Infantile hemangioma: factors causing recurrence after propranolol treatment

Shikonin reverses pyruvate kinase isoform M2-mediated propranolol resistance in infantile hemangioma through reactive oxygen species-induced autophagic dysfunction

Infantile hemangioma (IH) is the most common benign tumor in infancy. Propranolol, a nonselective β-adrenergic receptor blocker, is now the first-line therapy for IH. Recently, low sensitivity to propranolol therapy has become one major reason for the failure of IH treatment. However, the exact underlying mechanisms are yet to be fully elucidated. Here, we reported that pyruvate kinase isoform M2 (PKM2), an essential glycolytic enzyme, played a critical role in regulating the progression of IH and the therapeutic resistance of propranolol treatment. Shikonin reversed the propranolol resistance in hemangioma-derived endothelial cells and in hemangioma animal models. Moreover, shikonin combined with propranolol could induce excessive reactive oxygen species (ROS) accumulation and lead to autophagic dysfunction, which is essential for the enhanced therapeutic sensitivity of propranolol treatment. Taken together, our results indicated that PKM2 has a significant role in hemangiomas progression and therapeutic resistance; it could be a safe and effective therapeutic strategy for those hemangiomas with poor propranolol sensitivity combined with shikonin.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RATIONALE

Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management.

METHODS

Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value <0.05 was taken as significant.

RESULTS

In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049).

CONCLUSION

Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Long non-coding RNA breast cancer-associated transcript 54 sponges microRNA-1269b to suppress the proliferation of hemangioma-derived endothelial cells

Long non-coding RNA (lncRNA) breast cancer-associated transcript 54 (BRCAT54) and microRNA-1269b (miR-1269b) are two critical ncRNAs in cancer biology, while their roles in hemangioma are unknown. Our preliminary sequencing data revealed their altered expression in hemangioma and predicted they could interact with each other. This study was therefore carried out to investigate the roles of BRCAT54 and miR-1269b in hemangioma, with a focus on their interaction. In this study, hemangioma samples donated by 20 infantile hemangioma patients at proliferating-phase and 20 infantile hemangioma patients at involuting-phase were used. The expression of BRCAT54 and miR-1269b in hemangioma samples, as well as hemangioma-derived endothelial cells (HDECs) and human umbilical vein endothelial cells (HUVECs) were detected by RT-qPCR. IntaRNA 2.0 was applied to predict the interaction between BRCAT54 and miR-1269b, which was then confirmed by RNA-RNA pulldown assay. Accumulation of BRCAT54 in the subcellular location of HDECs was detected by subcellular fractionation assay. The role of BRCAT54 and miR-1269b in cell proliferation has been explored by the BrdU assay. Compared to proliferating-phase tissues, involuting-phase tissues exhibited decreased expression levels of BRCAT54 and increased expression levels of miR-1269b. HDECs had decreased expression levels of BRCAT54 and increased expression levels of miR-1269b compared to that of HUVECs. In HDECs, BRCAT54, which was detected in both nuclear and cytoplasm fractions, directly interacted with miR-1269b. BRCAT54 and miR-1269b did not affect the expression of each other, while BRCAT54 suppressed the role of miR-1269b in enhancing the proliferation of HDECs. BRCAT54 may sponge miR-1269b to suppress the proliferation of HDECs.

Propranolol Suppresses Proliferation and Migration of HUVECs through Regulation of the miR-206/VEGFA Axis

Propranolol has been used in the first-line therapy of infantile hemangioma (IH) for a number of years; however, the mechanisms through which propranolol regulates IH are not yet fully understood. In the present study, microRNA (miRNA/miR) sequencing analysis was performed to identify differentially expressed miRNAs in human umbilical vascular endothelial cells (HUVECs) treated with propranolol. Cell viability and apoptosis were detected using CCK-8 assay and flow cytometry, respectively. Cell migration was assessed using wound healing, Transwell, and tube formation assays. Methylation-specific PCR was then used to investigate the promoter methylation status. The levels of oxidative stress indicators, including superoxide dismutase, glutathione, and malondialdehyde were also detected. Finally, cell cycle analysis was performed using flow cytometry and western blotting. It was observed that propranolol induced the upregulation of miR-206 in HUVECs, which was caused by demethylation of the miR-206 promoter. Moreover, propranolol significantly inhibited the proliferation of HUVECs by inducing apoptosis, while these phenomena were reversed by miR-206 antagomir. VEGFA was found to be a target gene of miR-206. In addition, propranolol notably inhibited the migration and induced G1 arrest of the HUVECs, whereas these results were eliminated by miR-206 antagomir. Collectively, the findings of the present study demonstrated that propranolol may inhibit the proliferation and migration in HUVECs via modulating the miR-206/VEGFA axis. These findings suggest a novel mechanism through which propranolol suppresses the progression of IH.

