Hemangiomas and vascular malformations: unapproved treatments

Oral propranolol therapy for infantile hemangiomas beyond the proliferation phase: a multicenter retrospective study

Pharmacological therapies for infantile hemangiomas were considered effective only during the proliferative phases. Recently reported beneficial effects of propranolol may extend beyond the proliferative phase of infantile hemangiomas. The purpose of the study was to assess the effect of oral propranolol therapy for infantile hemangiomas beyond the proliferative phase of these lesions. Members of the Society for Pediatric Dermatology were invited to participate in a multicenter retrospective study. Only children with infantile hemangiomas with documented cessation of lesions' growth or those older than 12 months of age were eligible for the study. Clinical and demographic information and digital photographs before, at the start, and following the treatment were collected. Scaled panels of photographs were distributed among preselected experienced pediatric dermatologists. Visual analog scale was used to assess photographs for each case. Paired t-test was used for statistical analyses. Data on 49 eligible patients from eight pediatric dermatology centers was collected. Seven cases were excluded because of insufficient photographic documentation. The age of the patients at the start of propranolol therapy ranged 7 to 120 months (mean 28 mos, median 22 mos). The duration of propranolol therapy ranged 1 to 8 months (mean 3.6 mos). The mean visual analog scale score before the treatment was 6.8 ± 2.15, and mean reduction in the visual analog scale score at the assessment was 2.6 ± 1.74 (p < 0.001). The rate of visual analog scale reduction was 0.4 per month before the start of the therapy, while this rate was accelerated to 0.9 per months following the therapy (p < 0.001). No significant side effects were reported. We conclude that propranolol is effective in infantile hemangiomas, including post-proliferative phase, and should be considered as the first-line therapy in that setting.

Sclerotherapy for vascular malformations in the oral and maxillofacial region: treatment and follow-up of 66 lesions

PURPOSE

The aim of the present study was to relate the use of 5% monoethanolamine oleate in sclerotherapy for vascular malformations and to suggest a protocol for its use.

PATIENTS AND METHODS

A total of 53 patients with 66 vascular malformation lesions were treated with an intralesional injection of 5% monoethanolamine oleate at 0.1 mL/cm of lesion with at least a 15-day interval and as many as 4 applications. A descriptive statistical analysis was performed using SigmaPlot, version 9.0, software.

RESULTS

The treatment with the protocol suggested was effective in 65 cases, and in 1 case, surgical intervention was required.

CONCLUSIONS

Sclerotherapy was effective in the treatment of vascular malformations, and the method chosen was adequate for lesion resolution without complications.

Recent progress in studies of infantile hemangioma

A hallmark of infantile hemangioma, the most common tumor of infancy, is its dramatic growth after birth, by diffuse proliferation of immature endothelial cells, followed by spontaneous regression. The growth and involution of infantile hemangioma is quite different from other vascular anomalies, which do not regress and can occur at any time during life. Some hemangioma lesions can be extremely disfiguring and destructive to normal tissue and may even be life-threatening. Unfortunately, existing therapeutic approaches have limited success and significant adverse effects of some treatment modalities limit their use. Better understanding of the pathogenesis of hemangioma will enable the development of better therapeutic strategies. Here, we review recent studies and new hypotheses on the pathogenesis of the tumor. Detailed mechanisms of activated vascular endothelial growth factor signaling in tumor cells, identification of their origin and characterization of multipotent stem cells that can give rise to infantile hemangioma are shedding new light on this intriguing vascular tumor.

