Propranolol therapy for infantile hemangioma

Overview of the Head and Neck Hemangiomas: a 5-year Retrospective Study

Background

Infantile hemangiomas (IHs) are benign vascular tumors commonly observed in children. The pathogenesis of hemangiomas is complex and poorly understood. IH occur most commonly on the head and neck. There are different classification of them according to the depth, number, distribution and locations. A multidisciplinary approach is needed for the diagnosis and treatment of hemangiomas because it is easy to misdiagnose or decide on a wrong treatment in the existing single-treatment system.

Objective

In this retrospective study between 2018 and 2022 we provided an overview of the hemangiomas located in the head and neck in 232 patients, and the different treatment approaches used.

Results

Of the 232 patients 60.3 % were females and 38.7% males. The youngest age was 10 weeks old and the oldest age who underwent treatment was 79 years old. The most common lesion sites were the mid-cheek, the upper lip and the upper eyelid. 104 patients (53.4 %) underwent surgical intervention due to the location of the lesion, size and functional reasons. Meanwhile 128 patients (46.6 %) were observed and treated with propranolol and pulsed dye laser.

Conclusion

Hemangiomas are generally benign tumors. Hemangiomas present a number of diagnostic and therapeutic challenges; thus, early diagnosis by a specialist clinic is key in preventing associated morbidity with these vascular tumors.

Infantile Hemangiomas: A Review of Current Treatment Options

This literature review outlines the current pathogenesis, clinical features, and complications of infantile hemangiomas and explores the current treatment modalities, including corticosteroids, surgery, pulsed dye laser, and beta-blockers. Although oftentimes benign, these lesions can potentially lead to physical or cosmetic disfigurement in growing children. The issue of depth and location-dependent treatment for infantile hemangiomas is explored as it reveals which treatments are correlated with better outcomes in specific presentations. For example, beta-blockers were found to be an effective first-line treatment for superficial infantile hemangiomas specifically, whereas the pulsed dye laser procedure was shown to be an effective option for deep hemangiomas, speeding up the involution process when combined with other treatment modalities and reducing scarring in ulcerated hemangiomas. Although the various infantile hemangioma treatment modalities available are appropriately tailored to specific cases of hemangiomas, they are also not without significant, sometimes life-threatening complications. This is why this literature review aims to outline the therapeutic benefits and risks of all treatment modalities to aid in the establishment of optimal case-dependent treatments. [Pediatr Ann. 2023;52(5):192-197.].

Colorimetric analysis of images in the follow-up of infantile hemangiomas

BACKGROUND/OBJECTIVES

Infantile hemangiomas (IH) are common vascular tumors that appear early in life, have a rapid proliferative phase and slowly involute. There are no standardized ways to evaluate the regression of these lesions. We propose a colorimetric analysis of photographs to allow a more precise determination of IH treatment response and involution.

METHODS

Patients 1-10 months of age with superficial or mixed IH were included. The lesions were managed with 0.5% topical timolol ophthalmic solution. Patients were followed for 16 weeks with 6 evaluations each. Photographic images were taken with a red and green circle placed beside each hemangioma. The photographs were treated as to equalize the size, color, and brightness among them based on the colors of the two circles. A grading scale was established based on the color of the patient skin (0) and the color of the hemangioma at the beginning of treatment (100) by pixel analysis using Adobe Photoshop® software.

RESULTS

A total of 17 patients 1 to 10 months of age were included, of whom 16 were girls (94%). Fourteen lesions were superficial, and 3 were mixed IH. The median time prior to initiation of treatment was 105 days (44-232). All lesions showed some degree of clearing. The mean of lightening of color intensity observed was of 45% (17%-74%) over the period of follow-up.

CONCLUSIONS

The colorimetric analysis of the digital images allowed an accurate and objective evaluation of IH clearing.

Effect of oral propranolol on periocular Capillary Hemangiomas of Infancy

BACKGROUND

To assess the safety and efficacy of oral propranolol in the management of periocular Capillary Hemangiomas of Infancy (CHI).

METHODS

Medical records of 21 infants diagnosed with periocular capillary hemangioma during a period of 5 years from 2009 to 2014 were retrospectively reviewed. The data collected included demographic details, clinical features and details of imaging studies and response to the therapy. All patients received oral propranolol under the supervision of a pediatrician. The initial dose was 0.2-1 mg/kg body weight, which was increased to 2 mg/kg body weight (3 divided doses) in 48 h if there was no adverse reaction to the initial dose. The response to the treatment was assessed clinically as well as by radiographic imaging. Photographic documentation was done periodically.

RESULTS

Out of 21 patients, 18 were females and remaining three were males. The median age at the time of presentation was 4 months. The most common presenting feature was lid mass (n = 17, 80%) followed by proptosis (n = 7, 33%). Reddish discoloration of face was seen in 2 (1%) patients. All patients showed reduction in the size of the lesion. None of the patients included in this study had any adverse reaction to propranolol or recurrence following cessation of the therapy.

CONCLUSION

Oral propranolol is highly effective and safe in the treatment of periocular capillary hemangiomas in infants.

Diffuse neonatal hemangiomatosis presenting as congestive heart failure

Diffuse neonatal hemangiomatosis is a rare condition with a very high mortality rate if left untreated. We report a neonate having around 490 cutaneous and multiple diffuse liver hemangiomas presenting as congestive heart failure. Prompt treatment was instituted with decongestive drugs and prednisolone for anticipated life threatening complications due to hepatic hemangiomas. Propranolol was added later as it is known to precipitate congestive failure and also to avoid long-term complications of steroids. The child responded well. However, there is no consensus regarding the initial line of management, which needs to be individualized keeping in mind the efficacy, long-term side effects of the drug and the clinical presentation.

