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Bouwman FCM, Verhoeven BH, Klein WM, Schultze Kool LJ, de Blaauw I. Congenital Vascular Malformations in Children: From Historical Perspective to a Multidisciplinary Approach in the Modern Era-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:567. [PMID: 38790562 PMCID: PMC11119901 DOI: 10.3390/children11050567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024]
Abstract
Congenital vascular malformations (CVMs) are the result of an aberrant development during embryogenesis. Although these lesions are present at birth, they are not always visible yet. Once symptomatic, patients suffer from pain, bleeding, ulcers, infections or lymphatic leakage, depending on the subtype of vessels involved. Treatment includes conservative management, surgery, sclerotherapy, embolization and pharmacological therapy. The clinical presentation varies widely and treatment can be challenging due to the rarity of the disease and potential difficulties of treatment. This review gives an overview of the historical developments in diagnosis and classification and exposes the key elements of innovations in the past decades on the identification of genetic mutations and personalized treatment. These advances in the field and a multidisciplinary approach are highly valuable in the optimization of clinical care aimed at both curing or stabilizing the CVM and pursuing physical and psychosocial wellbeing.
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Affiliation(s)
- Frédérique C. M. Bouwman
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Bas H. Verhoeven
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Willemijn M. Klein
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Leo J. Schultze Kool
- Department of Medical Imaging, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (W.M.K.); (L.J.S.K.)
- Hecovan Center of Expertise for Hemangiomas and Vascular Malformations Nijmegen, VASCERN VASCA European Reference Center, Amalia Children’s Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
| | - Ivo de Blaauw
- Department of Pediatric Surgery, Amalia Children’s Hospital, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (F.C.M.B.); (B.H.V.)
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Leboulanger N, Bisdorff A, Boccara O, Dompmartin A, Guibaud L, Labreze C, Lagier J, Lebrun-Vignes B, Herbreteau D, Joly A, Malloizel-Delaunay J, Martel A, Munck S, Saint-Aubin F, Maruani A. French national diagnosis and care protocol (PNDS, protocole national de diagnostic et de soins): cystic lymphatic malformations. Orphanet J Rare Dis 2023; 18:10. [PMID: 36639640 PMCID: PMC9837920 DOI: 10.1186/s13023-022-02608-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/29/2022] [Indexed: 01/15/2023] Open
Abstract
Cystic lymphatic malformations (LMs) are rare chronic conditions which management differs according to the type (macrocystic LMs, microcystic LMs or both). Studies are lacking due to rarity of the pathology. We aimed to establish a French National Diagnosis and Care Protocol (PNDS: Protocole National de Diagnostic et de Soins), to provide health professionals with free open access synthesis on optimal management and care of patients with LMs ( https://www.has-sante.fr/upload/docs/application/pdf/2021-03/malformations_lymphatiques_kystiques_-_pnds.pdf ). The process included a critical review of the literature and multidisciplinary expert consensus. LMs are congenital but are not always discovered at birth. Nearly 75% of them are located in the head and neck because of the highly dense lymphatic system in this region. Physical examination (showing painless masses with normal skin color and depressible consistency, or cutaneous/mucosal lymphangiectasia) and color Doppler ultrasonography, usually allow for diagnosis. MRI (involving T2 sequences with fat saturation in at least two spatial planes) is the tool of choice for evaluating anatomical extension, characterizing lesions (microcystic and macrocystic), and before considering therapeutic management. A biopsy, coupled to a blood sample, can also be used for molecular biology analyses, to search for activating mutations of the PIK3CA gene, particularly with LM integrating in a syndromic form (CLOVES or Klippel-Trenaunay syndrome) but also in certain isolated (or common) LMs. The spontaneous evolution of LMs, in particular microcystic forms, is often toward progressive aggravation, with an increase in the number of vesicles, thickening, increased oozing and bleeding, while pure macrocystic LMs may regress due to "natural sclerosis", i.e. fibrosis secondary to an inflammatory reorganization after common infantile infections. In case of voluminous LMs or syndromic forms, functional and psychological repercussions can be major, deteriorating the patient's quality of life. LMs must be treated by physicians integrated in multidisciplinary teams, and be personalized. Management is a life-long process that involves one or several of these therapies: conservative management, physical therapy (compression), sclerotherapy, surgery, drugs such as mTOR inhibitors (sirolimus), that has shown efficacy in decreasing the volume of LMs, and, more recently, PI3K-inhibitors in syndromic forms. Psychological and social support is necessary, taking into account the patient and his family.