Abordagem terapêutica dos hemangiomas cutâneos na infância

FUNDAMENTOS: Hemangioma é um tumor benigno de células endoteliais comum na infância e de involução espontânea. OBJETIVO: Avaliar os tratamentos utilizados em 122 pacientes com hemangiomas cutâneos, tratados no Hospital Universitário de Brasília, de março de 2000 a dezembro de 2006. MÉTODOS: Utilizou-se coleta de dados em prontuários e aplicação de questionários aos pais. Foram analisados gênero, fatores pré-natais e perinatais, características clínicas, tipo de tratamento e resultados. RESULTADOS: A razão de sexo (F: M) foi de 1,5:1. 42, em pacientes que apresentavam hemangiomas superficiais, 13 profundos e 67 mistos; em 7 pacientes, havia associação com síndromes. Em 79 pacientes, localizavam-se no polo cefálico. Já em 98/122 dos pacientes, foram submetidos a tratamento único e 24/122 a múltiplos. No primeiro grupo, foi utilizada conduta expectante em 38 pacientes, compressão em 3, corticoide sistêmico em 18, corticoide intralesional em 13, corticoide tópico em 4, cirurgia convencional em 12, criocirurgia em 7, luz pulsada em 1 e imiquimod em 2. No segundo grupo, 15 fizeram 2 tipos de tratamentos e 9 necessitaram de 3 ou mais tratamentos. CONCLUSÃO: Os dados obtidos concordam com a literatura mundial, quanto a sexo e localização da lesão. A incidência de hemangiomas presentes ao nascimento foi maior que em outras publicações. Os resultados terapêuticos obtidos foram comparáveis aos publicados na literatura. A identificação dos hemangiomas que necessitam de tratamento, em que momento adequado para intervenção e a melhor opção terapêutica devem ser considerados.

Hemangioma versus vascular malformation: presence of nerve bundle is a diagnostic clue for vascular malformation

CONTEXT

Arteriovenous vascular malformations and hemangiomas are benign vascular lesions that are difficult to distinguish from one another clinically. Also, they may be confused with each other at histopathology. Therefore, histochemical stains for the presence of an artery are frequently used to distinguish between the two.

OBJECTIVE

Because it is clinically relevant to differentiate between arteriovenous vascular malformations and hemangiomas, this study was carried out to explore additional diagnostic clues that may help in the diagnosis and differentiation of these lesions.

DESIGN

A total of 167 cases of benign extracranial vascular lesions were retrieved from the anatomic pathology file of our institution. These comprised 66 cases diagnosed as arteriovenous vascular malformations and 101 cases previously diagnosed as hemangiomas. The hematoxylin-eosin-stained glass slides were reviewed, Movat pentichrome histochemical stain was used to identify elastic vessels (arteries/arterioles), and S100 immunostain was used to identify nerves within these vascular lesions. For immunohistochemistry, the avidin-biotin detection method was used.

RESULTS

With Movat stain, the presence of thick-walled elastic arteries was detected in 12 of the 101 cases previously diagnosed as hemangiomas, and these cases were therefore reclassified as vascular malformations. Using the same criterion, 2 of the 66 cases originally diagnosed as arteriovenous vascular malformations were reclassified as hemangiomas because they lacked arterial structures. Thus, with this strict criterion, we ended up with 91 cases of hemangiomas and 76 cases of arteriovenous vascular malformations. Intralesional nerves were identified in 91% (69/76) of cases of arteriovenous vascular malformations, including all the 12 arteriovenous vascular malformations previously diagnosed as hemangiomas. In contrast, no intralesional nerve was detected in any of the 91 hemangiomas.

CONCLUSIONS

These results show that nerve bundles are consistently present in vascular malformations and absent in hemangiomas and so can be used as a diagnostic clue to differentiate between these lesions. Also, in addition to describing a previously unreported component of vascular malformations, these data further confirm the hamartomatous nature of these lesions.

Life-threatening cutaneous conditions in neonates

One of the major medical concerns in neonates is their vulnerability to life-threatening complications. Early diagnosis of potentially serious medical conditions is essential in prevention of such complication by prompt administration of appropriate treatments. Recognition of cutaneous manifestations of potentially fatal diseases may assist a clinician in management of newborns. To overview the full spectrum of this category of conditions, Medline search was performed for cases of cutaneous manifestations associated with mortality during the first month of live that were published in the English language literature since 1977. This is a concise review of the clinical aspects of most of the potentially life-threatening disorders in neonates divided by basic morphology of their cutaneous manifestations.

Hemangioma da infância

As novas classificações disponíveis e os modernos recursos diagnósticos por imagem não só permitiram a diferenciação entre os tumores e as malformações vasculares, mas também modificaram de forma substancial a abordagem e o tratamento dessas anomalias. O hemangioma da infância, o mais comum dos tumores vasculares dessa faixa etária e objeto deste trabalho, é revisto do ponto de vista de suas características clínicas e laboratoriais, diagnóstico diferencial e opções terapêuticas. Embora a conduta expectante permaneça como o tratamento de escolha para a maioria dos casos, o julgamento crítico é crucial para o emprego de outras modalidades terapêuticas.