Response of deep tufted angioma to interferon alfa

Tufted angiomas of the head and neck

BACKGROUND

Tufted angiomas (TAs) are uncommon benign vascular tumors mostly located cutaneously or subcutaneously in the skin of the neck and upper trunk, which appear during childhood and grow slowly. TAs are a variant of lobular capillary hemangiomas. This is the first study to provide an overview of the current literature in combination with the authors' own clinical experience on this rare entity in the head and neck area with non-dermatological localization.

METHODS

A selective Medline and Google Scholar database search was performed. Additionally, we conducted an ICD-10-based database search on hemangiomas (D18.0) in the Charité SAP patient records.

RESULTS

We identified 13 reports in the literature consisting of 16 cases of TA of the head and neck. Males were predominantly affected by TAs (70.6%). The mean age of the patients at the time of surgery was 31.5 years; the mean maximum diameter of the tumors was 16.3 mm. Additionally, we report on one case of TA in our Department of Head and Neck Surgery. A male patient presented with swelling and redness of the left upper eyelid. Radiological examination with computed tomography showed a suprabulbar tumor with a diameter of 13 mm. The tumor was surgically removed via a transcutaneous blepharoplasty approach with the patient under general anesthesia.

DISCUSSION

There is only one other case report on the surgical excision of an intra-orbital TA described to date. Here, we present an epidemiological overview, therapeutic considerations, and differential diagnoses.

[Tufted angiomas of the head and neck. German version]

BACKGROUND

Tufted angiomas (TAs) are uncommon benign vascular tumors mostly located cutaneously or subcutaneously in the skin of the neck and upper trunk, which appear during childhood and grow slowly. TAs are a variant of lobular capillary hemangiomas. This is the first study to provide an overview of the current literature in combination with the authors' own clinical experience on this rare entity in the head and neck area with non-dermatological localization.

METHODS

A selective Medline and Google Scholar database search was performed. Additionally, we conducted an ICD-10-based database search on hemangiomas (D18.0) in the Charité SAP patient records.

RESULTS

We identified 13 reports in the literature consisting of 16 cases of TA of the head and neck. Males were predominantly affected by TAs (70.6%). The mean age of the patients at the time of surgery was 31.5 years; the mean maximum diameter of the tumors was 16.3 mm. Additionally, we report on one case of TA in our Department of Head and Neck Surgery. A male patient presented with swelling and redness of the left upper eyelid. Radiological examination with computed tomography showed a suprabulbar tumor with a diameter of 13 mm. The tumor was surgically removed via a transcutaneous blepharoplasty approach with the patient under general anesthesia.

DISCUSSION

There is only one other case report on the surgical excision of an intra- orbital TA described to date. Here, we present an epidemiological overview, therapeutic considerations, and differential diagnoses.

Response of tufted angiomas to low-dose aspirin

Tufted angioma (TA), also known as angioblastoma of Nakagawa, is an uncommon vascular tumor. Clinical presentation and evolution of TA can vary. There are many treatment modalities, but none are uniformly effective. We present two patients with TA without Kasabach-Merritt phenomenon (KMP) treated with low dose aspirin, which resulted in improved appearance, decreased bulk, and resolution of symptoms. Low-dose aspirin should be considered as a treatment option for large or symptomatic TA that are not associated with KMP.

Congenital leukemia cutis presenting as multiple violaceous lesions in a newborn

We present a case of congenital leukemia cutis that was the presenting sign of systemic acute myeloid leukemia. The initial diagnosis was benign hemangiomatosis because ultrasound of the liver was negative for visceral involvement. However, biopsy showed monocytic cells and led to a further workup which involved a bone marrow biopsy, giving the final diagnosis of acute myeloid leukemia with leukemia cutis. Even with a thorough knowledge of the differential diagnosis of such presenting lesions, a diagnostic biopsy is often needed for a final histologic diagnosis, to proceed with the proper course of treatment. We review congenital leukemia cutis and the differential diagnosis for violaceous lesions in the newborn that may be encountered by the pediatric plastic surgeon.

Treatment of a tufted angioma with intense pulsed light

Tufted angioma is a rare cutaneous angiomatous proliferation named because of its characteristic histologic pattern of grouped dermal capillary tufts. Lesions usually begin in infancy or early childhood but rarely are congenital. Clinical manifestations are dull red coalescent papules and plaques, most commonly located on the neck, shoulders, and upper back, and can sometimes be tender. Although transformation to malignancy has not been described, tufted angiomas do not tend to regress. Effective treatments reported in the literature are scarce. We report an adult case of tufted angioma, with unusual presentation as annular plaques, which was alleviated after treatment with intense pulsed light in terms of both cosmetics and discomfort.

