Educational paper: Pathogenesis of infantile haemangioma, an update 2014 (part I)

Infantile Scalp Hemangiomas: Surgical Management and Lessons Learned

Infantile hemangiomas (IH) are common benign vascular tumors in pediatric patients, often found on the scalp. While most IH naturally regress without intervention, surgical excision becomes necessary when severe anatomic or physiological complications arise. This review examines previously published case studies on pediatric scalp IH excisions, focusing on surgical outcomes and complications. A comprehensive search of the US National Library of Medicine National Institutes of Health (PubMed) database identified 19 relevant case studies. Most patients were female, with a wide age range at the time of excision. Various anatomic locations and sizes of the hemangiomas were observed. The reviewed literature demonstrates that surgical excision of scalp IH can be performed with minimal complications, even for sizable tumors. Successful outcomes and low complication rates highlight the effectiveness of surgical intervention in cases of life-threatening IH sequelae. Further research is warranted to explore optimal timing, techniques, and adjunct therapies for surgical management of scalp IH.

Infantile Hemangioma: A Cross-Sectional Observational Study

(1) Background: With an incidence of 4-10%, infantile hemangiomas (IH) are the most encountered benign tumors in infancy. Low birth weight (LBW), prematurity, female sex, multiple gestations, and family history of IH are some of the statistically proven risk factors for developing IH. The aim of our study was to evaluate the prevalence of IH in our clinic and its connection to maternal and perinatal factors. (2) Methods: We conducted a cross-sectional study, over three years (2020-2022), at the Clinical Hospital of Obstetrics and Gynecology, "Prof. Dr. P. Sârbu", in Bucharest, Romania. (3) Results: During this period, 12,206 newborns were born and we identified 14 infants with infantile hemangioma. In our study, the prevalence of infantile hemangioma was 0.11%. The prevalence of IH in pregnancies obtained through in vitro fertilization was 1%, in twin pregnancies it was 2.27%, and in those with placenta previa, it was 4.16%. (4) Conclusions: Our findings provide a solid image of the prevalence of IH in our country and underline that the development of IH is strongly connected to maternal and perinatal variables, such as: preterm newborns, in vitro fertilization, high blood pressure, anemia, hypothyroidism, placenta previa, and twin pregnancy.

Orbital Vascular Anomalies: A Nomenclatorial, Etiological, and Nosologic Conundrum

PURPOSE

Vascular anomalies are a heterogeneous group of disorders that frequently present in the periorbital region. They encompass 2 broad entities: vascular tumors, which possess a proliferative endothelium, and vascular malformations, which are basically localized defects of vascular morphogenesis. The primary goal of this review was to address inaccurate or controversial terminology in the oculoplastic literature concerning orbital and periorbital vascular anomalies and to categorize these lesions in an abridged and simplified hierarchical list that adheres as much as possible to the most recent (2018) iteration for the classification of vascular lesions proposed by the International Society for the Study of Vascular Anomalies (ISSVA). The secondary goal of this review was to review and update information regarding the genetic underpinnings of vascular anomalies and the downstream signaling pathways that are subsequently affected as a result of these genetic errors.

METHODS

A literature review was conducted in PubMed, MEDLINE, PubMed Central, National Center for Biotechnology Information Bookshelf, and Embase for several related keywords including "vascular anomalies, vascular malformations, vascular tumors, and cavernous venous malformation," both with and without adding the keywords "eyelid," "orbital," and "periorbital." In addition, a detailed search was conducted for controversial or obsolete keywords like "cavernous hemangioma," "lymphangioma," and "varices," again in their systemic and orbital/periorbital context.

RESULTS

Crucial issues in the 2018 ISSVA classification regarding the proper categorization of orbital vascular anomalies, particularly venous lesions, were critically evaluated and revised, and a regional, simplified, and abridged modification of the ISSVA 2018 classification was proposed.

CONCLUSIONS

Interdisciplinary and intradisciplinary dialogue concerning orbital vascular anomalies is seriously compromised due to the lack of a unanimous agreement on terminology and the absence of a unified classification concept system. The authors recommend that oculoplastic surgeons adopt ISSVA terminology whenever technically possible and scientifically sound. However, they also propose modifying the ISSVA 2018 classification specifically to adapt to the peculiarities of vascular anomalies in the periorbital region. At present, the simplified classification proposed here is a preliminary first step towards managing patients with orbital vascular anomalies with greater diagnostic and therapeutic precision, until such time in the future when the entire genetic makeup of orbital vascular anomalies is more completely elucidated. Optimistically, this could pave the way for a more robust classification and the ultimate therapeutic cure.

