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Labow BI, Alshamekh SA, Carlberg VM, Zacur JL, Uihlein LC, Mulliken JB, Liang MG. Infantile Hemangioma of the Breast: Long-Term Assessment of Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5506. [PMID: 38196847 PMCID: PMC10773794 DOI: 10.1097/gox.0000000000005506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/24/2023] [Indexed: 01/11/2024]
Abstract
Background The literature is meager regarding the natural history and outcomes of infantile hemangiomas (IHs) in the breast. Treatment in childhood may be considered due to psychosocial and physical concerns with breast development. Early surgical intervention may cause iatrogenic breast asymmetry and possibly impair lactation later in life. This study characterizes the clinical presentation, management, and long-term outcomes of IHs arising in the breast. Methods Female patients aged 11 years or older at presentation were included in a retrospective review of the Vascular Anomalies Center database for patients with IHs of the breast seen at our institution between 1980 and 2020. Breast development was ascertained by a structured telephone interview, physical examination, or photographs. Results A total of 10 patients met criteria for inclusion in this study. The median age at enrollment was 14 years (11-36 years). Breast asymmetry was noted in 60% of patients (n = 6). Of the four patients who underwent subtotal excision of breast IH, three developed ipsilateral breast hypoplasia. Breast asymmetry was also noted in three of five patients who did not receive medical treatment: two with hypoplasia and one with hyperplasia. No asymmetry was noted in the single patient who received corticosteroid. Conclusions IHs involving the nipple-areola complex can be associated with breast asymmetry. Hypoplasia was noted in patients not treated with corticosteroid or resection in childhood. These findings suggest that systemic treatment should be considered. Longitudinal follow-up on patients treated with propranolol will elucidate its possible benefits in minimizing breast asymmetry.
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Affiliation(s)
- Brian I. Labow
- From the Harvard Medical School, Boston, Mass
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| | - Shomoukh A. Alshamekh
- From the Harvard Medical School, Boston, Mass
- Dermatology Program, Boston Children’s Hospital, Boston, Mass
- Department of Dermatology, King Saud University, Riyadh, Saudi Arabia
| | - Valerie M. Carlberg
- From the Harvard Medical School, Boston, Mass
- Dermatology Program, Boston Children’s Hospital, Boston, Mass
- Dermatology Program, Children’s Hospital Wisconsin, Milwaukee, Wis
| | - Jennifer L. Zacur
- From the Harvard Medical School, Boston, Mass
- Dermatology Program, Boston Children’s Hospital, Boston, Mass
- St Joseph Mercy Chelsea Hospital, Chelsea, Mich
| | - Lily C. Uihlein
- From the Harvard Medical School, Boston, Mass
- Dermatology Program, Boston Children’s Hospital, Boston, Mass
- Department of Dermatology, Kaiser Permanente, Petaluma, Calif
| | - John B. Mulliken
- From the Harvard Medical School, Boston, Mass
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Mass
| | - Marilyn G. Liang
- From the Harvard Medical School, Boston, Mass
- Dermatology Program, Boston Children’s Hospital, Boston, Mass
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Rešić A, Benco Kordić N, Obuljen J, Bašković M. Importance of Determining Vascular Endothelial Growth Factor Serum Levels in Children with Infantile Hemangioma. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1914. [PMID: 38003963 PMCID: PMC10673278 DOI: 10.3390/medicina59111914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/10/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: A potential role of vascular endothelial growth factor (VEGF) in the pathophysiology of infantile hemangiomas (IH) is thought to be plausible. The primary objective of this study was to investigate the importance of determining VEGF serum levels at various stages of IH growth in children. Materials and Methods: A nested case-control study was conducted. For the purposes of the researched target group, samples of fifty (N = 50) children with IH without associated diseases at different stages of hemangioma growth (proliferative and involutional stages) were used. The control group consisted of one hundred (N = 100) healthy children comparable in terms of age and sex, in whom the existence of IH and vascular malformations was ruled out via clinical examination. An immunoassay (ELISA) was used to determine VEGF serum levels in hemangioma growth's proliferation and involution phases. Results: A comparison of serum levels of VEGF in the phases of proliferation and involution in the group of patients with IH did not show a statistically significant difference (p = 0.171). The control group had significantly higher serum VEGF levels than the patient group in both the proliferation phase (p = 0.009) and the involution phase (p = 0.019). In the proliferation phase, a multivariate regression model explained 15% of the variance in the dependent variable, without significant predictor variables, while in the involution phase, it explained 21% of the variance in the dependent variable, and the history of invasive prenatal procedures stood out as a significant predictor variable positively associated with serum VEGF levels (beta coefficient = 0.33; p = 0.043). Conclusions: Although IH is thought to be the result of the dysregulation of angiogenesis and vasculogenesis under the influence of angiogenic factors, especially VEGF, this study did not demonstrate that VEGF serum levels in the proliferation phase of hemangioma growth were higher than those in the involution phase, or in relation to the control group.
