Embolization therapy in the management of infantile hemangioma with Kasabach Merritt syndrome

The changing face of complicated infantile hemangioma treatment

Infantile hemangiomas are the most common vascular tumors of infancy. A multidisciplinary approach including dermatologists, otolaryngologists, plastic surgeons, hematologists/oncologists and interventional/diagnostic radiologists is crucial for appropriate management of children with complicated infantile hemangiomas. Since its unforeseen discovery in 2008, propranolol has become the first-line treatment for infantile hemangiomas, eclipsing systemic corticosteroids and radiologic intervention. There are still, however, uncommon indications for more aggressive interventional management. We review the 2014-updated International Society for the Study of Vascular Anomalies (ISSVA) classification for vascular anomalies. Additionally, we suggest management algorithms for complicated lesions, including recommendations for radiologic and surgical intervention.

Kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon: successful treatment with embolization and vincristine in two newborns

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor and has a high mortality in newborns when associated with Kasabach-Merritt syndrome (KMS). In two newborns with KHE and severe KMS refractory to medical treatment, emergency embolization led to clinical improvement in the acute neonatal setting by reducing tumor volume, increasing the platelet count, and improving other clotting parameters. Systemic vincristine treatment was added for further tumor control. Both patients remained symptom-free at long-term follow-up.

Kasabach-Merritt phenomenon: a single centre experience

OBJECTIVE

Kasabach-Merritt phenomenon (KMP) can lead to life-threatening bleeding, and its optimum treatment has not been established. We review the experience of managing KMP in a single institution.

METHODS

A retrospective chart review on all children with KMP treated at the Hospital for Sick Children, Toronto, over an 18 yr period was carried out.

RESULTS

All 15 patients had profound thrombocytopenia and hypofibrinogenemia at presentation, half had bleeding symptoms, and three had cardiac failure. All patients received corticosteroids. Five responded to steroids alone, given for an average of 13 wk, increasing platelets to >20 x 10(9)/L at a mean of 6.2 d and fibrinogen >1 g/dL at 25.6 d. Ten patients received at least one other therapeutic modality in addition to steroids, including vincristine, interferon, anti-platelet agents and pentoxifylline. Five patients received vincristine, for a mean of 6 wk, with two patients responding. Eight patients received interferon, for a mean of 4 months, with two patients responding. Overall, the mean time to increasing platelets >20 x 10(9)/L was 56 d, to >150 x 10(9)/L was 88 d and fibrinogen >1 g/dL 49 d. Ten patients showed a partial response to embolisation, with a mean of 2.8 procedures performed. Thrombotic complications occurred in 7%. Twelve patients remain alive, with relapse in six patients, all treated successfully. One patient died, and two patients have been lost to follow-up.

CONCLUSION

KMP is a rare condition, with significant morbidity and mortality. The therapeutic approach should include a multidisciplinary team and consensus on guidelines.

Non-traumatic splenic rupture in a patient with Kasabach-Merritt syndrome

This report presents a case illustrating the complications of Kasabach-Merritt syndrome in a 22-year-old man. The patient presented with acute abdominal pain and profound anaemia; a CT scan revealed intraperitoneal bleeding from spontaneous splenic rupture. The patient underwent initial emergency laparotomy and splenectomy, with a subsequent further laparotomy to control haemorrhage. Blood products requirements were extensive: 28 units red blood cells, 14 units fresh frozen plasma, 10 units platelets, 10 units cryoprecipitate and 2× Novo VII. He was then transferred to a nearby tertiary care unit for further management to control his coagulaopathy and he made a full recovery after 4 weeks.

Transcatheter arterial embolization in the treatment of extensive maxillofacial hemangioma in children

