Guidance Document for Hepatic Hemangioma (Infantile and Congenital) Evaluation and Monitoring

Diagnostic approach to hepatic vascular lesions: a paediatric perspective

The pathological evaluation of hepatic vascular lesions in children requires special consideration. Inconsistent terminology, rarity of pathology specimens and overlapping pathological features between various lesions may pose a serious diagnostic challenge. In this review, we highlight the importance of using the International Society for the Study of Vascular Anomalies (ISSVA) classification scheme to characterise these lesions. Selected entities are discussed, including hepatic vascular tumours exclusively seen in the paediatric age group, hepatic infantile haemangioma and hepatic congenital haemangioma. Vascular malformations, with emphasis on their syndromic associations (venous malformation in blue rubber bleb naevus syndrome) and complications (hepatocellular nodules in Abernethy malformation) are also covered.

How many is too many? A review of the significant numbers in pediatric skin lesions and their recommended evaluation

Pediatric dermatologists are frequently consulted to evaluate children for cutaneous signs of systemic disorders. Numerical thresholds of significance have been described in the dermatologic literature for various skin findings where the likelihood of an associated extracutaneous abnormality or known genetic syndrome increases significantly. Knowledge of these numerical thresholds facilitates diagnosis and management, which improves clinical outcomes and avoids severe complications. This review highlights the clinical presentation, complications, evaluation, and numerical significance, when applicable, for the following skin findings: infantile hemangiomas, capillary malformations, café-au-lait macules, hypopigmented macules, juvenile xanthogranulomas, pilomatricomas, and angiofibromas.

A 6-Week-Old Boy With Irritability and Abdominal Distension

A 6-week-old boy is brought to the hospital for fussiness and abdominal distension. He was febrile on presentation and was admitted to the hospital for further evaluation. On subsequent examinations, he continued to demonstrate abdominal distension and tenderness to palpation. Ultrasonography of the abdomen was performed and revealed a heterogeneous liver mass. With further diagnostics, a diagnosis was made and treatment initiated, with the infant experiencing resolution of his symptoms. Our panel of experts first discuss the management of an infant with abdominal distension, then discuss the evaluation of a liver mass in an infant, including oncologic, vascular, and infectious etiologies.

Can Dynamic Contrast-Enhanced MRI Be Used to Differentiate Hepatic Hemangioma from Other Lesions in Early Infancy?

Background  Confident diagnosis of hepatic hemangioma on imaging can avoid biopsy in early infancy and helps guide conservative management. Purpose  This article aims to determine if dynamic contrast-enhanced magnetic resonance imaging (MRI) can be used to differentiate liver hemangioma from other lesions in infants ≤ 100 days and to determine association of MRI features with hepatic lesions. Methods  MRI performed for liver lesions were retrospectively reviewed to note imaging characteristics and the MRI diagnosis. Final diagnosis was assigned based on pathology in available cases and by corroborative standard of reference including overall clinical features, lab findings, and follow-up. Results  Of 30 infants (18 boys, 12 girls; average age 42.2 days) included, 18 had solitary and 12 had multifocal lesions. Diagnoses in total 33 lesions included hemangiomas (23), hepatoblastoma (6), arteriovenous malformation (2), neuroblastoma metastases (1), and infarction (1). MRI and final diagnosis matched in 94% lesions with almost perfect agreement (kappa 0.86) for reader 1, and matched in 88% lesions with substantial agreement (kappa 0.71) for reader 2. Interobserver agreement for MRI diagnosis was substantial (kappa 0.62). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI in differentiating hemangioma from other lesions were 100, 90, 96, 100, and 97%, respectively. Centripetal (16/23) or flash (5/23) filling were only seen with hemangioma. There was no significant difference in alpha-fetoprotein elevation ( p 0.08), average size ( p 0.35), multifocality ( p 0.38), and intralesional hemorrhage ( p 1) between hemangioma and hepatoblastoma. Conclusion  Centripetal filling on dynamic imaging and absence of washout are characteristic MRI features of hepatic hemangioma that can help to differentiate it from other lesions in early infancy.

PIVKA-II combined with alpha-fetoprotein for the diagnostic value of hepatic tumors in children: a multicenter, prospective observational study

BACKGROUND

To investigate whether protein induced by vitamin K antagonist-II (PIVKA-II) combined with alpha-fetoprotein (AFP) can improve the diagnostic and differential diagnostic accuracy of childhood hepatic tumors.

METHODS

A multi-center prospective observational study was performed at nine regional institutions around China. Children with hepatic mass (Group T) were divided into hepatoblastoma group (Group THB) and hemangioendothelioma group (Group THE), children with extrahepatic abdominal mass (Group C). Peripheral blood was collected from each patient prior to surgery or chemotherapy. The area under the curve (AUROC) was used to evaluate the diagnostic efficiency of PIVKA-II and the combined tumor markers with AFP.

RESULTS

The mean levels of PIVKA-II and AFP were both significantly higher in Group T than Group C (p = 0.001, p < 0.001), in Group THB than Group THE (p = 0.018, p = 0.013) and in advanced HB than non-advanced HB (p = 0.001, p = 0.021). For the diagnosis of childhood hepatic tumors, AUROC of PIVKA-II (cut-off value 32.6 mAU/mL) and AFP (cut-off value 120 ng/mL) was 0.867 and 0.857. The differential diagnostic value of PIVKA-II and AFP in hepatoblastoma from hemangioendothelioma was further assessed, AUROC of PIVKA-II (cut-off value 47.1mAU/mL) and AFP (cut-off value 560 ng/mL) was 0.876 and 0.743. The combined markers showed higher AUROC (0.891, 0.895 respectively) than PIVKA-II or AFP alone.

CONCLUSIONS

The serum level of PIVKA-II was significantly higher in children with hepatic tumors, especially those with malignant tumors. The combination of PIVKA-II with AFP further increased the diagnostic performance.

TRIAL REGISTRATION

Clinical Trials, NCT03645655. Registered 20 August 2018, https://www.

CLINICALTRIALS

gov/ct2/show/NCT03645655 .

Clinical experience of infantile hepatic hemangioma

PURPOSE

To describe the clinical presentation, treatment preference, and relevant complications of infantile hepatic hemangioma (IHH) in propranolol era.

METHODS

The National Taiwan University Hospital integrated Medical Database (NTUH-iMD) was used to enroll twenty-one cases of IHH diagnosed from 2006 to 2020. Medical charts were retrospectively reviewed.

RESULTS

In nine patients (42.9%), IHH was found incidentally, and in seven patients (33%), it was detected during postnatal self-paid ultrasonography. Focal disease was determined in 17 patients, multifocal disease in 1 patient, and diffuse disease in 3 patients. Patients with diffuse disease had a lower hemoglobulin level than patients with focal IHH (9.38 vs. 12.6 mg/dL, p = 0.045). Two patients had Kasabach-Merritt phenomenon (KMP), one had hypothyroidism, and one had both. All patients with KMP had focal hepatic hemangiomas. Among the 17 patients with focal IHH, nine were prescribed propranolol, one was treated by surgical resection of the tumor, and the others had expectant management. All patients with multifocal and diffuse IHH were administered propranolol. One infant (7.7%) treated with propranolol had bradycardia initially but it subsided after dose adjustment.