Association of Infantile Hemangiomas and Retinopathy of Prematurity: Analysis of the Multicenter KID

INTRODUCTION

Retinopathy of prematurity (ROP) and infantile hemangiomas (IHs) both have similar proposed pathophysiological mechanisms. IH is more common in preterm than term infants. Hypoxia-induced mediators like vascular endothelial growth factor have been found elevated in children with hemangiomas. The aim of our study was to determine if there is an association between ROP and IH in preterm infants and to investigate racial/ethnic and gender differences of ROP and IHs in this cohort.

METHODS

We accessed the national multicenter Kids' Inpatient Database (KID) Healthcare Cost and Utilization Project (HCUP) including admissions at age ≤28 days. Eligible infants were identified by using ICD-9 codes of ROP and IH in infants with gestational age (GA) ≤32 weeks and/or birth weight ≤1,500 g during the years 2003, 2006, 2009, and 2012. A weight-based analysis was performed using SAS Enterprise Guide 7.1 for complex sample design.

RESULTS

In the cohort of 1,068,502 eligible infants, the prevalence of IH was 4.7 per 1,000 preterm admissions (<32 weeks). ROP prevalence was 16% for GA ≤26 weeks, 12.5% for GA 27-30 weeks, and 2.7% for GA 31-32 weeks. IH was significantly higher in infants with ROP; this relationship was consistent among all stages of ROP. Regression analysis showed that females are at increased risk of IH with ROP compared to males (adjusted odds ratio [aOR]: 2.00 [1.85-2.56]). White non-Hispanic premature infants had an increased risk of IH with concomitant ROP compared to both African American (aOR: 3.9 [2.63-4.76]) and Hispanic (aOR: 1.2 [1.14-1.38]) infants. However, African American infants had an increased risk of ROP compared to white non-Hispanic infants (aOR: 1.16 [1.07-1.14]). These genders and racial/ethnic disparities were consistent among GA categories.

CONCLUSIONS

To our knowledge, this is the largest cohort based on a national multicenter database comparing an association between ROP and IH. A strong association between ROP and IH may suggest similar risk factors and/or pathophysiology. A further role of genetic factors could explain racial/ethnic differences in both conditions despite similar pathogenesis. These findings may open up new bases of research for management and prevention strategies.

15,16-dihydrotanshinone I inhibits EOMA cells proliferation by interfering in posttranscriptional processing of hypoxia-inducible factor 1

Infantile hemangioma (IH), which threatens the physical and mental health of patients, is the most common benign tumor in infants. Previously, we found that 15,16-dihydrotanshinone I (DHTS) was significantly more effective at inhibiting hemangioma proliferation in vitro and in vivo than the first-line treatment propranolol. To investigate the underlying mechanism of DHTS, we used EOMA cells as a model to study the effect of DHTS. We compared the transcriptomes of control and DHTS-treated EOMA cells. In total, 2462 differentially expressed genes were detected between the groups. Kyoto Encyclopedia of Genes and Genomes pathway analysis revealed downregulated activity of the hypoxia-inducible factor 1 alpha (HIF-1α) signaling pathway in EOMA cells following treatment with DHTS. Thus, we investigated HIF-1α expression at protein and mRNA levels. Our results revealed that DHTS downregulated HIF-1α expression by interfering in its posttranscriptional processing, and the RNA-binding protein HuR participated in this mechanism. Our findings provide a basis for clinical transformation of DHTS and insight into pathogenic mechanisms involved in IH.

Infantile and congenital hemangiomas

Infantile hemangiomas (IHs) are the most common benign tumors of infancy. They typically appear after birth and undergo a period of rapid growth, followed by a gradual period of involution. Although the majority of IHs do not requirement treatment, oral propranolol is the first-line therapy for lesions that are at risk for life-threatening complications, functional impairment, ulceration, or permanent disfigurement. Rarely, IHs can be associated with structural anomalies. Congenital hemangiomas (CHs) are a distinct clinical entity, caused by a point mutation in GNAQ or GNA11. These lesions are typically present at birth and display a wide spectrum of clinical presentations. CHs can be distinguished from IHs by their unique histologic and radiographic features. Given the high-flow vascularity of CHs, surgical excision may be indicated due to the high risk of bleeding.