Approach to Infantile Hemangiomas

Infantile hemangiomas are a group of vascular tumors and are considered to be one of the most common tumors in infancy. Ambiguity still prevails over its origin, etiopathogenesis, and optimal management.

Assessment and causes of stridor

Stridor is a variably pitched respiratory sound, caused by abnormal air passage during breathing and often is the most prominent sign of upper airway obstruction. It is usually heard on inspiration (typically resulting from supraglottic or glottic obstruction) but also can occur on expiration (originating from obstruction at or below glottic level and/or severe upper airway obstruction). Stridor due to congenital anomalies may exist from birth or may develop within days, weeks or months. Various congenital and acquired disorders prevail in neonates, infants, children, and adolescents, and have to be distinguished. History, age of the child and physical examination together often allow a presumptive diagnosis. Further investigations may be necessary to establish a definite diagnosis, and flexible airway endoscopy is the diagnostic procedure of choice in most circumstances ("stridor is visible").

Pharmacologic Interventions for Infantile Hemangioma: A Meta-analysis

CONTEXT

Infantile hemangiomas (IH) may be associated with significant functional impact.

OBJECTIVE

The objective of this study was to meta-analyze studies of pharmacologic interventions for children with IH.

DATA SOURCES

Data sources were Medline and other databases from 1982 to June 2015.

STUDY SELECTION

Two reviewers assessed studies using predetermined inclusion criteria.

DATA EXTRACTION

One reviewer extracted data with review by a second.

RESULTS

We included 18 studies in a network meta-analysis assessing relative expected rates of IH clearance associated with β-blockers and steroids. Oral propranolol had the largest mean estimate of expected clearance (95%; 95% Bayesian credible interval [BCI]: 88%-99%) relative to oral corticosteroids (43%, 95% BCI: 21%-66%) and control (6%, 95% BCI: 1%-11%). Strength of evidence (SOE) was high for propranolol's effects on reducing lesion size compared with observation/placebo. Corticosteroids demonstrated moderate effectiveness at reducing size/volume (moderate SOE for improvement in IH). SOE was low for effects of topical timolol versus placebo.

LIMITATIONS

Methodologic limitations of available evidence may compromise SOE. Validity of meta-analytic estimates relies on the assumption of exchangeability among studies, conditional on effects of the intervention. Results rely on assumed lack of reporting bias.

CONCLUSIONS

Propranolol is effective at reducing IH size compared with placebo, observation, and other treatments including steroids in most studies. Corticosteroids demonstrate moderate effectiveness at reducing IH size/volume. The meta-analysis estimates provide a relative ranking of anticipated rates of lesion clearance among treatments. Families and clinicians making treatment decisions should also factor in elements such as lesion size, location, number, and type, and patient and family preferences.

Low concentration of rapamycin inhibits hemangioma endothelial cell proliferation, migration, and vascular tumor formation in mice

BACKGROUND

Vascular endothelial cell excessive proliferation is the main biological behavior of hemangioma. Rapamycin regulates the growth of endothelial cells by inhibiting mammalian target of rapamycin (mTOR). Thus hemangioma accompanied by excessive mTOR activation should be sensitive to rapamycin. We aimed to illustrate the effect of low-concentration rapamycin on hemangioma and provide a safe and effective drug therapy.

METHODS

Mouse hemangioendothelioma endothelial cells and Nu/Nu mice were used. Rapamycin was applied in a concentration from 1 nM to 20 nM. WST-1 cell proliferation and transwell migration assays were used to analyze vascular tumor proliferation and migration in vitro. Xenograft mouse models were used to test vascular tumor growth in vivo.

RESULTS

Low-concentration rapamycin (1 nM) inhibited hemangioendothelioma endothelial cell proliferation and migration in vitro and vascular tumor growth in vivo. The mechanism was decreased activation of the protein kinase B/mTOR/S6 ribosomal protein (S6) signaling pathway.

CONCLUSIONS

Rapamycin used in vitro was analogous to low serum concentration rapamycin (7-16 nM) and also significantly inhibited the growth of hemangioma. These results demonstrate a low-toxic drug therapy for hemangioma and encourage continued development of rapamycin and its analogs for use in vascular tumor therapy.

Congenital laryngeal anomalies

Introduction

It is essential for clinicians to understand issues relevant to the airway management of infants and to be cognizant of the fact that infants with congenital laryngeal anomalies are at particular risk for an unstable airway.

Objectives

To familiarize clinicians with issues relevant to the airway management of infants and to present a succinct description of the diagnosis and management of an array of congenital laryngeal anomalies.

Methods

Revision article, in which the main aspects concerning airway management of infants will be analyzed.

Conclusions

It is critical for clinicians to understand issues relevant to the airway management of infants.

Common conditions in pediatric surgery

Primary care physicians are generally the first contacts of the parents of children with any disease. Management protocols and methods of the surgical conditions in children have undergone changes over time and the aim of this review is to update the knowledge base of clinicians. New technologies like laparoscopy and endoscopic surgery are available for management. The optimal treatment of any surgical condition requires that appropriate procedure is performed at the optimal time by a pediatric surgeon who is best trained for management of these conditions.

Congenital intraosseous cavernous hemangioma of the skull: an unusual case

Intraosseous hemangiomas are benign vascular malformations mostly seen in the spine. They rarely occur in the skull. The usual age-group involved is the 2nd to 4th decades, and females outnumber males. We hereby report a rare case of congenital intraosseous cavernous hemangioma of the skull bone in a male infant. The patient underwent total excision of the lesion.