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Affiliation(s)
- Arnes Rešić
- Department of Pediatrics, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10 000 Zagreb, Croatia
- University Department of Health Studies, University of Split, Ruđera Boškovića 35, 21 000 Split, Croatia
| | - Nikolina Benco Kordić
- Department of Pediatrics, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10 000 Zagreb, Croatia
| | - Jasna Obuljen
- Department of Medical Biochemistry and Hematology, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10 000 Zagreb, Croatia
| | - Marko Bašković
- Department of Pediatric Surgery, Children’s Hospital Zagreb, Ulica Vjekoslava Klaića 16, 10 000 Zagreb, Croatia
- Scientific Centre of Excellence for Reproductive and Regenerative Medicine, School of Medicine, University of Zagreb, Šalata 3, 10 000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 3, 10 000 Zagreb, Croatia
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Blatt J, Brondon JE, Nieman EL, Phillips K, Pandya A. Repurposing of antiangiogenic agents for treatment of vascular anomalies. Pharmacol Ther 2023; 250:108520. [PMID: 37625520 DOI: 10.1016/j.pharmthera.2023.108520] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 08/27/2023]
Abstract
Vascular anomalies (VA) are developmental anomalies of veins, arteries, lymphatics or capillaries thought to be caused by mutations in genes that drive angiogenesis. Treatments targeting these genes are limited. We review the literature for conventional medications and products from traditional medicine cultures that have been found to have antiangiogenic activity. Fewer than 50 drugs with credible human activity in VA were identified and include β blockers, monoclonal antibodies, microtubule inhibitors, multi-kinase inhibitors, PIK3CA- and RAS-MAPK pathway inhibitors, and thalidomides. Other drug categories of potential interest are ACE-inhibitors, antifungals, antimalarials, MMP9-inhibitors, and over-the-counter compounds used in Eastern traditional medicine. Low toxicity for some offers the possibility of combined use with known effective agents. In addition to already familiar drugs, others with antiangiogenic capabilities already in use in children or adults may deserve further attention for repurposing for VA.
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Affiliation(s)
- Julie Blatt
- Division of Hematology Oncology, Department of Pediatrics, and the Lineberger Clinical Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Jennifer E Brondon
- Division of Hematology Oncology, Department of Pediatrics, and the Lineberger Clinical Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth L Nieman
- Department of Dermatology, Univerity of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Kynlon Phillips
- The Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Arti Pandya
- Division of Genetics and Metabolism, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Chiramel M, Katakam B, Gulati R, Gupta M, Munisamy M, S. Ranugha PS, Seetharam KA. IADVL SIG pediatric dermatology (academy) recommendations on Hemangioma of Infancy (HOI). Indian Dermatol Online J 2023; 14:172-186. [PMID: 37089858 PMCID: PMC10115319 DOI: 10.4103/idoj.idoj_52_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 03/12/2023] Open
Abstract
Hemangioma of infancy (HOI) is a benign vascular proliferation. Though resolution is the norm, potential complications make an accurate diagnosis and early management of importance. The Indian association of dermatologists, venereologists and leprologists (IADVL) special interest group (SIG) paediatric dermatology in association with IADVL academy did an extensive analysis of the literature on the clinical features, diagnosis, and management of HOI published between 2010 and 2021. Online meetings were conducted from February 2021 to March 2022 to reach a consensus on these recommendations which are made from an Indian perspective.
