[Infantile hemangiomas: differential diagnosis and associated anomalies]

A new clinical and dermoscopic monitoring of infantile hemangiomas treated with oral propranolol

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

[Management of vascular anomalies in children]

Vascular anomalies, which are broadly identified as "angiomas", are rare entities and often unknown by the medical sphere. They are divided in two different categories which carry different prognosis and management: "vascular tumors" and "vascular malformations". Their precise identification is crucial and involves a good knowledge of the biological classification published by Mulliken and Glowacki and that has recently been updated by the International Society for the Study of Vascular Anomalies (ISSVA). Vascular tumors are benign, common, inborn or not and most of the time disappear with growth. Vascular malformations are always congenital and growth with the child. They can involve type of vessels solely or combined with others. A rheologic differentiation between slow and fast flow malformations is essential in order to characterize the seriousness of the lesion. Frequently, their diagnosis is clinically established and the anamnesis is conducted to answer three questions that are the time of revelation of the lesion ("When?"), its aspect ("What?") and its evolution ("How?"). Further investigations are usually not required but a non-invasive imaging technique such as Doppler ultrasound could be useful if a doubt exists. Surgery is not mandatory and must always be well thought because its consequences might be disastrous. It must be left to cosmetic sequelae of these lesions or to lesions that are totally resectable without causing any unacceptable deformation.

Infantile Hemangioma: A Brief Review

Infantile hemangiomas as frequent infancy tumors have been a controversial issue of medical scientists worldwide. Their clinical aspects are various and their physiopathology is yet to be fully understood. Numerous publications outline the characteristics, causes, evolution possibilities and therapeutic approaches. Deciding whether to treat or not is the main question of this kind of pathology. Hemangiomas that have complications or can cause irreversible damage need therapy. This is a brief review of up-to-date information regarding the presentation of infantile hemangiomas and target-therapies.

[An atypical lacrymal cyst]

INTRODUCTION

Lacrimal cysts are rarely described and must be differentiated from diseases of the lacrimal gland. We present a rare case of lacrimal cyst developed from an accessory lacrimal gland.

CASE REPORT

The management consisted of excision using a tarsoconjonctivale approach.

DISCUSSION

Most cysts are diagnosed from the third decade, manifested by progressive exophthalmos. It is a benign disease. However, the differential diagnosis with malignancy is not excluded. Surgical resection is desirable if tumors become symptomatic.

[Spontaneous regression of a giant facial hemangioma]

Infantile cutaneous hemangioma is a benign vascular tumor and is very frequent in infants. The evolution is mostly favorable with spontaneous regression in 80% of cases. Clinical diagnosis is easy in its triphasic typical form with a phase of sometimes brutal postnatal growth, a phase of stabilization and a phase of slow secondary regression. We report a case of a giant facial hemangioma diagnosed at birth in full-term female newborn getting the right peri-orbital and fronto-temporal region. Initial evolution was marked by a fast increase of the tumor justifying its stake under prednisone at the age of 3 months but without improvement. At the age of 6 months, the patient was hospitalized for infection of the hemangioma with favorable evolution under oxacilline. Following evolution was marked by the total regression of the hemangioma at the age of 5 years at the price of peri-orbital cutaneous scars. We discuss here the diagnostic, therapeutic and evolutionary aspects of this pathology and review of the literature.

[Diagnosis and management of vascular anomalies]

Vascular anomalies are a complex pathological group. They are especially difficult to study because of confusion in the terminology used. The classification developed by the International Society for the Study of Vascular Anomalies (ISSVA) in 1996 allows using a common scientific language. There are two groups of lesions: vascular tumor and vascular malformation. The management of these anomalies is difficult and must involve an interdisciplinary approach including specialists in plastic surgery, radiology, pediatry and dermatology. We propose a simplified approach for the management of these pathologies. This approach is coming from the experience of Marseille (France) multidisciplinary team.

Venous malformation: update on aetiopathogenesis, diagnosis and management

The aim of this review was to discuss the current knowledge on aetiopathogenesis, diagnosis and therapeutic management of venous malformations (VMs). VMs are slow-flow vascular anomalies. They are simple, sporadic or familial (cutaneomucosal VMs or glomuvenous malformations), combined (e.g. capillaro-venous and capillaro-lymphaticovenous malformations) or syndromic (Klippel-Trenaunay, blue rubber bleb naevus and Maffucci). Genetic studies have identified causes of familial forms and of 40% of sporadic VMs. Another diagnostic advancement is the identification of elevated D-dimer level as the first biomarker of VMs within vascular anomalies. Those associated with pain are often responsive to low-molecular-weight heparin, which should also be used to avoid disseminated intravascular coagulopathy secondary to intervention, especially if fibrinogen level is low. Finally, development of a modified sclerosing agent, ethylcellulose-ethanol, has improved therapy. It is efficient and safe, and widens indications for sclerotherapy to sensitive and dangerous areas such as hands, feet and periocular area.

Elevated D-dimer level in the differential diagnosis of venous malformations

OBJECTIVE

To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs.

DESIGN

Prospective convenience sample accrued from 2 interdisciplinary sites.

SETTING

Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France

PARTICIPANTS

The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure Measurement of D-dimer levels.

RESULTS

A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%).

CONCLUSIONS

Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice.

Moderate size infantile haemangioma of the neck -- conservative or surgical treatment? : a case report

Introduction

Infantile haemangioma is the commonest benign tumour in infancy. While the management of the majority of small haemangiomas consists of simply watching or steroid treatment, giant and moderate size infantile haemangiomas are challenging problems, especially in health systems with limited resources in developing countries.

Case presentation

A one-year old boy was presented to us by his parents with a moderate size haemangioma on the posterior triangle of the left side of the neck. Clinical assessment and radiological examinations were helpful in confirming the diagnosis. Surgical excision was performed successfully without major morbidity. Partial necrosis of the skin flap developed shortly after the operation but healing was complete in eight weeks. There was no residual problem on review five years after the operation.

Conclusion

Early surgical excision of a moderate size infantile haemangioma may be justified especially when there is difficulty of follow-up, which can be a common problem in developing countries. This approach will prevent growth deformation, impact on nearby vital organs and psychological problems.