CONCLUSIONS

Most IHH is found incidentally or detected during postnatal ultrasonography screening. Patients with large focal lesions should also be screened for associated complications. Propranolol is the drug of choice and a safe therapeutic option for IHH, especially for focal tumors >5 cm as well as multifocal and diffuse lesions.

Complex lymphatic anomalies: Molecular landscape and medical management

The lymphatic system is one of the most essential and complex systems in the human body. Disorders that affect the development or function of the lymphatic system can lead to multi-system complications and life-long morbidity. The past two decades have seen remarkable progress in our knowledge of the basic biology and function of the lymphatic system, the molecular regulators of lymphatic development, and description of disorders associated with disrupted lymphangiogensis. In this chapter we will touch on the clinical features of complex lymphatic anomalies, new molecular knowledge of the drivers of these disorders, and novel developmental therapeutics for lymphatic disease.

ACR Appropriateness Criteria® Soft Tissue Vascular Anomalies: Vascular Malformations and Infantile Vascular Tumors (Non-CNS)-Child

Soft tissue vascular anomalies may be composed of arterial, venous, and/or lymphatic elements, and diagnosed prenatally or later in childhood or adulthood. They are divided into categories of vascular malformations and vascular tumors. Vascular malformations are further divided into low-flow and fast-flow lesions. A low-flow lesion is most common, with a prevalence of 70%. Vascular tumors may behave in a benign, locally aggressive, borderline, or malignant manner. Infantile hemangioma is a vascular tumor that presents in the neonatal period and then regresses. The presence or multiple skin lesions in an infant can signal underlying visceral vascular anomalies, and complex anomalies may be associated with overgrowth syndromes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Management of Neonatal Hepatic Hemangiomas: A Single-Center Experience Focused on Challenging Cases

Background: Management of hepatic hemangioma (HH) in infancy ranges from close monitoring to surgical resection. We analyzed the clinical characteristics and outcomes of HH according to its treatment options, with particular focus on challenging cases. Methods: Data of patients diagnosed with HHs in their first year of life and followed up for at least 1 year were retrospectively reviewed and divided into treatment and observation groups. Serial imaging results, serum alpha-fetoprotein (AFP) levels, medications, and clinical outcomes were compared. The detailed clinical progress in the treatment group was reviewed separately. Results: A total of 87 patients (75 in the observation group and 12 in the treatment group) were included. The median HH size at the initial diagnosis and the maximum size were significantly larger in the treatment group than the observation group (2.2 [0.5-10.3] cm vs. 1.0 [0.4-4.0] cm and 2.1 [0.7-13.2] vs. 1.1 [0.4-4.0], respectively; all p < 0.05]. The median initial and last serum AFP levels were significantly higher in the treatment group than in the observation group (76,818.7 vs. 627.2 and 98.4 vs. 8.7, respectively; all p < 0.05). Serum AFP levels in both groups rapidly declined during the first 3 months of life and were almost undetectable after 6 months. Among the challenging cases, a large (14 × 10 × 6.5 cm sized) focal HH was successfully treated using stepwise medical-to-surgical treatment. Conclusions: Patients with large HH and mild symptoms can be treated using stepwise pharmacotherapy. More aggressive surgical treatment of tumors unresponsive to initial pharmacotherapy may help shorten the treatment period and improve outcomes.

Unusual Case of Diffuse Neonatal Hemangiomatosis Case Report and Literature Review

Diffuse neonatal hemangiomatosis (DNH) is an infrequent condition characterized by the simultaneous occurrence of multiple cutaneous hemangiomas and the involvement of 3 or more organs. DNH is suspected when multiple hemangiomas are identified on the skin of the infant. Although it is benign in nature, DNH can lead to critical and life-threatening complications. Diagnosis primarily relies on clinical evaluation with a significant emphasis on imaging techniques. In this case report, we present an unusual pediatric case of diffuse infantile hemangioendothelioma, for which the investigative approach included ultrasound and CT scans. These imaging methods were instrumental in revealing the presence of lesions in the liver, thyroid, and brain, ultimately playing a pivotal role in making the diagnosis of DNH. A positive clinical and biological improvement was observed with corticosteroid treatment during a 3-month follow-up.

Diffuse infantile hepatic hemangioma successfully treated with propranolol orally: a case report and literature review

Background

Infantile hepatic hemangioma (IHH) is a common vascular, fast-growing hepatic tumor that is usually accompanied by multiple cutaneous hemangiomas. Diffuse IHH (DIHH) is a rare type of IHH that exhibits many tumors with nearly complete hepatic parenchymal replacement. At present, there is no specific standardized treatment plan for DIHH. Herein, we present the case of a 2-month-old girl with DIHH and without cutaneous hemangioma who achieved complete remission after undergoing propranolol monotherapy.

Case presentation

The infant with low birth weight was presented to the pediatric department with a 2-month history of persistent vomiting and feeding difficulty. Ultrasonography and abdominal magnetic resonance imaging revealed hepatomegaly and diffused intrahepatic lesions. A computed tomography-guided percutaneous liver biopsy was performed, and the pathological examination suggested the diagnosis was DIHH. The patient exhibited remarkably response to an increasing dose of oral propranolol, from 0.5 mg/kg to 2 mg/kg every day. The intrahepatic lesions were almost completely regressed after one year of treatment and no distinct adverse reaction was observed.

Conclusion

DIHH can induce life-threatening complications that require prompt interventions. Propranolol monotherapy can be an effective and safe first-line treatment strategy for DIHH.

Postnatal treatment and evolution patterns of giant fetal hepatic hemangioma: a case series of 29 patients

OBJECTIVES

To explore the clinical characteristics, postnatal treatment and prognosis of giant fetal hepatic hemangioma (GFHH).

METHOD

Retrospective analysis was performed on children with giant fetal hepatic hemangioma (maximum tumor diameter > 40 mm) diagnosed by prenatal ultrasound and MRI from December 2016 to December 2020. These patients were observed and treated at the Children's Hospital of Fudan University after birth. The clinical data were collected to analyze the clinical characteristics, treatment, and prognosis of GFHH using independent sample t tests or Fisher's exact tests.

RESULTS

Twenty-nine patients who were detected by routine ultrasound in the second and third trimester of pregnancy with giant fetal hepatic hemangiomas were included. The first prenatal ultrasound diagnosis of gestational age was 34.0 ± 4.3 weeks, ranging from 22 to 39 weeks. Of the patients, 28 had focal GFHHs and 1 had multifocal GFHHs. Surgery was performed, and the diagnosis was confirmed histopathologically in two patients. There were 8 cases with echocardiography-based evidence of pulmonary hypertension, 11 cases had a cardiothoracic ratio > 0.6, and 4 cases had hepatic arteriovenous fistula (AVF). The median follow-up time was 37 months (range: 14-70 months). During the follow-up, 12 patients received medical treatment with propranolol as the first-line therapy. The treatment group had a higher ratio of cardiothoracic ratio > 0.6 (P = 0.022) and lower albumin levels (P = 0.018). Four (14.8%) lesions showed postnatal growth before involuting. Complete response was observed in 13 (13/29) patients, and partial response was observed in 16 (16/29) patients.