miR-4458 directly targets IGF1R to inhibit cell proliferation and promote apoptosis in hemangioma

Hemangiomas (HAs) are benign neoplasms of the vasculature. MicroRNA-4458 (miR-4458) has been reported to function as a tumor suppressor in multiple malignancies, but its biological function in HAs remains unknown. In the present study, the potential role of miR-4458 in HA-derived endothelial cells (HDECs) was investigated. Firstly, reverse-transcription-quantitative PCR analysis was used to confirm the expression of miR-4458 in HDECs following transfection with miR-4458 mimics or inhibitor. Subsequently, MTT and EdU assays were performed and subsequently determined that miR-4458 overexpression significantly inhibited proliferation, and knockdown promoted cell proliferation in HDECs. Flow cytometry analysis revealed that miR-4458 overexpression induced cell cycle arrest, whereas knockdown reversed G0/G1 phase arrest and apoptosis. Furthermore, insulin-like growth factor 1 receptor (IGF1R) was identified as a target of miR-4458. IGF1R knockdown enhanced the effects of miR-4458 on cell proliferation, cell cycle G0/G1 phase arrest and apoptosis in HDECs. Taken together, the results revealed that miR-4458 targeting of IGF1R may serve as a novel therapeutic strategy for treating patients with HAs.

Efficacy and adverse effects of oral propranolol in infantile hemangioma: a meta-analysis of comparative studies

BACKGROUND

A number of clinical trials evaluated the efficacy and adverse effects of oral propranolol in the treatment of infantile hemangioma (IH), but the treatment has not yet been standardized. This meta-analysis aims to reevaluate the efficacy and adverse effects of oral propranolol in comparative studies and to provide a reliable basis for clinical administration in the therapy for IH.

METHODS

Data were obtained from PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure and Wanfang database, from inception to December 1st, 2018. The pooled risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and used to evaluate the effect size. The meta-analysis was performed using the random-effects model due to heterogeneity between the studies. The Cochrane Collaboration 6 aspects of bias, methodological index for non-randomized studies and the Newcastle-Ottawa Scale were used to assess the risk for bias. Sensitivity analysis, publication bias and subgroup analysis were performed.

RESULTS

Eighteen unique studies involving 2701 unique children were included in the analysis. The response rate was reported in 18 trials, which compared oral propranolol with other treatments. The heterogeneity was statistically significant (P < 0.00001, I² = 95%). The difference in the response rate was statistically significant (RR = 1.40, 95% CI 1.13-1.75) while compared with the controls. However, no significant difference in the adverse events rate (RR = 0.78, 95% CI 0.45-1.34) and relapse rate (RR = 1.45, 95% CI 0.66-3.16) were found. Otherwise, the subgroup analysis indicated that the RR was 1.64 (95% CI 0.24-11.36) for low-dose propranolol (1 mg/kg/day), 1.42 (95% CI 1.12-1.80) for medium dose (2 mg/kg/day) and 1.46 (95% CI 1.17-1.82) for high dose (3 mg/kg/day), but the high dose had higher adverse events rate than medium dose, with 3.60% and 86.22%, respectively. The effectiveness of propranolol therapy among cases of treatment duration less than 6 months (RR = 1.24, 95% CI 1.05-1.47) was inferior to that of treatment duration greater than or equal to 6 months (RR = 1.46, 95% CI 1.11-1.92).

CONCLUSIONS

This meta-analysis reveals that oral propranolol is superior to other treatments in improving response rate of IH and can be used as the first-line therapy for IH children. A dosage of 2 mg/kg/day propranolol orally may be a good choice for IH. However, further studies are essential.

Infantile hemangioma of the upper lip and enamel hypoplasia: Two case reports

Segmental infantile hemangiomas related to PHACE syndrome have recently been associated with enamel hypoplasia. We present two cases of solitary, localized upper lip infantile hemangioma with enamel hypoplasia of deciduous teeth.

Diagnosis and Management of Infantile Hemangiomas in the Neonate

Infantile hemangiomas (IH) are a common benign tumor of infancy, most being uncomplicated and not requiring therapy. Some IH may require treatment; the pediatric provider must be familiar with morphology, distribution, natural history, and associations of IH. Several treatment options are available for IH: current standard of care, oral propranolol. Other therapies include wound care; topical beta-blocker therapy for small, superficial, and uncomplicated IH; treatment of IH residua. In addition to functional compromise and other complications, potential for permanent deformity and eventual psychosocial stigmatization are important when considering the need for treatment of IH in a neonate or infant.

