Vincristine as a treatment for a large haemangioma threatening vital functions

Synthesis and Characterization of a Fe3O4@PNIPAM-Chitosan Nanocomposite and Its Potential Application in Vincristine Delivery

In this research, we conducted a systematic evaluation of the synthesis parameters of a multi-responsive core-shell nanocomposite (Fe₃O₄ nanoparticles coated by poly(N-isopropylacrylamide) (PNIPAM) in the presence of chitosan (CS) (Fe₃O₄@PNIPAM-CS). Scanning electron microscopy (SEM) was used to follow the size and morphology of the nanocomposite. The functionalization and the coating of Fe₃O₄ nanoparticles (Nps) were evaluated by the ζ-potential evolution and Fourier Transform infrared spectroscopy (FTIR). The nanocomposite exhibited a collapsed structure when the temperature was driven above the lower critical solution temperature (LCST), determined by dynamic light scattering (DLS). The LCST was successfully shifted from 33 to 39 °C, which opens the possibility of using it in physiological systems. A magnetometry test was performed to confirm the superparamagnetic behavior at room temperature. The obtained systems allow the possibility to control specific properties, such as particle size and morphology. Finally, we performed vincristine sulfate loading and release tests. Mathematical analysis reveals a two-stage structural-relaxation release model beyond the LCST. In contrast, a temperature of 25 °C promotes the diffusional release model. As a result, a more in-depth comprehension of the release kinetics was achieved. The synthesis and study of a magnetic core-shell nanoplatform offer a smart material as an alternative targeted release therapy due to its thermomagnetic properties.

Liver Transplantation for Rapidly Progressive Giant Hepatic Hemangioma With Diffuse Hemangiomatosis

Cavernous hemangiomas are the most common benign tumors of the liver and are usually asymptomatic. On the other hand, giant hemangioma and diffuse hepatic hemangiomatosis may become symptomatic by causing compression on adjacent structures, rupture, or consumptive coagulopathy. The coexistence of these 2 entities in an adult is extremely rare, and the literature, especially on their management, is sparse. We report the case of a young woman who developed a rapidly growing recurrent giant hemangioma and diffuse hepatic hemangiomatosis with significant pressure effects, raising the suspicion of a malignant tumor. She had previously undergone a liver resection and an aborted attempt at liver transplant elsewhere. As a preoperative measure, with an aim to shrink the tumor, she underwent arterial embolization and chemotherapy. After this procedure, she underwent deceased donor liver transplant. Her postoperative period was uneventful, and she was well at her 6-month follow-up. We highlight the challenges involved and the need for a multidisciplinary approach in managing these lesions. Liver transplant is an excellent option for patients who develop life-threatening complications or poor quality of life due to these benign liver tumors.

A Life Threatening Subglottic and Mediastinal Hemangioma in an Infant

Subglottic and mediastinal hemangioma are rare benign vascular tumors of childhood. They cause potentially life threatening condition which requires intervention. Several therapeutic options have been described in the literature with varying degrees of success and complications. We report a case of a stridulous 2-month old female infant with mediastinal and subglottic hemangioma. The child was treated with propranolol without the need for tracheostomy or any other surgical intervention, and with no reported side effects. Propranolol is an effective, non-invasive treatment for life threatening infantile hemangiomas compressing the airway, should be used as a firstline treatment for subglottic hemangiomas when intervention is required.

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.

Current treatment and management of infantile hemangiomas

Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.

Medical, Surgical, and Wound Care Management of Ulcerated Infantile Hemangiomas: A Systematic Review [Formula: see text]

Ulcerated infantile hemangiomas may present a therapeutic challenge, especially if there is concurrent hemorrhage or infection. The aim of this study was to systematically review the published evidence on the treatment of ulcerated hemangiomas, focusing on wound healing as the outcome of interest. We searched MEDLINE, Embase, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science from inception to July 2016. Seventy-seven studies met our inclusion criteria. One study was a randomized controlled trial, 30 were observational studies, and 46 were case reports or case series. There is significant heterogeneity among the methods used. We reviewed 1239 patients in total. Of the 197 treated with oral propranolol, 191 (97.0%) achieved complete ulcer healing. Thirty-one patients failed corticosteroid therapy (oral, intralesional, or topical) and were subsequently successfully treated with other therapies. Surgical resections were typically performed for larger hemangiomas and those causing complications. None of the therapies discussed appear to offer significant advantages over others. Therefore, treatment decisions should be individualized based on location of disease, extent, symptoms, feasibility, cost, and parental preference.

[Infantile hemangioma of the eyelid]

Hemangiomas are one of the most common vascular tumors in infancy. In most cases no therapy is necessary and spontaneous regression is observed; however, if they arise in the periocular region, immediate action is required as rapid growth frequently leads to obstruction of the visual field with the risk of developing amblyopia and orbital suppression up to permanent disfigurement and stigmatization of those affected. Novel pharmaceutical treatment options led to a significant paradigm shift in the treatment of pediatric hemangiomas.

