Update on hemangiomas and vascular malformations of the head and neck

Intraosseous hemangioma of the mandible: A rare case report

INTRODUCTION AND IMPORTANCE

Intraosseous hemangioma is a benign vascular tumour, it is mostly seen in long bones, vertebrae, and rarely on jaw bones, it usually occurs with its cavernous form. Medical literature is lacking a full description of capillary hemangioma of the jaws due to its rareness.

CASE PRESENTATION

A 68 year old male referred to the dentist for normal checking, without significant medical history nor presuming medications. The panoramic radiograph showed radiolucent lesion in the right mandibular body. Surgery was performed and the excisional biopsy was subjected to a private oral pathology lab for the definite diagnosis, which was capillary hemangioma.

CLINICAL DISCUSSION

Intraosseous hemangioma rarely occurs in the jaws. Normally it is asymptomatic and discovered accidently on radiographs. Radiological findings for intraosseous hemangiomas are not well documented. Treatment of intraosseous capillary hemangioma differs according to the dimension and size of the lesion.

CONCLUSION

This paper aims to guide the clinician to start including hemangioma in the differential diagnosis for translucent lesions located in the jawbones, when radiographs show the necessity of that, in order to avoid uncontrollable bleeding and even death during any surgical intervention.

Chronic excruciating forearm pain in a child with intra-neural hemangioma: A challenging case report

INTRODUCTION AND IMPORTANCE

Cavernous hemangioma is a rare form of hemangioma. It usually arises in the central nervous system, but the tumor has also been reported in the liver, retina and skin with a lower prevalence. Its occurrence into the peripheral nerves has only been reported a few times. Herein, we report an extremely rare case of intra-neural hemangioma in the ulnar nerve and discuss the complications we faced following surgery.

CASE PRESENTATION

We present a 6-year-old boy with history of severe progressive left forearm pain in the last two years. Imaging studies revealed a soft tissue mass and histopathological exam was in favor of a cavernous hemangioma. Patient underwent surgery to excise the tumor. Despite temporary response, he began to experience excruciating pain shortly after surgery which caused him to adopt bizarre postures.

CLINICAL DISCUSSION

In the more common form of nerve involvement in a hemangioma, the nerve is displaced and surrounded by the tumor. However, in cases with intra-neural involvement, the nerve would have to be sacrificed. This case report brings some rare but important characteristics of a hemangioma in to attention, such as the intra-neural location, possibility of recurrence and aggravating pain with bizarre positions as a result.

CONCLUSION

In cases of intra-neural hemangioma, there is a chance that the patient experiences recurrence and/or excruciating pain following surgery. The orthopedic surgeon should be prepared for the possibility of nerve transfer, repeat surgeries and the need for prolonged palliative pain suppression modalities in the approach to intra-neural hemangioma.

Giant Mesenteric Mixed Hemangioma Misdiagnosed as Ovarian Cyst: A Case Report and a Literature Review

Hemangiomas are congenital vascular disorders that occur primarily in the face and neck, extremely rare in the mesentery. Here, we report a rare small mesenteric mixed hemangioma. A 34-year-old woman was admitted to the gynecology department for an extended menstrual cycle. A cystic multi-atrial mass at the right anterior of uterus was observed by ultrasound examination, which was about 12.5 × 9.5 × 14.9 cm in size. The gynecologist mostly considered the possibility of the ovarian cyst. However, there was a huge multi-atrial cyst in the small intestine mesentery without the right ovarian cyst in the surgical exploration. The grape-like cystic mass about 15 cm in diameter adhered to the mesenteric root of the small intestine. The cyst was diagnosed as the mesenteric mixed hemangioma in the final histopathology.

Combination of Sclerotherapy and Dual-Wavelength Laser in the Management of Infantile Hemangiomas in Chinese Infants

OBJECTIVE

To evaluate the efficacy and safety of combination therapy with sclerotherapy and dual-wavelength pulsed dye laser (PDL) & Nd:YAG for infantile hemangiomas (IHs).

PATIENTS AND METHODS

Fifty-nine patients with IH received treatment with sclerotherapy and dual-wavelength PDL & Nd:YAG treatment at 4-week intervals. Observers assessed the size and color of IH using a size rating scale and color rating scale before and after treatments.

RESULTS

The study showed that IH improved significantly after several sessions of treatment. Sclerotherapy reduced the size of IH, whereas dual-wavelength laser lightened the color of IH. No serious adverse effects occurred.

CONCLUSION

Combined sclerotherapy and dual-wavelength laser treatment is an effective and safe option for IH.