Kaposiform hemangioendothelioma

Kaposiform hemangioendothelioma (KHE) is a rare, locally aggressive vascular neoplasm that mainly occurs during childhood. It generally originates on the skin, usually affecting deeper tissue by infiltrative growth. It appears as one or multiple masses, and in most cases is associated to consumptive coagulopathy (Kasabach-Merritt syndrome), and lymphangiomatosis. Although visceral involvement is very uncommon, several cases with bone, retroperitoneal, or mediastinal involvement have been described. These tumors tend to be locally invasive, but are not known to produce distant metastases. The development of KHE in adolescents or in adults is very rare, but cases have also been described. Several factors are associated with the outcome of patients with KHE: accessibility to surgical excision, location (cutaneous versus visceral), size of tumoral mass, clinical response to interferon and glucocorticoids, and the absence of lymphangiomatosis and Kasabach-Merritt syndrome, may result in partial remissions. On the other hand, bulk visceral masses lead to a 40-50% mortality rate, mainly due to progressive failure of the infiltrated organ(s), in spite of interferon, glucocorticoids, and combined chemotherapy. In conclusion, the onset of a consumptive coagulopathy following the presence of a vascular tumor, in children as well as in older patients, should spark suspicion of KHE, among other entities.

Angioblastoma showing aggravation after treatment with long-pulsed Nd:YAG laser (1064 nm)

Angioblastoma usually develops in infancy or early childhood on the neck or upper trunk. It is known to be slowly progressive and benign in nature, but treatment guidelines have not yet been established. Spontaneous regression has been occasionally documented, and treatment with pulsed dye laser, excision, high-dose steroids, and interferon alpha have been successful in individual patients. Our patient experienced partial response to interferon alpha injection, and for further treatment, long-pulsed Nd:YAG laser (1064 nm) treatment was performed. However, unexpectedly, the tumor was rapidly aggravated. We report this occurrence to increase awareness of trauma-induced aggravation phenomena in angioblastoma.

Off-label uses of biologics in dermatology: Interferon and intravenous immunoglobulin (Part 1 of 2)

The introduction of a number of biologic therapies into the market has revolutionized the practice of dermatology. These therapies include interferons, intravenous immunoglobulin, infliximab, adalimumab, etanercept, efalizumab, alefacept, and rituximab. Most dermatologists are familiar with the Food and Drug Administration-approved indications of these medications. However, numerous off-label uses have evolved. As part 1 of a 2-part series, this article will review the literature regarding the off-label uses of the interferons and intravenous immunoglobulin in dermatology.

Tumeur vasculaire géante de l’adulte : angiome en touffe ou hémangioendothéliome kaposiforme

INTRODUCTION

Tufted angioma and kaposiform hemangioendothelioma are two rare benign but aggressive vascular tumours that occur mainly in children.

OBSERVATION

A 72 year-old man consulted for a 50 cm wide vascular tumour of the right shoulder which was increasing for 10 years. On histological examination there were features of tufted angioma and kaposiform hemangioendothelioma.

DISCUSSION

The tumour of this patient was atypical because of its big size never described before. The histological association of aspects which could correspond to tufted angioma and kaposiform hemangioendothelioma seems to confirm recent publications which support the hypothesis that these two tumours are two evolutive stages of one and only entity.

Familial predisposition to tufted angioma: identification of blood and lymphatic vascular components

Tufted angioma is a rare benign vascular lesion of unknown etiology which mainly affects children under 5 years. It is characterized by nodules or tufts of capillary-sized vessels in the dermis. Here we report the second familial occurrence of tufted angioma, with a mode of inheritance compatible with a monogenic autosomal dominant trait with reduced penetrance. A preliminary investigation was performed to exclude association between the predisposition and certain candidate genes including KDR (kinase insert domain receptor), TEK (TEK tyrosine kinase endothelial), ACVRL1 (activin receptor-like kinase 1), ENG (endoglin) and FLT4 (fms-like tyrosine kinase 4). KDR, ENG and FLT4 were all compatible with linkage, with haplotypes being shared between three affected individuals and the one obligate carrier available for testing. TEK and ACVRL1 could essentially be excluded. Finally, we provide definitive evidence for the existence of both blood and lymphatic vascular elements in the lesion.

Response of childhood tufted angioma to the pulsed-dye laser

Tufted angioma is a rare, benign cutaneous angiomatous proliferation, which often presents in the first few years of life. Lesions commonly affect the neck, upper trunk, and shoulders and can sometimes be tender. Effective treatments reported in the literature are scarce. We report a case of tufted angioma in a child, which had a successful outcome after treatment with the pulsed-dye laser both in terms of cosmesis and alleviation of pain and discomfort.

