Preliminary Study of Fibrin Glue Combined With Pingyangmycin for the Treatment of Venous Malformations in the Oral and Maxillofacial Region

Management of vascular malformations in the Oral and maxillofacial region: A systematic review

OBJECTIVE

The purpose is to determine the comprehensive review and the current concepts on the management of vascular malformation and to evaluate the long term outcomes, recurrence and complication rate.

METHODS

This systematic review followed PRISMA guidelines and registered in PROSPERO (CRD42020173735). The PUBMED, EBSCO, SCOPUS and NDH databases were used to perform a comprehensive search of articles published up until July 2020. The database search identified 1719 articles. After an intricate review, 34 studies were estimated for eligibility.

RESULTS

A total of 1719 patients with mean age of 27.48 years were treated for vascular malformation in the oral and maxillofacial region. Moderate heterogeneity was observed for the outcome (P = 0.166; 95% CI:1.01-1.46, I² = 48%). As determined by one-way ANOVA, there was no statistically significant difference between the type of diagnosis and the recurrence (F = 2.313, p = 0.092) and the complication rate (F = 2.112, p = 0.117).

CONCLUSION

In accordance with the available scientific literature, this review has highlighted the modalities and advancement in the management of vascular malformations. Complications and recurrence were reported in all types of management. It can be avoided by careful diagnosis, pre-operative assessment and treatment planning.

What is the preferred concentration of ethanolamine oleate for sclerotherapy of oral vascular anomalies?

Background

This study compared three different concentrations of EO (1.25%, 2.5% and 5%) for the treatment of oral vascular anomalies (OVAs).

Material and Methods

This was a retrospective comparative analysis of patients with OVAs treated with EO. Anomalies smaller than 20 mm were included. The patients were treated with 1.25% (G1), 2.5% (G2), and 5% (G3) and clinical data were obtained. The number of sessions, the final volume and dose of EO were statistically analyzed to verify effectiveness and safety of the treatment. The different concentrations of EO were compared considering the number of sessions, the final volume and total dose of EO. Analysis of covariance (ANCOVA) was used to evaluate the influence of covariates on the outcomes. A p-value < 0.05 was considered significant.

Results

Nineteen women and 11 men with a median age of 54 years were included. The OVAs were most frequent in the lip (n=14) and cheek (n=9). All lesions exhibited complete clinical healing within 28 days. Patients of G3 required fewer sessions than those of G2 (p=0.017), a lower final volume compared to the other groups (p<0.001), and a lower total dose than G1 (p<0.001). Patients of G1 used a lower total dose than G2 (p=0.003).

Conclusions

The concentration of 5% EO performed better than 1.25% and 2.5% for sclerotherapy of OVAs measuring up to 20 mm. This preliminary result should be the preferred concentration of EO to provide an effective and safe treatment of OVAs.

Key words:Ethanolamine oleate, sclerotherapy, vascular malformations, hemangioma, oral mucosa.

Embolization and sclerotherapy of maxillofacial arteriovenous malformations with the use of fibrin glue combined with pingyangmycin

OBJECTIVE

The objectives of this study were to document the results of using fibrin glue (FG) combined with pingyangmycin (PYM) for the embolism and sclerotherapy of maxillofacial arteriovenous malformations (AVMs).

STUDY DESIGN

We reviewed the associated clinical data from December 2012 to June 2017 for 25 patients with maxillofacial AVMs. The major treatment method was direct percutaneous puncture and injection of FG combined with PYM. Treatment outcomes were assessed through physical examination, Doppler ultrasonography, computed tomography, and 3-dimensional computed tomography angiography scans. Follow-up time ranged from 12 months to 3 years after the last treatment (mean 21 months).

RESULTS

Of the 25 lesions, 80% showed greater than 90% reduction, 12% showed greater than 75% reduction, and 8% showed greater than 50% reduction. Superficial skin necrosis or mucous ulcer occurred in 3 patients and healed without intervention. Regrowth was observed in 3 patients with extensive lesions involving multiple anatomic regions.

CONCLUSIONS

These data suggest that embolization and sclerotherapy with the use of FG combined with PYM are safe and effective for the treatment of small- to medium-sized, locally dilated maxillofacial AVMs. For AVMs involving multiple anatomic regions, combined application of this approach with other options should be considered.

A clinical study of pingyangmycin sclerotherapy for venous malformation: an evaluation of 281 consecutive patients

WHAT IS KNOWN AND OBJECTIVE

In China, lidocaine together with 2 mg/mL of pingyangmycin (PYM, also known as bleomycin A5) is recommended for the treatment of venous malformations (VMs). The purpose of this study was to investigate whether lidocaine has a synergistic effect with PYM in improving the therapeutic outcomes of patients with VMs. Additionally, this study aimed to evaluate the outcomes of sclerotherapy for VMs using an intralesional injection of a low concentration of PYM (0·5 mg/mL).

METHODS

A total of 281 patients with VMs were treated with 0·5 or 2 mg/mL of PYM with or without lidocaine and dexamethasone (DEX). All of the patients received a direct intralesional injection at a rate of 1 mL/min, and the volume of the solution varied from 1·5 to 6·0 mL per injection.