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Affiliation(s)
- Nicolas Leboulanger
- Otolaryngology - Head and Neck Surgery Department. National Reference Center for Rare Otolaryngological Malformations (MALO), Necker Enfants Malades Hospital, 149 Rue de Sèvres, 75015, Paris, France. .,INSERM U955, Paris Cité University. ERN Cranio, Paris, France.
| | - Annouk Bisdorff
- grid.411296.90000 0000 9725 279XDepartment of Interventional Radiology, Lariboisière Hospital, Paris, France
| | - Olivia Boccara
- grid.412134.10000 0004 0593 9113Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), Necker Enfants Malades Hospital, Paris, France
| | - Anne Dompmartin
- grid.411149.80000 0004 0472 0160Department of Dermatology, CHU Côte de Nacre, Caen, France
| | - Laurent Guibaud
- grid.413852.90000 0001 2163 3825Department of Radiology, Hôpital Mère-Enfant, CHU de Lyon, Lyon, France
| | - Christine Labreze
- grid.42399.350000 0004 0593 7118Department of Dermatology, Pellegrin Hospital, CHU de Bordeaux, Bordeaux, France
| | - Jacques Lagier
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Bénédicte Lebrun-Vignes
- grid.411439.a0000 0001 2150 9058Pharmacovigilance Unit, AP-HP, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - Denis Herbreteau
- grid.411167.40000 0004 1765 1600Department of Neuroradiology and Interventional Radiology - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France
| | - Aline Joly
- grid.411167.40000 0004 1765 1600Department of Maxillofacial Surgery - Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, 37044 Tours, Cedex 9 France
| | - Julie Malloizel-Delaunay
- grid.411175.70000 0001 1457 2980Department of Vascular Medicine, Rangueil Hospital, CHU de Toulouse, Toulouse, France
| | - Arnaud Martel
- grid.410528.a0000 0001 2322 4179Department of Ophthalmology, CHU de Nice, Nice, France
| | - Stéphane Munck
- grid.460782.f0000 0004 4910 6551Département d’enseignement et de Recherche en Médecine Générale, Retines, Healthy, Université Côte d’Azur, 06000 Nice, France
| | | | - Annabel Maruani
- grid.411167.40000 0004 1765 1600Department of Dermatology and Reference Center for Rare Diseases and Vascular Malformations (MAGEC), CHRU de Tours, Tours, France ,grid.12366.300000 0001 2182 6141INSERM 1246 ‑ SPHERE, Universities of Tours and Nantes, 37000 Tours, France
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Yoshida T, Asakura Y, Miura S, Endo M, Akasaka M. Streptococcal Toxic Shock Syndrome in a Child With Venous Malformation. Cureus 2022; 14:e21096. [PMID: 35165555 PMCID: PMC8829108 DOI: 10.7759/cureus.21096] [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] [Accepted: 01/10/2022] [Indexed: 11/21/2022] Open
Abstract
We report the case of a child with a venous malformation (VM), in whom streptococcal toxic shock syndrome (STSS) developed from cellulitis. A six-year-old boy with VM of the left lower limb had a fever and left lower limb pain since the afternoon of the day before admission. He presented with swelling, redness, heat, and tenderness on an area extending from the sole of the foot to the lower leg on the left side. Disturbance of consciousness gradually appeared, and he was admitted to the intensive care unit. We administered intravenous antibiotics and an immunoglobulin. On day two of hospitalization, group A hemolytic streptococci were detected in the blood culture. We managed the patient in coordination with a plastic surgeon for consideration of surgical interventions. The local findings subsequently improved to change the antibiotics promptly without debridement, and he was discharged after 14 days of antibiotic therapy. In this case, the VM may have contributed to the worsening of the infection. In children with VM, soft tissue inflammation with local pain and fever must be treated promptly, with the expectation of prompt surgical intervention, because the condition can progress to sepsis and necrotizing fasciitis.
