Efficacy of Intralesional Steroid Injection in Head and Neck Hemangioma: A Systematic Review

Intralesional betamethasone versus oral propranolol for localized infantile hemangiomas of the lip

Infantile hemangiomas (IHs) of the lips are associated with an increased risk of incomplete involution and ulceration, causing disfigurement. Treatment with oral propranolol (OPT) has credible efficacy but takes months to complete. Thus, this study aimed to investigate the efficacy of intralesional betamethasone injection (IBI) as an alternative treatment for protruding localized IHs of the lips. To investigate the efficacies of OPT and IBI, we designed a prospective, noninferiority, parallel-group study. The primary outcome assessed was treatment response rate. Secondary outcome assessments included lesion size changes and surgical rate. Additionally, complication rates and treatment durations of OPT and IBI were compared. The treatment response rate of IBI was not inferior to that of OPT (95.7% vs. 76.0%, respectively; a difference of 19.7%, 95% confidence interval [CI], -4.4% to 41.6%). The average surgical rate in the IBI group was significantly lower than that in the OPT group (8.7% vs. 40%, respectively; p = 0.012), and the average duration of treatment for IBI was shorter than that of OPT (2.1 months vs. 6.3 months, respectively; p < 0.001). There were no severe adverse drug events in either group. If not managed properly, small, localized lip IHs may cause disfigurement in a child. Our study demonstrated that IBI is as effective as OPT in treating protruding localized lip IHs. Moreover, IBI treatment has a shorter duration and lower surgical rate than OPT. With proper care, IBI is an effective treatment modality for small and localized lip IHs.

New Findings in the Multidisciplinary Management of a Fetal Intrapericardial Teratoma: A Case Report

INTRODUCTION

Fetal intrapericardial teratoma is a rare tumor that can be diagnosed by antenatal ultrasonography early in pregnancy.

CASE PRESENTATION

A fetal intrapericardial teratoma was detected on routine ultrasonography in the second trimester of pregnancy. At 31 weeks gestation, a marked increase in tumor size, fetal ascites, and pericardial effusion were observed, indicating that preterm delivery would be inevitable. Corticosteroid prophylaxis (24 mg of betamethasone in two doses of 12 mg 24 h apart) initiated for prophylaxis of respiratory distress syndrome led to a reduction in fetal ascites and pericardial effusion. Betamethasone therapy (4 mg/per day) was continued with the aim to postpone the expected date of delivery. Gestation was extended for more than 2 weeks. At 33 weeks and 5 days gestation, the neonate was delivered by elective cesarean section with ex utero intrapartum treatment and immediately submitted to fetal cardiac surgery. The infant was discharged from the hospital in good health about 4 months later.

CONCLUSION

The present report draws attention to improvement in fetal status and extension of gestation achieved with maternal low-dose corticosteroid therapy on antenatal ultrasound finding of fetal ascites and pericardial effusion due to intrapericardial teratoma.

Bleomycin-triamcinolone sclerotherapy in the management of propranolol resistant infantile hemangioma of the maxillofacial region: A single arm prospective evaluation of clinical outcome and Doppler ultrasound parameters

INTRODUCTION

Propranolol has emerged as a first line agent in the management of hemangiomas. With increased use of propranolol, studies have also focused on relapses following propranolol therapy. Our current study evaluates the role of bleomycin triamcinolone sclerotherapy for the management of propranolol resistant Infantile Hemangioma (IH). We also evaluated the role color Doppler USG for response assessment of sclerotherapy.

METHODS

Patients with Propranolol resistant (Non- responders/ Partial responders) IHs were included in the study. Patients received intralesional bleomycin at a dose of 0.5 IU/kg followed by intralesional injection of triamcinolone at a dose of 2mg/kg body weight. Clinically patients were grouped into excellent, partial and non responders. Doppler parameters; Resistivity index (RI), Pulsatility index(PI) and Peak systolic velocity (PSV) were used to evaluate the response to sclerotherapy. These parameters were evaluated prior to sclerotherapy and 3 months following completion of therapy. The clinical responses of the patients were compared with the change in Doppler parameters before and after treatment.

RESULTS

A total of 115 participants were considered for analysis; 60.86% had excellent response, 32.17% had partial response and 6.95% had poor response. There was a significant change in terms of RI, PI and PSV in patients who were either excellent or partial responders. Poor responders did not have a significant change in Doppler parameters.

CONCLUSION

Combined bleomycin- triamcinolone sclerotherapy is an effective therapy for the management of propranolol resistant IHs. Doppler parameters RI, PI and PSV are reliable indicators of response in the management of IH.