Curative effect and safety of propranolol combined with prednisone in the treatment of infantile hemangiomas

The object of this study was to analyze the curative effect and safety of propranolol combined with prednisone in the treatment of infantile hemangiomas (IHs). Forty-four children with IHs on the head and face at the proliferative phase admitted to Jinan Center Hospital Affiliated to Shandong University were randomly divided into two groups. Children in group A took orally propranolol 2 mg/kg/day in three divided doses combined with prednisone 2 mg/kg/day in two divided doses in the first two weeks; children in group B took orally propranolol alone, and the dose was the same as that in group A. The treatment time of the two groups was up to 6 months, and the clinical curative effect and the incidence rate of adverse reactions were compared between the two groups. In the comparison of the curative effect between two groups of children with the tumor size decrease as the evaluation index, the total effective rate of group A was 100%, which was better than that of group B (81.82%), and the results were significantly different (P<0.05). In the same comparison with the surface of hemangiomas becoming flat and the color becoming light as evaluation indexes, the total effective rates of group A were 95.45 and 100%, which was not significantly different (P>0.05) compared with those of group B (86.36 and 77.27%) with a significant difference. The treatment in group A was superior to that in group B in terms of the curative effect on IH children younger than 6 months and was effective for different types of IHs. In group A, adverse reactions included loss of appetite (n=1) and bronchial and upper respiratory tract infections (n=1); in group B, adverse reactions included crying at night (n=1), lowered heart rate (n=1) and loss of appetite (n=2). The incidence rate of adverse reactions was compared between the two groups, and the difference was not significant (P>0.05), indicating that the combination therapy did not aggravate adverse reactions, and adverse reactions in the two groups were less and not severe. In the treatment of IHs, propranolol combined with prednisone can significantly reduce the tumor volume at the proliferative phase and significantly improve the tumor color with a low incidence rate of adverse reactions in a mild degree. Children have high tolerance to this treatment method, and the treatment method is highly safe and of great significance in clinical practice.

Curcumin induces apoptosis and inhibits proliferation in infantile hemangioma endothelial cells via downregulation of MCL-1 and HIF-1α

BACKGROUND

Curcumin has been used as an alternative medicine for the treatment of infantile hemangiomas (IHs); however, the mechanism underlying the effectiveness of curcumin in IHs remains largely unclear.

METHODS

In this study, we isolated primary human hemangioma endothelial cells (HemECs) from fresh surgical specimens of 3 patients. We treated HemECs by curcumin and investigated the alterations in proliferative and apoptotic signaling pathways with cell counting kit-8, flow cytometry, western blotting, immunofluorescence, and real-time polymerase chain reaction.

RESULTS AND CONCLUSION

We found that curcumin potently inhibited proliferation in HemECs, achieving low-micromolar IC50 (the half maximal inhibitory concentration) value. We also observed that treatment with curcumin induced apoptosis in HemECs, as evidenced by positively Annexin-V-FITC staining, caspase-3 activation, and cleavage of poly(adenosine diphosphate-ribose) polymerase (PARP) in the treated cells. Moreover, we showed that curcumin suppressed the expression of antiapoptotic protein myeloid cell leukemia-1 (MCL-1), hypoxia-inducible factor 1α (HIF-1α), and vascular endothelial growth factor (VEGF).Altogether, our study suggests that the effectiveness of curcumin in IHs may be associated with its potent antiproliferative and apoptotic activities in HemECs.

Combined oral propranolol with intralesional injection of triamcinolone acetonide in treatment of infantile periocular hemangiomas

Aim

To evaluate the clinical effectiveness of combined oral propranolol with intralesional injection of triamcinolone acetonide in the treatment of infantile periorbital capillary hemangioma.

Patients and Methods

This prospective interventional study included children diagnosed with periocular infantile hemangiomas in the proliferative phase with vision-threatening lesions. The children presented to the oculoplastic unit in Sohag University Hospital in the period between January 2016 and February 2017 and were treated with a combined intralesional injection of triamcinolone acetonide with oral propranolol, with a follow-up period of 6 months. Treatment response was evaluated according to the size of the tumor (horizontal diameter); additionally, complications of both treatment methods were recorded.

Results

This study included 33 infants: 21 females (64%) and 12 males (36%). The mean age at the time of injection was 4.9±2.6 months. The study included three modes of treatment response: regression of the tumor, 28 patients (85%); stabilization, three patients (9%); and failure, two patients (6%), which necessitated repeated intralesional injection of triamcinolone but with minimal response. Regarding complications, only one patient reported with subconjunctival hemorrhage during intralesional injection of steroids; there were no recorded cases of hypotension, bradycardia, or hypoglycemia during the course of oral propranolol treatment. After the end of the follow-up period, there were no reported cases of recurrent increase in the size of the regressed group of infantile hemangiomas with stable tumor size.

Conclusion

Combined oral propranolol with intralesional injection of triamcinolone acetonide is the effective method of treatment for infantile periorbital capillary hemangioma with minimal adverse effects.

A Diagnostic Program of Vascular Tumor and Vascular Malformations in Children According to Modern Classification

The aim of the study was to analyze the cohort of inpatient children with vascular anomalies according to the globally accepted classification introduced by the ISSVA.

METHODS

The study included 205 inpatient children within the time period of the years 2010-2015. Types of vascular anomalies (VAs), age of patients, diagnostic procedures, and anatomical localization of VAs were analyzed.

RESULTS

65 patients of first year of life had vascular tumors, with prevalence of infantile hemangiomas (IHs) in 57 (87.7%) patients. 45 children had IHs localized within soft tissues, whereas 7 patients suffered from IHs of the liver, and 5 children from IHs of the respiratory tract. Most patients with soft tissue IHs were diagnosed only with ultrasound; СT or MRI diagnostics were performed on 5 (8.8%) patients, and biopsy was carried out in 2 (4.4%) children. Vascular malformations (VM) were diagnosed in 140 (68.3%) patients. Ultrasound investigation (US) was the screening method. MRI was performed to confirm the diagnosis of low-flow VM, whereas for high-flow VM CT angiography and selective angiography were useful. Venous malformations were diagnosed in 17 (12.1%) patients, and 112 (80.0%) had cystic LM, among them children under the age of 2 years prevailed. Arteriovenous malformations were diagnosed in 5 (3.8%) patients, ages 2-14 years.