CONCLUSIONS

Fetal giant hepatic hemangioma is mainly localized, and its clinical outcome conforms to RICH (rapidly involuting) and PICH (partially involuting), but some fetal giant hepatic hemangiomas will continue to grow after birth and then gradually decrease. For uncomplicated giant fetal hepatic hemangioma, postnatal follow-up is the main concern, while those with complications require aggressive medical treatment. Propranolol may have no effect on the volume change of GFHH.

Update on the Pathology of Pediatric Liver Tumors: A Pictorial Review

Liver tumors in children are uncommon and show remarkable morphologic heterogeneity. Pediatric tumors may arise from either the epithelial or mesenchymal component of the liver and rarely may also show both lines of differentiation. Both benign and malignant liver tumors have been reported in children. The most common pediatric liver tumors by age are benign hepatic infantile hemangiomas in neonates and infants, malignant hepatoblastoma in infants and toddlers, and malignant hepatocellular carcinoma in teenagers. Here, we provide an up-to-date review of pediatric liver tumors. We discuss the clinical presentation, imaging findings, pathology, and relevant molecular features that can help in the correct identification of these tumors, which is important in managing these children.

Pediatric hepatic vascular tumors: clinicopathologic characteristics of 33 cases and proposed updates to current classification schemes

Pediatric hepatic vascular tumors (HVTs) are rare neoplasms with features distinct from their cutaneous counterparts. Their behavior ranges from benign to malignant, with each subtype having therapeutic differences. Histopathologic descriptions of large cohorts are scarce in the literature. Thirty-three putative HVTs diagnosed from 1970 to 2021 were retrieved. All available clinical and pathologic materials were reviewed. Lesions were reclassified according to the World Health Organization (WHO) classification of pediatric tumors [1] as hepatic congenital hemangioma (HCH; n = 13), hepatic infantile hemangioma (HIH; n = 10), hepatic angiosarcoma (HA; n = 3), and hepatic epithelioid hemangioendothelioma (HEH; n = 1). Vascular malformations (n = 5) or vascular-dominant mesenchymal hamartoma (n = 1) were excluded. HCH frequently showed involutional changes, whereas HIH often had anastomosing channels and pseudopapillae formation. HA had solid areas with epithelioid and/or spindled endothelial morphology, significant atypia, increased mitoses, high proliferation index, and occasionally necrosis. On morphology analysis, a subset of HIH showed features worrisome for progression to HA including solid glomeruloid proliferation, increased mitoses, and epithelioid morphology. The widely metastatic and fatal HEH was observed in a 5-year-old male with multiple liver lesions. Immunohistochemically, HIHs and HA were Glucose transporter isoform 1 (GLUT-1) positive. One HIH patient died from postoperative complications, whereas 3 are alive without disease. Five HCH patients are alive and well. Two of three HA patients died of disease, and 1 is alive without recurrence. To our knowledge, this is the largest series of pediatric HVTs reviewing clinicopathologic features based on current Pediatric WHO nomenclature [1]. We highlight diagnostic challenges and propose inclusion of an intermediate category between HIH and HA which warrants closer follow-up.

Prenatal ultrasound diagnosis of congenital infantile fibrosarcoma and congenital hemangioma: Three case reports

BACKGROUND

Congenital infantile fibrosarcoma (CIF) and congenital hemangioma (CH) have similarities on prenatal ultrasound and are rare.

CASE SUMMARY

We report 3 cases of fetuses with superficial hypervascular tumors, confirmed by postnatal pathology as CIF (1 case) and CH (2 cases, including 1 in a twin fetus). In Case 1, a mass with a rich blood supply in the fetal axilla was discovered by prenatal ultrasound at 28+0 wk of gestation. The postpartum pathological diagnosis was CIF, the mass was surgically removed, and the prognosis of the child was good. In Case 2, at 23+1 wk of gestation, a mass was discovered at the base of the fetus's thigh on prenatal ultrasound. The postpartum pathological diagnosis was CH. After conservative treatment, the mass shrank significantly. Case 3 occurred in a twin fetus. At 30+0 wk of gestation, prenatal ultrasound revealed a bulging mass with a rich blood supply on the abdominal wall of one of the fetuses. Three weeks later, the affected fetus died, and the unaffected baby was successfully delivered by emergency cesarean section. The affected fetus was pathologically diagnosed with CH.

CONCLUSION

Prenatal ultrasound can provide accurate information, such as the location, size and blood supply of a surface mass in a fetus. We found similarities between CIF and CH in prenatal ultrasound findings. Although it is difficult to distinguish these conditions by prenatal ultrasound alone, for superficial hypervascular tumors that rapidly increase in size in a short period, close ultrasound monitoring of the fetus is required to quickly address possible adverse outcomes.

MRI-based deep learning model for differentiation of hepatic hemangioma and hepatoblastoma in early infancy

Hepatic hemangioma (HH) and hepatoblastoma (HBL) are common pediatric liver tumors and present with similar clinical manifestations with limited distinguishing value of serum AFP in early infancy. An accurate differentiation diagnostic tool is warranted for optimizing treatments and improving prognosis. The present study aimed to develop an innovative and cost-effective diagnostic tool to differentiate HH and HBL in early infancy using advanced deep learning (DL) techniques. One hundred forty patients ≤4 months old diagnosed as HH or HBL with histological specimens were recruited from two institutions assigned into a training set with cross-validation and a testing set for external validation, respectively. Based on MRI images, imaging diagnoses were interpreted by two radiologists, and imaging-derived radiomic features were extracted by pretrained convolutional neural networks (CNNs)-Xception extractor via DL analysis. A nomogram model was constructed integrating predictive clinical variables, radiologist-based interpretation, and DL features, evaluated comprehensively on diagnostic and calibration accuracy. The DL-based model performed an area under the receiver operating characteristic curve (AUC) of 0.966 for the training cohort and 0.864 for the testing cohort. The radiologist-interpreted differentiation model showed an AUC of 0.837 in the testing cohort. The integrated nomogram model represented an increasing performance with an AUC of 0.887, accuracy of 78.57%, sensitivity of 76.19%, and specificity of 80.95% in the testing cohort.

CONCLUSION

 The MRI-based integrated model, a noninvasive preoperative diagnostic tool, yielded favorable efficacy for differentiating HH and HBL in early infancy, which might reduce the patients' costs of repetitive and unnecessary examinations or over-treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05170282.

WHAT IS KNOWN

• Hepatic hemangioma (HH) and hepatoblastoma (HBL) are common pediatric liver tumors and present with similar clinical manifestations with limited distinguishing value of serum AFP in early infancy. • Considering the rare incidence of infantile hepatic tumors, the distinguishing accuracy between HBL and HH for cases in early infancy is unsatisfactory for radiologists' recognition solely.

WHAT IS NEW

• The MRI-based integrated model, a noninvasive preoperative diagnostic tool yielded favorable efficacy for differentiating HH and HBL in early infancy, which might reduce the patients' costs of repetitive and unnecessary examinations or over-treatment.