Infantile hemangioma frequently occurs in the maxillofacial region as an extensive mass involving many vital structures. As such, many children are found to have an unresectable hemangioma at the initial diagnosis. In the present study transcatheter arterial embolization (TAE) alone or in combination with surgery and local injection of bleomycin A has been attempted to improve the treatment of these lesions. The results of evaluating the effectiveness and therapeutic role of TAE in these extensive maxillofacial hemangiomas in children are presented. We retrospectively analyzed the records of 17 children with maxillofacial hemangioma treated between 1997 and 2004. Altogether, 17 patients (11 boys, 6 girls) were diagnosed as having an extensive maxillofacial hemangioma based on its clinical manifestation, color Doppler ultrasonography, and sometimes computed tomography. They underwent selective TAE alone or TAE followed by surgical excision. For the children with Kasabach-Merritt syndrome, systemic corticosteroid therapy was administered first. All the children had an excellent response after TAE treatment without obvious complications, and the size of the hemangioma body markedly decreased. Local injection of bleomycin A was then undertaken in four children and surgical removal in five. All the children achieved successful disappearance of the hemangioma, with no recurrence during the follow-up period of 5 to 86 months. TAE is thus a reliable and effective therapeutic choice for extensive maxillofacial hemangioma in children, alone or as a preoperative adjunctive measure. It improves the feasibility of complete resection and effects the disappearance of these potentially dangerous bulky tumors with little bleeding and few complications.

Case report: Kasabach-Merritt syndrome: a review of the therapeutic options and a case report of successful treatment with radiotherapy and interferon alpha

We describe the successful treatment of a neonate with Kasabach-Merritt syndrome who received local irradiation and interferon alpha therapy after failure of corticosteroid treatment. A male neonate, born after an uneventful pregnancy, had a huge haemangioma involving the upper right cervical region as well as severe thrombocytopenia. He was treated with corticosteroids, interferon alpha and radiotherapy. Prednisolone therapy (5 mg kg(-1) day(-1)) was started at 41 days of age. No therapeutic effect was observed after 2 weeks. At this time the tumour size had increased dramatically, platelet counts had decreased progressively and coagulation abnormalities had developed. Because corticosteroid therapy had been ineffective and the child was in a life-threatening condition, irradiation was delivered up to a total dose of 9.5 Gy in five fractions. Simultaneously, prednisolone therapy was slowly decreased and interferon alpha therapy (3 million U m(-2) day(-1)) was started and continued for 6 weeks. After irradiation with 9.5 Gy and beginning interferon alpha therapy, the tumour decreased in size and coagulation parameters normalized within 4 weeks. 6 months later, platelet counts and coagulation parameters were still normal. The tumour had further decreased in size. No acute severe side effects were observed. Radiation therapy combined with interferon alpha treatment is an alternative treatment modality when high dose corticoid steroid therapy has been ineffective in patients with Kasabach-Merritt syndrome, despite the risks of growth delay and secondary malignancy. In children showing no response to corticosteroids, radiotherapy and/or interferon alpha should be considered in Kasabach-Merritt syndrome.

Thrombocytopenic coagulopathy (Kasabach-Merritt phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma

Children with a large vascular tumor and associated Kasabach-Merritt coagulopathy respond inconsistently to therapy and have a high mortality rate. For this reason, we undertook a retrospective study of 21 such patients, and focused on clinical, radiographic, and histopathologic features. The male to female ratio was 1:1.6. Tumor was noted at birth in 50 percent of patients; the remainder appeared throughout infancy. The location was cervicofacial (n = 2), shoulder/upper limb (n = 4), trunk including retroperitoneum (n = 11), and lower limb (n = 4). These tumors grew rapidly to large size and were characterized by cutaneous purpura, edema, and an advancing ecchymotic margin. In contrast to common hemangioma, magnetic resonance imaging showed diffuse enhancement with ill-defined margins, cutaneous thickening, stranding of subcutaneous fat, hemosiderin deposits, and small feeding and draining vessels. All tumors were Kaposiform hemangioendothelioma (KHE); none were infantile hemangioma. Light microscopy showed irregular lobules or sheets of poorly formed, small vascular channels infiltrating and entrapping normal tissues. Characteristic features included spindle-shaped endothelial cells, diminished pericytes and mast cells, microthrombi, and hemosiderin deposits. Wide endothelial intercellular gaps and incomplete basement membranes were seen by electron microscopy. Dilated, hyperplastic, lymphaticoid channels were prominent in one tumor. KHE in 14 infants was treated with interferon alpha-2a: 6 had accelerated regression; 2 had stabilization of growth; and 6 evidenced no response. The mortality rate was 24 percent (5 of 21); this included three infants with retroperitoneal KHE. Kasabach-Merritt phenomenon does not occur with common hemangioma. Rather it is associated with the more aggressive KHE and rarely with other vascular neoplasms. Variable response to current pharmacologic therapy underscores our inadequate knowledge of the pathogenesis of thrombocytopenia in KHE.