Update on infantile hemangioma

The International Society for the Study of Vascular Anomalies classifies vascular anomalies into vascular tumors and vascular malformations. Vascular tumors are neoplasms of endothelial cells, among which infantile hemangiomas (IHs) are the most common, occurring in 5%-10% of infants. Glucose transporter-1 protein expression in IHs differs from that of other vascular tumors or vascular malformations. IHs are not present at birth but are usually diagnosed at 1 week to 1 month of age, rapidly proliferate between 1 and 3 months of age, mostly complete proliferation by 5 months of age, and then slowly involute to the adipose or fibrous tissue. Approximately 10% of IH cases require early treatment. The 2019 American Academy of Pediatrics clinical practice guideline for the management of IHs recommends that primary care clinicians frequently monitor infants with IHs, educate the parents about the clinical course, and refer infants with high-risk IH to IH specialists ideally at 1 month of age. High-risk IHs include those with life-threatening complications, functional impairment, ulceration, associated structural anomalies, or disfigurement. In Korea, IHs are usually treated by pediatric hematology-oncologists with the cooperation of pediatric cardiologists, radiologists, dermatologists, and plastic surgeons. Oral propranolol, a nonselective beta-adrenergic antagonist, is the first-line treatment for IHs at a dosage of 2-3 mg/kg/day divided into 2 daily doses maintained for at least 6 months and often continuing until 12 months of age. Topical timolol maleate solution, a topical nonselective beta-blocker, may be used for small superficial type IHs at a dosage of 1-2 drops of 0.5% gel-forming ophthalmic solution applied twice daily. Pulse-dye laser therapy or surgery is useful for the treatment of residual skin changes after IH involution.

Paediatrics: how to manage infantile haemangioma

Infantile haemangiomas (IHs) are relatively common benign vascular tumours found in the paediatric population. They have varying sizes and involve different depths in the skin leading to various colours, shapes and textures. Although considered harmless in most cases, they may lead to life-threatening complications or cause permanent disfigurations and organ dysfunction. For problematic IHs, the treatment options include oral and topical beta-blockers, systemic corticosteroids, laser treatment, and surgery. In this narrative review, the treatment options for problematic IH are compared and delivered concisely to facilitate the clinical decisions from practitioners, including those in primary care settings. Oral propranolol is currently considered the first-line intervention for problematic IHs. For superficial lesions, there is robust evidence for the use of topical timolol maleate. Systemic corticosteroids are sometimes used in specific situations such as resistance or contraindications to beta-blockers. Surgical excision can be considered in cases requiring urgent intervention such as airway obstruction; this can be done alongside laser therapies for the removal of residual tissue or when reconstructing areas of deformity. The combination of multiple treatment modalities may lead to a more rapid clinical response.

Clinical Practice Guideline for the Management of Infantile Hemangiomas

Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.

Role of intralesional bleomycin and intralesional triamcinolone therapy in residual haemangioma following propranolol

With the emergence of propranolol as the first choice of treatment for problematic infantile haemangioma at many centres, the number of patients with a partial or non-response to propranolol has also been growing. This study investigated the role of intralesional bleomycin and triamcinolone in patients with residual disease following propranolol therapy for infantile haemangioma. Sixty-seven patients with residual haemangioma were assigned randomly to receive either intralesional bleomycin (group A, n=36) or intralesional triamcinolone (group B, n=31). The response to treatment and adverse effects were assessed in both groups. All patients received at least four doses and a maximum of six doses of the assigned drug. In group A (mean follow-up 9.38months), 47.2% had an excellent response and 44.4% a good response. In group B (mean follow-up 7.42months), 25.8% had an excellent response and 48.4% a good response. There was no difference in overall response between the groups (P=0.074). Among patients who were initially non-responders to propranolol, bleomycin showed a better response than triamcinolone (P=0.037). This may be due to an overlap in the mechanism of action of propranolol and triamcinolone. Thus, intralesional bleomycin should be preferred in patients with no initial response to propranolol therapy, while bleomycin or triamcinolone can be used in patients with a partial response to propranolol therapy, as they have equal efficacy.

