Beta-blockers as therapy for infantile hemangiomas

Ramsay Hunt Syndrome: A Rare Complication of Herpes Zoster Infection With an Incidental Finding of Submandibular Hemangioma

Ramsay Hunt syndrome is a rare viral condition that develops from the varicella zoster virus that affects the face's geniculate ganglion. It has been defined by a herpes zoster oticus, which can be associated with further cranial nerve lesions and acute peripheral facial nerve palsies. In this case, we present a 73-year-old female patient who presented to the outpatient department (OPD) with unbearable pain in the lower left cheek that she had been experiencing for the last four days. The reported pain was continuous and could be described as deep-aching and burning. Facial swelling was observed in relation to the lower lip, especially in the vermillion area; there was ulceration, paralysis seen on the left face, and swelling on the submandibular region. Intravenous corticosteroids and antiviral drugs were administered to her for seven days as an association therapy. In this report, the authors want to stress the necessity of using adequate clinical examination and early intervention in the case of the Ramsay Hunt syndrome.

Vascular Lesions

Vascular lesions impact up to 5% of children and range in clinical impact from minor cutaneous aberrations to large masses impacting both form and function. Vascular lesions may be characterized as tumors or malformations. Establishing a clear diagnosis is imperative to understanding the natural history of a vascular lesion and developing a treatment plan. Medical, surgical, intralesional, and laser therapy are all effective and indicated on a case-by-case basis. There are a number of important surgical considerations for operative management of these lesions.

Treatments of Epistaxis in Hereditary Hemorrhagic Telangiectasia: Systematic Review and Network Meta-Analysis

PURPOSE OF REVIEW

To analyze and compare the effects of epistaxis treatments for Hereditary Hemorrhagic Telangiectasia (HHT) patients.

RECENT FINDINGS

Of total of 21 randomized controlled trials (RCT), the data from 15 RCTs (697 patients, 7 treatments: timolol, propranolol, bevacizumab, doxycycline, tacrolimus, estriol/estradiol, and tranexamic acid) were pooled for the meta-analyses while the other 6 studies (treatments: electrosurgical plasma coagulation, KTP laser, postoperative packing, tamoxifen, sclerosing agent, and estriol) were reviewed qualitatively. When compared to placebo, propranolol offered the most improved epistaxis severity score, mean difference (MD), -1.68, 95% confidence interval (95%CI) [-2.80, -0.56] followed by timolol, MD -0.40, 95%CI [-0.79, -0.02]. Tranexamic acid significantly reduced the epistaxis frequency, MD -1.93, 95%CI [-3.58, -0.28]. Other treatments had indifferent effects to placebo. Qualitative analysis highlighted the benefits of tamoxifen and estriol. The adverse events of tranexamic acid, tacrolimus, propranolol, and estradiol were significantly reported. Propranolol, timolol, tranexamic acid, tamoxifen, and estriol were effective treatments which offered benefits to HHT patients in epistaxis management. Adverse events of tranexamic acid, tacrolimus, propranolol, and estradiol should be concerned.

Infantile Hemangiomas: A Review of Current Treatment Options

This literature review outlines the current pathogenesis, clinical features, and complications of infantile hemangiomas and explores the current treatment modalities, including corticosteroids, surgery, pulsed dye laser, and beta-blockers. Although oftentimes benign, these lesions can potentially lead to physical or cosmetic disfigurement in growing children. The issue of depth and location-dependent treatment for infantile hemangiomas is explored as it reveals which treatments are correlated with better outcomes in specific presentations. For example, beta-blockers were found to be an effective first-line treatment for superficial infantile hemangiomas specifically, whereas the pulsed dye laser procedure was shown to be an effective option for deep hemangiomas, speeding up the involution process when combined with other treatment modalities and reducing scarring in ulcerated hemangiomas. Although the various infantile hemangioma treatment modalities available are appropriately tailored to specific cases of hemangiomas, they are also not without significant, sometimes life-threatening complications. This is why this literature review aims to outline the therapeutic benefits and risks of all treatment modalities to aid in the establishment of optimal case-dependent treatments. [Pediatr Ann. 2023;52(5):192-197.].