CONCLUSIONS

Clinical manifestations of vascular anomalies have clear age features. Among hospitalized children vascular tumors add up to 31.7% and VM - up to 68.3%.

The pigment epithelium-derived factor (PEDF): an important potential therapeutic agent for infantile hemangioma

In previous studies, the expression and the role of proangiogenic factors in infantile hemangiomas have been well studied. However, the role of angiogenic inhibitors has been revealed rarely. The expression of PEDF, as the strongest and safe endogenous inhibitor, is still unrecognized until the current study. In order to investigate the expression and significance of the pigment epithelium-derived factor (PEDF) in the proliferating and regressing phases of infantile hemangiomas, the expression of PEDF, VEGF, Ki-67, and CD34 protein in hemangioma tissues was examined with immunohistochemical polymer HRP method in 42 cases during the proliferative phase, 40 cases during the regressing phase, and 11 cases of non-involuting congenital hemangiomas (NICHs). Meanwhile, the mRNA expression of these factors was detected with quantitative realtime RT-PCR. We found the protein and mRNA expression of PEDF in regressing phase was significantly higher than those in proliferative phase and NICHs (P < 0.001), while the protein and mRNA expression of VEGF were much lower (P < 0.001). The microvessel density (MVD), Ki-67 changes, and the expression of PEDF and VEGF were found significantly correlated. These results indicated that the reduction of VEGF and increase in PEDF are causative to the evolution of infantile hemangioma. PEDF may play a key role in the spontaneous regression of infantile hemangioma and may become an important potential therapeutic agent for infantile hemangioma.

Oral encapsulated vascular malformation: An undescribed presentation in the mouth

Vascular lesions have been classified in two broad categories, hemangiomas and malformations. Encapsulated vascular lesions have not been reported in the oral cavity, but they were described in other sites, mainly in the orbit. Herein, we present a case of an oral encapsulated vascular lesion located in the right buccal mucosa of a 69-year-old male, including histological and immunohistochemical description and a literature review.

Key words:Buccal mucosa, hemangioma, vascular malformation, oral cavity.

Unusual intraosseous capillary hemangioma of the mandible

Intraosseous hemangioma is a benign vascular neoplasm, which is mostly seen in vertebrae, maxillofacial bones, and long bones. Intraosseous hemangioma is rarely seen on jaw bones compared to other skeletal bones and usually occurs in the cavernous form. Capillary intraosseous hemangioma of jaws is an uncommon form of intraosseous hemangioma and has not been thoroughly described so far. In this study, a case of capillary intraosseous hemangioma of the mandible was presented with relevant literature review.

Treatment with propranolol for infantile hemangiomas: A case series of 106 infants

The aim of the present study was to investigate the clinical benefit and side effects of propranolol treatment in 106 children with infantile hemangiomas (IHs). A retrospective chart review was conducted on all children who attended the clinic between September 16, 2009 and November 11, 2013. Propranolol was administered in a progressive schedule reaching 1.0-1.5 mg/kg/day, divided into three doses. Demographic data, clinical features, imaging, treatment regimens and outcomes were investigated. Any adverse effects following medication were evaluated and managed accordingly. Preliminary analysis of the data showed the inclusion of 106 children (71 female and 35 male) with a mean age and weight at onset of treatment of 5.1 months and 7.3 kg, respectively. All 106 patients responded positively to treatment. Side effects that required intervention and/or close monitoring included diarrhea (n=10), hypotension (n=7), nightmares (n=2), agitation (n=1) and cold extremities (n=1). No long-term adverse effects were observed in any of the patients. In conclusion, propranolol administered orally at 1.0-1.5 mg/kg/day had a rapid therapeutic effect for resolving IHs with few complications.

Common pediatric head and neck congenital/developmental anomalies

Pediatric head and neck neuroradiology is a broad and complex topic. This article focuses on several of the common and sometimes challenging pediatric head and neck congenital/developmental anomalies physicians may encounter in clinical practice. Although some diagnoses may be evident on physical examination, others may present a diagnostic dilemma. Patients may initially present with a variety of secondary findings. Imaging serves an important role in making a diagnosis, guiding referral, and in some cases even providing treatment options through interventional radiology. Key diagnostic criteria and critical points of interest for each diagnosis are presented.