Outcome of radiation therapy for patients with Kasabach-Merritt syndrome

PURPOSE

The efficacy of radiation therapy for Kasabach-Merritt syndrome, which is characterized by a huge hemangioma with consumption coagulopathy, remains controversial. In this study, we retrospectively investigated the treatment outcome of radiation therapy for seven neonates with Kasabach-Merritt syndrome.

METHODS AND MATERIALS

During the past 25 years we have seen seven children with Kasabach-Merritt syndrome who were treated with radiation therapy. Their ages ranged from 1 day to 5 months, with a median age of 1 month. The hemangioma was located in the extremities in four of seven children. Tumor sizes ranged from 70 cm to more than 150 cm in greatest diameter. Initial platelet counts were all less than 40,000/mm3 except for one patient. In principle, the total dose applied to the hemangioma was 8-10 Gy, with a daily dose of 1 Gy five times a week.

RESULTS

Four of seven hemangiomas responded dramatically, with a concomitant rise of the platelet count to radiation therapy. Although the remaining three hemangiomas, all of which were ill circumscribed by widespread overlying shiny, dusky purple skin, became less tense during radiation therapy. Disseminated intravascular coagulopathy was not improved, but they have responded favorably to two or three courses of radiation therapy with an extended radiation field by 1.5 years of age. As a result, all seven patients are now surviving with no evidence of hemangioma or hematological abnormalities. Shortening of the extremity was observed in three patients who received multiple courses of radiation therapy.

CONCLUSIONS

Radiation therapy appears to be one of the effective treatment options for Kasabach-Merritt syndrome despite the risk of growth delay and malignancy.

Successful treatment of infantile hemangiomas with interferon-alpha-2b

PURPOSE

Hemangiomas are benign tumors occurring in 10% of infants. A small percentage are complicated by blockage of vital structures, consumptive coagulopathy, or heart failure, resulting in a mortality of -20% of patients with complications. Here, we describe four infants with complicated hemangiomas responding to interferon-alpha-2b therapy.

PATIENTS AND METHODS

Four children with hemangiomas were treated with interferon-alpha-2b for complicating heart failure (1), visual impairment (2), or coagulopathy (1). Patients received interferon-alpha-2b alone or in conjunction with corticosteroid therapy over 2 to 9 months. Imaging studies and urinary basic fibroblast growth factor (bFGF) levels were used to monitor treatment response.

RESULTS

Three of four patients demonstrated involution of the hemangiomas with improvement in their coagulopathy or visual impairment. The fourth patient expired due to cardiac complications despite radiologic evidence of hemangioma involution. Side effects associated with interferon-alpha-2b treatment included elevated transaminases (2) and leukocytosis (2), which resolved upon completion of therapy. One patient developed mild gross motor delay (1), which improved after cessation of therapy. Decreased urinary bFGF levels correlated with hemangioma involution.

CONCLUSION

Interferon-alpha-2b therapy is an effective, well-tolerated treatment for complicated hemangiomas. Measurement of urinary bFGF levels may provide an objective method for monitoring treatment response.

Infants with Kasabach-Merritt syndrome do not have "true" hemangiomas

OBJECTIVE

In 1940 Kasabach and Merritt described an infant with a vascular anomaly, extensive purpura, and thrombocytopenia; they called his lesion "capillary hemangioma." Hemangioma is a benign tumor that grows in infancy and is characterized by proliferation of endothelial cells and regression during childhood. Although Kasabach-Merritt syndrome (KMS) is frequently mentioned as a possible complication of hemangioma, our experience suggests that the anatomic vascular lesion underlying the thrombocytopenia is not a "true," classic, involuting type of hemangioma of infancy and childhood.

STUDY DESIGN

We reviewed the clinical and hemostasis data and the response to treatment in 22 cases of KMS, and we analyzed the biopsy specimens of 15 of them.

RESULTS

Clinically none of the 22 patients had classic hemangioma. There was no female preponderance. All patients had severe thrombocytopenia (lowest platelet count = 3000/mm3) and consumption of fibrinogen. Histologically, none had the typical "capillary," involuting type of hemangioma of infancy: they exhibited either a tufted angioma or a kaposiform hemangioendothelioma pattern; all specimens also contained numerous abnormal lymphatic-like vessels; lymphatic malformation was the major component in two patients. The infants exhibited a heterogeneous response to a number of therapeutic regimens, as noted in other reports. Severe morbidity was present; three of our patients died, and one had leg amputation. "Residua" were, in fact, residual vascular neoplasia, variable in duration, and not a stable fibrofatty residuum, as in classic involuted hemangioma; only the hematologic phenomenon was "cured" after a period of years.