Propranolol therapy for infantile hemangioma: our experience

Objective

Hemangiomas are the most common benign vascular tumors of infancy. Although most infantile hemangiomas (IHs) have the ability to involute spontaneously after initial proliferation and resolve without consequence, intervention is required in a subset of IHs, which develop complications resulting in ulceration, bleeding, or aesthetic deformity. The primary treatment for this subset of IHs is pharmacological intervention, and propranolol has become the new first-line treatment for complicated hemangiomas. Here, we evaluated the efficacy of propranolol on proliferation IH in a clinical cohort including 578 patients.

Methods

We retrospectively reviewed a total of 578 IH patients who were treated with oral propranolol from January 2010 to December 2012. Responses to the propranolol treatment were graded as: excellent, good, poor, or no response. Based on the response to propranolol treatment (once daily at a dose of 1.0 mg/kg for patients younger than 2 months; twice daily at daily total dose of 2 mg/kg for patients older than 2 months), additional pharmacotherapies or surgery were used for IH patients for satisfactory clinical outcome.

Results

Five hundred and sixty (96.9%) of 578 IH patients in our study responded to oral propranolol treatment, and the response rate was significantly different for different ages of patients (P<0.05), with the youngest patients having the highest response rate. The mean time of treatment was 6 months (range, 3–12 months). For example, response rate to propranolol was 98.1% in patients younger than 2 months, compared with 93.3% in patients older than 2 months and younger than 8 months, and 73.7% in patients older than 8 months. One hundred and thirty one patients who exhibited incompletely involuted hemangiomas were further treated with timolol maleate (n=89) or pulsed dye laser (n=42). One hundred and seventeen (89.3%) of 131 patients showed a positive response. There were no instances of life-threatening complications after propranolol. However, minor side effects were observed including 10 (1.73%) cases of sleep disturbance, 7 (1.21%) cases of diarrhea, and 5 (0.86%) cases of bronchospasm.

Conclusion

IH requires early intervention. During the involution phase, tapering propranolol dosage can be done to minimize side effects before discontinuing treatment. For patients exhibiting telangiectasia and chromatosis after propranolol treatment, administration of a 0.5% solution of timolol maleate or pulse dye laser is an effective therapeutic approach for complete involution.

Approach to haemangiomatosis causing congestive heart failure

Haemangiomas represent the most common tumour of infancy. Although most cases are cutaneous benign lesions, multiple skin haemangiomas are associated with visceral involvement, especially of the liver. Hepatic haemangiomatosis may be complicated by high-output cardiac failure due to high-flow arteriovenous connections within the lesions. Different therapeutic strategies for treating haemangiomatosis causing heart failure include medical, surgical and interventional modalities. This study aimed to review the treatment options, discuss their benefits and flaws and propose a practical therapeutic approach for this medical situation.

CONCLUSION

Our approach incorporates heart failure medications, dietary support and propranolol as first-line treatment, while corticosteroids, vincristine, percutaneous intervention and surgery are reserved for refractory cases.

Evidence-Based Medicine in the Treatment of Infantile Hemangiomas

Over the past decade, the treatment of infantile hemangiomas has undergone dramatic breakthroughs. This review critically evaluates the latest literature that supports the myriad treatment options for infantile hemangiomas. It chronicles the fading role of steroid therapy and evolution of propranolol use as the major treatment modality. Although propranolol is helping this disease become more of a medical disease and less of a surgical dilemma, the report also reveals a continued search to find nonsystemic treatment options. In summary, this is an evidence-based medicine review for the treatment of infantile hemangiomas.

Pharmacological therapies for infantile hemangiomas: A clinical study in 853 consecutive patients using a standard treatment algorithm

Infantile hemangiomas are the most common infantile benign vascular tumor. While most infantile hemangiomas proliferate then involute, some may persist and require treatment for reasons including risk of disfigurement or functional impairment. Treatments currently include observation, pharmacological therapy, laser, cryosurgery, surgery and radiotherapy. Although pharmacological therapy is a well accepted treatment option, limited studies have evaluated the efficacy of different drug therapies. In this study, we compare different pharmacological modalities in the management of infantile hemangiomas. The study included 853 infants with proliferative infantile hemangiomas who were treated with topical timolol, oral propranolol, intralesional pingyangmycin, or intravenous vincristine from 2009 to 2012. Treatment stratification was based on clinical severity of the tumor. Response to the treatment was clinically evaluated and graded as: excellent, good, poor, or no response. Response to pharmacological therapies was excellent in almost all infantile hemangiomas. In addition, patients younger than 8 months responded highly to pharmacological treatment (89.1%), while patients older than 8 months were less responsive to treatment (36.3%). There were no instances of life-threatening complications. Overall, these findings support the efficacy of timolol, propranolol, pingyangmycin and vincristine in the treatment of infantile hemangiomas, especially in the youngest patient cohort (8 months or younger).

A prospective study to assess the efficacy and safety of oral propranolol as first-line treatment for infantile superficial hemangioma

Purpose

To determine the efficacy and safety of oral propranolol as a first-line treatment for superficially located infantile hemangioma (IH) and propose an assessment tool to measure treatment response.

Methods

Patients with superficial IH under 1 year of age were prospectively recruited between May 2012 and December 2013 at the Department of Pediatrics of Chungbuk National University Hospital. Propranolol was administered to 12 infants (median age, 3.8 months) while monitoring cardiovascular and adverse metabolic effects. If a patient showed no adverse events, the dosage was gradually increased up to 3 mg/kg/day and maintained for 1 year. We used our own scoring system to assess treatment response using parameters like change in color, and longest diameter, and thickness of the IH.