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Dikmen Z, Turhan O, Özbal A, Bütün V. In-situ formation of fluorophore cross-linked micellar thick films and usage as drug delivery material for Propranolol HCl. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2022; 279:121452. [PMID: 35667138 DOI: 10.1016/j.saa.2022.121452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/21/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
Polyethylene glycol monomethyl ether-block-poly(glycidyl methacrylate)-block-poly[2-(diethylamino)ethyl methacrylate] triblock copolymer was synthesized to prepare self-assembled micron sized films via a novel approach named as "phase separated micellar self assembly method". Liquid-air interface self assembly method via slow solvent evaporation was used to obtain micellar films. Cross-linking of polymer films was carried out by diffusion of fluorophore cross-linker into polymer solution from subphase. In-situ micellar formation was triggered via driven forces such as molecular interactions and slow evaporation of solvent. Thiazolo[5,4-d]thiazole based cross-linker fluorophores containing alkali subphases were used to prepare highly fluorescent cross-linked micellar films. Micellar morphologies of the films were characterized with SEM while the cross-sections of fluorophore cross-linked films were observed with TEM analysis to examine diffusion of the dye as nano-sized particles into the polymer film. Convenience and usability of the micellar films as drug delivery material were demonstrated with Propranolol HCl release via UV-Vis spectroscopic studies. Optical properties of the films before and after drug release were determined via photoluminescence spectroscopy to be able to sense the completion of the drug release process. Swelling and shrinkage properties of the films were also determined in different pH values. These highly fluorescent polymer films have great potential as drug delivery materials and biomedical sensing applications.
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Affiliation(s)
- Zeynep Dikmen
- Faculty of Engineering, Department of Biomedical Engineering, Eskisehir Osmangazi University, 26040 Eskisehir, Turkey
| | - Onur Turhan
- Institute of Science, Polymer Science and Technology Department, Eskisehir Osmangazi University, 26040 Eskisehir, Turkey
| | - Ayşegül Özbal
- Facullty of Science and Letters, Department of Chemistry, Eskisehir Osmangazi University, 26040 Eskisehir, Turkey
| | - Vural Bütün
- Facullty of Science and Letters, Department of Chemistry, Eskisehir Osmangazi University, 26040 Eskisehir, Turkey.
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Infantile Hemangiomas. Dermatol Clin 2022; 40:383-392. [DOI: 10.1016/j.det.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Li CX, Li H, Zhou YC, Gong ZC, Ling B. Application of topical betaxolol to cure superficial infantile hemangioma: A pilot study. Pediatr Int 2022; 64:e15384. [PMID: 36222187 DOI: 10.1111/ped.15384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Beta-blockers have gradually become an attractive option for the treatment of infantile hemangiomas. Topical application is preferred to oral administration because of their potential systemic adverse effects. The aim of this study is to investigate the effect of betaxolol in treating superficial infantile hemangioma. METHODS Seventy-four infants admitted to the First Affiliated Hospital of Xinjiang Medical University from 2018 to 2019 were observed and recorded. Variables such as color, size, tension, and thickness were recorded monthly and evaluated using visual analog scales. Multi-factor analysis of variance with repeated measurements and the non-parametric Kruskal-Wallis H test were used to compare clinical effectiveness across the different groups. RESULTS After 6 months of treatment, 33.78% (25/74) showed excellent results, 55.41% (41/74) had good responses, 8.11% (6/74) had moderate responses, and 2.70% (2/74) had poor responses. Local discomfort and systemic complications were not found. There was no significant difference in gender and location of occurrence among groups (p > 0.05), and the effect of topical application of betaxolol was optimum in the children aged 0-3 months (p = 0.002). None of three age groups had statistically significant difference in heart rate and blood pressure after accepting treatment (1 month, p = 0.618; 4 months, p = 0.138; 6 months, p = 0.757). CONCLUSIONS Our study showed that topical administration of betaxolol was effective and well tolerated for superficial infantile hemangiomas, particularly in the early proliferative stage. However, its safety and efficacy need further research.