Role of Thrombospondin-1 and Nuclear Factor-κB Signaling Pathways in Antiangiogenesis of Infantile Hemangioma

BACKGROUND

Propranolol is the first-line drug for treatment of infantile hemangioma. However, its mechanism of action remains unclear. Nuclear factor-κB is highly expressed in tumors, directly or indirectly promoting angiogenesis. Thrombospondin-1 is the most important antiangiogenesis protein in vivo. These proteins mediate signaling pathways, probably playing an important role in hemangioma treatment. This study explored the synergistic regulation of thrombospondin-1 and nuclear factor-κB signaling pathways in the treatment of hemangioma with propranolol.

METHODS

The hemangioma-derived endothelial cells were sorted out from the specimens of proliferative hemangioma by flow cytometry. Furthermore, a BALB/c nude mouse hemangioma model was established. Viability and proliferation of hemangioma-derived endothelial cells and the role of thrombospondin-1 and nuclear factor-κB signaling pathways were observed after propranolol administration in vitro and in vivo.

RESULTS

The expression of thrombospondin-1 and its receptor CD36 in hemangioma-derived endothelial cells gradually increased with the increase in propranolol concentration, whereas the expression of nuclear factor-κBp65, phosphorylated inhibitor of κB alpha (p-IκBα), and phosphorylated inhibitor of nuclear factor-κB kinase beta (p-IκKβ) weakened gradually (p < 0.05). In vivo, the tumors shrank gradually after propranolol treatment, with an increase in thrombospondin-1 and CD36 and a decrease in nuclear factor-κBp65, p-IκBα, and p-IκKβ (p < 0.05). Glucocorticoid improved the antiangiogenesis mediated by thrombospondin-1/CD36 and inhibited the angiogenesis mediated by nuclear factor-κB/IκB (p < 0.05). Negative regulation occurred between the two signaling pathways.

CONCLUSION

The treatment of infantile hemangioma with propranolol is promising to promote thrombospondin-1-mediated antiangiogenesis and to block nuclear factor-κB-mediated angiogenesis.

Nonepithelial Tumors and Tumor-like Lesions of the Skin and Subcutis in Children

This overview of mesenchymal tumors presenting in the skin and/or subcutis in children brings together the range of neoplasms and hamartomas which are seen in this age-group. It is not surprising from the perspective of the pediatric or general surgical pathologist that vascular anomalies, including true neoplasms and vascular malformations, are the common phenotypic category. Since there is considerable morphologic overlap among these lesions, clinicopathologic correlation may be more important than for many of the other mesenchymal tumors. The skin and subcutis are the most common sites of clinical presentation for the infantile myofibroma which is the most common of fibrous mesenchymal tumors in children. Several of the other mesenchymal tumors are more common adults-like dermatofibrosarcoma protuberans, but nonetheless have an important presence in children, even as a congenital neoplasm. A lipomatous tumor in a young child should be considered as a possible manifestation of an overgrowth syndrome.

Phosphoinositide 3-kinase: a new kid on the block in vascular anomalies

Vascular anomalies are broadly divided into vascular tumours and malformations. These lesions are composed of abnormal vascular elements of various types, and mainly affect infants, children, and young adults. Vascular anomalies may be painful, may be complicated by bleeding, infection, or organ dysfunction, and can have secondary effects on other tissues. Current treatment strategies include surgical excision, pulsed laser, and sclerotherapy, which are invasive, with risks of recurrence. There are growing pharmacological options for these vascular anomalies, but, to date, no specific targeted therapies have been developed. Phosphoinositide 3-kinases (PI3Ks) constitute a family of lipid kinases that are involved in signal transduction and vesicular traffic, and that modulate important cellular processes such as proliferation, growth, and migration. Recent findings have indicated that the PI3K signalling pathway is important in the pathogenesis of vascular anomalies. This provides an opportunity to use PI3K inhibitors, which are in clinical trials for cancer treatment, for such lesions. Here, we provide an update on the classification of vascular anomalies, with their major features, and discuss the role of the PI3K signalling pathway in the pathogenesis of vascular anomalies, and their clinical implications and therapeutic opportunities. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Vascular Lesions

