Vascular tumors and vascular malformations: are we at the dawn of a better knowledge?

Topical sirolimus for the treatment of cutaneous manifestations of vascular anomalies: A case series

BACKGROUND

Vascular anomalies (VA), characterized by the abnormal development or growth of blood and/or lymphatic vessels, encompasses a spectrum of conditions with a range of symptoms and complications. VA are frequently associated with cutaneous complications that can cause significant morbidity. Systemic sirolimus has previously been shown to be effective in the treatment of complicated VA. There are limited studies to date on the use of topical sirolimus for the treatment of cutaneous manifestations of VA.

METHODS

Retrospective review of medical records of pediatric patients with VA treated with topical sirolimus at a single quaternary pediatric institution. Response was determined by clinical subjective and objective measures of improvement.

RESULTS

Twenty-three patients with cutaneous VA manifestations were treated with topical sirolimus. Median age was 14 (range 4-27 years). The main indication for treatment was complication of lymphatic blebbing (82%, n = 19) including lymphatic fluid leakage, bleeding, pain, pruritus, swelling, or recurrent infection. Treatment course ranged from 109 to 1424 days with median of 622 days. No major side effects were reported. Eighty-six percent of patients (n = 20) had subjective or objective improvement of cutaneous lesions. Lymphatic blebbing complications improved in 90% (n = 17) of individuals. Eighty-two percent (n = 14) of patients not receiving concurrent systemic sirolimus demonstrated improvement with topical therapy. One patient electively stopped treatment due to pruritus and burning sensation.

CONCLUSION

Topical sirolimus appears to be a beneficial therapy for lymphatic blebbing associated with lymphatic malformations or mixed malformations with a lymphatic component, although benefit in other VA remains unclear. Topical sirolimus was well-tolerated with minimal side effects.

Blue rubber bleb nevus syndrome as a cause of lower digestive bleeding

Introduction. Blue rubber bleb nevus syndrome is a rare disorder that is characterized by multiple recurrent vascular malformations that involve the skin and the gastrointestinal tract. The disease can present chronic anemia and severe episodes of gastrointestinal bleeding. Case Report. A 41-year-old man was admitted with recurrent episodes of lower gastrointestinal bleeding and anemia that had worsened over the last 3 months. The physical examination showed soft, diffuse, compressible, bluish nodules on all of the skin surfaces of the body. A biopsy from one of these skin lesions allowed a histological diagnosis of cavernous hemangioma. He submitted to a colonoscopy, which showed hemorrhoids and a plane vascular lesion mainly located on the right colon with recent signs of bleeding; this lesion was treated by local excision and sclerosis. The pathological study of the colon specimens also reflected the presence of cavernous hemangioma. The cutaneous hemangiomas and the presence of colonic venous malformations were compatible with blue rubber bleb nevus syndrome. The patient presented a favorable follow-up with clinical control of the anemia and without relapse of the gastrointestinal bleeding two years after the procedure. Conclusion. Although rarely diagnosed, blue rubber bleb nevus syndrome may be responsible for lower digestive bleeding.

The use of Onyx for embolization of peripheral vascular malformations in pediatric patients

PURPOSE

The management of congenital peripheral vascular malformations (VMs) can present a difficult therapeutic challenge. Endovascular transcatheter embolization of peripheral VMs is widely accepted as a first therapeutic option for many VMs. However, data describing the use of Onyx are limited in children with peripheral VMs. Our aim is to retrospectively evaluate the results of transcatheter arterial embolization with Onyx for peripheral VMs in children.

MATERIALS AND METHODS

We analyzed clinical and imaging records of 16 patients who underwent 25 embolization procedures by using Onyx for peripheral VMs. In eight cases, embolization procedures were performed once; in seven cases, twice; and in one case, thrice.

RESULTS

Embolization was technically complete in 4 patients and incomplete in 12 patients. Clinically, complete success was achieved in nine patients, and partial success was achieved in six patients. In one patient, reflux to the anterior and posterior tibial arteries caused peripheral ischemia, and the patient was referred to undergo plastic surgery. There were no complications in the other 15 patients.

CONCLUSION

With future studies to better characterize the safety profile of this agent in peripheral vasculature, embolization with Onyx may become a valuable treatment option for peripheral VMs in pediatric patients.

Lymphatic malformations: Current cellular and clinical investigations

Objective: Summarize current knowledge of lymphatic malformation development, biology, and clinical outcome measures.

Methods: Panel presentation of lymphatic malformation biology and measurement of head and neck malformation treatment outcomes.

Results: Characterization of lymphatic malformation endothelial and stromal cells may lead to biologically based treatment. Traditionally, lymphatic malformation treatment outcomes have been measured according to reduction of malformation size. Currently, methods to measure functional outcomes following lymphatic malformation treatment are lacking. This is particularly apparent when the malformation directly involves the upper aerodigestive tract.