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Affiliation(s)
- Chen-Xi Li
- Department of Oral and Maxillofacial Surgery & Oncology, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Stomatological Research Institute of Xinjiang Autonomous Region, Urumqi, China.,Laboratory for Tumor Genetics and Regenerative Medicine, Department of Oral and Maxillofacial Surgery, Department of Neurology, the Head and Neurocenter, University Hospital Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Hong Li
- Department of Oral and Maxillofacial Surgery & Oncology, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Stomatological Research Institute of Xinjiang Autonomous Region, Urumqi, China
| | - Yu-Chuan Zhou
- Department of Oral and Maxillofacial Surgery & Oncology, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Stomatological Research Institute of Xinjiang Autonomous Region, Urumqi, China
| | - Zhong-Cheng Gong
- Department of Oral and Maxillofacial Surgery & Oncology, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Stomatological Research Institute of Xinjiang Autonomous Region, Urumqi, China
| | - Bin Ling
- Department of Oral and Maxillofacial Surgery & Oncology, The First Affiliated Hospital of Xinjiang Medical University, School/Hospital of Stomatology Xinjiang Medical University, Stomatological Research Institute of Xinjiang Autonomous Region, Urumqi, China
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Leung AKC, Lam JM, Leong KF, Hon KL. Infantile Hemangioma: An Updated Review. Curr Pediatr Rev 2021; 17:55-69. [PMID: 32384034 DOI: 10.2174/1573396316666200508100038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/20/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life. OBJECTIVE To familiarize physicians with the natural history, clinical manifestations, diagnosis, and management of infantile hemangiomas. METHODS A Pubmed search was conducted in November 2019 in Clinical Queries using the key term "infantile hemangioma". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. RESULTS The majority of infantile hemangiomas are not present at birth. They often appear in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches. Then, they grow rapidly in the first 3 to 6 months of life. Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated. Deep lesions are bluish and dome-shaped. Infantile hemangiomas continue to grow until 9 to 12 months of age, at which time the growth rate slows down to parallel the growth of the child. Involution typically begins by the time the child is a year old. Approximately 50% of infantile hemangiomas will show complete involution by the time a child reaches age 5; 70% will have disappeared by age 7; and 95% will have regressed by 10 to 12 years of age. The majority of infantile hemangiomas require no treatment. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration in areas where serious complications might ensue, interference with vital structures, life- or function-threatening complications, and significant disfigurement. CONCLUSION Treatment should be individualized, depending upon the size, rate of growth, morphology, number, and location of the lesion (s), existing or potential complications, benefits and adverse events associated with the treatment, age of the patient, level of parental concern, and the physician's comfort level with the various treatment options. Currently, oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas. Topical timolol may be considered for superficial infantile hemangiomas that need to be treated and for complicated infantile hemangiomas in patients at risk for severe adverse events from oral administration of propranolol.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
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Rotter A, de Oliveira ZNP. Das infantile Hämangiom: Pathogenese und Wirkmechanismus von Propranolol. J Dtsch Dermatol Ges 2019; 15:1185-1191. [PMID: 29228484 DOI: 10.1111/ddg.13365_g] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 07/14/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Anita Rotter
- Department of Dermatology, University of São Paulo Medical School, Brazil
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Novoa M, Baselga E, Beltran S, Giraldo L, Shahbaz A, Pardo‐Hernandez H, Arevalo‐Rodriguez I. Interventions for infantile haemangiomas of the skin. Cochrane Database Syst Rev 2018; 4:CD006545. [PMID: 29667726 PMCID: PMC6513200 DOI: 10.1002/14651858.cd006545.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infantile haemangiomas (previously known as strawberry birthmarks) are soft, raised swellings of the skin that occur in 3% to 10% of infants. These benign vascular tumours are usually uncomplicated and tend to regress spontaneously. However, when haemangiomas occur in high-risk areas, such as near the eyes, throat, or nose, impairing their function, or when complications develop, intervention may be necessary. This is an update of a Cochrane Review first published in 2011. OBJECTIVES To assess the effects of interventions for the management of infantile haemangiomas in children. SEARCH METHODS We updated our searches of the following databases to February 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, LILACS, and CINAHL. We also searched five trials registries and checked the reference lists of included studies for further references to relevant trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of all types of interventions, versus placebo, active monitoring, or other interventions, in any child with single or multiple infantile haemangiomas (IHs) located on the skin. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The primary outcome measures were clearance, a subjective measure of improvement, and adverse events. Secondary outcomes were other measures of resolution; proportion of parents or children who consider there is still a problem; aesthetic appearance; and requirement for surgical correction. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included 28 RCTs, with a total of 1728 participants, assessing 12 different interventions, including lasers, beta blockers (e.g. propranolol, timolol maleate), radiation therapy, and steroids. Comparators included placebo, an active monitoring approach, sham radiation, and interventions given alone or in combination.Studies were conducted in a number of countries, including China, Egypt, France, and Australia. Participant age ranged from 12 weeks to 13.4 years. Most studies (23/28) included a majority of females and different types of IHs. Duration of follow-up ranged from 7 days to 72 months.We considered most of the trials as at low risk of random sequence generation, attrition bias, and selective reporting bias. Domains such as allocation concealment and blinding were not clearly reported in general. We downgraded evidence for issues related to risk of bias and imprecision.We report results for the three most important comparisons, which we chose on the basis of current use. Outcome measurement of these comparisons was at 24 weeks' follow-up.Oral propranolol versus placeboCompared with placebo, oral propranolol 3 mg/kg/day probably improves clinician-assessed clearance (risk ratio (RR) 16.61, 95% confidence interval (CI) 4.22 to 65.34; 1 study; 156 children; moderate-quality evidence) and probably leads to a clinician-assessed reduction in mean haemangioma volume of 45.9% (95% CI 11.60 to 80.20; 1 study; 40 children; moderate-quality evidence). We found no evidence of a difference in terms of short- or long-term serious adverse events (RR 1.05, 95% CI 0.33 to 3.39; 3 studies; 509 children; low-quality evidence), nor in terms of bronchospasm, hypoglycaemia, or serious cardiovascular adverse events. The results relating to clearance and resolution for this comparison were based on one industry-sponsored study.Topical timolol maleate versus placeboThe chance of reduction of redness, as a measure of clinician-assessed resolution, may be improved with topical timolol maleate 0.5% gel applied twice daily when compared with placebo (RR 8.11, 95% CI 1.09 to 60.09; 1 study; 41 children;low-quality evidence). Regarding short- or long-term serious cardiovascular events, we found no instances of bradycardia (slower than normal heart rate) or hypotension in either group (1 study; 41 children; low-quality evidence). No other safety data were assessed, and clearance was not measured.Oral propranolol versus topical timolol maleateWhen topical timolol maleate (0.5% eye drops applied twice daily) was compared with oral propranolol (via a tablet taken once per day, at a 1.0 mg/kg dose), there was no evidence of a difference in haemangioma size (as a measure of resolution) when measured by the proportion of patients with a clinician-assessed reduction of 50% or greater (RR 1.13, 95% CI 0.64 to 1.97; 1 study; 26 participants; low-quality evidence). Although there were more short- or long-term general adverse effects (such as severe diarrhoea, lethargy, and loss of appetite) in the oral propranolol group, there was no evidence of a difference between groups (RR 7.00, 95% CI 0.40 to 123.35; 1 study; 26 participants; very low-quality evidence). This comparison did not measure clearance.None of our key comparisons evaluated, at any follow-up, a subjective measure of improvement assessed by the parent or child; proportion of parents or children who consider there is still a problem; or physician-, child-, or parent-assessed aesthetic appearance. AUTHORS' CONCLUSIONS We found there to be a limited evidence base for the treatment of infantile haemangiomas: a large number of interventions and outcomes have not been assessed in RCTs.Our key results indicate that in the management of IH in children, oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harms. We found no evidence of a difference between oral propranolol and topical timolol maleate with regard to reducing haemangioma size, but we are uncertain if there is a difference in safety. Oral propranolol is currently the standard treatment for this condition, and our review has not found evidence to challenge this. However, these results are based on moderate- to very low-quality evidence.The included studies were limited by small sample sizes and risk of bias in some domains. Future trials should blind personnel and participants; describe trials thoroughly in publications; and recruit a sufficient number of children to deduce meaningful results. Future trials should assess patient-reported outcomes, as well as objective outcomes of benefit, and should report adverse events comprehensively. Propranolol and timolol maleate require further assessment in RCTs of all types of IH, including those considered problematic, as do other lesser-used interventions and new interventions. All treatments should be compared against propranolol and timolol maleate, as beta blockers are approved as standard care.