Extensive severe intraorbital arteriovenous malformations: report of a rare laser complication and successful management

Arteriovenous malformations (AVMs) are rare congenital errors of vascular morphogenesis, characterised by abnormal direct communications between arteries and veins, bypassing the normal capillary bed. Apart from the central nervous system, typical locations include the head and neck, and less frequently limbs, trunk or internal organs. AVMs of the head and neck often become clinically evident and symptomatic only in later childhood and are characterised by a history of variable growth, sometimes leading to large, deforming, pulsating masses with a propensity to massive haemorrhage. Therapeutic strategy is based on selective embolisation, surgical excision, or a combination of both. Radical surgical excision of local AVMs is the only effective treatment but it may be mutilating, especially for AVMs of the head and neck. Laser therapy represents a good option to treat the cutaneous aspects of AVMs nevertheless, its efficacy is limited. To the date, pharmacological therapy for AVMs is still on debate due to its controversial outcomes as it seems not as effective as other treatments and usually requires a longer course of application. However, pharmacological therapy could be useful in selected patients and for AVMs nonresponsive to traditional treatment, allowing them to obtain acceptable results without serious complications. This paper reports the case of a serious laser complication of extensive intraorbital AVM successfully treated by local reconstruction and topical pharmacological treatment.

The Use of Beta-Blockers in Hereditary Hemorrhagic Telangiectasia-Related Epistaxis: A Systematic Review

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease affecting 1 in 5000 individuals. Epistaxis is seen in more than 90% of patients with HHT. Severe recurrent epistaxis can significantly decrease quality of life and may be resistant to standard treatment measures. Dysregulation of angiogenesis has been shown to cause the proliferation of abnormal blood vessels. As such, antiangiogenic treatments have been investigated including beta-blockers.

OBJECTIVE

A systematic review of the efficacy of beta-blockers in topical treatment of epistaxis in patients with HHT based on epistaxis duration, frequency, and severity.

METHODS

A systematic search was performed using the PubMed, Embase via Ovid, and Cochrane databases. The Preferred Items for Systematic Reviews and Meta-Analyses guidelines were followed. Studies that measured the efficacy of beta-blocker treatment of epistaxis in patients with HHT were included for qualitative analysis.

RESULTS

Five studies (3 randomized controlled trials and 2 case series) with a total of 132 patients were included. Administration (systemically or topically via a spray or gel) of timolol and propranolol showed mixed evidence of improvement in epistaxis frequency, severity, and duration when compared with control groups. The evidence for propranolol appears more promising than timolol.

CONCLUSION

There are significant limitations in the included studies, and further investigation with larger longitudinal or randomized prospective trials is recommended. The available evidence suggests that beta-blocker treatment may have a positive effect on HHT-related epistaxis.

Β-blockers activate autophagy on infantile hemangioma-derived endothelial cells in vitro

The mechanisms underlying the success of propranolol in the treatment of infantile hemangioma (IH) remain elusive and do not fully explain the rapid regression of hemangiomatous lesions following drug administration. As autophagy is critically implicated in vascular homeostasis, we determined whether β-blockers trigger the autophagic flux on infantile hemangioma-derived endothelial cells (Hem-ECs) in vitro.

MATERIAL AND METHODS

Fresh tissue specimens, surgically removed for therapeutic purpose to seven children affected by proliferative IH, were subjected to enzymatic digestion. Cells were sorted with anti-human CD31 immunolabeled magnetic microbeads. Following phenotypic characterization, expanded Hem-ECs, at P2 to P6, were exposed to different concentrations (50 μM to 150 μM) of propranolol, atenolol or metoprolol alone and in combination with the autophagy inhibitor Bafilomycin A1. Rapamycin, a potent inducer of autophagy, was also used as control. Autophagy was assessed by Lysotracker Red staining, western blot analysis of LC3BII/LC3BI and p62, and morphologically by transmission electron microscopy.

RESULTS

Hem-ECs treated with either propranolol, atenolol or metoprolol displayed positive LysoTracker Red staining. Increased LC3BII/LC3BI ratio, as well as p62 modulation, were documented in β-blockers treated Hem-ECs. Abundant autophagic vacuoles and multilamellar bodies characterized the cytoplasmic ultrastructural features of autophagy in cultured Hem-ECs exposed in vitro to β-blocking agents. Importantly, similar biochemical and morphologic evidence of autophagy were observed following rapamycin while Bafilomycin A1 significantly prevented the autophagic flux promoted by β-blockers in Hem-ECs.

