter) occurred on the ventral tongue tip (20 patients), lower lip (11 patients), and floor of the mouth (six patients). The amount of sclerosant per injection ranged from 0.2ml to 1ml. At the 6-month follow-up, 33 patients showed resolution with no recurrence. One patient showed a significant response with a 5-mm-diameter nodule remaining after two sclerotherapies. Three patients who underwent two or more sclerotherapies failed to show an improvement. The overall cure rate was 91.9% (96.8% for mucoceles of the minor salivary gland, 66.7% for ranulas). Complications were rare and mild. Sclerotherapy with promethazine hydrochloride injection for the treatment of mucoceles is safe. It is effective for mucoceles of the minor salivary glands, but its application for ranulas requires further investigation.

New onset dysphagia and pulmonary aspiration following sclerotherapy for a complex cervical venolymphatic malformation in an infant: Case report and review of the literature

We present the case of a 2-year-old male with a complex left cervical venolymphatic malformation who underwent doxycycline sclerotherapy at 12 months of age complicated by new onset pulmonary aspiration. A review of the literature reveals this to be a rare complication of sclerotherapy and only the second reported case.

METHODS

Procedural details with associated imaging including endoscopic airway and swallowing evaluation are included. A literature review of cervical and laryngeal sclerotherapy complications was performed and discussed.

RESULTS

A 12-month-old male underwent sclerotherapy with doxycycline for a complex parapharyngeal and paralaryngeal venolymphatic malformation. The postoperative course was complicated by new onset dysphagia, aspiration, and decreased laryngeal sensation. Gastric feeding and swallowing therapy were necessary due to prolonged difficulty. The sclerotherapy treatment resulted in near elimination of the cervical components of the lesion at 12 months follow up. The child progressed to total oral feeding by 17 months post-treatment with no evidence of decreased laryngeal sensation. An extensive literature review identified only one reported case of new onset dysphagia and decreased laryngeal sensation after doxycycline sclerotherapy.

CONCLUSIONS

Doxycycline sclerotherapy for cervical venolymphatic malformations rarely can cause adjacent neural injury resulting in laryngeal complications. Our case report and literature review suggest that symptom management and appropriate aspiration precautions are necessary in infants or children with presumed vagus or laryngeal nerve injury, and injury is likely only temporary.

Sclerotherapy with Adjunctive Stasis of Efflux (STASE) in Venous Malformations: Techniques and Strategies

Venous malformations are very commonly encountered in interventional radiologic practice. Indications for therapy are clearly defined based on the lesion's impact on patient's quality of life. Screening laboratory coagulation studies in patients with historical or lesion morphologic risk factors often reveal abnormal coagulation parameters consistent with localized intravascular coagulation or more severe coagulopathic states. These may require chronic or periprocedural medical management to avoid potentially life-threatening disseminated intravascular coagulation or other thromboembolic phenomena. Once a multidisciplinary decision to treat a venous malformation is made, one must decide between percutaneous and/or surgical techniques. Sclerotherapy with adjunctive stasis of efflux (STASE) techniques have become the mainstay of therapy for most venous malformations as they are well-tolerated and effective. STASE techniques work primarily by (i) the administration of sclerosant(s) exerting an inhibitory and/or endotheliocidal effect on venous malformation endothelium leading to thrombosis, involution, and fibrosis, and secondarily via adjunctive outflow occlusion using any combination of local compression, balloons, gelatin, coils, laser, radiofrequency, or adhesives to improve sclerosant penetration and dwell-time in the lesion. Adhesives alone can fill the lesion to facilitate surgical resection in some cases. Common sclerosants in modern practice include sodium tetradecyl sulfate, bleomycin, polidocanol, ethanol, and hypertonic saline. Most agents can be given directly in unmodified or "neat" form or can be mixed with a gas to form a sclerofoam or embolic such as gelatin to form a sclerogel. Choice and method of sclerosant delivery in each patient is based on the intraluminal lesion volume, architecture, vital structure proximity, agent toxicity, viscosity, and level of experience of the interventional radiologist with that particular agent. Multi-session STASE therapy usually reduces symptoms of chronic pain or mass with low risk of known complications of skin or nerve impairment, compartment syndrome, hemoglobinuria, deep venous thrombosis, or pulmonary phenomena.