Extracranial vascular malformations (hemangiomas and vascular malformations) in children and adolescents - diagnosis, clinic, and therapy

The field of extracranial vascular anomalies is considered as special focus of pediatric otolaryngology and it has shown a rapid development during the last years. The reason for this interest is finally also due to the global acceptance of the classification introduced by the ISSVA (International Society for the Study of Vascular Anomalies). Hemangiomas are the most frequently observed vascular tumors. Today the systemic propranolol therapy is mostly used for therapy of hemangiomas requiring treatment. Increasingly, the topical application of beta blocker is discussed while the benefit in the head and neck seems to be limited. Vascular malformations are classified according to the morphology of the affected part of the vascular system in arterial, venous, arterio-venous, lymphatic, capillary, and combined vascular malformations. Conventional surgery, sclerosing therapy, and laser treatment are invasive options for the treatment of lymphatic malformations. The options for the treatment of venous malformations could be significantly improved during the last years. In this context, the use of Nd:YAG laser, the conservative treatment of the localized disseminated intravascular coagulation with low-molecular weight heparin, the re-discovery of bleomycin as effective sclerosing agent, and the improvement of alcohol-based embolization agents must be mentioned. Today the treatment with dye laser is the preferred therapy for capillary malformations and it is superior to other therapeutic options as for example photodynamic therapy. Arterio-venous malformations as representatives for high-flow lesions are the high-risk lesions. Frequently they are compared to malignant head and neck tumors, in particular when a curative treatment can no longer be assured because of diffuse or multifocal extent and when the disease shows a progressive course. The combined treatment of embolization and surgical resection and if necessary consecutive defect reconstruction have turned out to be appropriate for arterio-venous malformations. Incurable findings are still a major challenge. Despite the introduction of antiangiogenetic drugs in oncology, the medicamentous therapeutic approach could not be established for arterio-venous malformations up to now.

Update on the classification of hemangioma

Despite the fact that a biological classification of congenital vascular tumors and malformations was first published in 1982 by Mulliken and Glowacki, significant confusion still prevails due to the indiscriminate and interchangeable use of the terms hemangioma and vascular malformation. Hemangiomas are true neoplasms of endothelial cells and should be differentiated from vascular malformations which are localized defects of vascular morphogenesis. On an analysis of various scientific articles and latest edition of medical text books an inappropriate use of various terms for vascular lesions was found, contributing further towards the confusion. The widely accepted International Society for the Study of Vascular Anomalies (ISSVA) classification differentiates lesions with proliferative endothelium from lesions with structural anomalies and has been very helpful in standardizing the terminologies. In addition to overcoming obstacles in communication when describing a vascular lesion, it is important that we adhere to the correct terminology, as the therapeutic guidelines, management and follow-up of these lesions differ.

Cavernous hemangioma of tongue: management of two cases

Hemangiomas are benign tumours of infancy and childhood, most commonly located in the head and neck region and occur more frequently in the lips, tongue and palate. The treatment depends upon lesion location, size and evolution stage and the patient's age. This paper describes the management of cavernous hemangioma in a 2 -year -old child and 14 -year -old child using different approaches.

[Lymphatic malformations in the head and neck region. Clinical aspects and therapeutic options]

Lymphatic malformations are congenital abnormalities of the lymphatic system which occur predominantly in the head and neck region. According to their dominant clinical and morphological characteristics, these are classified into micro- and macrocystic forms. Established therapies for lymphatic malformations include conventional surgery, sclerotherapy and laser treatment. Despite the significant improvements in therapeutic options seen in recent years, treatment of extensive lymphatic malformations remains an interdisciplinary challenge. Close-knit interdisciplinary cooperation is necessary to provide optimized care for affected individuals.

Hemangioma of the buccal fat pad

Hemangiomas are benign vascular neoplasms characterized by an abnormal proliferation of blood vessels. Buccal fat pad (BFP) is a rare place for hemangioma. In this report, clinical, radiographic, and histopathological findings are described in a rare case of hemangioma with phleboliths involving the BFP, and a review is made of the international literature on this subject.

Localization and treatment of lingual venous and arteriovenous malformations

Venous and arteriovenous malformations of the tongue can cause haemorrhage, airway obstruction, difficulties in chewing and swallowing, speech problems as well as orthodontic abnormalities. The purpose of the present study was to evaluate their exact topography, clinical features, morphologic aspects and management. A retrospective review on all patients with venous and arteriovenous malformations of the tongue who presented between 1998 and 2010 was performed. Medical records were analysed with respect to age and sex distribution, exact localization, symptoms and clinical presentation, management and treatment outcome. Forty-four patients with tongue malformations were analysed. The malformations affected all areas of the tongue as well as the base of the tongue without predilection areas. Nd:YAG laser and CO2 laser therapy provided good results primarily in localized malformations, while in advanced malformations the management was multi-modal since a complete surgical excision was often impossible. The hypothesis that vascular malformations of the tongue occur more frequently along the course of the feeding vessels cannot be confirmed. The therapeutic approach is determined by the exact topography, haemodynamic properties, morphologic aspects and related clinical symptoms as well as patient-specific features.

Multiple venous malformations with phleboliths: radiological-pathological correlation

Vascular malformations are congenital lesions that are present at birth and do not regress. However, they often present later in life. They are subdivided into two categories: (1) slow- or low-flow and (2) fast- or high-flow malformations. Low-flow malformations contain combinations of capillary, venous, and lymphatic components. Venous malformations can occur anywhere in the body, but are most frequently seen in the head and neck (40%). These lesions present in a variety of ways, from a vague blue patch to a soft blue mass, which may be single isolated or may occur in multiple areas. Treatment depends on the type of lesion, the location, degree of involvement, and the clinical symptoms. Here we are report the imaging and histopathologic findings in a patient with multiple venous malformations affecting the left side of the face and trunk.