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Affiliation(s)
- Monica Novoa
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Eulalia Baselga
- Hospital de la Santa Creu i Sant PauPaediatric Dermatology DepartmentPare M Claret 167BarcelonaSpain08025
| | - Sandra Beltran
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Lucia Giraldo
- Hospital San Jose‐Fundacion Universitaria de Ciencias de la SaludPaediatric Dermatology DepartmentCarrera 19, No. 8A‐32BogotaColombia
| | - Ali Shahbaz
- University of AlbertaDepartment of Dermatology8‐112 Clinical Science BuildingEdmontonAlbertaCanadaT6G 2G3
| | - Hector Pardo‐Hernandez
- Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau) ‐ CIBER Epidemiología y Salud Pública (CIBERESP)C. Sant Antoni Maria Claret 171BarcelonaCatalunyaSpain08041
| | - Ingrid Arevalo‐Rodriguez
- Universidad Tecnológica EquinoccialCochrane Ecuador. Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC). Facultad de Ciencias de la Salud Eugenio EspejoAv. Mariscal Sucre s/n y Av. Mariana de JesúsQuitoEcuador
- Hospital Ramon y Cajal (IRYCIS)Clinical Biostatistics UnitMadridSpain
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Rotter A, de Oliveira ZNP. Infantile hemangioma: pathogenesis and mechanisms of action of propranolol. J Dtsch Dermatol Ges 2017; 15:1185-1190. [PMID: 29193649 DOI: 10.1111/ddg.13365] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 07/14/2017] [Indexed: 01/21/2023]
Abstract
Infantile hemangioma (IH) is the most common benign tumor of childhood, with a prevalence of 4 % to 10 %. It is characterized by a proliferative rapid growth phase, which starts after a few weeks of life, followed by a slow regression phase. In IH cases that are potentially disfiguring or life-threatening (10 % to 15 % of all cases), systemic therapy should be promptly initiated. Data source The present study reviews published scientific articles available in reliable electronic databases. Selected were all studies that evaluated the pathogenesis of IH and the mechanisms of action of propranolol. Conclusions The pathogenesis of IH has not been fully elucidated. Studies show that, in the proliferative phase of IH, there is an imbalance of angiogenic factors and an increase in the levels of vascular endothelial growth factor and matrix metalloproteinases 2 and 9. In the regression phase, the levels of these factors decrease, whereas those of antiangiogenic factors, including tissue inhibitors of matrix metalloproteinases, increase. Since 2008, propranolol has become the drug of choice in the treatment of IH, targeting vascular tone, angiogenesis, and apoptosis. Current insights into the pathogenesis of IH allow for the development of new therapeutic strategies.