Reactive Oxygen Species Are Necessary for Bleomycin A5-Induced Apoptosis and Extracellular Matrix Elimination of Nasal Polyp-Derived Fibroblasts

BACKGROUND:

The pathology of chronic rhinosinusitis with nasal polyp (CRSwNP) is characterized by the infiltration of a large number of fibroblasts, resulting in extracellular matrix (ECM) deposition. Intralesional bleomycin A5 (BLE) injection has proved to be effective and safe, providing a novel treatment for CRSwNP. However, the mechanism is not clearly understood.

OBJECTIVES:

The aim of this study is to explore the possible mechanism of BLE-induced apoptosis in nasal polyp-derived fibroblasts (NPDFs).

MATERIAL AND METHODS:

Dichloro-dihydro-fluorescein diacetate probe, cell migration assays, and cell cycle analysis were used to detect the growth characteristics and basal reactive oxygen species (ROS) traits of NPDFs. Annexin V/propidium iodide and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay was used to detect BLE-induced apoptosis. As a control, the antioxidant glutathione (GSH) was used to abrogate ROS induced by BLE. Western blot analysis was used to evaluate the effects of BLE on apoptosis and the ECM proteins of NPDFs.

RESULTS:

The results showed that NPDFs had more active growth characteristics and higher basal ROS levels than normal nasal mucosa fibroblasts (NMFCs). NPDFs were more sensitive to BLE-induced apoptosis and ROS accumulation. GSH abrogation inhibits BLE-induced ECM degradation and apoptosis in NPDFs through a mitochondrial-mediated pathway.

CONCLUSIONS:

BLE induced NPDF apoptosis and ECM degradation through a mitochondrial-mediated pathway and in a ROS-dependent manner.

Acute Lung Toxicity After Intralesional Bleomycin Sclerotherapy

Bleomycin has progressively been used to treat low-flow vascular malformations in children. No significant systemic side effects have been reported in large series after low doses, but some authors are still concerned about its use. We report a case of a severe acute lung toxicity after a low dose of a second bleomycin intralesional injection in a 5-year-old girl. She had no risk factors and presented a cervical low-flow venous malformation. Twenty-four hours after this second administration, she presented with fever and respiratory distress. A chest radiograph showed bilateral opacities and computerized tomography revealed extensive and diffuse lung ground-glass opacities. The patient started to receive intravenous methylprednisolone, but she experienced progressively increased dyspnea, and montelukast was added. She improved and was discharged from the hospital without oxygen support, with montelukast and prednisolone for tapering doses during months. Five months after onset, the patient is developing well, is active, and walks and talks without dyspnea. A new low-dose computed tomography shows improvement in radiologic findings. This is the second case of pulmonary toxicity observed in a child after bleomycin intralesional administration, and the first reported after the lowest dose of this drug to date (7 mg: 0.28 mg/kg; 10 U: 0.4 U/kg). A delay in the diagnosis and treatment of this complication can be fatal. Any physician who treats these patients must be alert and consider this complication in children with respiratory symptoms after bleomycin sclerotherapy. Early detection of pulmonary toxicity would allow prompt therapy and could avoid pulmonary damage.

Treatment of Early-stage Extracranial Arteriovenous Malformations with Intralesional Interstitial Bleomycin Injection: A Pilot Study