Neonatal hepatic hemangioma with intestinal obstruction: A report of two cases

To explore the treatment experience of neonatal hepatic hemangioma (HH) with intestinal obstruction. Case 1 was 2.5 kg at birth and was 7 days old at the time of the visit. Case 1 underwent surgery 2 weeks after birth, and it was confirmed that HH was located in the left inner lobe of the liver, and it adhered to the ileocecal area to form an acute angle, leading to intestinal obstruction. The intestinal obstruction was significantly relieved. Postoperative pathology showed that case 1 had a congenital hemangioma. Case 1 started breastfeeding 3 days after the operation; the bowel function was well recovered, and the abdominal distension was significantly relieved. The child was discharged 1 week after the operation. Case 2 was 2.7 kg at birth and was 1 day old at the time of the visit. Case 2 was operated on 2 days after birth. During the operation, it was confirmed that the hepatic blood vessels were in the right anterior lobe of the liver. Postoperative pathology showed that case 2 had an infantile hemangioma. The posterior intestinal obstruction was significantly relieved. Case 2 began to drink a small amount of water on the 5th day after the operation and started breastfeeding on day 7. The abdominal distension was significantly relieved, and the stools were normal. reexamination showed no obvious recurrence of HH during a 2-year follow-up. Active surgical treatment should be considered if there is a risk of intestinal perforation to prevent serious complications.

Congenital hepatic hemangioma: an unusual case report of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) in newborns is a rare but serious condition that often requires immediate intervention and quick diagnosis of the correct etiology to prevent mortality. Congenital hepatic hemangioma (CHH) is an example of an extrathoracic etiology of PH.

CASE PRESENTATION

Herein, we report the case of a newborn with a giant liver hemangioma, who presented with an early onset of PH and was successfully treated with intra-arterial embolization.

CONCLUSIONS

This case illustrates the importance of suspicion and prompt evaluation of CHH and related systemic arteriovenous shunts among infants with unexplained PH.

Coexisting Infantile Hepatic Hemangioma and Hepatoblastoma in a Neonate: A Case Report

Infantile hepatic hemangioma and hepatoblastoma are the most common benign and malignant tumors of the liver in the neonatal and early childhood periods, respectively. However, the simultaneous occurrence of these 2 tumors in the same liver lesion is very rare. We report a case of a newborn infant diagnosed with a liver mass by ultrasound examination 4 days after birth. Serum alpha-fetoprotein (AFP) was elevated for his age (32,881.7 ng/mL). The liver mass was resected. Macroscopically, an externally protruding mass measuring 6 × 4 × 3.5 cm was identified. Microscopically, we observed the coexistence of infantile hepatic hemangioma and epithelial hepatoblastoma components within the tumor. The infantile hepatic hemangioma component was composed of multiple small vascular channels lined by endothelial cells. In the hepatoblastoma component, tumor cells were arranged in a 2- to 3-cell-thick trabecular formation. Immunohistochemistry indicated that the tumor cells in the infantile hepatic hemangioma component expressed CD34, CD31, FLI1, and ERG, and those in the hepatoblastoma component expressed hepatocyte, keratin AE1/AE3 and keratin 8, glypican 3, glutamine synthetase, and AFP. Pathological examination confirmed the presence of an infantile hepatic hemangioma combined with epithelial hepatoblastoma (fetal type). The boy did not undergo chemotherapy after the operation. Regular follow-up through serum AFP levels and liver ultrasound for 16 months to date show that the serum AFP levels decreased continuously to normal levels, with no signs of tumor recurrence or metastasis. The coexistence of infantile hepatic hemangioma and hepatoblastoma is rare. Hepatoblastoma should be considered in neonates with liver tumors and elevated AFP.

Incidental Findings in Pediatric Patients: How to Manage Liver Incidentaloma in Pediatric Patients

The World Federation for Ultrasound in Medicine and Biology (WFUMB) is addressing the issue of incidental findings (IFs) with a series of publications entitled "Incidental imaging findings-the role of ultrasound". IFs in the liver of newborns and children are rare and much less commonly encountered than in adults; as a result, they are relatively much more frequently malignant and life-threatening, even when they are of benign histology. Conventional B-mode ultrasound is the well-established first line imaging modality for the assessment of liver pathology in pediatric patients. US technological advances, resulting in image quality improvement, contrast-enhanced ultrasound (CEUS), liver elastography and quantification tools for steatosis have expanded the use of ultrasound technology in daily practice. The following overview is intended to illustrate incidentally detected liver pathology covering all pediatric ages. It aims to aid the examiner in establishing the final diagnosis. Management of incidentally detected focal liver lesions (FLL) needs to take into account the diagnostic accuracy of each imaging modality, the patient's safety issues (including ionizing radiation and nephrotoxic contrast agents), the delay in diagnosis, the psychological burden on the patient and the cost for the healthcare system. Moreover, this paper should help the pediatric clinician and ultrasound practitioner to decide which pathologies need no further investigation, which ones require interval imaging and which cases require further and immediate diagnostic procedures.

Clinical and Pathological Features of Congenital Hepatic Hemangioma in Children: A Retrospective Analysis

Objective: We reviewed our experience with congenital hepatic hemangiomas (CHH) to assess the effectiveness of our treatment strategies. Methods: Clinical and pathologic features of children with CHH were reviewed. Results: Twenty-two cases of CHH were collected, 17 were resected and 5 were followed until resolution. In 17 with alpha-feto-protein (AFP) levels, 9 were elevated with 5 decreasing to normal before surgery. In six with tumors under 3 cm, five regressed between 1 and 13 months, one required removal 5 years after initial diagnosis. Postoperative histopathology of 17 cases showed abnormal vascular hyperplasia without lobular architecture. CD34 was expressed in all tumors, glucose transporter 1(Glut1) was negative. Conclusion: If the tumor is less than 3 cm, AFP is normal and there are no obvious complications, the lesion can be followed with regular assessment imaging. Surgical resection is an option in tumors less than 3 cm which have not regressed over time.

Hepatic hemangiomas in childhood: the spectrum of radiologic findings. A pictorial essay

Hepatic hemangiomas (HHs) are the most common benign liver tumors in infancy, but despite their frequent occurrence, their radiologic appearance may be particularly challenging to assess, owing to unique anatomical and development features that distinguish their subtypes in the pediatric population. There are 3 main patterns of the lesions recognized in HHs: focal, multifocal and diffuse. Medical care strategies range from simple observation to surgery, and a timely diagnosis is crucial to establish the most appropriated clinical management and therapy. Ultrasound (US) is typically the first level examination of pediatric vascular anomalies, able to meet a satisfactory diagnosis and has proved very helpful to assess for involution through serial imaging. CT and MRI are second-level methods seldom performed, offering an anatomical panoramic view and clarification when US is non-conclusive. Histologic confirmation is rarely required. HHs show a variable sonographic appearance, with hypoechoic (mostly) or hyperechoic solitary\multifocal mass and wide features. Hepatic vessels assessment reveals an abnormal flow, enlarged vasa, decreased resistive index (RI) values, scarce blood supply distally to lesions and hyper vascular regions inside them. In this pictorial essay, we review HHs subtypes in further details, illustrate US, CT and MRI findings and clarify a recurrent dispute over the existing terminology.

A Retrospective Analysis of Clinical Characteristics, Treatment Modalities and Outcome of the Patients With Infantile Hepatic Hemangiomas: Single-center Experience From Turkey

OBJECTIVE

Hepatic hemangiomas (HH) are the most common vascular tumors of the liver. It is important to distinguish hemangiomas from malignant liver tumors.