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Maruani A, Tavernier E, Boccara O, Mazereeuw-Hautier J, Leducq S, Bessis D, Guibaud L, Vabres P, Carmignac V, Mallet S, Barbarot S, Chiaverini C, Droitcourt C, Bursztejn AC, Lengellé C, Woillard JB, Herbreteau D, Le Touze A, Joly A, Léauté-Labrèze C, Powell J, Bourgoin H, Gissot V, Giraudeau B, Morel B. Sirolimus (Rapamycin) for Slow-Flow Malformations in Children: The Observational-Phase Randomized Clinical PERFORMUS Trial. JAMA Dermatol 2021; 157:1289-1298. [PMID: 34524406 DOI: 10.1001/jamadermatol.2021.3459] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Sirolimus is increasingly being used to treat various vascular anomalies, although evidence of its efficacy is lacking. Objective To assess the efficacy and safety of sirolimus for children with slow-flow vascular malformations to better delineate the indications for treatment. Design, Setting and Participants This multicenter, open-label, observational-phase randomized clinical trial included 59 children aged 6 to 18 years with a slow-flow vascular malformation who were recruited between September 28, 2015, and March 22, 2018, in 11 French tertiary hospital centers. Statistical analysis was performed on an intent-to-treat basis from December 4, 2019, to November 10, 2020. Interventions Patients underwent an observational period, then switched to an interventional period when they received oral sirolimus (target serum levels, 4-12 ng/mL). The switch time was randomized from month 4 to month 8, and the whole study period lasted 12 months for each patient. Main Outcomes and Measures The primary outcome was change in the volume of vascular malformations detected on magnetic resonance imaging scan (with centralized interpretation) per unit of time (ie, between the interventional period and the observational period). Secondary outcomes included subjective end points: pain, bleeding, oozing, quality of life, and safety. Results Among the participants (35 girls [59.3%]; mean [SD] age, 11.6 [3.8] years), 22 (37.3%) had a pure venous malformation, 18 (30.5%) had a cystic lymphatic malformation, and 19 (32.2%) had a combined malformation, including syndromic forms. Variations in the volume of vascular malformations detected on magnetic resonance imaging scans associated with the duration period were not overall significantly different between the interventional period and the observational period (all vascular malformations: mean [SD] difference, -0.001 [0.007]; venous malformations: mean [SD] difference, 0.001 [0.004]; combined malformations: mean [SD] difference, 0.001 [0.009]). However, a significant decrease in volume was observed for children with pure lymphatic malformations (mean [SD] difference, -0.005 [0.005]). Overall, sirolimus had positive effects on pain, especially for combined malformations, and on bleeding, oozing, self-assessed efficacy, and quality of life. During sirolimus treatment, 56 patients experienced 231 adverse events (5 serious adverse events, none life-threatening). The most frequent adverse event was an oral ulcer (29 patients [49.2%]). Conclusions and Relevance This observational-phase randomized clinical trial allows for clarifying the goals of patients and families when starting sirolimus therapy for children older than 6 years. Pure lymphatic malformations seem to be the best indication for sirolimus therapy because evidence of decreasing lymphatic malformation volume per unit of time, oozing, and bleeding and increasing quality of life was found. In combined malformations, sirolimus significantly reduced pain, oozing, and bleeding. Benefits seemed lower for pure venous malformations than for the 2 other subgroups, also based on symptoms. Trial Registration ClinicalTrials.gov Identifier: NCT02509468; clinicaltrialsregister.eu Identifier: 2015-001096-43.