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Affiliation(s)
- Anita Rotter
- Department of Dermatology, University of São Paulo Medical School, Brazil
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Developing a Nanoparticle-Delivered High-Efficacy Treatment for Infantile Hemangiomas Using a Mouse Hemangioendothelioma Model. Plast Reconstr Surg 2017; 138:410-417. [PMID: 27465164 DOI: 10.1097/prs.0000000000002403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Current treatments for infantile hemangiomas have unpredictable outcomes. The authors' aim was to develop a nanoporphyrin-delivered, high-efficacy treatment for infantile hemangiomas using a mouse hemangioendothelioma model. METHODS The authors injected mouse hemangioendothelioma cells intradermally to axillary regions of 5-week-old, female, nude mice (n = 19) to induce hemangioendothelioma growth. They documented nanoporphyrin accumulation in hemangioendotheliomas using positron emission tomography. For the treatment study, the authors randomized hemangioendothelioma-bearing nude mice (n = 9) into three groups (n = 3 each). Group I received only saline injections. Group II received only laser treatment after saline injection, and group III received laser treatment after nanoporphyrin injection through the tail vein. The authors followed up the treatment response with digital caliper measurements. RESULTS Hemangioendotheliomas started to grow approximately 1 week after inoculation and resembled infantile hemangiomas histologically. Nanoporphyrin uptake in hemangioendotheliomas was 19.7 ± 2.2, 16.7 ± 2.02, 8.4 ± 0.3, and 4.9 ± 0.6 percent injected dose per gram of tissue at 3, 6, 24, and 48 hours after injection, respectively. Nanoporphyrin uptake was significantly higher than in blood at 24 and 48 hours after injection (p < 0.05). Results of ex vivo biodistribution study were consistent with positron emission tomographic imaging. Hemangioendotheliomas in group III started to regress 1 day after the treatment and disappeared totally by day 21. The difference between tumor volumes in group III and other groups was significant on days 17 and 21 (p < 0.05). CONCLUSIONS Nanoporphyrin accumulated in hemangioendotheliomas at high concentrations, enabling a high-efficacy photodynamic therapy. Given the similarities between hemangioendotheliomas and infantile hemangiomas, this treatment potentially can be a high-efficacy treatment for infantile hemangiomas.
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Abstract
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.
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Affiliation(s)
- Anil Abraham
- Department of Dermatology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Anupa Mary Job
- Department of Dermatology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Gillian Roga
- Department of Dermatology, St. John's Medical College Hospital, Bengaluru, Karnataka, India
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Abstract
OBJECTIVES The aim of the present study was to document the clinical presentation, diagnostic studies, and therapy of gastrointestinal infantile hemangiomas. METHODS This is a retrospective analysis of children with gastrointestinal hemangiomas culled from our Vascular Anomalies Center database. We detailed the location of visceral and cutaneous tumors, as well as radiologic and procedural methods used for diagnosis and treatment. RESULTS A total of 9 of the 16 children (14 girls and 2 boys) with hollow visceral hemangiomas also had cutaneous lesions. The most common extravisceral sites were regional facial lesions (n = 6), multifocal lesions (n = 2), and a solitary chest lesion (n = 1). Presenting symptoms were melena and hematochezia in the first 4 months of life (n = 14); several infants required multiple blood transfusions. The most frequent locations were small bowel and mesentery. One-half of the patients (n = 8) were diagnosed by laparotomy; the majority (n = 12) had suspicious radiologic findings. Corticosteroid and/or propranolol were the most common therapies. CONCLUSIONS Melena and hematochezia, sometimes with profound anemia, in the first 4 months of life, suggest the possibility of intestinal infantile hemangioma even in the absence of cutaneous tumor. Intestinal bleeding, particularly in association with a regional facial lesion, should initiate workup: ultrasonography, computed tomography, and magnetic resonance imaging display diagnostic features. First-line treatment is medical management; bowel resection may be necessary, particularly for perforation.
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Funk T, Prok L, Brown LD, Bruckner AL. Multifocal vascular tumors and fetal hydrops. J Pediatr 2014; 164:1214-8. [PMID: 24433827 DOI: 10.1016/j.jpeds.2013.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/22/2013] [Accepted: 12/06/2013] [Indexed: 01/23/2023]
Affiliation(s)
- Tracy Funk
- Department of Dermatology, University of Colorado, Aurora, CO
| | - Lori Prok
- Department of Dermatology, University of Colorado, Aurora, CO; Department of Pediatrics, University of Colorado, Aurora, CO
| | - Laura D Brown
- Department of Pediatrics, University of Colorado, Aurora, CO
| | - Anna L Bruckner
- Department of Dermatology, University of Colorado, Aurora, CO; Department of Pediatrics, University of Colorado, Aurora, CO.