MATERIALS AND METHODS

The patients 0 to 1 years old, were diagnosed with HH and followed up in the oncology outpatient clinic between 2009 and 2020 were included in the study.

RESULTS

A total of 127 patients with the diagnosis of HH were included in the study. Of the patients, 99 (78%) had focal, 20 (15.7%) had multifocal, and 8 (6.3%) had diffuse HHs. Surgery was performed and the diagnosis was confirmed histopathologically in 6 patients (4.7%). During the follow-up, 16 (12.5%) patients received medical treatment. Thirteen (10.2%) were treated with propranolol, 2 (1.5%) with corticosteroids, and 1 (0.8%) with propranolol and corticosteroids. Complete response was obtained in 9 (9/16) patients and partial response was obtained in 6 (6/16) patients with medical treatment.

CONCLUSION

Although HH is a benign tumor, it is important to make its differential diagnosis with malignant tumors of the liver. Over the years, the need for histopathologic examination for diagnosis has decreased. The success rate of propranolol is high, and the need for other treatment options with a high side-effect profile has decreased significantly since 2008.

Mortality predictive factors in congenital hepatic hemangioma: a case-control study

Congenital hepatic hemangiomas (CHHs) are benign vascular tumors whose clinical, histological, and genetic correlation has recently been described in patients with long-term survival, although no mortality risk factors have been identified to date. The aim of this study is to analyze predictors of mortality in patients with CHH. A retrospective single-center case-control study of consecutive CHH patients diagnosed in our institution between 1991 and 2021 was performed, who were classified into two groups according to their survival. Demographic, gestational, imaging, and laboratory data at diagnosis were collected and compared between both groups. A total of 29 patients were included (12 males; 17 females) of whom 5 died as a result of CHH evolution due to cardiac failure and coagulopathy, with a median age of 11 days until death. No differences in demographic or gestational data were reported. There were neither differences when comparing imaging tests, nor in location, number of affected liver segments, or CHH estimated volume. Upon laboratory data at diagnosis, deceased patients had a significant elevation of median liver enzymes [glutamic-oxaloacetic transaminase (359 u/L vs. 45 u/L; p < 0.01) and glutamic-pyruvic transaminase (313 u/L vs. 20 u/L; p < 0. 01)], as well as a decreased median platelet count (85,250/µL vs. 337,000/µL; p < 0.01), prothrombin activity (54% vs. 93%; p < 0.01), and fibrinogen (131 mg/dL vs. 284 mg/dL; p < 0.01), with no differences in blood count or biochemistry data.

CONCLUSIONS

CHH clinical behavior can be innocuous or life-threatening. Thrombocytopenia, coagulation disorders, and increased liver enzymes at diagnosis seem to be the main predictors of mortality.

WHAT IS KNOWN

• Congenital Hepatic Hemangiomas (CHHs) are benign vascular tumors whose clinical behavior can be innocuous or life-threatening.

WHAT IS NEW

• Thrombocytopenia, coagulation disorders and increased liver enzymes at diagnosis seem to be the main predictors of mortality in these patients.

Treatment of Symptomatic Focal Hepatic Hemangioma with Propranolol in Neonates: Is It Efficient?

Hepatic hemangiomas (HH) - classified into congenital hepatic hemangiomas (CHH) or infantile hepatic hemangiomas (IHH) - are benign vascular tumors that are mainly asymptomatic, but may cause clinical problems that require treatment. While focal, multifocal, and diffuse IHH are responsive to propranolol treatment, CHH is mainly focal and thought to be resistant to treatment with propranolol. The clinical and imaging distinctions between CHH and IHH in cases of focal lesions can be challenging, while histopathological distinction is mostly lacking in the clinical setting. We report 4 neonatal symptomatic cases of focal HH treated with propranolol, with partial or complete resolution of the tumor, and the positive hemodynamic effect of propranolol in one case. We believe that although clear differentiation cannot be achieved between CHH and IHH without histopathological examination in cases of focal HH in neonates, propranolol treatment should be attempted in symptomatic cases since its benefits outweigh the possible small risk of side effects of propranolol.

Hybrid lung lesions in children with segmental infantile hemangiomas, a new association?

Infantile hemangiomas (IHs) are the most common tumors of infancy and, in rare instances, can present in the setting of congenital structural anomalies or as part of syndromic disorders. In this study, we present three cases of children with segmental IHs born with concurrent pulmonary anomalies: congenital pulmonary airway malformations and bronchopulmonary sequestration. To date, no known association between these entities and hemangiomas has been described.

Management of infantile hemangiomas: Recent advances

Infantile hemangiomas (IHs) are benign vascular tumors commonly observed in children. A small number of cases can manifest as organ or system dysfunction, permanent scarring, or even disfigurement. Currently, diagnosis is mainly based on clinical history, physical examination, and auxiliary inspection. In the treatment of a hemangioma, the functional damage caused by the lesion and complications that may endanger the patient’s life should be given priority. This suggests that identification, diagnosis, and referral to specialists during the early stages of IHs are important factors in preventing related complications and obtaining a better prognosis. During the past few decades, researchers have explored different treatments according to the condition, including oral or topical drugs, topical drug injections, laser surgery, and surgical treatment. However, oral propranolol remains a well-accepted first-line treatment. This article will primarily focus on the recent advances in the clinical diagnosis and treatment of hemangiomas, along with a literature review on the subject.

Consumptive Hypothyroidism due to Hepatic Hemangiomas: A Case Series and Review of the Literature

Consumptive hypothyroidism (CH) is a rare and potentially overlooked complication of hepatic hemangiomas (HH) overexpressing the enzyme deiodinase, which converts thyroxine (T4) to reverse triiodothyronine (rT3).

Materials and methods

Here, we report a case series of 3 patients and a systematic review of the literature.

Results

Hypothyroidism (mean serum TSH 52.03 mIU/L) was detected at a mean age of 4.6 months (range 3-6) in 3 infants with infantile hepatic hemangiomas, treated with thyroxine (mean dose 12 µg/kg/day). All received treatment with propranolol (1-3 mg/kg/day) from the mean age of 4 months. Hormonal treatment was stopped at a mean age of 20 months (range 12-30). Hypothyroidism reoccurred in a patient concurrently with the increase of liver lesions, requiring liver transplantation (LT) at age 39 months.Literature review retrieved 42 studies (48 patients): HH (n = 43) were isolated in 24 infants and associated with cutaneous hemangiomas in 19. Hemangiomas were only cutaneous in 5.In the first 43 patients, hypothyroidism was detected at a mean age of 1 month; 21 of 43 patients were prescribed propranolol alone (n = 8) or associated with other medicaments (n = 13); 2 of 43 patients underwent LT. Hormonal treatment consisted of T4 in 35 of 43 patients and T3 in 10.CH associated with only cutaneous and extrahepatic visceral hemangiomas (n = 5), detected at a mean age of 7 months (TSH mean levels at diagnosis of 150.3 mIU/L). Three of 5 patients received treatment with propranolol ± other medicaments. All 5 patients were treated with T4.