Tufted angioma: a report of five cases

Tufted angioma is a rare, benign, vascular tumor, characterized histologically by tufts of capillary-sized vessels in the dermis. Five patients were diagnosed over a 10-year period. All developed the lesions within the first year of life. Four were Chinese and one was Indian. There was no sex predilection. All the lesions occurred on the limbs, mainly proximally, with 40% affecting the upper and 60% the lower limbs. The appearance ranged from erythematous, indurated, annular nodules to plaques. In two patients the lesions had overlying red papules, and hypertrichosis was present in three cases. The lesions were tender in all patients. No complications such as ulceration, bleeding, or Kasabach-Merritt syndrome occurred. All were treated conservatively, with improvement in tenderness in three of four patients after a period of 5 months to 4 years. Decrease in size occurred in one of four patients after 2 years. Our series differs from previous ones in that all the patients developed the lesions before the age of 1 year, all lesions occurred on the limbs, and all were tender. Tenderness and hypertrichosis, in addition to induration, may be useful in the clinical differentiation from common hemangioma.

Tufted angiomas: variability of the clinical morphology

In 1989 Wilson Jones and Orkin first described tufted angioma, which has the unifying histologic feature of circumscribed angiomatous tufts and lobules within the dermis. Tufted angioma may take unusual forms clinically. We describe five children less than 3 years of age with tufted angiomas, demonstrating the variability of the morphology of this vascular tumor. Two of the lesions were congenital. Three presented as indurated, vascular-appearing plaques, one of which had associated hypertrichosis. One lesion appeared clinically compatible with a hemangioma of infancy, but continued to enlarge after the child was 32 months old. The remaining lesion was a nearly circumferential, soft tissue tumor of the left forearm with tortuous vessels and a smaller overlying vascular stain. All of these lesions demonstrated the characteristic histology of tufted angioma. The clinical and histopathologic differential diagnosis as well as treatment options for tufted angioma are reviewed.

Congenital tufted angioma

A 7-year-old Filipino girl presented to the dermatology clinic with a slowly enlarging plaque on the inner aspect of her upper left arm. Although she had this lesion since birth, it had gradually enlarged and become indurated and slightly painful. The histopathologic examination showed a vascular proliferation within the dermis, with a "cannonball" appearance consistent with a tufted angioma. We review the literature and discuss the clinical presentation of this rare vascular tumor.

The interferons

The interferons are a group of naturally occurring biologic response modifiers that exhibit antiviral, antiproliferative, differentiating, and immune-enhancing properties. This interesting group of compounds has been found to be effective for the treatment of condylomata acuminata, skin cancers, high-risk melanoma, hepatitis C, mycosis fungoides, and keloid scars. The advantages of these agents must be weighed against their toxicities, the number of treatments, and cost.

Tufted angioma (angioblastoma): case report and review of 41 cases in the Japanese literature

We report a 53-year-old man with a 2-year history of a violaceous indurated plaque on the shoulder. Although angiosarcoma was clinically suspected, histological examination revealed numerous lobules ('tufts') with cleft-like vascular lumina throughout the dermis and subcutaneous tissue. Tumour cells had no nuclear atypia and were positive for CD34, but almost negative for factor VIII-related antigen. These findings were compatible with a diagnosis of tufted angioma, or angioblastoma. We reviewed 41 cases reported in Japan and found that, although most patients presented during the first year of life (23/41), the condition does occur throughout childhood and adult life. Both sexes are affected equally and, contrary to some reports, it is unlikely that oestrogens have a pathogenic role.

Successful treatment of angiosarcoma of the scalp by intralesional cytokine therapy and surface irradiation

An 88-year-old woman presented to us with angiosarcoma of the scalp that had developed over a 6-month period following previous trauma. Despite explicit information concerning the extremely malignant potential of the tumour the patient refused any surgical intervention. However, she agreed to receive local, intralesional interferon alpha-2b and interleukin-2 therapy. After partial remission of the tumour, the intralesional cytokine injections were combined with surface radiotherapy. This combination therapy led to a 2-year remission of both the tumour and sonographically suspicious cervical lymph nodes. Apart from the typical, moderate side-effects of interferon alpha-2b and interleukin-2 the therapy was well tolerated. In conclusion, in our limited experience intralesional cytokine therapy--alone as well as in combination with surface irradiation--seems to be an alternative therapeutic option for patients who is not a candidate for surgery.