Infantile Hemangiomas: An Update on Pathogenesis and Treatment

Infantile hemangiomas are the most common benign vascular tumors in infancy. This review includes an update on the current knowledge on pathogenesis, a discussion on indications for treatment, and a review of the mechanisms underlying the different treatment methods. Although most infantile hemangiomas require only active observation because of their natural course, which results in involution, about 10% present with complications that require immediate treatment. The basic treatment includes systemic and topical options. In cases of insufficient response or rebound growth, other forms of treatment should be considered. In some cases, combined therapy might be initiated.

Value of Doppler ultrasound scans in deciding whether to treat infantile haemangioma with oral propranolol

BACKGROUND

Oral propranolol (Pr) must be administered until the end of the proliferation phase of infantile haemangioma (IH). This phase may be difficult to assess, particularly where a deep component is involved. Doppler ultrasound scans (DUS), which identify vascular activity (VA), could assist the clinician in making the correct therapeutic decision (CTD).

PATIENTS AND METHODS

All children with IH treated with Pr for at least 3 months and up to the age of 9 months, and who also underwent DUS, were enrolled in this retrospective, single-centre, observational study. The quality of DUS as a binary diagnostic test for IH proliferation was assessed, together with its value in deciding whether to discontinue Pr (at the end of the presumed proliferation phase) or resume this drug (in the case of suspected recurrence).

RESULTS

A total of 29 children were enrolled and 45 DUS were performed. Thirty-nine (87%) DUS were of high quality (80% sensitivity, 95% specificity) and made a major, moderate, or minimal contribution to the CTD in respectively 20%, 60% and 7% of cases.

DISCUSSION

DUS proved to be a high-value tool. They were essential in some cases of IH, mainly periocular and localised forms, and those involving deep components, in which the question of discontinuing Pr arose (age>1 year) and where clinical examination had not been sufficient to make the CTD. Furthermore, in the vast majority of cases, they provide a helpful examination and complement clinical findings in terms of patient follow-up and reaching a CTD.

CONCLUSION

DUS is an effective and complementary tool to clinical investigation.

Enhanced efficacy of propranolol therapy for infantile hemangiomas based on a mesoporous silica nanoplatform through mediating autophagy dysfunction

Infantile hemangioma is one of the most common vascular tumors, which might result in morbidity and mortality without timely intervention. Propranolol is currently the first-line therapy for hemangiomas, but its potential side effects and high frequency of administration make it urgent to develop a suitable drug delivery system for propranolol. In the present study, we formulated a propranolol delivery system based on mesoporous silica nanoparticles (PRN@MSN) and investigated the interplay between autophagic activities mediated by nanoparticles and improved therapeutic efficacy of PRN@MSN. The results showed that PRN@MSN nanoparticles exhibited higher cytotoxicity compared with free propranolol in vitro and in vivo, which could induce excessive autophagosome accumulation through increased autophagosome formation and impaired autophagic degradation. Inhibition of autophagy in the early stage could attenuate the cytotoxicity of PRN@MSN. ROS generation was essential for nanoparticle-mediated autophagy and cytotoxicity, and PRN@MSN-induced autophagy dysfunction could enhance endoplasmic reticulum (ER) stress in hemangioma stem cells. Our study revealed a promising PRN delivery system based on a mesoporous silica nanoplatform that could induce autophagy dysfunction with excessive autophagosome accumulation to promote the therapeutic efficacy of PRN therapy. PRN@MSN drug delivery system combined with autophagy modulation may act as a promising treatment pattern in the treatment of hemangiomas.