Results

Eleven out of 12 patients completed the protocol with consistent improvement of hemangiomas during therapy. Patients on propranolol showed a more than 50% involution in the first 3 months, with additional steady involution until 1 year. Patients with the highest scores at 1 month maintained their score and showed better responses until treatment termination. The patient with the lowest score at 1 month did not show any further regression and stopped propranolol treatment 4 months after initiation. In two children with recurrences after successful therapeutic regression, propranolol was effective after being reintroduced. Propranolol treatment was not interrupted in any patient due to adverse events.

Conclusion

Oral propranolol at 3 mg/kg/day showed a consistent, rapid, and therapeutic effect on superficial IHs without significant adverse events.

Kasabach-Merritt syndrome: clinical vs. surgical treatment

Kassabach-Merritt syndrome is a combination of capillary hemangioma and thrombocytopenia that predisposes to bleeding with petechiae, ecchymosis and spontaneous bruising. Treatment is generally started with corticosteroids, interferon alpha or chemotherapy. We present the case of a child (aged 1 year and 9 months) with a giant hemangioma, from the root of the thigh to the knee, and thrombocytopenia. Treatment was started with corticosteroids, without improvement, and then intra-tumor and cutaneous bleeding appeared spontaneously. The patient's clinical condition precluded prescription of vincristine and interferon and emergency tumor resection was conducted because of extreme thrombocytopenia and bleeding. The child then began to develop sepsis with hypotension and ischemia of remnant tissues. This case presented a therapeutic challenge, which is the subject of this article.

De novo transcriptome sequencing and digital gene expression analysis predict biosynthetic pathway of rhynchophylline and isorhynchophylline from Uncaria rhynchophylla, a non-model plant with potent anti-alzheimer's properties

Background

The major medicinal alkaloids isolated from Uncaria rhynchophylla (gouteng in chinese) capsules are rhynchophylline (RIN) and isorhynchophylline (IRN). Extracts containing these terpene indole alkaloids (TIAs) can inhibit the formation and destabilize preformed fibrils of amyloid β protein (a pathological marker of Alzheimer’s disease), and have been shown to improve the cognitive function of mice with Alzheimer-like symptoms. The biosynthetic pathways of RIN and IRN are largely unknown.

Results

In this study, RNA-sequencing of pooled Uncaria capsules RNA samples taken at three developmental stages that accumulate different amount of RIN and IRN was performed. More than 50 million high-quality reads from a cDNA library were generated and de novo assembled. Sequences for all of the known enzymes involved in TIAs synthesis were identified. Additionally, 193 cytochrome P450 (CYP450), 280 methyltransferase and 144 isomerase genes were identified, that are potential candidates for enzymes involved in RIN and IRN synthesis. Digital gene expression profile (DGE) analysis was performed on the three capsule developmental stages, and based on genes possessing expression profiles consistent with RIN and IRN levels; four CYP450s, three methyltransferases and three isomerases were identified as the candidates most likely to be involved in the later steps of RIN and IRN biosynthesis.

Conclusion

A combination of de novo transcriptome assembly and DGE analysis was shown to be a powerful method for identifying genes encoding enzymes potentially involved in the biosynthesis of important secondary metabolites in a non-model plant. The transcriptome data from this study provides an important resource for understanding the formation of major bioactive constituents in the capsule extract from Uncaria, and provides information that may aid in metabolic engineering to increase yields of these important alkaloids.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2164-15-676) contains supplementary material, which is available to authorized users.

Propranolol for infantile haemangiomas: experience from a tertiary center

Aim:

Infantile haemangiomas are the most common tumor of infancy. We report the use of propranolol for treatment of problematic and complicated haemangiomas.

Patients and Methods:

Propranolol was given to 52 children with mean age of 18.2 months at onset of treatment. After clinical and electrocardiographic evaluations, propranolol was administered with a starting dose of 2 mg/kg per day, given in 3 divided doses. Monthly follow up was done, response to oral propranolol therapy and any complications of therapy were recorded. Response to propranolol was classified as Complete Response, Excellent Response, Partial Response and Non Responder.

Results:

Total 49 patients showed significant improvement after propranolol therapy out of which 4 patients were complete responder, 30 patients (56.7%) were excellent responders; 15 patients (28.8%) were partial responders. 3 patients (5.7%) had growth of haemangiomas despite propranolol therapy and were classified as non-responder. Side effect like hypotension, rashes, gastroesophageal reflux was reported by 3 patients. In our study mean duration of treatment was 6.5 months. At the end of treatment propranolol was stopped by with gradual tapering of dose over a period of 2 weeks.

Conclusion:

Propranolol administered orally at 2 mg/kg per day has rapid effective therapeutic effect in treatment of ulcerated haemangiomas and it appears to be a valuable and effective treatment option for infantile haemangiomas beyond the proliferative phase, and esthetically disfiguring haemangiomas.