Vascular tumors arising in port-wine stains: two cases of pyogenic granuloma and a case of acquired tufted angioma

Three female patients affected by intradermal vascular tumors were presented. The lesions were acquired and developed from preexisting port-wine stains (PWS). Among the three patients observed, two had a pyogenic granuloma (PG) and the third patients had tufted angiomas. As reported earlier, formation of a PG within the lesion of a PWS supports the assumption that arteriovenous anastomoses are associated with its pathogenesis. Occurrence of tufted angioma from a PWS, as well as coexisting but separate PWS has been reported. However, the tufted angiomas of our patient were located in different sites, one in the PWS and others separate from the PWS. This has never previously been reported.

The infant with a vascular tumor

Vascular birthmarks look alike in various tints of blue, pink, or red. These anomalies are either vascular tumors or vascular malformations. Hemangioma is the most common vascular tumor of infancy, typically appearing in the neonatal period. Hemangiomas grow rapidly during the first year of life and regress slowly during childhood. Treatment is indicated for problematic or endangering hemangiomas, usually the administration of corticosteroids or interferon-alfa, and in some instances, embolization or surgical resection. The more aggressive and rare vascular tumors, kaposiform hemangioendothelioma and tufted angioma, are often associated with thrombocytopenia and coagulopathy (Kasabach-Merritt phenomenon) and less responsive to pharmacological therapy. Vascular tumors, particularly hemangioma, are often confused with vascular malformations; although etiology, histology, and clinical behavior are quite different. Vascular lesions should be biopsied if there is any suspicion of malignancy.

Interferons in dermatology. Present-day standard

Since the first clinical trials in the early 1980s with recombinant interferon, it was possible to show for a variety of indications that cytokines, especially interferons, at certain doses and at respective intervals, when applied in combination with other pharmaceutical compounds open new powerful therapeutic possibilities. Worldwide, recombinant interferon is licensed, especially in dermato-oncology, for the indication of HIV-associated Kaposi's sarcoma, cutaneous T-cell lymphoma, and recently for adjuvant therapy of high-risk malignant melanoma. Recombinant interferon is at present not licensed for dermatologic indication (septic granulomatosis). At the end of our century the indication spectrum for interferons as monotherapy and as combination therapy will undoubtedly be extended. Larger and controlled studies will prove the importance of interferons in dermato-oncology as well as in inflammatory and infectious dermatoses. The combination of interferons with standard therapies will surely be of the utmost importance in dermatotherapy.

Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms

This second part of our review about vascular proliferations summarizes the clinicopathologic features of the cutaneous vascular hyperplasias and benign neoplasms. Hyperplasias comprise a heterogeneous group of vascular proliferations that eventually show a tendency to regression. Angiolymphoid hyperplasia with eosinophilia is included within the group of hyperplasias because of its historical denomination and its reactive nature, probably as a consequence of an arteriovenous shunt, although usually the lesions do not regress. Pyogenic granuloma, bacillary angiomatosis, intravascular papillary endothelial hyperplasia, and pseudo-Kaposi's sarcoma qualify as vascular hyperplasias because they regress when the stimulus that initiated them is removed. Benign neoplasms form a large group of hemangiomas with distinctive clinicopathologic characteristics, although some of them are of recent description and may produce diagnostic difficulties. We classified cutaneous benign vascular neoplasms according to their cell lineage of differentiation, for example, endothelial, glomus cell, and pericytic differentiation. Subsequent categories are established according to the size of the involved vessels (capillaries, venules and arterioles, or veins and arteries) or the nature of the proliferating vessels (blood or lymphatic vessels). Capillary and cavernous hemangiomas have been the terms classically used to name the most common variants of benign vascular neoplasms (i.e., infantile hemangiomas), but they are not the most appropriate denominations for these lesions. First, these names are not contrasting terms. Furthermore, most of the socalled "cavernous" hemangiomas are not hemangiomas (neoplasms) at all, but venous malformations. The most important conceptual issue is that, at any point in time, a particular hemangioma has its own histopathologic pattern throughout the depth of the lesion. For these reasons, we classified hemangiomas into superficial and deep categories. Some of the lesions reviewed have been recently described in the literature, and they may histopathologically mimic lesions of Kaposi's sarcoma; these include targetoid hemosiderotic hemangioma, microvenular hemangioma, tufted hemangioma, glomeruloid hemangioma, kaposiform hemangioendothelioma, spindle-cell hemangioendothelioma, and benign lymphangioendothelioma. In each of these lesions, we update and emphasize those clinical and histopathologic features that are helpful for differential diagnosis with lesions of authentic Kaposi's sarcoma in any of its three stages of development (patch, plaque, or nodule).

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.