Conclusions: The etiology and pathogenesis of head and neck lymphatic malformations are poorly understood, but understanding is improving through ongoing investigation. Reduction of lymphatic malformation size is generally possible, but further work is necessary to optimize methods for measuring therapeutic outcomes in problematic areas.

Multidetector CT angiography of pediatric vascular malformations and hemangiomas: utility of 3-D reformatting in differential diagnosis

BACKGROUND

Vascular malformations can be difficult to diagnose and classify. Accurate classification is important because treatments and prognosis vary based on the type of lesion. Diagnosis is based on a combination of clinical features with a variety of imaging techniques, including US, MRI/MRA, CT, and conventional angiography.

OBJECTIVE

We hypothesized that imaging features seen on 3-D reformatted images obtained with multidetector CT angiography (CTA) would aid in differential diagnosis of types of vascular anomalies.

MATERIALS AND METHODS

We retrospectively reviewed CT scans of 11 patients with vascular lesions and pathologically proven diagnoses in which 3-D reformatting was obtained.

RESULTS

The 3-D images accurately diagnosed hemangiomas and lymphangiomas in all cases, in contrast to diagnosis by clinical criteria and planar CT, which was difficult or inaccurate. The 3-D CTA did not aid in the distinction between venous malformations and arteriovenous malformations (AVM), which appeared similar.

CONCLUSIONS

Our preliminary observations suggest that volume-rendered reformatting is helpful in categorizing clinically significant vascular head and neck lesions, resulting in more diagnostic value than planar CT imaging alone. In particular, 3-D CTA might allow accurate differentiation of hemangiomas from AVM, and of lymphangiomas from other types of lesions, which was, in our series, not possible using clinical examination or conventional planar CT angiography.

Blue rubber bleb nevus syndrome associated with consumption coagulopathy: treatment with interferon

The blue rubber bleb nevus syndrome (BRBNS) is a rare vascular malformation syndrome with cutaneous and visceral lesions frequently associated with serious, even fatal bleeding. No systemic therapy is currently available. We report here a case with disseminated skin and gastrointestinal venous malformations and findings of disseminated intravascular coagulation that was treated with interferon beta. The disseminated intravascular coagulation manifestations were cleared with the treatment. The regression of the coagulopathy in our patient led us to think that the use of interferon beta in BRBNS might be beneficial.

MR imaging of soft tissue tumors and tumor-like lesions

The evaluation of a soft tissue mass in a child should proceed with a differential diagnosis in mind, based on the clinical history, age of the child, and location of the abnormality. Small, superficial masses can be initially evaluated with sonography. More extensive or deep lesions usually require cross-sectional imaging. With the exception of myositis ossificans, magnetic resonance (MR) imaging has largely replaced the use of computed tomography. MR imaging is used to delineate the extent of a lesion, to evaluate response to therapy, and to monitor postoperative complications. There is great overlap in the MR imaging characteristics of benign and malignant lesions, making tissue sampling imperative for diagnosis.

Lymphangiolipoma of the lower extremity: 5-year radiological follow-up after radiotherapy treatment

This report describes a lymphangiolipoma located in the extremity in a young woman. Radiotherapy effectively controlled recurrent lymphangiolipoma of the left upper leg that had been judged inoperable by limb-sparing surgical resection. In the case presented here, a dose of 50 Gy in 25 fractions over 5 weeks was employed without long-term complications after 5-year follow-up.

Kasabach-merritt syndrome

BACKGROUND

Kasabach-Merritt syndrome (KMS) is a consumptive coagulopathy associated with the presence of a large vascular lesion. It is often a frustrating condition to treat and it carries a high mortality rate. There are currently no known treatment guidelines. Kasabach-Merritt syndrome is associated with kaposiform hemangioendothelioma (KHE) and tufted angioma (TA); these lesions, when associated with KMS, are locally invasive, aggressive vascular tumors. Treatment options include supportive care, local therapies, and drug and surgical management. In most recent case reports, a multimodal approach to therapy is taken.

OBJECTIVE AND CONCLUSION

The objective of this article is to provide a comprehensive review of KMS and give an up-to-date summary of treatment options. The clinical presentation, laboratory findings, vascular pathology, and pathophysiology will also be discussed.

Blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome is a rare disorder characterized by distinctive cutaneous and gastrointestinal venous malformations that usually cause massive or occult gastrointestinal hemorrhage and iron deficiency anemia secondary to the bleeding episodes. It is even a rare cause of gastrointestinal hemorrhage during childhood. We describe a 6-year-old boy who had multiple venous malformations all over his body. He also suffered from several episodes of melena, chronic anemia, and growth retardation. The endoscopic examination of the gastrointestinal tract revealed multiple bluish-black sessile and polypoid venous malformations in various sizes. It was possible to remove the largest venous malformations causing massive bleeding during colonoscopy.