Approach to the patient with an infantile hemangioma

Infantile hemangioma is the most common soft tissue tumor of childhood. Despite its frequency, it has only been in the last decade that these lesions have been better characterized and become the subject of significant clinical and translational research. Although most infantile hemangiomas are uncomplicated and do not require intervention, they can be a significant source of parental distress, cosmetic disfigurement, and morbidity. The wide spectrum of disease in the morphology of these lesions and in their behavior has made it difficult to predict the need for treatment and has made it challenging to establish a standardized approach to management.

Periocular capillary hemangioma: management practices in recent years

Purpose

To present a case series on the management options for capillary hemangiomas involving the eyelid and orbit.

Methods

This is a retrospective chart review of clinically diagnosed capillary hemangioma cases involving the periocular region treated at two local eye institutions. The patients’ demographics and clinical presentation – including visual acuity, refractive error, periorbital and orbital examinations, and ultrasound and magnetic resonance imaging findings – were reviewed. The clinical progression, modalities of treatment, and treatment outcomes were studied.

Results

Sixteen cases of capillary hemangiomas involving the eyelid and orbit were studied. The mean age at consultation was 9.6 months (range: 1 month–72 months). The majority were females (75%), with 50% presenting as upper-eyelid hemangiomas and the remaining as lower-eyelid (38%) and glabellar (12%) lesions. Combined superficial and deep involvement was common (64%). Cases whose lesions were located at the upper eyelid or superior orbit led to amblyopia (25%). Fifty-six percent of cases (9/16) were managed conservatively, and 44% (7/16) underwent treatment with either single-agent (n = 4) or combined treatments (n = 3).

Conclusion

Close monitoring of visual development and prompt institution of amblyopia therapy for children with periocular capillary hemangiomas generally preserve vision. Extensive lesions that affect the visual axis require local and systemic treatments, alone or in combination, in order to reduce the size and impact of lesions on the eyeball, to reduce induced refractive error and visual occlusion, and to prevent the development of amblyopia, in order to achieve good visual outcomes.

Management of infantile hemangiomas : current and potential pharmacotherapeutic approaches

Infantile hemangiomas (IH), benign vascular neoplasms, are the most common tumors of infancy and childhood. Most IH are medically insignificant; however, a proportion will require treatment because of interference with vital structures, threat of significant disfigurement, ulceration, or bleeding. This article reviews current and potential pharmacotherapeutic approaches to the treatment of IH. While corticosteroids have long been considered the mainstay of medical therapy for IH, several new treatments have recently emerged, the most promising of which is oral propranolol. Topical timolol and imiquimod are additional new therapies that may also prove to be effective, particularly for the treatment of superficial IH.

Infantile hemangiomas: an update

Infantile hemangioma (IH) is a common vascular tumor of infancy. Although benign, infants with IH can experience complications including ulceration, visual and airway impairment, and residual scarring and disfigurement. It is often challenging for clinicians to predict which tumors are in need of systemic treatment. However, data from various demographic and other studies have revealed further insights into this tumor. This article reviews the identification, evaluation, and management of high-risk IHs, including the indications for treatment and the use of systemic treatments such as corticosteroids, β-blockers, and vincristine.

Early Surgical Excision of Giant Congenital Hemangiomas of the Scalp in Newborns: Clinical Indications and Reconstructive Aspects

Background:

Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions.

Objective:

We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp.

Methods:

The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely.

Conclusion:

Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age.

Cervicofacial hemangiomas: pattern, clinical management, and treatment outcomes

OBJECTIVE

The aim of this study was to evaluate treatment outcomes following various managements of hemangiomas.

STUDY DESIGN

Sixty-two patients were included and retrospective review conducted. Based on clinical management, each patient was assigned different treatment groups: steroid, sclerotherapy, surgical, and combined therapy. Treatment outcomes were evaluated based on improvement in size, color, and texture by a blinded panel of 4 raters including 3 doctors and 1 patient or patient's parents. Finally, comparison of outcomes between groups was analyzed.

RESULTS

The results revealed that there was reduction in size and improvement in color and texture following intervention in each group. No significant difference in outcome was observed between groups regarding change in size and texture. However, color change was better in combined and surgical treatment groups.

CONCLUSIONS

A favorable outcome can be achieved following appropriate intervention during all stages of development of hemangiomas.

Propranolol for problematic head and neck hemangiomas: an analysis of 37 consecutive patients

OBJECTIVE

Infantile hemangiomas (IHs) on head and neck are frequently encountered. Recently, propranolol was introduced as a novel pharmacologic treatment for IH. But the impact of propranolol for the treatment of IHs especially the side effects have not yet been well described. This article aimed to describe the effects and side effects of propranolol treatment in 37 children with problematic hemangiomas on head and neck.

STUDY DESIGN

Data were collected from the medical charts of patients treated between October 2008 and November 2010. Serial examinations and photographs were obtained to evaluate perceived therapeutic response and complications of oral propranolol in the course of their therapy.

RESULTS

Thirty-seven infants with propranolol-treated problematic head and neck hemangiomas were included and all patients had a good response. Most of patients were subjectively noticed an obvious improvement within one week from the onset of therapy. 29 patients endured the treatment of propranolol for 3 months with no recurrence, 6 patients endured prolonged course of treatment for 5/6 months. 2 patients who endured the treatment of propranolol for 3 months were found recurrence in two weeks. So the propranolol was given again for another 3 months. There were no severe adverse reactions. Minor side effects included diarrhea, light sleeping, and nausea.