Vascular lesions in childhood are comprised of vascular tumors and vascular malformations. Vascular tumors encompass neoplasms of the vascular system, of which infantile hemangiomas (IHs) are the most common. Vascular malformations, on the other hand, consist of lesions due to anomalous development of the vascular system, including the capillary, venous, arterial, and lymphatic systems. Capillary malformations represent the most frequent type of vascular malformation. IHs and vascular malformations tend to follow relatively predictable growth patterns in that IHs grow then involute during early childhood, whereas vascular malformations tend to exhibit little change. Both vascular tumors and vascular malformations can demonstrate a wide range of severity and potential associated complications necessitating specialist intervention when appropriate. Evaluation and treatment of the most common types of vascular lesions are discussed in this article. [Pediatr Ann. 2016;45(8):e299-e305.].

Current trends in medical management of infantile hemangioma

PURPOSE OF REVIEW

Infantile hemangiomas are the most common benign, soft-tissue tumors of infancy, affecting between 5 and 10% of newborns, and up to 30% of premature infants. Morbidity may include disfigurement and scarring, difficulty in feeding, ulceration, vision loss, airway compromise, congestive heart failure, and death. Advances in understanding the pathogenesis of infantile hemangiomas have given rise to a number of promising treatments. This article reviews the current options for medical management of infantile hemangiomas.

RECENT FINDINGS

In the proliferative phase of infantile hemangiomas, vascular endothelial growth factor and basic fibroblast growth factor have shown increased expression, and vascular endothelial growth factor expression has been up-regulated by adrenergic stimulation. Moreover, the role of the renin-angiotensin system in the pathogenesis of infantile hemangiomas has been demonstrated. Numerous medical options have been under investigation. Since 2008, propanolol has become the first-line therapy, whereas other medical treatments are used less frequently or when propanolol is unsuccessful.

SUMMARY

Propranolol has been recently adopted as the first-line medical treatment for complicated infantile hemangiomas. Although emerging treatment options and modalities have shown promising results, there need to be high-quality multicenter randomized trials to support these preliminary data.

Treatment of infantile haemangiomas: recommendations of a European expert group

With a prevalence of 2.6-4.5 %, infantile haemangiomas (IH) represent the most common tumour of infancy. While the majority of IH does not require therapy and regresses spontaneously, about 10 % of IH exhibit complications such as obstruction, ulceration or disfigurement. With the advent of oral propranolol, many conventional treatment options have become obsolete. This paper summarizes current recommendations for management of complicated IH. These recommendations have been written by an expert group after a consensus process including bibliographic review, several drafts of synthesis, meetings with quantitative voting system and redaction of an approved final manuscript.

CONCLUSION

Oral propranolol is the first-line agent for the treatment of complicated IH.

WHAT IS KNOWN

• Infantile haemangiomas (IH) are the most common tumours of infancy. Within a very short period after its discovery and long before the publication of randomized controlled trials, propranolol has become the number one agent for the treatment of complicated IH. What is New: • We report IH treatment recommendations of an international, interdisciplinary team of experts, based on an up-to-date review of the literature.

CD105 expression in oral capillary hemangiomas and cavernous hemangiomas

Capillary hemangioma (capillary lobular hemangioma) and cavernous hemangioma (venous malformation) are relatively common oral tumors/malformations and are characterized by increased numbers of normal and abnormal blood vessels. However, the causes of these lesions are not well understood. CD105 (endoglin) is predominantly expressed in proliferating blood endothelial cells (ECs). We analyzed expressions of CD105, CD34, von Willebrand factor, Ki-67, cyclooxygenase-2 (COX-2), and vascular endothelial growth factor (VEGF)-A in 31 capillary hemangiomas and 34 cavernous hemangiomas. Staining scores were calculated as the product of the proportion score and intensity score. Morphologically normal oral mucosa specimens (n = 10) were simultaneously evaluated as normal controls. As compared with cavernous hemangiomas and normal controls, capillary hemangiomas had higher staining scores for CD105, VEGF-A, and COX-2. The Ki-67 labeling index was significantly higher in capillary hemangiomas than in cavernous hemangiomas and normal controls (P < 0.01). These findings suggest that the biological characteristics of capillary and cavernous hemangiomas are quite different. The ECs of capillary hemangiomas actively proliferated and were generally regulated by VEGF-A. In contrast, the ECs of cavernous hemangiomas lacked proliferative activity. These results suggest that angiogenesis and vasodilatation of pre-existing blood vessels are important in the development of capillary hemangioma and cavernous hemangioma, respectively.