RESULTS AND DISCUSSION

No significant differences were observed in the clinical outcomes between the PYM and PYM + lidocaine treatment groups (P > 0·05). The clinical outcomes were similar between the groups that were treated with 0·5 and 2 mg/mL of PYM, but the swelling and pain in the patients who were treated with 0·5 mg/mL of PYM were less severe compared with the patients who were treated with 2 mg/mL of PYM. A total of 29 patients with VM lesions on the glans penis were treated with 0·5 mg/mL of PYM + 0·5% lidocaine. Of these patients, 26 were cured, whereas three experienced a marked improvement.

WHAT IS NEW AND CONCLUSION

Lidocaine does not have a synergistic effect with PYM in improving the therapeutic outcomes of patients with VMs. Sclerotherapy with a low concentration of PYM (0·5 mg/mL) combined with lidocaine and DEX is a safe and effective therapy for small superficial VMs of critical organs, such as the lips and the glans penis.

Proapoptotic effect and the mechanism of action of pingyangmycin on cavernous hemangiomas

This study aimed to investigate the proapoptotic effects and the mechanism of action of pingyangmycin (PY) on cavernous hemangioma. The rat spleen was used as a model of cavernous hemangioma. PY was injected into the spleen and the pathological changes were observed at different time-points. Apoptosis was detected using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay and transmission electron microscopy (TEM). The expression levels of the apoptosis-related protein, caspase-3, were determined using immunohistochemistry and image analysis. Rats injected with normal saline were the control group. Injection of normal saline did not damage rat spleens. On days 2 and 5 following PY injection, the spleens exhibited slight swelling. On days 8 and 14, atrophic changes were observed and the splenic sinus endothelial cells were damaged. At various time-points following PY injection, the apoptotic cells were observed by TEM. The TUNEL assay showed that apoptosis occurred widely among the splenic sinus endothelial cells and other splenic cells. The apoptotic rate and caspase-3 expression levels increased with prolonged PY exposure. PY induced apoptosis of splenic sinus endothelial cells through the caspase-3 activation pathway, and resulted in endothelial cell necrosis and fibroblast hyperplasia.

A Step-by-Step Practical Approach to Imaging Diagnosis and Interventional Radiologic Therapy in Vascular Malformations

Within vascular anomalies, vascular malformations are those present at birth that grow with the patient and exhibit abnormal dilated vascular channels lined by mature endothelium. Vascular tumors, the other group of vascular anomalies, demonstrate endothelial hypercellularity. Vascular malformations are further divided into low-flow varieties (capillary, venous, and lymphatic malformations) and high-flow varieties (arteriovenous malformation and fistula). All malformations exhibit a predictable group of clinical patterns that vary in severity and rate of progression. The interventional radiologist must incorporate this clinical data with characteristic ultrasound and magnetic resonance findings to arrive at a diagnosis. One must then decide in a multidisciplinary fashion, based on objective clinical criteria and image-based morphology, if the patent is a candidate for intervention. Sclerotherapy is a technique used to treat vascular malformations whereby an endothelial-cidal agent is introduced into the endoluminal compartment to initiate vascular closure. The high flow rate of an arteriovenous malformation requires the incorporation of superselective transarterial, direct, and transvenous access with flow reduction techniques to deliver adequate dose of sclerosant and embolic to the nidus. Satisfactory outcomes are seen in over half of all malformations patients. Similar treatment-related complications are seen between malformations but are lowest in lymphatic and highest in arteriovenous malformations.

Treatment guideline for hemangiomas and vascular malformations of the head and neck

Vascular anomalies are among the most common congenital and neonatal dysmorphogenesis, which are separated into hemangiomas and vascular malformations. They can occur in various areas throughout the body, with 60% being located in the head and neck. The true mechanism of pathogenesis of vascular anomalies is still unclear. Various treatment methods have been reported, and there are still controversies over the selection of different treatment modalities. Based on the clinical and basic research and current literature, the Chinese Division of Oral and Maxillofacial Vascular Anomalies formulated a treatment guideline for hemangiomas and vascular malformations of the head and neck, which will be modified and updated periodically based on new medical evidence and research.

Percutaneous sclerotherapy of massive venous malformations of the face and neck using fibrin glue combined with OK-432 and pingyangmycin

BACKGROUND

Surgical excision is useful only for localized and limited lesions. The purpose of this study was to evaluate the clinical curative effect of percutaneous sclerotherapy of massive venous malformations of the face and neck using fibrin glue combined with OK-432 and pingyangmycin.

METHODS

Eighteen patients with massive venous malformations were treated with an injection of fibrin glue combined with OK-432 and pingyangmycin.

RESULTS

All the patients had extreme swelling postoperatively with no major complications. The follow-up period ranged from 6 to 12 months. Twelve lesions were completely involuted, 4 lesions were mostly involuted, and 2 lesions were partially involuted. All of the patients had normal liver and kidney functions. None of the patients presented with hematologic toxic effects or signs of pulmonary involvement.

CONCLUSION

Percutaneous sclerotherapy using fibrin glue combined with OK-432 and pingyangmycin provided a simple, safe, and reliable alternative treatment for massive venous malformations.