Effectiveness and safety of polidocanol for the treatment of hemangiomas and vascular malformations: A meta-analysis

A meta-analysis was conducted to investigate the efficacy and safety of polidocanol versus other conventional therapies in treating hemangiomas (HMs) and vascular malformations (VMs). Literature search was conducted in the Cochrane, Embase, PubMed, Web of Science, CNKI, CBM, VIP, and WanFang databases until March 5, 2017. A meta-analysis was conducted using Revman 5.3 software. A total of 19 randomized controlled trials (RCTs) involving 1,514 participants met the inclusion criteria. Regarding the effectiveness, statistically significant differences were observed between polidocanol and all the independent treatments (p = .006), but not between polidocanol and pingyangmycin (p = .16). Combination therapy of polidocanol with any other conventional treatments (p = .0001), pingyangmycin (p = .005) or hemoclip (p = .008) elicited a better response compared to treatment with these treatments independently. A meta-analysis on the risk of adverse events (AEs) showed a lower risk for polidocanol versus other treatments, for example, all the conventional treatments used independently (p < .00001) and pingyangmycin (p < .00001). Combination therapy of polidocanol with pingyangmycin also yielded a significantly lower risk of AEs (p < .00001). Polidocanol is at least as effective as other conventional therapies on HMs and VMs (especially venous malformations). The former is much safer. Combining its use with other treatments may produce excellent results. Our study provides strong evidence supporting the use of polidocanol for HMs and VMs.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Effectiveness and Safety of Oral Propranolol versus Other Treatments for Infantile Hemangiomas: A Meta-Analysis

BACKGROUND

Epidemiological studies evaluating treatments for infantile hemangiomas have produced inconsistent results. A meta-analysis of published data was conducted to investigate the effectiveness and safety of oral propranolol versus other treatments for infantile hemangiomas.

METHODS

A meta-analysis was conducted based on literature (published from 1960 to December 1, 2014) found on the PubMed, EMBASE, and OVID search engines. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for the outcome measures. Heterogeneity, publication bias and subgroup analysis were performed.

RESULTS

A total of 61 studies involving 5,130 participants met the inclusion criteria. Propranolol was found to be a more effective modality in treating IHs (ORs = 0.92; 95%CI, 0.89-0.95) and had fewer complications compared to the other treatments including systemic steroids (ORs = 0.68; 95% CI, 0.59-0.76); laser ablation (ORs = 0.55; 95% CI, 0.43-0.67); other beta-adrenergic blockers (ORs = 0.56; 95% CI, 0.50-0.61) and surgery (ORs = 0.55; 95% CI, 0.28-0.81). A subgroup analysis of propranolol showed that a dose of 2 mg/kg/day or more yielded better outcomes (ORs = 0.92; 95% CI, 0.88-0.95; ORs = 0.95; 95% CI, 0.89-1.00), and IHs that had not been previously treated had better responses to propranolol treatment (ORs = 0.95; 95% CI, 0.91-0.98).

CONCLUSIONS

The meta-analysis demonstrated that propranolol was more effective and safer than other therapies in treating IHs. It provides strong evidence for supporting the use of propranolol as a first-line therapy for IHs.

Propranolol versus corticosteroids in the treatment of infantile hemangioma: a systematic review and meta-analysis

BACKGROUND

Infantile hemangiomas are benign vascular neoplasms that can cause numerous functional or cosmetic problems. The authors reviewed the pathogenesis of hemangioma and compared the efficacy and complications related to therapy with propranolol versus corticosteroids.

METHODS

A comprehensive review of the literature was conducted from 1965 to March of 2012 using MEDLINE, PubMed, Ovid, Cochrane Review database, and Google Scholar. All articles were reviewed for reports of clinical cases, reported side effects, doses, duration of treatment, number of patients, and response rate to treatment.

RESULTS

A total of 1162 studies were identified. Of those, only 56 articles met inclusion criteria after review by two independent reviewers (A.I. and J.K.). For the meta-analysis, 16 studies comprising 2629 patients and 25 studies comprising 795 patients were included. Less than 90 percent of patients treated with corticosteroids responded to therapy, compared with 99 percent of patients treated with propranolol after 12 months of follow-up. Meta-analysis demonstrated the corticosteroid studies to have a pooled response rate of 69 percent versus the propranolol response rate of 97 percent (p < 0.001).

CONCLUSIONS

Propranolol is a relatively recent therapy of hemangiomas with fewer side effects, a different mechanism of action, and greater efficacy than current first-line corticosteroid therapy. Many of these studies do not have the same patient population or duration/regimen of treatment for hemangiomas; however, based on available data in the literature, it appears that propranolol could be an emerging and effective treatment for infantile hemangiomas. Further randomized controlled trials are recommended.

Management of infantile hemangiomas : current and potential pharmacotherapeutic approaches

Infantile hemangiomas (IH), benign vascular neoplasms, are the most common tumors of infancy and childhood. Most IH are medically insignificant; however, a proportion will require treatment because of interference with vital structures, threat of significant disfigurement, ulceration, or bleeding. This article reviews current and potential pharmacotherapeutic approaches to the treatment of IH. While corticosteroids have long been considered the mainstay of medical therapy for IH, several new treatments have recently emerged, the most promising of which is oral propranolol. Topical timolol and imiquimod are additional new therapies that may also prove to be effective, particularly for the treatment of superficial IH.