Is oestrogen therapy justified in the treatment of hereditary haemorrhagic telangiectasia: a biochemical evaluation

Gender differences in hereditary hemorrhagic telangiectasia severity

Background

Gender differences in organ involvement and clinical severity have been poorly described in hereditary hemorrhagic telangiectasia (HHT). The aim of this study was to describe differences in the severity of HHT manifestations according to gender.

Methods

Severity was measured according to Epistaxis Severity Score (ESS), Simple Clinical Scoring Index for hepatic involvement, a general HHT-score, needing for invasive treatment (pulmonary or brain arteriovenous malformations -AVMs- embolization, liver transplantation or Young’s surgery) or the presence of adverse outcomes (severe anemia, emergency department -ED- or hospital admissions and mortality).

Results

One hundred forty-two (58.7%) women and 100 (41.3%) men were included with a mean age of 48.9 ± 16.6 and 49 ± 16.5 years, respectively. Women presented hepatic manifestations (7.1% vs 0%) and hepatic involvement (59.8% vs 47%), hepatic AVMs (28.2% vs 13%) and bile duct dilatation (4.9% vs 0%) at abdominal CT, and pulmonary AVMs at thoracic CT (35.2% vs 23%) more often than men. The Simple Clinical Scoring Index was higher in women (3.38 ± 1.2 vs 2.03 ± 1.2), and more men were considered at low risk of harboring clinically significant liver disease than women (61% vs 25.3%). These differences were mantained when considering HHT1 and HHT2 patients separetely. Duodenal telangiectasia were more frequent in men than women (21% vs 9.8%). Invasive treatments were more frequently needed in women (28.2% vs 16%) but men needed attention at the ED more often than women (48% vs 28.2%), with no differences in ESS, HHT-score, anemia hospital admissions or mortality.

Conclusions

HHT women showed more severe hepatic involvement than men, also among HHT1 and HHT2 patients. Women had higher prevalence of pulmonary AVMs and needed invasive procedures more frequently, while men needed attention at the ED more often. These data might help physicians to individualize HHT patients follow-up.

Lack of significant estrogen and progesterone receptor expression in nasal telangiectasias in hereditary hemorrhagic telangiectasia: an immunohistochemical analysis

CONCLUSION

This immunohistochemical study of estrogen and progesterone receptors could not confirm a significant expression in nasal telangiectasias. Thus, a specific effect of these hormones or anti-hormone therapy on malformed nasal vessels has to be questioned and only offered under strict clinical control.

OBJECTIVE

The efforts to control recurrent epistaxis in hereditary hemorrhagic telangiectasia (HHT) using alternative methods are very intense. Hormone or anti-hormone therapy has frequently been postulated and the reported results are controversial. Therefore it was important to find an explanation regarding a possible impact of hormonal therapies by immunohistochemical evaluation of progesterone and estrogen receptor expression on nasal telangiectasias of affected patients.

METHODS

Tissue samples of nasal mucosa with evidence of telangiectasias from 14 patients with HHT were analyzed for the expression of progesterone and estrogen receptors on the nuclei of endothelial cells of the malformed vessels using immunohistochemistry.

RESULTS

Progesterone receptors were not detected in any of the cases and only two cases showed a weak expression of estrogen receptors with an immunoreactive score of 2/12.

[Nasal cavity dermoplasty as a treatment of recurrent bleeding in Rendu-Osler-Weber's disease]

INTRODUCTION

Rendu-Osler-Weber's (ROW) disease is a systemic disorder of blood vessels classified as a capillary malformation. The most common manifestation of hereditary hemorrhagic teleangiectasia is recurrent epistaxis. The diagnosis of ROW disease is made clinically using the Curacao criteria. Management of epistaxis is usually difficult and many types of treatment have been described.

MATERIAL AND METHODS

We report 12 patients, 7 female and 5 male, aged 52 to 78 with ROW disease and recurrent epistaxis with frequency varying from 5 episodes monthly to 3 - 5 episodes daily. In most of them blood transfusion was required. The patients were treated with intranasal dermoplasty described by Saunders. The dermoplasty was performed on the septal, lateral or both walls of the anterior part of the nasal cavities.