CONCLUSION

Our data suggest that autophagy may be ascribed among the mechanisms of action of β-blockers suggesting new mechanistic insights on the potential therapeutic application of this class of drugs in pathologic conditions involving uncontrolled angiogenesis.

Overexpression of Annexin A1 is associated with the formation of capillaries in infantile hemangioma

Infantile hemangioma is a common benign tumor in infants. However, the molecular mechanism that controls the proliferation and differentiation of hemangioma is not well understood. Annexin A1 (ANX A1) is a phospholipid-binding protein involved in a variety of biological processes, including inflammation, cell proliferation and apoptosis. To explore the significance of ANX A1 in the process of proliferation or differentiation of hemangioma, proliferating and involuting hemangioma tissues were collected to detect the expression of ANX A1 using immunohistochemistry and western blotting. Normal skin tissues were used as the negative control. The results revealed that ANX A1 was upregulated in the proliferative phase of hemangioma, and its expression was decreased when the hemangioma entered the involuting phase. Additionally, in the proliferative phase, the strongest staining of ANX A1 was observed in newly born capillaries, and the staining of ANX A1 became weaker in enlarged vessels, indicating that ANX A1 plays an important role in promoting the formation of capillaries. The expression of hypoxia-inducible factor (HIF)-1α was positively associated with the expression trend of ANX A1, suggesting that the overexpression of ANX A1 may be associated with the increase of HIF-1α. In summary, the results of the present study revealed that the expression of ANX A1 was increased in proliferating hemangioma tissue, and that high expression of ANX A1 may be closely associated with the formation of capillaries in infantile hemangioma.

Surgical management of a massive congenital hemangioma of the tongue in an infant: A rare case report

Hemangiomas of the tongue may reach a massive size resulting in functional compromise. Surgical resection, despite the risk of hemorrhage, may be the only option if conservative measures such embolization are futile in reducing its size.

Cell Populations Expressing Stemness-Associated Markers in Vascular Anomalies

Treatment of vascular anomalies (VAs) is mostly empirical and, in many instances unsatisfactory, as the pathogeneses of these heterogeneous conditions remain largely unknown. There is emerging evidence of the presence of cell populations expressing stemness-associated markers within many types of vascular tumors and vascular malformations. The presence of these populations in VAs is supported, in part, by the observed clinical effect of the mTOR inhibitor, sirolimus, that regulates differentiation of embryonic stem cells (ESCs). The discovery of the central role of the renin-angiotensin system (RAS) in regulating stem cells in infantile hemangioma (IH) provides a plausible explanation for its spontaneous and accelerated involution induced by β-blockers and ACE inhibitors. Recent work on targeting IH stem cells by inhibiting the transcription factor SOX18 using the stereoisomer R(+) propranolol, independent of β-adrenergic blockade, opens up exciting opportunities for novel treatment of IH without the β-adrenergic blockade-related side effects. Gene mutations have been identified in several VAs, involving mainly the PI3K/AKT/mTOR and/or the Ras/RAF/MEK/ERK pathways. Existing cancer therapies that target these pathways engenders the exciting possibility of repurposing these agents for challenging VAs, with early results demonstrating clinical efficacy. However, there are several shortcomings with this approach, including the treatment cost, side effects, emergence of treatment resistance and unknown long-term effects in young patients. The presence of populations expressing stemness-associated markers, including transcription factors involved in the generation of induced pluripotent stem cells (iPSCs), in different types of VAs, suggests the possible role of stem cell pathways in their pathogenesis. Components of the RAS are expressed by cell populations expressing stemness-associated markers in different types of VAs. The gene mutations affecting the PI3K/AKT/mTOR and/or the Ras/RAF/MEK/ERK pathways interact with different components of the RAS, which may influence cell populations expressing stemness-associated markers within VAs. The potential of targeting these populations by manipulating the RAS using repurposed, low-cost and commonly available oral medications, warrants further investigation. This review presents the accumulating evidence demonstrating the presence of stemness-associated markers in VAs, their expression of the RAS, and their interaction with gene mutations affecting the PI3K/AKT/mTOR and/or the Ras/RAF/MEK/ERK pathways, in the pathogenesis of VAs.