Conclusions

Periodical thyroid function assessment is necessary in patients with hepatic hemangiomas, particularly when lesions' size and number increase rapidly.

Comparison of Hepatectomy and Hemangiomas Stripping on Patients with Giant Hepatic Hemangiomas

Objective. To compare the value of a hepatectomy and hemangioma stripping on patients with giant hepatic hemangiomas. Methods. Seventy-four patients with giant hepatic hemangiomas were retrospectively analyzed from data collected from their hepatobiliary surgeries performed from June 2010 to June 2015 at the People’s Hospital of Ningxia and the general hospital affiliated with Ningxia Medical University. The patients were divided into a hepatectomy group (37 patients) and a hemangioma-stripping group (37 patients). Conditions of each group were compared before and after surgery and comprised of surgery duration, intraoperative blood loss, blood transfusion, duration of hepatic blood occlusion, and hospital stay. Any complications after surgery, such as pleural effusions, bile leakage, and abdominal hemorrhage, were also observed. Results. In the hemangioma-stripping group, the surgery time was 2.38 ± 0.93 h, intraoperative blood loss was 889.19 ± 756.37, blood transfusion amount was 723.78 ± 801.14, the duration of hepatic blood occlusion 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. In the hepatectomy group, surgery time was 3.26 ± 1.16 h, intraoperative blood loss was 1551.35 ± 1755.88 mL blood transfusion amount was 1693.24 ± 2117.72 mL, duration of hepatic blood occlusion was 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. The difference between the groups was statistically significant (P < 0.05). The pleural effusion incident rate in the former group was lower than that of the latter group, and the difference was statistically significant. Conclusions. Hemangiomas stripping is an effective method by which to cure hepatic hemangioma, with the advantages being a relatively easy surgery with less patient trauma, rapid recovery, and fewer complications. This method should be used more often in clinical settings.

How we approach hemangiomas in infants

Pediatric oncologists are increasingly involved in the management of benign vascular tumors and their associated life-threatening complications. Hemangiomas are the most common referring diagnosis to multidisciplinary vascular anomalies clinics. However, as contemporary research has revealed, hemangiomas are not a single, easily defined entity but rather a diverse set of related vascular tumors, each having a unique natural history, growth pattern, and response to therapy. This manuscript seeks to illustrate how we evaluate and manage these complex tumors, their complications, and associated syndromes, while remaining ever vigilant for malignant hemangioma mimickers such as soft tissue sarcomas and congenital leukemia.

Clinical evaluation of transcatheter arterial embolization combined with propranolol orally treatment of infantile hepatic hemangioma

PURPOSE

To assess the efficacy of transcatheter arterial embolization (TAE) plus propranolol treatment for infantile hepatic hemangioma (IHH).

METHODS

A retrospective study of symptomatic IHH and hemodynamic changes in IHH was conducted between 2016 and 2019.

RESULTS

There were five boys and seven girls with diffuse lesions (n = 7) and multifocal lesions (n = 5). Hepatomegaly and abdominal distension (n = 6) were the predominant clinical presentations. Seven patients (58.3%) had multiple cutaneous hemangiomas. Pulmonary arterial hypertension, heart failure (n = 4), and hypothyroidism (n = 4) were observed. A total of 17 TAE procedures were performed in 12 IHH cases, with a technical success rate of 100%. All patients received standard propranolol orally, and one patient was orally administered metacortandracin. Two patients died of heart failure and multiple organ dysfunction caused by an enlarged liver. In addition, one patient was not reexamined after discharge. Of the remaining nine children, the average follow-up time was 10.78 months (range 2-28 months), and they all responded well to TAE combined with oral propranolol.

CONCLUSION

TAE combined with propranolol is safe and effective for the treatment of IHH, demonstrating low complication rates.

How we approach the diagnosis of a vascular anomaly

Vascular anomalies represent a diverse group of complex disorders that can cause significant complications, including coagulopathies, pain, and decreased function. The diagnosis of vascular anomalies is often challenging due to heterogeneity of presenting phenotypes and overlapping clinical features with other pediatric conditions. Pediatric hematologists/oncologists (PHO) are uniquely positioned for an essential role in diagnosing, managing, and coordinating the multidisciplinary care required to maximize the quality of life of these patients. Here, we review the diagnostic approach involved in patients with vascular anomalies and utilize cases to highlight the challenges involved, and how PHOs can play a vital part in the care of these patients.

A Case of Infantile Hepatic Hemangioendothelioma/Hemangioma at Maharaj Nakorn Chiang Mai Hospital

Infantile hepatic hemangioendothelioma/hemangioma is the most common benign hepatic vascular tumor of infancy, comprising approximately 1% of all childhood tumors. The tumor can present during the fetal or neonatal period as a hepatic mass. Common presentations include abdominal distension and a palpable hepatic mass. Clinico-radio-pathological correlation is essential for a definite diagnosis. Frequent complications such as congestive heart failure, thrombocytopenia, anemia, and Kasabach-Merritt syndrome should be investigated. Chemotherapy has been reported as an effective treatment option. Surgical resection has an essential role for symptomatic patients with medical treatment failure or other certain conditions such as refusal to take medication. Furthermore, prenatal diagnosis is essential for better patient outcomes due to prompt treatment in the neonatal period. We report a case of a female infant at 39 weeks of gestation who was delivered from a 32-year-old mother. The infant was in utero diagnosed by ultrasonography with a hepatic mass, most likely hemangioma. The mass was resected after birth and it was diagnosed as infantile hepatic hemangioendothelioma type II. The course of the disease was excellent and the patient was cured after treatment.

Incidental Liver Lesions in children: A practical and evidence-based approach

Incidental liver lesions are increasingly being discovered in the context of the increased use of ultrasound studies and the majority are benign. In children, although individually rare, the differential diagnosis is broad and therefore a systematic approach is of utmost importance to reduce the radiological and disease burden in children and their families. This review article collected current evidence and provides fundamental information for the clinician regarding specific differential diagnoses and unique imaging features of benign liver lesions in children. Ultimately, we propose a practical stepwise approach mainly involving clinical and radiological workup. Laboratory tests and histopathological examination may be necessary in the presence of red flags or in indeterminate lesions.

Magnetic Resonance Imaging Evaluation of Hemangioma Resection for Encephalofacial Angiomatosis (Sturge-Weber Syndrome) in Children under Intelligent Algorithm

This study was aimed to evaluate the clinical efficacy of hemangioma resection in the treatment of infantile encephalofacial angiomatosis (Sturge–Weber syndrome, SWS) through magnetic resonance imaging (MRI) images, and intelligent algorithms were employed to process MRI images. A retrospective study of 45 children diagnosed with facial hemangioma admitted to hospital was conducted. Then, MRS images were acquired, and a mathematical model for MRI image denoising and reconstruction was constructed based on nonlocal similar block low-rank prior algorithms. The processing effect was assessed regarding the peak signal-to-noise ratio (PSNR) and structural similarity (SSIM). Finally, MRI images were collected to analyze the difference between the metabolites of N-acetylaspartic acid (NAA), creatine (Cr), choline (Cho), and their ratios in the lesions of the children before and after treatment. The improvement rate was analyzed through a twelve-month follow-up. The algorithm test results showed that compared with the classic K-singular value decomposition (K-SVD) denoising algorithm and the Sparse MRI reconstruction algorithm, the proposed algorithm processed MRI images more clearly and had more detailed information. The quantitative results showed that the PSNR and SSIM in the image processed by the algorithm proposed were remarkably large. The clinical treatment results showed that compared with those before treatment, the nCho level after treatment, the ratio of Cho/Cr and Cho/NAA were remarkably reduced, and the difference was remarkable (P < 0.05). The follow-up results showed that the considerable improvement rate was 88.89%, the postoperative organ remodeling rate was 17.78%, and the probability of reoperation was only 6.67%. In summary, the introduction of intelligent algorithms for denoising and reconstruction of MRI images can remarkably improve image quality and help doctors use image information to diagnose diseases and evaluate treatment effects. The hemangioma resection for the treatment of pediatric SWS had a high treatment improvement rate and was worthy of clinical adoption.