RESULTS

In all the patients the graft was taken completely. Two patients had scars and narrowing of nasal valve region. Recurrence and increase in the intensity of nasal bleeding were observed in 3 patients. In the course of further therapy the second partial septal dermoplasty was successfully performed in 2 of them. The second surgery revealed new bleeding teleangiectases beyond of the dermal graft.

CONCLUSION

Nasal cavity dermoplasty remains an effective way of reducing epistaxis and blood transfusion in patients with ROW disease and subjectively improves their quality of life. The surgical treatment can be repeated, if nasal bleeding recur.

A novel mutation in ALK-1 causes hereditary hemorrhagic telangiectasia type 2

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal-dominant bleeding disorder and has two variants, HHT1 and HHT2, associated with mutations in the ENG and ALK-1 genes, respectively. We identified one Chinese HHT2 family to investigate the pathogenic gene and its possible mechanism of action by mutation screening and functional study. One substitution mutation (1717C>T) in exon 10 of the ALK-1 was found by sequencing of all exons of ENG and ALK-1 and caused a R479X mutation in the ALK-1 protein. ALK-1 mRNA and plasma thrombomodulin were measured by real-time quantitative PCR and ELISA, respectively. There was no significant difference in the expression levels of ALK-1 mRNA between patients and healthy individuals. A significantly higher level of thrombomodulin was found in HHT patients. These findings indicate that the mutation causes truncation of the ALK-1 protein at the post-transcriptional level; the plasma thrombomodulin may provide an easy diagnostic indicator in HHT patients.

Epistaxis in patients with hereditary hemorrhagic teleangiectasia

Introduction. Spontaneous recurrent epistaxis is the most common clinical manifestation of hereditary hemorrhagic teleangiectasia (HHT). It occurs in more than 90% of HHT patients and is the most distressing symptom. Nasal teleangiectasias tend to increase with age both in size and number, so epistaxis is heavier and more frequent. For patients with mild to moderate disease, there are many adequate treatment options. For those with severe disease, most treatments offer just a hemorrhage-free interval. Experienced otorhinolaryngologists who treat epistaxis in these patients often use the adage "to do as little as possible for as long as possible". Management of acute epistaxis. The recommendations for the management of acute epistaxis include: compression, use of topical antifibrinolytics, laser therapy, argon plasma coagulation therapy, fibrin sealant spray or gelatin sponge soaked in adrenaline. In cases of heavy acute epistaxis, an epistaxis balloon combined with artery ligation and/or embolization is the most effective treatment. Nasal packing and electrocauterisation should be avoided to prevent further trauma to the blood vessels. Treatment of recurrent epistaxis. Management of recurrent epistaxis includes topical application of laser energy (argon, Nd: YAG, KTP/532 and diode, not CO2), argon plasma coagulation in combination with 0.1% estriol ointment, caustics, antifibrinolytics, bleomycin and sclerosing substances. Systemic estrogen-progesterone at doses used for oral contraception may eliminate bleeding in women with heavy epistaxis. Systemic antifibrinolitics (used with extreme precaution) and septal dermoplasty give good results. The only method which successfully and permanently solves the problem of severe refractory epistaxis in hereditary hemorrhagic teleangiectasia is closure of the nasal cavities. .