Identification of putative biomarkers for Infantile Hemangiomas and Propranolol treatment via data integration

Infantile hemangiomas (IHs) are the most common benign tumors in early childhood. They show a distinctive mechanism of tumor growth in which a rapid proliferative phase is followed by a regression phase (involution). Propranolol is an approved treatment for IHs, but its mechanism of action remains unclear. We integrated and harmonized microRNA and mRNA transcriptome data from newly generated microarray data on IHs with publicly available data on toxicological transcriptomics from propranolol exposure, and with microRNA data from IHs and propranolol exposure. We identified subsets of putative biomarkers for proliferation and involution as well as a small set of putative biomarkers for propranolol's mechanism of action for IHs, namely EPAS1, LASP1, SLC25A23, MYO1B, and ALDH1A1. Based on our integrative data approach and confirmatory experiments, we concluded that hypoxia in IHs is regulated by EPAS1 (HIF-2α) instead of HIF-1α, and also that propranolol-induced apoptosis in endothelial cells may occur via mitochondrial stress.

Liposuction for large facial involuted infantile hemangiomas in children: clinical evaluation and management strategies

BACKGROUND

Large involuted infantile hemangioma (IH) can cause facial disfigurement and functional impairment and constitute a major concern to children and parents. Liposuction for large involuted IH has been reported in some case reports. However, systematic study is seldom and the patient outcome is uneven.

METHODS

Thirteen eligible patients who underwent liposuction treatment at Shanghai Ninth People's Hospital between August 2016 and August 2018 were reviewed. IH lesions were evaluated according to their timing, components, involvement, and location. Liposuction was performed to address the volumetric residue.

RESULTS

Between August 2016 and August 2018, 13 patients, four boys and nine girls, with an average age of 8 ± 4.4 years underwent the liposuction for large facial involuted IH. Clinical follow-up ranges from 3 to 18 months. In two cases, lipectomy and facelift were undertaken in conjunction with liposuction. One patient needs a secondary revision due to the residual facial asymmetry. All patients were satisfied with the outcomes.

CONCLUSIONS

Liposuction for large involuted IH is reliable and underreported in the literature. With proper patient evaluation and good counseling on realistic expectations, liposuction for large facial involuted IH can be expected to achieve excellent results with a low complication rate in pediatric population.

Nasolabial Flap Based on the Upper Lateral Lip Subunit for Large Involuted Infantile Hemangiomas of the Upper Lip

BACKGROUND

Large involuted upper lip infantile hemangioma is a challenge for plastic surgeon because of high visibility of disfigurement. To achieve an optimal reconstruction with matched color and texture, nasolabial flap based on the upper lateral lip subunit is used for the upper lip reconstruction.

METHODS

Records of 8 patients who underwent upper lip reconstruction from 2014 to 2018 at Shanghai Ninth People's Hospital were reviewed. After flap design according to the contralateral upper lip subunit, nasolabial flap was dissected and rotated to the defect. The donor site was subsequently closed by extensive undermining cheek skin tissue. The incisions were hidden in the border of lateral upper lip subunit.

RESULTS

There were a few deformities observed, including scar hypertrophy (4/8), alar flaring (2/8), and lower lid bulking (1/8). Five patients received following trimming procedures because of residual scars or deformity. All the patients were satisfied with the postoperative results. No obvious complications were observed.

CONCLUSIONS

The nasolabial flap based on the upper lateral lip subunit is a safe, effective, and reliable technique for correction of severe upper lip defect caused by large involuted infantile hemangioma. Although subsequent trimming procedures are required in some complicated cases, satisfactory results can still be achieved.

Evaluating the Clinical Outcomes of Parotid Hemangiomas in the Pediatric Patient Population

INTRODUCTION

Infantile hemangiomas (IHs) are the most common tumor of the parotid gland in children; however, there is no standard protocol for the treatment of IH. The generally accepted practice is to begin the patient on β-blocker therapy if there are no contraindications.

OBJECTIVE

The purpose of this study is to better understand the challenges and successes of management of pediatric patients with parotid IH.

METHODS

This retrospective study analyzed 15 patients diagnosed with parotid IH from 2009 to 2016 who were cared for at a tertiary care center. Demographic information, lesion characteristics, and treatment course were obtained through patient chart review.

RESULTS

Fifteen pediatric patients with parotid IH were evaluated. The female:male ratio was 4:1; the average age of diagnosis was 8.75 months. Most lesions were greater than 3 cm in their widest dimension (73.3%), and 13 patients underwent imaging to further clarify the parotid mass in their clinical workup. Fourteen patients began treatment with propranolol; 10 patients saw complete resolution of their IH (66.7%) and 3 had a partial response to β-blocker therapy (20%). After discontinuation of propranolol, 2 patients had regrowth 2 to 3 months later after regression and were restarted on therapy. The average duration of treatment was 9.9 ± 8.45 months. The known adverse effects of propranolol-hypoglycemia, hypotension, bradycardia, and bronchospasm-were not observed in any patient.