CONCLUSION

Propranolol appears to be an effective and well-tolerated treatment for problematic IH on head and neck.

Pharmacologic therapies for infantile hemangioma: is there a rational basis?

BACKGROUND

Infantile hemangioma is the most common tumor of infancy. The majority of cases are managed conservatively, but intervention is necessary in approximately 10 percent of cases because of the threat to life or function or because of tissue distortion or destruction. The mainstay treatment for these problematic proliferating infantile hemangiomas is pharmacologic therapy, mostly discovered serendipitously.

METHODS

This review examines the rational basis of the hitherto empirical pharmacologic therapies for the enigmatic infantile hemangioma, in light of new knowledge regarding its biology, including the critical roles of stem cells and the renin-angiotensin system.

RESULTS

Steroids have remained the first-line therapy for problematic infantile hemangioma for over 40 years despite their known side effects and failure rates. Vincristine has emerged as an alternative to interferon for steroid-resistant cases because of interferon's adverse effects, especially neurotoxicity. β-Blockers are now the preferred first-line therapy for problematic cases. There is increasing evidence that infantile hemangioma is a disorder of aberrant proliferation and differentiation of primitive mesoderm-derived neural crest phenotypic cells. This primitive phenotype that gives rise to a hemogenic endothelium intermediate has the ability to undergo primitive erythropoiesis and terminal mesenchymal differentiation.

CONCLUSIONS

The recent discovery of the crucial role of stem cells and the inferred role of the renin-angiotensin system in the biology of infantile hemangioma underscores the possibility of even more targeted therapies, by using modulators of the renin-angiotensin system, on infantile hemangioma. The observation of the potential role of these traditional antihypertensive agents in stem cell biology may lead to better understanding of developmental biology and tumor stem cell growth.

Evaluation of intralesional propranolol for periocular capillary hemangioma

BACKGROUND

The purpose of this study was to evaluate the use of intralesional propranolol injection in the management of periocular capillary hemangioma.

METHODS

A prospective study was performed in 22 consecutive patients with periocular hemangioma. Twelve patients underwent intralesional propranolol injection and ten patients underwent intralesional triamcinolone injection. The size of the lesion was measured serially every week during the first month, every 2 weeks for the second month, and then monthly for another 2 months. The refractive error and degree of ptosis if present were measured before injection and at the end of the study.

RESULTS

There was reduction in the size of hemangioma, astigmatic error, and degree of ptosis in both groups. The difference in outcome between both groups was not statistically significant. Rebound growth occurred in 25% of the propranolol group and 30% of the steroid group but responded to reinjection. No adverse effects were reported during or after intralesional propranolol injection.

CONCLUSION

Intralesional propranolol injection is an alternative and effective method for treatment of infantile periocular hemangioma.

Intralesional bleomycin injection treatment for vascular birthmarks: a 5-year experience at a single United Kingdom unit

BACKGROUND

The authors present their experience using an established chemotherapeutic agent as a scarless treatment for vascular birthmarks. One hundred sixty-four of more than 600 patients seen in the authors' center received intralesional bleomycin injection over 5 years.

METHODS

Patient demographics, clinical response, treatment, and complication details were recorded prospectively. Respiratory surveillance was provided by adult and pediatric pulmonologists. Eighty-one venous malformations, 39 hemangiomas, 26 lymphatic malformations, 10 mixed malformations, two arteriovenous malformations, two cystic hygromas, two capillary malformations, and two angiokeratomas underwent intralesional bleomycin injection.

RESULTS

The authors observed that 45.7 percent of patients completed treatment in a mean of 3.8 sessions and mean duration of 107 days. Complete resolution occurred in 56.0 percent, with a 93.3 percent overall response rate, and 82.7 percent of lesions demonstrated complete response or significant improvement. Three patients developed transient skin hyperpigmentation. One patient each developed skin ulceration, blistering, infection, swelling, headache, bruising, and rash. One patient required intubation following treatment of a panfacial and thoracic lymphatic malformation. A full recovery ensued. No patients developed pulmonary fibrosis. One venous malformation recurred.

CONCLUSIONS

The authors' single-site multidisciplinary team has successfully treated complex and recurrent vascular anomalies with acceptable complication and recurrence profiles. These findings represent the authors' experience and provide a reference for the management of these challenging lesions.

Management of hemangiomas and other vascular tumors

Vascular tumors of childhood are typically benign. The 4 most common types are infantile hemangioma (IH), congenital hemangioma (CH), kaposiform hemangioendothelioma (KHE), and pyogenic granuloma (PG). Vascular tumors must be differentiated from vascular malformations. Although tumors and malformations may appear as raised, blue, red, or purple lesions, their management differs significantly.