Endoscopic nonembolized resection of an extensive sinonasal cavernous hemangioma: A case report and literature review

Sinonasal hemangiomas, although rare, must be considered in the evaluation of intranasal masses with profuse epistaxis. Although the availability of literature discussing cavernous hemangiomas in this location is limited, there have been no case reports of exclusively soft tissue sinonasal cavernous hemangiomas extending to the anterior skull base (ASB) that were resected purely endoscopically. Here, we describe the successful endoscopic resection of an extensive right sinonasal cavernous hemangioma extending to but not invading the ASB. Although highly vascular, in select cases, these tumors can be successfully resected endoscopically without embolization by experienced endoscopic sinus and skull base surgeons.

[Venous and arteriovenous malformations in the head and neck region. Therapeutic options and challenges]

Venous malformations are the prototype low-flow malformations in the head and neck region. Arteriovenous malformations (AVM) represent the main high-flow malformations. In recent years it has been possible to significantly optimize the therapeutic options for venous malformations. In addition to conventional surgery, laser treatment and sclerotherapy have become established techniques and the importance of embolization with new alcohol-based materials is increasing. AVM are progressive and destructive diseases. Therapy of choice is usually a combined treatment comprising embolization and surgical removal of the arteriovenous nidus. This curative approach is usually possible if diagnosis is made at an early stage. Incomplete embolization or sole ligation of the arterial supply causes progression. There is a clear need for improved therapeutic methods and pharmacotherapeutic approaches.

Oral capillary hemangioma: a clinical protocol of diagnosis and treatment in adults

PURPOSE

Hemangiomas are benign vascular anomalies characterized by benign proliferation of blood vessels. There are no well-defined criteria for the diagnosis and treatment of oral capillary hemangioma (OCH). The objective of this study is to report a safe, effective, and low-cost protocol for diagnosis and treatment of OCH.

MATERIALS AND METHODS

Eight patients were diagnosed with OCH, through two physical examination maneuvers-the diascopy and head lowering maneuver with abdominal compression (HLMAC). The treatment performed was sclerotherapy with ethanolamine oleate, weekly, until the disappearance of the lesion. No local anesthetics were administered prior to the sclerosing agent injection.

RESULTS

All cases showed a complete remission of the lesions after sclerotherapy. There were no visible scars or compromise esthetics or normal function, and there was no evidence of recurrence. Only one patient had superficial ulceration, which remained asymptomatic and healed without specific treatment.

CONCLUSIONS

This protocol was effective in the diagnosis of OCH through two physical examination maneuvers with low-cost and easy implementation, the diascopy and the HLMAC. The low concentration associated with a reduced amount of the sclerosing agent was responsible for the excellent results in the cases treated.

Lymphatic malformations of the orbit

Objectives

Lymphatic malformations of the orbit are rare lesions that constitute approximately 1% to 8% of all orbital masses. They are difficult to treat since they do not remain within anatomic boundaries and tend to penetrate into normal orbital structures. The aim was to analyze clinical courses and therapy options in patients with lymphatic malformations of the orbit.

Methods

Thirteen patients with orbital lymphatic malformations confirmed by magnetic resonance imaging between 1998 and 2009 were enrolled in this study. Patients' charts were retrospectively reviewed to analyze clinical courses and treatment options.

Results

Four patients suffered from isolated intraorbital lymphatic malformations without conjunctival involvement, in three of them the masses were completely resected, in one patient close controls were performed. Three patients had isolated intraorbital lymphatic malformations with conjunctival involvement. Surgical volume reduction of the exterior parts of the lymphatic malformation were performed without any complications and satisfying outcome in these cases. Six patients suffered from intra- and periorbital lymphatic malformations. In 3 patients a watch-and-wait strategy was initiated. In the other 3 patients a surgical therapy was performed, one patient additionally received sclerotherapy with OK-432; however, these 3 patients suffered from residual lymphatic malformations.

Conclusion

The presented cases underline the inconsistencies in the malformations behavior and underscore the inability to make specific recommendations regarding treatment. The treatment decision should be based on the size and location of the lymphatic malformation. The untreated patient must be watched for signs of visual detoriation, which may signal the need for therapeutic intervention.

Sinonasal cavernous haemangioma: a case report

Cavernous haemangiomas arising in the paranasal sinuses are very rare. Even though the lesion is benign in nature, its imaging features are non-specific, leading to an incorrect pre-operative diagnosis in most patients. We present a case of a maxillary sinus cavernous haemangioma in a young male. The clinical presentation and imaging characteristics of this entity are reviewed.

Topical propranolol for treatment of superficial infantile hemangiomas

BACKGROUND

"Wait-and-see" is a common principle for most superficial infantile hemangiomas (IHs) because of their expected involution. Topical propranolol has recently been reported to be an effective treatment for superficial IHs.

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of 1% propranolol ointment in the treatment of superficial IHs.

METHODS

A retrospective chart review was performed on 25 children (21 female and 4 male) with a median age of 4 months (range, 1-10 months). A total of 28 lesions were treated with 1% propranolol ointment. Topical propranolol was applied thrice daily for a mean duration of 21 weeks (range, 5-59 weeks). Changes in the size, texture, and color of the tumor were monitored and recorded at regular intervals. The treatment response was evaluated using a 3-point scale system: good, partial, and no response. Adverse effects after medication were evaluated and managed accordingly.