CONCLUSION

In the treatment of parotid IH, propranolol is the generally accepted first-line therapy, as compared to corticosteroid or interferon α injections of years past. Parotid hemangiomas, however, have a lower response rate to propranolol and a similar recurrence rate compared to IH at other sites. The treatment duration necessary tends to be longer. Future studies will aim at identifying and evaluating potential predictors of outcomes to help inform the management of parotid hemangiomas.

MicroRNAs for the pediatric otolaryngologist

The scope of pediatric otolaryngology is broad and encompasses a wide variety of diseases in which the fundamental phenotype-causing abnormality exists at the level of gene regulation and expression. Development of novel molecular biology instruments to diagnose disease, monitor treatment response, and prevent recurrence will facilitate the delivery of appropriate surgical and adjuvant medical treatments with lower morbidity. MicroRNAs (miRNAs) have emerged as a relatively new class of molecules that directly modulate gene expression and are abnormally expressed in a multitude of disease processes including those within the scope of pediatric otolaryngology. Functionally, miRNAs control multiple cellular functions including angiogenesis, cell proliferation, cell survival, genome stability, and inflammation. These short, non-protein coding RNA molecules are present and stable in tissue, blood, saliva, and urine, making them ideal disease biomarkers. The simple structure of miRNAs and their ability to directly modulate the expression of specific genes lends exciting therapeutic potential to miRNA-based therapies. Here we review the current literature of miRNAs as it relates to diseases within the scope of pediatric otolaryngology, and discuss their potential as diagnostic biomarkers and therapeutic targets.

Infantile hemangiomas: what have we learned from propranolol?

PURPOSE OF REVIEW

Infantile hemangiomas are the most common vascular tumor of infancy. Treatment of infantile hemangiomas was revolutionized when propranolol, a nonselective β-blocker, was reported to be effective therapy. In this review, we highlight the lessons learned using propranolol to treat infantile hemangiomas. We also describe the ongoing effort to understand the mechanism of action of propranolol.

RECENT FINDINGS

Although the pathogenesis of infantile hemangiomas is not fully understood, maternal hypoxic stress and embolization of placental tissue are suggested to be critical components in their development. The mechanism of action of propranolol remains unclear, however various molecular mechanisms are detailed in this review. Propranolol treatment remains a well tolerated therapy, with low risk of adverse events or long-term neurocognitive effects. Dosing recommendations and optimal treatment duration vary among studies, and should be altered in patients with certain medical conditions such as Posterior fossa anomalies, Hemangioma, Arterial lesions, Cardiac abnormalities/coarctation of the aorta, Eye anomalies (PHACE) syndrome.

SUMMARY

Propranolol is a well tolerated and effective treatment for infantile hemangiomas. The efficacy of propranolol for infantile hemangiomas is clear, however questions pertaining to mechanism of action, pretreatment risk stratification, and optimal dosing remain unanswered. The guidelines for managing infantile hemangiomas with propranolol will continue to adapt as research catches up to clinical experience.

Prolonged growth of infantile hemangioma after pulsed dye laser and oral propranolol treatment

Infantile hemangiomas are the most common tumor of childhood and undergo rapid growth during early infancy followed by gradual involution. After involution, residual lesions sometimes remain. Oral propranolol usually induces earlier involution and redness reduction of infantile hemangiomas. However, the optimal treatment duration is unknown and infantile hemangiomas sometimes recur after cessation of treatment. We report three Japanese patients with recurrent infantile hemangiomas on their cheek. These patients were a 1-month-old female baby with a superficial infantile hemangioma, a 3-month-old female baby with a mixed infantile hemangioma and a 4-month-old male baby with a mixed infantile hemangioma. Two of them also received pulsed dye laser treatment. They did not reach complete or nearly complete resolution of infantile hemangiomas at week 25. These patients experienced regrowth of their infantile hemangioma after 20 months of age and took propranolol after the age of 24 months. There were no severe adverse effects. Propranolol may not only be therapeutic but also prophylactic. Patients with infantile hemangiomas who have taken oral propranolol should be followed up at least 6 months after cessation of treatment, especially infantile hemangiomas on the cheek, and those with partial response to propranolol may require close attention in prolonged growth.