CONCLUSIONS

KMS is a distinctive disease of infancy, but the underlying vascular lesion is not a "true," classic, involuting type of hemangioma of infancy. This is a different vascular tumor with a resemblance pathologically to either tufted angioma or kaposiform hemangioendothelioma in association with lymphatic-like vessels. Whether the underlying lesion in KMS is a single anatomic entity or heterogeneous cannot be definitely concluded from this study. We need a better understanding of the pathogenesis of KMS to improve our therapeutic management.

Interferon-alpha-2a for the treatment of complex hemangiomas of infancy and childhood

OBJECTIVE

The authors describe the use of interferon-alpha-2a (IFN-alpha-2a) in the treatment of complex hemangiomas and review the role of interferon (IFN) in this example of an angiogenic disease.

SUMMARY BACKGROUND DATA

Hemangiomas are the most frequent tumors of infants and children. They grow rapidly for 6 to 8 months and then resolve over a period of years. Approximately 5% produce life-, sight-, or limb-threatening complications, with mortality rates between 20% and 50%. Aggressive therapy with steroids, arterial ligation or embolization, or surgery has been used in these situations with variable results and high morbidity. Recently, IFN-alpha was found to be effective treatment in these complex hemangiomas.

METHODS

Four infants and one child were treated with IFN-alpha-2a at an initial subcutaneous dose of 1 million units/m2/day and a sustained dose of 3 million units/m2/day for 5 to 11 months. Appropriate laboratory values were monitored and adverse reactions and ultimate response to therapy were recorded.

RESULTS

Two patients experienced minor complications that were managed easily. Three patients had total or near-total regression of the hemangioma, one had partial (50%) regression, and one had stabilization but no regression after an average of 7.1 months of IFN therapy.

CONCLUSION

Interferon-alpha inhibits angiogenesis and endothelial cell migration and proliferation in vitro. The patients in this study add to the growing number who have benefited from IFN therapy. As such, IFN-alpha should be considered as a first-line agent in treating complex hemangiomas of infants and children.

Granulomatous arteritis with massive eosinophilic leukocyte infiltration and transient peripheral eosinophilia subsequent to transarterial embolization therapy with a gelatin sponge

A 38-year-old man presented with a cavernous hemangioma in the liver. Transarterial embolization (TAE) using a gelatin sponge was carried out 14 days prior to surgical resection of the tumor. Granulomatous arteritis with massive infiltration by eosinophilic leukocytes and histiocytes was present at the periphery of the hemangioma, and transient eosinophilia in the peripheral blood occurred six days after resection. Granulomatous arteritis was evident in medium-sized arteries and there was narrowing or occlusion of the vascular lumen. In the granulomatous cellular infiltrates in the arteries, giant cells of the foreign body type were numerous. An eosinophilic substance differing from fibrin was present in some of the vascular lumina. As this showed staining for collagen, it was considered likely to be fragments of the gelatin sponge. The patient had no symptoms of fever, chills or general fatigue. The clinical course and pathologic findings suggest a causative role of the gelatin sponge in this case of granulomatous arteritis. Vascular change, a rare complication of TAE therapy, may be induced by a hypersensitivity reaction against the intra-arterial gelatin sponge.

Kasabach-Merritt syndrome

The Kasabach-Merritt syndrome includes the triad of vascular tumors, thrombocytopenia, and a hemorrhagic diathesis. The vascular tumors are usually benign but the associated coagulopathy may be life threatening. We describe a patient whose clinical course illustrates the potential difficulties in management.

Pulmonary thromboembolism from a large hemangioma in a 4-week-old infant

A female infant with an extensive congenital hemangioma of the left knee region was treated medically for consumption coagulopathy; the hemangioma began to shrink, the coagulopathy improved, and the infant was clinically well when she died suddenly at the age of 4 weeks. The cause of death was a saddle pulmonary thromboembolus which had originated in the hemangioma. This is the first documented case of fatal thromboembolism complicating a conservatively managed extensive neonatal hemangioma. Causes of neonatal thromboembolism are reviewed.