Purpose To assess the efficacy and safety of intralesional interstitial bleomycin injection in the treatment of early-stage (Schobinger stage I or II) extracranial arteriovenous malformations (AVMs). Materials and Methods This prospective study involved 34 patients with early-stage AVMs, as defined by the Schobinger staging system. The patients received intralesional interstitial bleomycin injected at a maximum dose of 15 000 IU or 1000 IU per kilogram of body weight for children who weighed less than 15 kg per procedure for a total of 6 months (once every month). Therapeutic outcome was evaluated by the degree of devascularization at angiography and the clinical outcome 3 months after the last treatment. Further follow-up was evaluated based on further clinical outcome. Adverse events were recorded according to the Society of Interventional Radiology classification. Results Of the 34 patients with early-stage AVM, 32 (mean age, 20.5 years; 24 female [75%]) completed the study. The results showed that 27 (84.4%, 95% confidence interval [CI]: 71.1, 97.7) patients were responsive to bleomycin injection, including nine (28.1%) with a complete response. Four (12.5%) patients showed no response, and one (3.1%) patient experienced worsening 3 months after the last treatment. During further follow-up (mean follow-up time, 20.7 months; range, 5-28 months), the outcome remained stable in 31 (96.9%) of the 32 patients. A major complication, anaphylactic shock, was observed in one (3.1%, 95% CI: 0, 9.5) patient. Common minor complications included hyperpigmentation, nausea, pruritus, and bullae. Conclusion Intralesional interstitial bleomycin injection is a feasible approach for early-stage AVMs and yields safe and effective outcomes. ^© RSNA, 2017.

Bleomycin sclerotherapy for lymphatic malformation after unsuccessful surgical excision: case report

Lymphatic malformations (LMs) are benign cystic masses resulting from the abnormal development of lymphatic channels. Lymphatic malformations occur primarily in the head and neck region. Surgical excision of lymphatic malformation is followed by high rate of recurrence and a high risk of complications. Bleomycin is an established antineoplastic drug. It can be used as a sclerosing agent in vascular anomalies. We present a child who was unsuccessfully treated with four surgical resections, with peripheral palsy of facial nerve as complication. The lymphatic malformation was successfully treated in our institution with intralesional administration of bleomycin.

Intralesional Bleomycin Injections for Vascular Malformations: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular malformations are congenital anomalies of the vascular system. Intralesional bleomycin injections are commonly used to treat vascular malformations. However, pulmonary fibrosis could potentially be a severe complication, known from systemic bleomycin therapy for malignancies. In this study, the authors investigate the effectiveness and safety of bleomycin (A2, B2, and A5) injections for vascular malformations, when possible relative to other sclerosants.

METHODS

The authors performed a PubMed, Embase, Cochrane Central Register of Controlled Trials, and gray literature search for studies (1995 to the present) reporting outcome of intralesional bleomycin injections in patients with vascular malformations (n ≥ 10). Predefined outcome measures of interest were size reduction, symptom relief, quality of life, adverse events (including pulmonary fibrosis), and patient satisfaction.

RESULTS

Twenty-seven studies enrolling 1325 patients were included. Quality of evidence was generally low. Good to excellent size reduction was reported in 84 percent of lymphatic and 87 percent of venous malformations. Pulmonary fibrosis was never encountered. Meta-analysis of four studies on venous malformations treated with bleomycin versus other sclerosants showed similar size reduction (OR, 0.67; 95 percent CI, 0.24 to 1.88) but a significantly lower adverse event rate (OR, 0.1; 95 percent CI, 0.03 to 0.39) and fewer severe complications after bleomycin. Symptom relief, quality of life, and patient satisfaction were reported inadequately.

CONCLUSIONS

The authors' data suggest that bleomycin is effective in reducing the size of lymphatic and venous malformations, and leads to a lower adverse event rate and fewer severe complications than other sclerosants. The included literature does not provide evidence that pulmonary fibrosis is a complication of intralesional bleomycin injections. This study represents the "best available" evidence; however, only low- to moderate-quality studies were available.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Safety and efficacy of bleomycin sclerotherapy for microcystic lymphatic malformation

PURPOSE

Sclerotherapy is the mainstay of treatment of macrocystic lymphatic malformation (LM), but the response using traditional sclerosants is much less beneficial in microcystic lesions. Intralesional bleomycin has been reported to be effective in microcystic LM; however, its use is limited by concerns about pulmonary fibrosis. The purpose of this study was to evaluate the safety and efficacy of bleomycin sclerotherapy in microcystic LM.