Infantile Hemangioma: A Current Review

Infantile hemangiomas (IHs) are common vascular lesions which are benign but can cause significant functional and cosmetic morbidity. Since the fortuitous discovery of propranolol being effective to treat IH over a decade ago, the therapy and prognosis for children with IH have improved dramatically. Oral propranolol (as well as other oral beta-blockers and topical timolol) are safe and effective treatments, and have now supplanted other therapies. Making the correct diagnosis is crucial, because other vascular lesions can mimic IH. In addition, IH can be the first manifestation of an underlying syndrome. For IH requiring treatment, initiating treatment early is key to optimizing success. Therefore, early recognition and referral, if necessary, are important. Continued research on IH, both basic science and clinical, should result in continued advances.

Successful Management of Massive Congenital Hepatic Hemangioma and Systemic Hypertension With Sirolimus

Congenital hepatic hemangioma (CHH) is a common benign vascular tumor of the liver, seen in infancy. The clinical manifestations vary from incidental findings to life-threatening complications. The authors present here a case of an infant with massive CHH who developed systemic hypertension because of compression of the right renal artery by the CHH and did not respond to other lines of treatment. After sirolimus therapy, the CHH size decreased and antihypertensive drugs were no longer necessary. In a critical situation, if the embolization and/or steroids do not seem to control the situation, then adding sirolimus may be considered as secondary therapy with good additive effects.

Etiology of neonatal cholestasis after emerging molecular diagnostics

BACKGROUND

In the pediatric group, most cholestatic patients had disease onset at 0-3 months of age, and more and more are found to have specific genetic defects after failing to obtain a definite diagnosis by routine evaluation. To investigate the etiological diagnosis for the newborns with cholestasis during the neonatal period after emerging molecular tests comprehensively.

METHODS

We conducted a retrospective study to evaluate clinical characteristics, etiologies and outcomes in infants with neonatal cholestasis after emerging molecular diagnostics from January 1st to December 31st, 2019 in Children's Hospital of Fudan University.

RESULTS

There were 160 cases of neonatal cholestasis with mean gestational age (GA) 32.6±4.8 weeks and birth weight (BW) 1,880±991 g, composing 3.4% of total neonatal admissions in 2019. Overall 97.5% (n=156) patients had a definite diagnosis, including 9 obtaining a genetic diagnosis after adding molecular test in routine evaluation, which made the diagnosis rate for cholestasis increased by 5.6%. The most common etiology of cholestasis in the neonatal period was parenteral nutrition-associated cholestasis (PNAC) 48.8% (n=78), followed by cardiovascular and circulatory disorders 18.1%, biliary anatomic obstruction 12.5%, infection 8.7% and genetic disorders 5.6%. PNAC and biliary anatomic obstruction were the most common etiology of cholestasis for preterm and term infants respectively. The mortality rate is 2.5% (n=4) and 91.9% (n=147) patients totally recovery or improve in follow-up.

CONCLUSIONS

The causes of cholestasis in neonates are complicated, molecular diagnostics can improve the etiological diagnosis for newborns with cholestasis. But still, quite amount of causes are remediable and transient during the neonatal period, gene test may help to rule out genetic causes and enhance confidence in judging prognosis.

Diagnosis and Follow-up of Incidental Liver Lesions in Children

Incidental liver lesions are identified in children without underlying liver disease or increased risk of hepatic malignancy in childhood. Clinical and imaging evaluation of incidental liver lesions can be complex and may require a multidisciplinary approach. This review aims to summarize the diagnostic process and follow-up of incidental liver lesions based on review of the literature, use of state-of-the-art imaging, and our institutional experience. Age at presentation, gender, alpha fetoprotein levels, tumor size, and imaging characteristics should all be taken into consideration to optimize diagnosis process. Some lesions, such as simple liver cyst, infantile hemangioma, focal nodular hyperplasia (FNH), and focal fatty lesions, have specific imaging characteristics. Recently, contrast-enhanced ultrasound (CEUS) was Food and Drug Administration (FDA)-approved for the evaluation of pediatric liver lesions. CEUS is most specific in lesions smaller than 3 cm and is most useful in the diagnosis of infantile hemangioma, FNH, and focal fatty lesions. The use of hepatobiliary contrast in MRI increases specificity in the diagnosis of FNH. Recently, lesion characteristics in MRI were found to correlate with subtypes of hepatocellular adenomas and associated risk for hemorrhage and malignant transformation. Biopsy should be considered when there are no specific imaging characteristics of a benign lesion. Surveillance with imaging and alpha fetoprotein (AFP) should be performed to confirm the stability of lesions when the diagnosis cannot be determined, and whenever biopsy is not feasible.

Infantile hepatic hemangiomas: looking backwards and forwards

Infantile hepatic hemangiomas (IHHs) are common benign tumors seen in the liver of infants. IHHs are true infantile hemangiomas (IHs) and have phases of proliferation and involution parallel to those of cutaneous IHs. The definition and classification of IHH are still confusing in the literature. The mechanisms during the pathogenesis of IHH have yet to be discovered. The clinical manifestations of IHH are heterogeneous. Although most IHH lesions are asymptomatic, some lesions can lead to severe complications, such as hypothyroidism, consumptive coagulopathy, and high-output congestive cardiac failure. Consequently, some patients can possibly encounter a fatal clinical condition. The heterogeneity of the lesions and the occurrence of disease-related comorbidities can make the treatment of IHH challenging. Oral propranolol is emerging as an effective systemic approach to IHH with obvious responses in tumor remission and symptom regression. However, the precise clinical characteristics and treatment strategies for patients with severe IHH have not yet been well established. Here, we summarize the epidemiology, pathogenic mechanism, clinical manifestations, diagnosis, and treatment of IHH. Recent updates and future perspectives for IHH will also be elaborated.

[The most common benign cutaneous neoplasms of vascular, muscular, and adipose tissue and their treatment]

Benign cutaneous vascular and cutaneous neoplasms arising from muscle or adipose tissue are rare. Their definition and classification are still controversially discussed. Histopathological and immunohistochemical studies, together with the new genetic tests, contribute significantly to the correct description of the various benign neoplasms of cutaneous origin. Clarifying whether a lesion is benign is fundamental for prognosis and therapeutic management. In most cases, surgical excision is the treatment of choice. Dermatologists should be familiar with the classifications of the most common benign cutaneous neoplasms of vascular, muscular, and adipose tissue and be able to recommend the procedures currently used for an accurate diagnosis. Ensuring that a lesion is benign and a good surgical outcome are essential for the patient.