RESULTS

Of the 28 hemangiomas, 16 (57%) demonstrated good response, 9 (33%) showed a partial response, and 3 (10%) had no response. Among all the IHs, 90% showed either good or partial responses to topical 1% propranolol ointment treatment. No systemic complication was observed in any of the patients.

LIMITATIONS

This report is a retrospective uncontrolled study.

CONCLUSIONS

Topical therapy with 1% propranolol ointment may be a safe and effective method for the treatment of superficial IHs and can be used as an adjuvant treatment measure during the wait-and-see period.

Anti-proliferative effect of glucocorticoids on mesenchymal cells in juvenile angiofibromas

BACKGROUND

Glucocorticoids (GCs) not only regulate metabolic and inflammatory mechanisms, but also are known to suppress tumor growth. Despite previous detection of glucocorticoid receptors (GRs) in juvenile angiofibromas, their distribution and function have not further been studied.

METHODS

Juvenile angiofibroma tissue (n = 30), nasal mucosa specimens (n = 10), subepithelial stroma of nasal mucosa (n = 20), and primary fibroblasts from juvenile angiofibroma (n = 6) and nasal mucosa samples (n = 6) were analyzed by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and immunofluorescence staining. The antiproliferative effect of GCs (dexamethasone, prednisolone, and hydrocortisone) in vitro was assessed using a bromdeoxyuridine (BrdU) assay.

RESULTS

An upregulation of GR transcripts and protein was shown in juvenile angiofibroma tissue and primary mesenchymal cells compared to nasal mucosa. Application of GCs resulted in a significantly higher antiproliferative effect on juvenile angiofibroma versus nasal mucosa fibroblasts in vitro.

CONCLUSION

Expression of GRs and antiproliferative effects of GCs on juvenile angiofibroma fibroblasts offer novel options for the treatment of this unique fibrovascular tumor.

EXIT (Ex utero Intrapartum Treatment) in lymphatic malformations of the head and neck: discussion of three cases and proposal of an EXIT-TTP (Team Time Procedure) list

OBJECTIVES

Ex utero Intrapartum Treatment (EXIT) is a technique to secure the fetal airway while oxygenation is maintained through utero-placental circulation. The aim of the study is to present three cases of fetal lymphatic malformation of the head and neck that required EXIT and to summarize EXIT details.

METHODS

The cases were studied before the delivery and EXIT was planned with a multidisciplinary team. The key factors of EXIT are considered and the type, stage and clinical score of the three lymphatic malformations are defined.

RESULTS

In the three cases of EXIT the time working on placental support to secure the airway was 9, 7, and 9 min, respectively (from the hysterotomy to clamping the umbilical cord). Procedures performed on the airway were laryngo-tracheo-bronchoscopy in the first case, laryngoscopy and intubation in the second one, laryngoscopy, drainage of the lymphatic macro-cyst, and intubation in the third case. A sketching to detail the EXIT steps are presented: EXIT-Team Time Procedure list (EXIT-TTP list). Lymphatic malformations were classified as mixed (micro/macro-cystic) in two cases, and macro-cystic in one. de Serres Stage was IV, V and II. Therapy varied in the three neonates (surgery alone, surgery+Picibanil+Nd-YAG, or Picibanil alone).

CONCLUSIONS

In case of prenatal suspicion of airway obstruction, EXIT should be planned with a multidisciplinary team. The EXIT-Team Time Procedure list (EXIT-TTP list), reviews the most critical phases of the procedure when different teams are working together. The type of lymphatic malformation, the anatomic location and the clinical score predict the outcome.

Refractive and structural changes in infantile periocular capillary haemangioma treated with propranolol

PURPOSE

To evaluate the optical and anatomical effects of oral propranolol treatment for infantile periocular capillary haemangioma.

METHODS

All children diagnosed with infantile capillary haemangioma in 2008-2010 at a tertiary paediatric medical centre underwent comprehensive evaluation, including imaging, by a multidisciplinary team followed by oral propranolol treatment. Clinical follow-up was performed regularly until the lesions disappeared. Main outcome measures included changes in anatomical extraocular extension, refractive sphere and cylindrical power, and spherical equivalent in the involved eye before and after treatment and between the two eyes.

RESULTS

A total of 30 patients (8 male; mean age at diagnosis, 1.6±2.8 months) participated. The lesions affected the left eye in 53.3% and were located preseptally in 83.3%. Four patients (13.3%) received steroids before propranolol. A treatment dosage of 2 mg/kg per day was started at mean age 5.0±4.5 months, 3.3±4.3 months from disease onset. Side effects occurred in 11 patients and warranted a dose reduction (to 1 mg/kg per day) in 3 and treatment termination in 1. Findings were significant for mean reduction in involved extraocular area (P<0.0001), post-treatment reduction in mean cylindrical power in involved eyes (P=0.02), pre- and post-treatment differences in mean cylindrical power between involved and uninvolved eyes (P=0.02 and P=0.01, respectively), and post-treatment change in absolute values of mean spherical power between involved and uninvolved eyes (P=0.025).