Low-dose propranolol for multiple hepatic and cutaneous hemangiomas with deranged liver function

We report here the case of an infant with multiple hepatic and cutaneous infantile hemangiomas (IHs) associated with deranged liver function who was treated successfully with low-dose propranolol. We also discuss our recent data that show that IH is a developmental anomaly of hemogenic endothelium derived from primitive mesoderm with a neural crest-cell phenotype. We previously presented evidence that this hemogenic endothelium is governed by the renin-angiotensin system, which we propose can account for both the action of propranolol and the process of spontaneous involution of IH. We further speculate on the possibility of using inhibitors of angiotensin-converting enzyme and that of angiotensin II receptor 2 as potential alternative therapies.

Kasabach-Merritt syndrome: case reports of successful treatment with partial tumor resection and vincristine chemotherapy

Kasabach-Merritt syndrome is a life-threatening and localized consumption coagulopathy, characterized with profound thrombocytopenia and microangiopathic anemia. The huge tumor is the major cause of rapid platelet destruction, so we supposed the reduction of tumor size could reduce the platelet destruction and improve the clinical condition. In our cases, the vascular tumor occupied one of the extremities, or the head or face. However, removal of the whole tumor would have resulted in the amputation of this extremity or the destruction of the face, and partial tumor removal was suitable. The wound could be repaired with skin graft. Vincristine chemotherapy after the operation was necessary to prevent the enlargement of the remaining tumor. Two cases which were ineffectively treated by other means were treated in this way.

Management of complicated hemangiomas with vincristine/vinblastine: Quantitative response to therapy using MRI

PURPOSE

To quantify the efficacy of vincristine and vinblastine in the treatment of complicated hemangiomas.

DESIGN

Retrospective review.

METHODS

Charts were reviewed to identify patients treated with vincristine or vinblastine for complicated hemangiomas from August 2002 to October 2007. Only patients who received both a pre and post-treatment magnetic resonance imaging (MRI) were considered. A database was created which includes patient gender, age at treatment initiation, rationale for treatment, hemangioma location, number of cycles of chemotherapy received, and complications of treatment. A single pediatric radiologist calculated lesion volumes from both pre and post-treatment MRI which were compared to quantify treatment response.

RESULTS

Seven patients (2 male, 5 female) met criteria. Mean age at treatment initiation was 20 weeks (median 14, range 5-60). Rationale for treatment included four patients (57%) with proptosis/orbital compromise and one patient each (14%) with heart failure, airway compression, and hemangiomatosis with rapid growth of multiple lesions. Patients received a mean of 2.86 cycles of chemotherapy (median 3, range 1-5). Twelve lesions were identified and analyzed for pre and post-treatment volume on MRI in the seven patients. Eleven of twelve (92%) lesions decreased in size after treatment. The mean volume ratio of hemangiomas at the conclusion of chemotherapy was 0.45 compared to pre-treatment size (median 0.18, range 0-2.19) Orbital compromise, airway compression, and cardiac failure either improved or resolved in all patients. Three complications of treatment were seen in seven patients (42%) including bacteremia with anemia, peripheral neuropathy and motor delay. All complications resolved after cessation of chemotherapy.

CONCLUSIONS

Treatment of complicated hemangiomas with vincristine or vinblastine can control growth and improve symptoms in the majority of patients. Treatment often requires multiple cycles of chemotherapy. Complications of treatment are common, but reversible.

Infantile hemangioma

Infantile hemangiomas (IHs) are the most common soft tissue tumors of childhood. The wide spectrum of disease has made it difficult to predict need for treatment and has made it challenging to establish a standardized approach to management. This article provides the reader with an up-to-date discussion of IH, identifying features of this condition which predict need for treatment as well as associated complications and reviewing management.

Current management of infantile hemangiomas

During the past several years, there have been new advancements in the management of infantile hemangiomas (IHs). In many patients, no treatment is ever necessary--because IHs are well known for their natural history of spontaneous involution. However, a significant minority of hemangiomas do require treatment. Moreover, they are very heterogeneous, making the decision of when, how, and why to intervene quite variable. The least common but most important rationale for intervention is the presence of a life- or function-threatening complication, where prompt therapeutic intervention is a necessity. A much more common scenario is ulceration, where appropriate management is needed to expedite healing and control pain. Increasingly, the life-altering aspects of hemangioma are being recognized as a rationale for treatment because permanent scarring and disfigurement can result even if involution is complete. Treatments for IHs currently include topical, intralesional, and systemic therapies. Laser and surgical modalities are also sometimes used depending on the clinical scenario. In the absence of rigorous evidence-based studies, clinicians must carefully weigh the risks and benefits of medical or surgical treatments versus observation alone in tailoring management to the specific clinical situation at hand.

Propranolol for infantile hemangiomas: early experience at a tertiary vascular anomalies center

OBJECTIVES/HYPOTHESIS

Propranolol has recently been introduced as a novel pharmacologic treatment for infantile hemangiomas. Systematic examination of this treatment in a tertiary care setting has not been described. This study explores the impact of propranolol on both proliferative and involuting hemangiomas at a tertiary vascular anomalies center.

STUDY DESIGN

Retrospective single institution review.

MATERIALS AND METHODS

We reviewed children treated with propranolol for problematic hemangiomas followed by a blinded prospective analysis of serial photographs taken during the course of their therapy. Parental questionnaires were obtained to evaluate perceived therapeutic response and complications to oral propranolol.