The effectiveness and safety of topical β-receptor blocker in treating superficial infantile haemangiomas: A meta-analysis including 20 studies

AIMS

To evaluate the effectiveness and safety of topical β-receptor blocker in treating superficial infantile haemangiomas (SIH) and compare the effectiveness and safety of topical β-receptor blocker against other therapies.

METHODS

A search of the literature using PubMed, Embase, Cochrane Review database, China National Knowledge Infrastructure and Wanfang were performed to identify the studies that estimated the effectiveness and safety of topical β-receptor blocker in treating SIH, the fixed-effect or random-effects meta-analytical techniques were applied to assess the outcomes.

RESULTS

Twenty studies, involving 2098 patients, were included to conduct this analysis. Topical propranolol and topical timolol were discovered to be as effective as oral propranolol in treating SIH (propranolol, odds ratio [OR] = 0.486, 95% confidence interval [CI] 0.165, 1.426, P = .189; timolol, OR = 0.955; 95%CI 0.700, 1.302; P = .769), and topical timolol was more effective than topical imiquimod (OR = 2.561; 95%CI 1.182, 5.550; P = .017), observation (OR = 18.458; 95%CI 5.660, 60.191; P < .001) and topical saline solutions (OR = 19.193; 95%CI 8.837, 41.683; P < .001) in treating SIH. The comparison between topical propranolol and oral propranolol led to no discovery of significant difference in the incidence of adverse effects (OR = 1.258; 95%CI 0.471, 3.358; P = .647). Compared with oral propranolol, topical timolol was associated with fewer incidences of adverse effects (OR = 0.191; 95%CI 0.043, 0.858; P = .031). No significant difference in the incidence of adverse effects was found when topical timolol and topical imiquimod were compared (OR = 0.077; 95%CI 0.005, 1.206; P = .068).

CONCLUSION

This meta-analysis provided evidence that topical β-receptor blockers (propranolol and timolol), especially timolol, may replace oral propranolol as a first-line treatment for SIH.

Beta blockade as adjunctive breast cancer therapy: A review

Pre-clinical data has shown that beta adrenergic stimulation can affect the development and progression of many types of cancer. The use of beta blockers as an anti-neoplastic therapy has been studied in retrospective trials and observational trials, but no definitive conclusions about efficacy have been made. Within the realm of breast cancer, significant advances in therapy have led to improved survival outcomes, yet there is room for improvement. Beta adrenergic blockade may prove an effective adjunct to standard breast cancer therapy, with little associated toxicity. This article provides a review of the published literature on beta blockade as an adjunctive cancer therapy, with a focus on breast cancer.

Propranolol inhibits the activity of PI3K, AKT, and HIF-1α in infantile hemangiomas

PURPOSE

We sought to evaluate effect of propranolol in the treatment of infantile hemangiomas by quantifying the amount of phosphatidylinositol 3-kinase (PI3K), protein kinase B (AKT), and hypoxia-inducible factor-1α (HIF-1α).

METHODS

Hemangioma tissue was isolated from an infant patient and implanted into nude mice to establish a hemangioma model. Twenty-four hemangioma-model nude mice were divided into two groups including a control group (saline, by gastrogavage) and an experimental group (propranolol, by gastrogavage). The hemangioma-model nude mice were euthanized and tumors were removed at 30 and 50 days (before and after treatment). HE staining was used to observe the histopathological changes, and western blot and quantitative real-time PCR were used to describe levels of protein and mRNA expression of PI3K, AKT, and HIF-1α.

RESULTS

Propranolol treatment decreased tumor size as compared to the control group. Protein and mRNA expression levels of PI3K, AKT, and HIF-1α were lower in the experimental group at day 50 compared to the control group at day 50 and the experimental group at day 30 (p < 0.05).

CONCLUSION

Propranolol can promote regression of infantile hemangiomas, which may be related to the inhibition of PI3K, AKT, and HIF-1α activity.

Medical Management of Vascular Anomalies

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.