CONCLUSIONS

Early diagnosis of infantile periocular capillary haemangioma and prompt treatment with propranolol lead to a significant reduction in the involved ocular area, in astigmatism, and prevent ocular/facial disfiguration/deformation, without rebound. Propranolol is recommended as the preferred treatment compared with other accepted therapies.

Sclerotherapy for lymphatic malformations in children: a scoping review

PURPOSE

This scoping review assesses the literature and summarizes the current evidence on sclerotherapy for the treatment of lymphatic malformations in pediatric patients.

METHODS

A comprehensive search of published and unpublished literature was conducted using multiple databases. Title, abstract, and full-text screening was conducted by 2 independent clinicians. All discrepancies were resolved during consensus meetings.

RESULTS

A total of 182 articles were retrieved. Forty-four articles were removed as duplicates, and 11 articles were added after reviewing prominent studies. After full-text abstraction, 44 articles and 2 conference proceedings (N = 882 patients) were included in the final results. Twelve articles were classified as level II and 34 articles as level IV evidence. Picibanil (OK-432) was the primary agent used in most included studies. Postinjection symptoms with OK-432 were primarily fever, swelling, and erythema at the site. Life-threatening complications were uncommon and involved postinjection swelling of cervical lesions causing airway compromise.

CONCLUSIONS

The literature regarding sclerotherapy for lymphatic malformations is of a low level of evidence and suffers from a lack of standardization. Randomized clinical trials focused on OK-432, bleomycin, or alcoholic solution of zein; standardized dosing protocols; and consistent and reliable outcome reporting will be necessary for further development of treatment guidelines.

Hemangiomas of the nasal tip: an approach to a therapeutic challenge

OBJECTIVE

Hemangiomas of the nasal tip (HNT) are commonly described as "Cyrano" or "Pinocchio nose". They may cause significant aesthetic and functional impairment. It is still controversial how and when HNT should be treated. The risk of severe complications like irreversible contour deformities, growth disturbance, ulcerations, and nasal obstruction may obligate a therapeutic intervention. The aim of this study is to overview and to analyze different therapeutic approaches which were practiced over the last decade in two specialized centers.

METHODS

This is a retrospective study which includes the analysis of demographic parameters, extent of the lesion, therapeutic interventions, outcome, and follow-up interventions. The analysis includes a blinded evaluation of photographic series for evaluation of the extension at the time of presentation and of the final outcome.

RESULTS

Twenty-three children with HNT were analyzed who presented from 04/01/1998 to 03/31/2009. The age at presentation ranged from 1 to 63 months. On 6 patients (26%) conventional surgery was performed, 6 (26%) were treated with Nd:YAG laser, 6 (26%) were only observed, in 3 cases (13%) cryotherapy and in 2 patients (9%) treatment with Propranolol was performed. The results were evaluated between 9 months and 10.5 years after treatment (mean: 35.5 months). Limited lesions which were only observed showed a good tendency of regression. Significant wound healing disturbance and scar formation was observed after Nd:YAG laser therapy. Secondary rhinoplasty in adulthood was recommended to two patients.

CONCLUSION

Limited lesions do not require therapy. The results with Propranolol are encouraging. Laser- and cryo-therapy have to be critically reevaluated. Treatment of choice for lesions that are not suitable for beta blockers and residual disease is conventional surgery.

Markers of vascular differentiation, proliferation and tissue remodeling in juvenile nasopharyngeal angiofibromas

Juvenile nasopharingeal angiofibroma (JNA) is a histologically benign locally aggressive tumor characterized by irregular vessels embedded in a fibrous stroma. Excessive vascularity results in bleeding complications, and the inhibition of angiogenesis is a promising strategy for managing extensive JNA tumors. To better characterize the endothelial components of JNA, we aimed to evaluate markers of vascular differentiation and proliferation, such as friend leukemia integration-1 (FLI-1) and endoglin, lymphatic markers, including podoplanin and vascular endothelial growth factor receptor 3 (VEGFR3) and its cognate ligand VEGFC, GLUT-1, a diagnostic marker that discriminates between hemangiomas and vascular malformations, and two markers of tissue remodeling, stromelysin 3 (ST3) and secreted acid protein rich in cysteine (SPARC). Antigens were assessed immunohistochemically in vessels and stromal cells of JNA archival cases (n=22). JNA endothelial cells were positive for endoglin, VEGFC and FLI-1, whereas podoplanin and VEGFR3 were negative in all cases. Both endothelial cells and fibroblasts stained for ST3 and SPARC. GLUT-1 was investigated in JNA cases, in infantile hemangiomas (n=123) and in vascular malformations (n=135) as controls. JNAs and vascular malformations were GLUT-1-negative, while hemangiomas showed positive staining. The presence of markers of endothelial differentiation and proliferation highlighted the hyper-proliferative state of JNA vessels. The absence of podoplanin and VEGFR3 underscores their blood endothelial cell characteristic. The absence of GLUT-1 discriminates JNAs from hemangiomas. ST3 and SPARC up-regulation in endothelial cells and fibroblasts may contribute to a compensatory signaling for controlling angiogenesis. Some of these markers may eventually serve as therapeutic targets. Our results may aid in the understanding of JNA pathophysiology.