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Abstract
Propranolol has replaced corticosteroids as preferred first-line therapy for the management of infantile hemangiomas (IH). The topical β-blocker timolol is now an alternative to oral propranolol and watchful waiting for smaller IH. Research in the last decade has provided evidence-based data about natural history, epidemiology, and syndromes associated with IH. The most pressing issue for the clinician treating children with IH is to understand current data to develop an individualized risk stratification for each patient and determine the likelihood of complications and need for treatment. This article emphasizes the nuances of complicated clinical presentations and current treatment recommendations.
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Affiliation(s)
- Katherine B Püttgen
- Division of Pediatric Dermatology, Department of Dermatology, Johns Hopkins University School of Medicine, 200 North Wolfe Street, Unit 2107, Baltimore, MD 21287, USA.
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Identification of serum regression signs in infantile hemangioma. PLoS One 2014; 9:e88545. [PMID: 24599340 PMCID: PMC3943717 DOI: 10.1371/journal.pone.0088545] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/08/2014] [Indexed: 12/31/2022] Open
Abstract
Vessel proliferation underlies a number of serious pathological conditions. Infantile Hemangioma (IH) is a low-aggressive vascular tumor, interesting as an in vivo model of spontaneous tumor regression. Identifying mechanisms underlying IH spontaneous regression may then help to elucidate vessel-growth control, strongly deregulated in other serious conditions such as sarcoma, melanoma, diabetic retinopathy. The present study was aimed at identifying early regression indicators within hematological parameters. Thirty-four blood samples were collected from IH diagnosed babies (20-months median age), spontaneously regressing with age. Nineteen serum standard blood-tests were carried out using diagnostic reagents; in addition, serum-expression of 27 cytokine/chemokines was measured. Samples were divided in three age-groups, namely ≤12, 13 to 24 and >24 months-age, respectively. Red-cells count, Hemoglobin, Hematocrit, Neutrophils, Lymphocytes, MCP-1 and MIP-1beta were significantly different in the three age-groups, according to one-way ANOVA analysis. The same parameters showed a significant Pearson-correlation with age, supporting the direct link of age with IH-regression. ROC analysis showed that red-cells count, Hemoglobin, Hematocrit, MCP-1 and MIP-1beta levels significantly discriminate IH in the proliferating-phase from IH in the regressing-phase. Such data indicate for the first time that standard hematological tests and cytokine serum-expression values may effectively discriminate proliferating- from regressing-IH, unrevealing early regression signs, and demonstrate that standard blood-tests may have novel unsuspected diagnostic/prognostic relevance in altered vessel-growth conditions.
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Abstract
PURPOSE OF REVIEW Congenital melanocytic nevi (CMN) and infantile hemangiomas are commonly encountered in newborns and may present diagnostic and therapeutic dilemmas for medical practitioners. Herein, we review and discuss these two important clinical entities and focus on core issues and recent advances. RECENT FINDINGS Melanoma risk for patients with CMN is greatest in infants with large CMN located on the trunk, CMN greater than 40 cm, and multiple satellite nevi. Recent histological and molecular findings have been described to assist in differentiating benign proliferative nodules arising in CMN from melanoma. Multiple CMN and associated neurological lesions have recently been shown to be due to a single postzygotic mutation in NRAS [neuroblastoma RAS viral (v-ras) oncogene homolog]. Over the last several years, numerous advancements have occurred in redefining the clinical course of infantile hemangiomas, describing clinical syndromes associated with infantile hemangiomas and treating complicated infantile hemangiomas. The nonselective β-blocker propranolol has become first-line therapy for the treatment of complicated infantile hemangiomas. Topical timolol shows promise for the treatment of certain types of infantile hemangiomas. SUMMARY Although most CMN and infantile hemangiomas do not require active intervention, understanding which lesions may impact the overall health of the infant assists in early intervention. This article touches on core concepts in the clinical evaluation and treatment of CMN and infantile hemangioma.
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Blei F. Update December 2013. Lymphat Res Biol 2013. [DOI: 10.1089/lrb.2013.1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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