RESULTS

Thirty-two children with complete photo documentation were treated with oral propranolol for infantile hemangiomas between September 2008 and June 2009. Twenty-seven patients began therapy during the proliferative phase of their lesions (mean age, 4.9 months), whereas five patients began during the involutional phase (mean age, 19.4 months). Ninety-seven percent of patients displayed improvement in the quality of their hemangiomas during propranolol therapy. Patients were determined to be excellent responders (n = 16, 50%), partial responders (n = 15, 47%), or nonresponders (n = 1, 3%). Partial and nonresponders received adjuvant therapy (75%, laser therapy; 31%, steroid injections). Ten patients experienced minor but reportable side effects to propranolol, including somnolence (27.2%), gastroesophageal reflux (9.1%), respiratory syncytial virus exacerbation (4.5%), and rash (4.5%).

CONCLUSIONS

Propranolol may revolutionize the treatment of problematic hemangiomas that cause imminent functional or cosmetic sequelae. At therapeutic doses, propranolol is safe and effective in the majority of patients. Adjunctive therapies may still be required. Minor side effects, expected from beta-blocker therapy, are common but easily managed.

[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.

Vincristine: Can its therapeutic index be enhanced?

Vincristine is one of the most widely used and more effective drugs in paediatric oncology. The dose-limiting toxicity of neuropathy, lack of proven neuroprotective measures and an incomplete understanding of the pharmacokinetics and pharmacogenetics of vincristine have limited its therapeutic potential. Recent advances in the understanding of vincristine pharmacokinetics and pharmacogenetics, and potential methods of preventing neurotoxicity are reviewed which could enable dose escalation and dose individualisation in order to enhance the therapeutic index.

Unexpected matrix diseases and novel therapeutic strategies

Within the framework of a broad definition of the extracellular matrix (ECM), this review discusses three genetic disorders in which major pathogenetic features have been traced back to alterations in the levels/activities of matrix components. In each case, disease-associated alterations are found both intra- and extracellularly. The nature of the ECM involvement is surprising, offers an exciting therapeutic opportunity, and deepens our understanding of ECM-cell interactions. The first of these disorders, cherubism, is a case of inflammatory bone loss in the jaws of children for reasons that are surprisingly systemic in nature, considering the local nature of the disease. The primary defect involves an intracellular signaling molecule, but a major pathogenetic component and therapeutic target of the disease is the extracellular cytokine tumor necrosis factor alpha. The second disorder, Knobloch syndrome, is caused by recessive mutations in collagen XVIII. Although this protein has been classified as belonging to a group of structural macromolecules, the consequence of the mutations is impairment of cellular metabolism. The third disorder, infantile hemangioma, is a common tumor of capillary endothelial cells in infancy. The tumor appears within a few days/weeks after birth, grows rapidly over several months, and regresses over several years. The proliferative phase is the result of constitutively high levels of vascular endothelial cell growth factor (VEGF)-dependent signaling through VEGF receptor 2 (VEGFR2), but recent studies have led to the surprising conclusion that abnormalities in a cell-surface receptor complex controlling expression of the VEGF decoy receptor VEGFR1 is the underlying cause.

Proposal for Staging Airway Hemangiomas

OBJECTIVE: To describe a method of airway infantile hemangioma staging using standardized assessment of airway narrowing, and hemangioma location and volume, as determined with endoscopy and CT angiography.

STUDY DESIGN: Case series with chart review.

SETTING: Tertiary pediatric hospital, 2003-2008.

SUBJECTS AND METHODS: Subjects included airway hemangioma patients evaluated at a tertiary pediatric hospital. Data collected were age at first symptoms, diagnostic evaluation, percent airway compromise, and estimated hemangioma volume. Data were analyzed with descriptive and Fisher exact statistics.

RESULTS: Twelve patients were identified and seven had complete data sets. Mean age at first symptoms was 1.9 months (SD 1.09 months, range 0.5-4 months). Evaluation consisted of nasopharyngoscopy, microlaryngoscopy, CT angiography, and/or MRI. Mean laryngeal airway narrowing was estimated at 63.75 percent (SD 19.0%, range 40%-90%). Total hemangioma volume was less in patients with isolated (focal) endolaryngeal hemangiomas compared with airway hemangiomas associated with extralaryngeal (segmental) hemangiomas. Airway hemangioma stages were stage one (5 of 12; 41.6%), stage two (6 of 12; 50.0%), and stage three (1 of 12; 8.3%).

CONCLUSION: This method of airway hemangioma staging may be applicable to treatment planning and used to measure treatment outcomes.

Emerging Concepts in Airway Infantile Hemangioma Assessment and Management

OBJECTIVE: The purpose of this study was to evaluate changes in airway infantile hemangioma treatment.

STUDY DESIGN: Retrospective.

SUBJECTS: Airway hemangioma patients, tertiary pediatric hospital.

METHODS: Data collected included age at diagnosis, evaluation methods, hospitalizations, airway size, and interventions. Patients were divided into group A (1981–1993) and group B (1994–2005) and were analyzed using descriptive statistics, the Fisher exact test, and the Student t test.