Orbital and periorbital vascular anomalies--an approach to diagnosis and therapeutic concepts

CONCLUSION

A correct and universally accepted terminology based on the biologic behavior of orbital vascular anomalies is essential to avoid misleading diagnoses, to choose an adequate therapy regimen, and to compare different therapeutic approaches. The management of these diseases is multi-modal and an interdisciplinary challenge.

BACKGROUND

There is persisting terminological and clinical confusion about vascular anomalies involving the orbit. Review of the literature reveals a diverse or misleading terminology and a lack of consensus for the treatment of vascular malformations or vascular tumors of the orbit.

METHODS

This study comprised a detailed analysis of cases presenting with orbital vascular anomalies followed by an extensive review of the literature.

RESULTS

Thirty-six patients were analyzed, among them 19 patients with peri- and/or intraorbital hemangiomas, 3 with intraorbital and 2 with periorbital venous malformations, 2 with orbital involvement of complex vascular malformations, and 10 with lymphatic malformations involving the orbit.

[Propranolol therapy to treat problematic hemangiomas : a new standard therapy makes its debut]

Small hemangiomas sometimes produce large findings. Depending on localization, local therapy is not always possible. According to a case described in the literature, a hemangioma in an infant regressed following cardiologically indicated Propranolol. This experience has been used in numerous other cases since then and Propranolol has been administered for the indication of a hemangioma. Even in cases of very large hemangiomas rapid improvement has been observed; successful results persisted even after discontinuation. Particularly in cases of problematic localisation, such as in the eye area, prompt therapeutic success is important in order to prevent blindness. Relevant studies are in the preparatory phase.

Propranolol therapy for infantile haemangiomas: review of the literature

OBJECTIVES

Haemangiomas are the most common tumors of infancy affecting approximately 1 in 10 children. Unlike other tumors, haemangiomas enter an involution phase, during which they usually regress over the next several months to years. Sometimes intervention is required due to proliferative growth which is complicated by ulceration, bleeding, persistent aesthetic deformity or infection.

METHODS

Review of the literature.

RESULTS

Propranolol, a nonselective beta-blocker, has recently been introduced as a novel modality for the treatment of proliferating haemangiomas. The exact mechanism of action of propranolol in the treatment of haemangiomas remains unclear, but vasoconstriction, down-regulation of angiogenic factors such as VEGF and bFGF and up-regulation of apoptosis of capillary endothelial cells may be responsible for the reduction of haemangiomas. Besides, an inhibition of MMP-9 and HBMEC expression by propanolol is discussed as possible mechanism influencing the growth of haemangiomas. However, there are different case reports of successfully treated infants in the current literature.

CONCLUSION

There is the obtain that propranolol will detach steroids in the therapy for infantile haemangiomas.

Laser treatment of mucosal venous malformations of the upper aerodigestive tract in 50 patients

We examined the clinical appearance of mucosal venous malformations of the upper aerodigestive tract with regard to their accessibility to laser therapy and further assessed the value of treatment of these lesions with the Nd:YAG and CO(2) lasers. A retrospective study was performed in 50 patients who had undergone laser treatment for mucosal low-flow vascular malformations of the upper aerodigestive tract. Records were reviewed for demographic data, extent of the lesion, treatment modality, required number of therapy sessions and the therapeutic outcome. Follow-up was performed by postinterventional clinical examination and additional interview by phone for current status. Between 1 July 2001 and 30 September 2008 32 women and 18 men received laser treatment and were followed up until 30 June 2009. The lesions were classified into three grades according to their extent and clinical presentation, as follows: grade 1 <2 cm, asymptomatic or mild symptoms; grade 2 2-4 cm, asymptomatic or mild symptoms; and grade 3 > or =4 cm or multiple locations (more than two) or severe symptoms such as dyspnoea, pain or dysphagia. Of the 50 patients, 13 (26%) were classified as having grade 1 disease, 22 (44%) grade 2 disease, and 15 (30%) grade 3 disease. Treatment in 39 patients was solely with the Nd:YAG laser using the noncontact or interstitial technique. Resection using the CO(2) laser was performed in six patients, and combined conventional surgery and Nd:YAG laser therapy in five patients. The applied grading reflects the extent of laser therapy and also the number of therapy sessions performed in patients treated with the Nd:YAG laser. Resection with the CO(2) laser is suitable for grade 1 lesions. In advanced lesions a combined therapeutic approach and multiple sessions are necessary. The Nd:YAG laser is still a valuable therapeutic tool for the treatment of venous malformations of the mucosa.

Orbital lymphatic malformation showing the symptoms of orbital complications of acute rhinosinusitis in children: a report of 2 cases

Orbital lymphatic malformations are benign cystic malformations of the lymphatic system. The present report shows two cases with symptoms of orbital complications of acute rhinosinusitis with proptosis, compressive optic neuropathy, loss of vision and cellulites in children. Magnetic resonance imaging (MRI) revealed a well-demarcated intraorbital mass with heterogeneous signal conformable with lymphatic malformation in both cases. A tumor extirpation was performed via lateral orbitotomy in both cases. Postoperatively the symptoms and especially the loss of vision improved completely. Histological analysis of the surgical specimens verified lymphatic malformations of the orbit. Orbital lymphatic malformations can mimic the symptoms of orbital complications of acute rhinosinusitis. The existence of lymphatic malformation should be considered in every orbital complication of rhinosinusitis in children.