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Affiliation(s)
- Annabel Maruani
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Elsa Tavernier
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Olivia Boccara
- Department of Dermatology and Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Necker), University Hospital Necker-Enfants Malades, Paris, France
| | | | - Sophie Leducq
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Department of Dermatology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Didier Bessis
- Department of Dermatology, University Hospital Center of Montpellier, Montpellier, France
| | - Laurent Guibaud
- University Hospital Center of Lyon, Consultation Multidisciplinaire Lyonnaise des Angiomes, Lyon, France
| | - Pierre Vabres
- Department of Dermatology, University Hospital Center of Dijon, Dijon, France
| | - Virginie Carmignac
- Department of Dermatology, University Hospital Center of Dijon, Dijon, France
| | - Stéphanie Mallet
- Department of Dermatology, University Hospital Center of Marseille, Marseille, France
| | - Sébastien Barbarot
- Department of Dermatology, University Hospital Center of Nantes, Nantes, France
| | | | | | | | - Céline Lengellé
- Centre Hospitalier Régional Universitaire Tours, Department of Clinical Pharmacology, Regional Pharmacovigilance Center, Tours, France
| | - Jean-Baptiste Woillard
- Centre Hospitalier Universitaire Limoges, Department of Pharmacology and Toxicology, University of Limoges, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 850, Limoges, France
| | - Denis Herbreteau
- University of Tours, Centre Hospitalier Régional Universitaire Tours, Department of Neuroradiology, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Anne Le Touze
- Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Surgery, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | - Aline Joly
- Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Maxillofacial Surgery, Reference Center for Genodermatoses and Rare Skin Diseases (Maladies Génétiques rares à Expression Cutanée-Tours), Tours, France
| | | | - Julie Powell
- Department of Pediatric Dermatology, Hospital Sainte-Justine, Montréal, Québec, Canada
| | - Hélène Bourgoin
- Centre Hospitalier Régional Universitaire Tours, Department of Pharmacy, Tours, France
| | - Valérie Gissot
- Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Bruno Giraudeau
- University of Tours, University of Nantes, Institut National de la Santé et de la Recherche Médicale, SPHERE U1246, Tours, France.,Centre Hospitalier Régional Universitaire Tours, Institut National de la Santé et de la Recherche Médicale Clinical Investigation Center 1415, Tours, France
| | - Baptiste Morel
- University of Tours, Centre Hospitalier Régional Universitaire Tours, Department of Pediatric Radiology, Tours, France
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Padia R, Bly R, Bull C, Geddis AE, Perkins J. Medical Management of Vascular Anomalies. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2018; 4:221-236. [PMID: 30505648 PMCID: PMC6261360 DOI: 10.1007/s40746-018-0130-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This chapter will summarize the most recent literature regarding the current state of medical treatment for vascular anomalies. RECENT FINDINGS Research into the biology of these anomalies has strengthened our understanding of each anomaly and has helped to pave the way for more tailored treatment options involving molecular and/or genetic targets. SUMMARY While there is still a role for surgical intervention, medical therapies that target the etiology of vascular anomalies may represent an alternative or adjunctive approach in the management of these lesions.
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Affiliation(s)
- Reema Padia
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle Children's Hospital and Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, United States
| | - Randall Bly
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle Children's Hospital and Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, United States
| | - Catherine Bull
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle Children's Hospital and Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, United States
| | - Amy E. Geddis
- Cancer and Blood Disorders Clinic, Seattle Children's Hospital, Seattle, Washington, United States
| | - Jonathan Perkins
- Division of Pediatric Otolaryngology, Department of Surgery, Seattle Children's Hospital and Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, United States
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