[Mutational spectrum and its prognostic significance in childhood acute lymphoblastic leukemia based on next-generation sequencing technology]

Objective: This study analyzed the correlation between genetic mutation and prognostic significance in childhood acute lymphoblastic leukemia (ALL) . Methods: Targeted exome by next-generation sequencing (NGS) technology was used to carry out molecular profiling of untreated 141 children with ALL in Fujian Medical University Union Hospital from November 2016 to December 2019. Correlation of genetic features and clinical features and outcomes was analyzed. Results: Among the 141 pediatric patients with ALL, 160 somatic mutations were detected in 83 patients (58.9% ) , including 37 grade Ⅰ mutations and 123 grade Ⅱ mutations. Single nucleotide variation was the most common type of mutation. KRAS was the most common mutant gene (12.5% ) , followed by NOTCH1 (11.9% ) , and NRAS (10.6% ) . RAS pathway (KRAS, FLT3, PTPN11) , PAX5 and TP53 mutations were only detected, and NRAS mutations was mainly found in B-ALL while FBXW7 and PTEN mutations were only found, and NOTCH1 mutation was mainly detected in T-ALL. The average number of mutations detected in each child with T-ALL was significantly higher than in children with B-ALL (4.16±1.33 vs 2.04±0.92, P=0.004) . The children were divided into mutation and non-mutation groups according to the presence or absence of genetic variation. There were no statistically significant differences in sex, age, newly diagnosed white blood cell count, minimal or measurable residual disease monitoring results, expected 3-year event-free survival (EFS) and overall survival (OS) between the two groups (P>0.05) . On the other hand, the proportion of T-ALL and fusion gene negative children in the mutant group was significantly higher than the non-mutation group (P=0.021 and 0.000, respectively) . Among the patients without fusion gene, the EFS of children with grade I mutation was significantly lower than children without grade I mutation (85.5% vs 100.0% , P=0.039) . Among children with B-ALL, the EFS of those with TP53 mutation was significantly lower than those without TP53 mutation (37.5% vs 91.2% , P<0.001) . Conclusion: Genetic variation is more common in childhood ALL and has a certain correlation with clinical phenotype and prognosis. Therefore, targeted exome by NGS can be used as an important supplement to the traditional morphology, immunology, cytogenetics, and molecular biology classification.

HEPATIC VASCULAR TUMORS IN CHILDREN: POTENTIAL RISKS, OPTIMAL IMAGING AND THE ROLE OF SURGICAL INTERVENTION

OBJECTIVE

The aim: To revise the case-series of hepatic vascular tumors (HVT), particularly to identify optimal visualization, management and role of surgical intervention.

PATIENTS AND METHODS

Materials and methods: Out of 96 children with hepatic tumors who hospitalized in a single center from 2011 to 2020, 20 (20,8%) were diagnosed HVT. Hepatic Hemangiomas (HHs) were presented in 19 patients and Kaposiform hemangioendotelioma (KHE) in one case. To determine the type of HH we used radiological classification. For visualisation contrast-enhanced MRI (n=7, 30%) and cCT (n=15,70%) were used. Follow-up period was 14-77 months.

RESULTS

Results: All HVT were revealed by sonogram at the age of 0-5 m, with 4 (20%) diagnosed prenatally. Male to female ratio was 3:2. Beta-blockers were prescribed to 12 patients with HHs. Treatment duration was from 6 to 24 month. Steroid therapy was initial in cases when it was impossible to prescribe the curative dose of beta-blockers. Complications of propranolol treatment were transitory bradycardia (n=7) and transitory hypoglycemia (n=2). After vincristine chemotherapy decreases the tumor size by 54%, that allowed a safe liver resection. 4 (20%) patients - two multifocal HHs, one diffuse HH and in patient with KHE manifested congestive heart failure and pulmonary hypertension Mortality rate is 5% (n=1), this patient died against progressive cardiovascular failure.

CONCLUSION

Conclusions: life-threatening complication of HVT was congestive heart failure. Early treatment is beneficial for complications prevention. Surgical treatment is optional for KHE when can be removed safely.

Medical Management of Infantile Hemangiomas: An Update

Infantile hemangioma (IH) is the most common benign vascular tumor of infancy, affecting about 5% of infants. It has a characteristic growth pattern of early rapid proliferation followed by progressive involution. Although most IH evolve favorably, complications are observed in 10-15% of cases, justifying treatment. For over 10 years now, propranolol has become the first-line therapy for complicated IH, revolutionizing their management and their prognosis. In this article, we review the clinical features, associations, complications/sequelae and therapeutic approaches for IH, focusing on current medical therapy. Indications for treatment and various treatment options, including propranolol and other oral β-blockers, topical timolol, and corticosteroids are presented. Current controversies regarding oral propranolol such as pre-treatment screening, in- vs out-patient initiation of treatment, early and potential long-term side effects and recommended monitoring are discussed.

Is primary hepatic angiosarcoma in children an indication for liver transplantation?-A single-centre experience and review of the literature

PHA in the paediatric population is an extremely rare and aggressive malignant soft tissue neoplasm, with less than 50 cases published worldwide. The prognosis is dismal. If the tumour is unresectable, one treatment option is LT. In this article, the current available literature is reviewed and additionally, three cases of paediatric patients with PHA who underwent LT at Karolinska University Hospital, Sweden, are presented. Based on the literature and our own experience, there is undoubtedly possible good outcome of LT due to PHA. On the contrary, no patients have survived PHA without LT. PHA in paediatric patients should be recommended to LT in selected patients. Effect of modern adjuvant chemo and RT should be evaluated further based on international registry for such rare cases of PHA.

Application value of computer-assisted surgery system in pediatric hepatic hemangioma

PURPOSE

To explore the treatment of pediatric hepatic hemangioma and the role of the Hisense computer-assisted surgery (Hisense CAS) system in diagnosis and treatment.

METHODS

We collected the clinical and follow-up data of all pediatric hepatic hemangioma cases in our pediatric surgery department from March 2008 to March 2021 for retrospective analysis. The Hisense CAS system was used to create three-dimensional (3D) reconstructions based on computed tomography data.

RESULTS

There were 71 patients, mainly infants (prenatal to 39 months). There were more males than females (42 vs. 29), and the alpha-fetoprotein level was significantly increased in 8 cases. 3D reconstruction by the Hisense CAS system showed that hepatic artery tracking was helpful for the differential diagnosis of pediatric hepatic hemangioma. Twenty-three children treated with propranolol showed significant differences in the tumour diameter, volume, and tumour-to-liver volume ratio after treatment (all P < 0.05). Compared with early surgical treatment, the curative effect of this approach was obvious.

CONCLUSION

As a non-surgical treatment for symptomatic pediatric hepatic hemangioma, propranolol can replace surgical resection to a certain extent and reduce the proportion of children who need surgical intervention. Hisense CAS has advantages in evaluating the tumour volume before and after propranolol treatment. The liver volume and the liver tumour volume percentage provide new perspectives for evaluating the tumour outcome.