METHODS

The medical records and imaging studies of all patients with microcystic or combined LM who underwent percutaneous image-guided sclerotherapy using bleomycin were retrospectively reviewed. Only patients with pre- and postprocedure imaging were included. Thirty-one patients with a mean age of 13.4 years (range 3 months-31 years) were treated. Response was graded as complete (>90% size reduction), partial (25-90%), or minimal/no response (<25%). Pulmonary function tests (PFT) and chest X-rays were performed before the procedure. PFT were repeated at 6 months and 1 year postprocedure. Annual postprocedure chest X-rays were also performed.

RESULTS

The malformations were located in the head and neck (n = 27) and trunk (n = 4). The number of procedures ranged from 1 to 4 (mean 1.7). Up to 1 U/kg of bleomycin was injected per session, with a maximum of 15 U. The mean follow-up period was 3.2 years (range 1.5-5 years). There was complete response in 38% (n = 12), partial response in 58% (n = 18), and no response in 3% (n = 1). No complications were identified.

CONCLUSIONS

Preliminary indicate that sclerotherapy of microcystic LMs using bleomycin is effective and safe.

Intralesional bleomycin injection treatment for vascular birthmarks: a 5-year experience at a single United Kingdom unit

BACKGROUND

The authors present their experience using an established chemotherapeutic agent as a scarless treatment for vascular birthmarks. One hundred sixty-four of more than 600 patients seen in the authors' center received intralesional bleomycin injection over 5 years.

METHODS

Patient demographics, clinical response, treatment, and complication details were recorded prospectively. Respiratory surveillance was provided by adult and pediatric pulmonologists. Eighty-one venous malformations, 39 hemangiomas, 26 lymphatic malformations, 10 mixed malformations, two arteriovenous malformations, two cystic hygromas, two capillary malformations, and two angiokeratomas underwent intralesional bleomycin injection.

RESULTS

The authors observed that 45.7 percent of patients completed treatment in a mean of 3.8 sessions and mean duration of 107 days. Complete resolution occurred in 56.0 percent, with a 93.3 percent overall response rate, and 82.7 percent of lesions demonstrated complete response or significant improvement. Three patients developed transient skin hyperpigmentation. One patient each developed skin ulceration, blistering, infection, swelling, headache, bruising, and rash. One patient required intubation following treatment of a panfacial and thoracic lymphatic malformation. A full recovery ensued. No patients developed pulmonary fibrosis. One venous malformation recurred.

CONCLUSIONS

The authors' single-site multidisciplinary team has successfully treated complex and recurrent vascular anomalies with acceptable complication and recurrence profiles. These findings represent the authors' experience and provide a reference for the management of these challenging lesions.

Percutaneous sclerotherapy of massive macrocystic lymphatic malformations of the face and neck using fibrin glue with OK-432 and bleomycin

Picibanil (OK-432) and bleomycin have been used as alternative sclerosing agents for lymphatic malformations. This study evaluated the clinical curative effect of sclerotherapy using fibrin glue combined with OK-432 and bleomycin for the treatment of macrocystic lymphatic malformations of the face and neck. Fifteen paediatric patients (6 males; 9 females, aged 13 months to 14 years) who had received percutaneous sclerotherapy for massive macrocystic lymphatic malformations of the face and neck were retrospectively reviewed. Affected regions included the neck, parotid region and parapharynx, mouth floor, face and cheek, and orbital regions. All patients showed preoperative symptoms of space-occupying lesions between 4 cm × 5 cm and 12 cm × 16 cm in size. Fibrin glue with OK-432 and bleomycin was injected under general anaesthesia. All patients received preoperative and follow-up CT scans. Outcomes were assessed by three surgeons. All patients exhibited mid-facial swelling for 3-4 weeks after surgery, but no major complications. Follow-up periods ranged from 8 to 16 months. Eight lesions were completely involuted, five were mostly involuted, and two were partially involuted. Percutaneous sclerotherapy using fibrin glue with OK-432 and bleomycin provided a simple, safe, and reliable alternative treatment for massive macrocystic lymphatic malformations of the face and neck.