RESULTS: Thirty-two subjects were identified. Nasopharyngoscopy was used more in group B (11/16 [69%]) than group A (4/16 [25%], P = 0.032). CT angiography (3/16 [19%]) and laryngeal distractors (11/16 [69%]) were only used in group B; these techniques showed airway hemangiomas to be “transglottic,” not just “subglottic.” Intralesional steroids alone (3/16 [19%]) and primary hemangioma excision (2/16 [13%]) were new treatments used in group B. Frequent direct laryngoscopies (>six) correlated with tracheotomy (5/32 [16%], P = 0.015). Presenting age (<2 months) impacted treatment more than airway hemangioma size.

CONCLUSIONS: New methods of airway infantile hemangioma assessment changed our concept of airway hemangiomas and their primary treatment.

Vasculogenesis in infantile hemangioma

Infantile hemangioma is a vascular tumor that occurs in 5-10% of infants of European descent. A defining feature of infantile hemangioma is the dramatic growth and development into a disorganized mass of blood vessels. Subsequently, a slow spontaneous involution begins around 1 year of age and continues for 4-6 years. The growth and involution of infantile hemangioma is very different from other vascular tumors and vascular malformations, which do not regress and can occur at any time during childhood or adult life. Much has been learned from careful study of the tissue morphology and gene expression patterns during the life-cycle of hemangioma. Tissue explants and tumor-derived cell populations have provided further insight to unravel the cellular and molecular basis of infantile hemangioma. A multipotent progenitor cell capable of de novo blood vessel formation has been isolated from infantile hemangioma, which suggests that this common tumor of infancy, long considered to be a model for pathologic angiogenesis, may also represent pathologic vasculogenesis. Whether viewed as angiogenesis or vasculogenesis, infantile hemangioma represents a vascular perturbation during a critical period of post-natal growth, and as such provides a unique opportunity to decipher mechanisms of human vascular development.

The role of the hematologist/oncologist in the care of patients with vascular anomalies

Pediatric hematologist/oncologists have a critical role in the diagnosis and management of patients who have complex vascular anomalies. They provide the clinical and medical skills needed to diagnose, treat, and manage these patients. Hematologist/oncologists also provide support for clinical trials and drug development to further treatment options for these patients.

Genomic imprinting of IGF2 is maintained in infantile hemangioma despite its high level of expression

Hemangioma, the most common tumor of infancy, is characterized by rapid growth and slow regression. Increased mRNA expression of insulin-like growth factor 2 (IGF2) has been detected in the proliferating phase by cDNA microarray analysis, but the underlying mechanism causing the increase remains unknown. Here, using quantitative real-time polymerase chain reaction (PCR) and immunohistochemistry, we show that IGF2 is highly expressed in both proliferating and involuting phase hemangioma, but is not detectable in other vascular lesions such as pyogenic granuloma, venous malformation, lymphatic malformation, or in normal infant skin. Loss of imprinting of the Igf2 gene has been associated with IGF2 overexpression in a variety of childhood tumors. To determine if loss of imprinting and consequent bi-allelic expression might contribute to the increased expression of IGF2, we examined the genomic imprinting status of Igf2 in 48 individual hemangiomas. We determined allele-specific Igf2 expression using reverse transcriptase-PCR combined with analysis of an Apa I-sensitive restriction fragment length polymorphism. Similar to heterozygous normal skin controls, all 15 informative hemangiomas showed uniform mono-allelic expression of Igf2. Therefore, loss of imprinting is not involved in the increased expression of IGF2 in infantile hemangioma.

Current treatment practices in the management of cutaneous haemangioma

Haemangiomas are common, benign tumours of the vascular endothelium which present within the first few weeks of life. Clinically, they are very heterogeneous, with size, location and rate of proliferation having a significant effect on the risk of complications. Most haemangiomas are uncomplicated, and can be observed for spontaneous involution. However, some may be life- or function-threatening and require treatment. Corticosteroids, which may be used topically, intralesionally or systematically, are the mainstay of therapy. IFN-alpha, vincristine and cyclophosphamide are therapeutic options for complicated haemangiomas which do not respond to corticosteroids. Vascular-specific laser therapy may be considered for superficial haemangiomas, ulcerated haemangiomas or postinvolution sequelae, such as telangiectasia. A periorbital haemangioma that obstructs the visual axis or exerts pressure on the globe is an ocular emergency; systemic corticosteroids and patching of the unaffected eye should be instituted as soon as possible.

Update on hemangiomas and vascular malformations

PURPOSE OF REVIEW

Our knowledge base in the area of vascular anomalies is growing rapidly. With greater understanding of classification and diagnosis, as well as with the numerous areas of research bringing further awareness on the complexity of these lesions, we are improving our ability to treat them. We will attempt in this article to summarize the developments in the field of vascular anomalies over the last year.

RECENT FINDINGS

Emphasis on correct classification is still a high priority in the literature and yet there remains a great deal of misinformation. Many new developments in the basic science of these lesions are allowing better understanding of why these lesions occur while improving our management in these patients. Advances in laser surgery as well as sclerotherapy techniques have improved our ability to treat extensive lesions and also improve patients' quality of life.

SUMMARY

Many new and exciting areas of discovery occur almost daily in the field of vascular anomalies. Due to the breadth of this topic, it is certain that not all articles can be reviewed however the author has tried to present the most recent and clinically relevant breakthroughs in the field.