High prevalence of hepatic focal nodular hyperplasia in subjects with hereditary hemorrhagic telangiectasia

A vascular pathogenesis of hepatic focal nodular hyperplasia (FNH) has been suggested; this study was aimed to evaluate in families with hereditary hemorrhagic telangiectasia (HHT) the prevalence of FNH, relating it to presence and stage of hepatic vascular malformations (VMs). Fifty-two HHT families underwent a screening program including abdominal Doppler sonography (US) searching for hepatic VMs; we classified them as minimal, moderate and severe, depending on the number and degree of abnormalities found by Doppler US. Presence of focal liver lesions was recorded. Diagnosis of FNH was made if at least two examinations, whether color Doppler US, liver scintigraphy, dynamic computed tomography (CT) or magnetic resonance (MR), showed suggestive findings. FNH was found in five out of 274 subjects (1.8%). All five were affected by HHT. Thus, percentage related to the group of affected patients increased to 2.9; 4/5 presented severe liver VMs. Female-to-male ratio was 4:1. FNH was single in three cases; tumor size ranged between 20 and 90 mm. During follow-up, no lesion showed a reduction in size, three showed an increase. Prevalence of FNH in patients with HHT is far greater than that reported in the general population; Doppler US role in its diagnosis and follow-up is highlighted.

Hormonal and Antihormonal Therapy for Epistaxis in Hereditary Hemorrhagic Telangiectasia

OBJECTIVES/HYPOTHESIS

Objectives were to assess available information on hormonal therapy for bleeding in hereditary hemorrhagic telangiectasia (HHT), to determine whether there is a role for hormonal therapy as an initial therapeutic option, and to report the second known case of response in HHT to antihormonal therapy.

STUDY DESIGN

Literature review and case report.

METHODS

The literature on hormonal and antihormonal therapy for HHT was reviewed. Medical records for the case reported in the present study were evaluated to confirm the diagnosis and assess responses to surgical and nonsurgical treatments.

RESULTS

All reports of success using hormonal therapy for HHT-related bleeding were either retrospective or uncontrolled with the exception of two. Anecdotal evidence with high-dose estrogen appeared to show success, but serious side effects have discouraged use. One controlled trial found no benefit for intermediate dose, single-agent estrogen. The other controlled trial appeared to show benefit with low-dose estrogen-progesterone in HHT with gastrointestinal tract bleeding and was supported by an uncontrolled study showing efficacy in epistaxis. The case reported in the present study demonstrated long-term cessation of epistaxis with tamoxifen in a postmenopausal woman.

CONCLUSIONS

Systemic estrogen-progesterone at doses used for oral contraception may eliminate bleeding in symptomatic HHT and is a reasonable initial option in fertile women. There is no information on possible effects of lower-dose estrogen-progesterone used in postmenopausal women for hormone replacement therapy. Tamoxifen has dramatically eliminated HHT-related bleeding in two cases. It is well tolerated in postmenopausal women and should be considered for randomized clinical trials.

Diagnosis and management of gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia

OBJECTIVE

Our aim was to report our experience with treating GI bleeding in patients with hereditary hemorrhagic telangiectasia (HHT).

METHODS

Consecutive patients with GI bleeding referred to the Yale University Vascular Malformation Center underwent clinical evaluation and endoscopy. Hb and blood transfusion requirements for 1 yr before and after evaluation were documented. Patients with a mean Hb <or= 8 mg/dl or blood transfusion requirements >or= 12 units packed red blood cells (PRBC)/yr were defined as patients with significant bleeding. Drug therapies, including ethinyl estradiol/norethindrone, danazol, and aminocaproic acid, were prescribed on an individual patient basis.

RESULTS

The study included 43 HHT patients with a mean age of 57 yr. Endoscopy revealed telangiectases in the esophagus (1/41), stomach (33/41), duodenum (33/41), jejunum (5/9), and colon (10/32). Patients with > 20 telangiectases visualized on esophagogastroduodenoscopy had a significantly lower mean Hb of 7.9, compared with 9.4 (p = 0.007), and a trend toward higher blood transfusion requirements. Non-HHT-related causes of GI bleeding were diagnosed in four patients. During a mean follow up of 18.9 months, the group of 40 patients with HHT-related bleeding had improvements in their mean Hb and blood transfusion requirements.

CONCLUSIONS

Some HHT patients with GI bleeding improve on drug therapies, but others fail. Transfusion-dependent GI bleeding is difficult to manage, and optimal management may include both medical and endoscopic treatments.