Appraisal of efficacy and safety of intralesional injection of high concentration of bleomycin A5 for treatment of huge macrocystic lymphatic malformations in cervical region

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee

BACKGROUND

Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment.

METHODS

Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question.

RESULTS

The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered.

CONCLUSION

Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

LEVEL OF EVIDENCE: 4

Sclerotherapy vs. surgical excision for lymphatic malformations of the head and neck: a systematic review and meta-analysis

OBJECTIVES

Lymphatic malformations (LMs) are abnormal lymphatic vessels with cystic characteristics, categorized as macrocystic, microcystic, or a combination of both. They represent the second most common vascular malformations, and their management involves multidisciplinary approaches based on clinical assessments and imaging studies. LMs manifest as a challenge to medical professionals in the head and neck, posing functional and aesthetic concerns. Our systematic review aims to compare the efficacy of sclerotherapy and surgery for LMs, identifying optimal treatment modalities for each scenario.

METHODS

We searched four electronic databases for related studies. Data were extracted from the included studies. We calculated the pooled rate ratios with 95% confidence intervals (CIs). The I2 test was used to detect heterogeneity. The inclusion of the studies required the following prerequisites: 1- Studies focusing on any lymphatic malformations in the head and neck, whether microcystic, macrocystic, or a mix of both; 2- Studies performed on more than ten patients; 3- All interventions used as surgery, sclerotherapy, or both.

RESULTS

We included 58 studies in our systematic review, of which 45 were eligible for the meta-analysis. For macrocystic LMs, sodium tetradecyl sulfate (STS) mixed with ethanol and excision achieved the highest complete response rates at (92.9%) and (92.5%), respectively. Surgical excision showed the lowest poor response rate. Polidocanol microfoam had the highest poor response rate (11.1%). In microcystic LMs, combining sclerotherapy with excision showed the highest complete response rate (70.3%) and the lowest poor response rate (1.3%). Picibanil had the lowest complete response rate (9.1%) and the highest rate of poor response (61.4%). In mixed LMs, surgical excision had the highest complete response rate (70.3%).

CONCLUSION

Both surgical excision and STS combined with ethanol are highly effective for treating macrocystic LMs, achieving similar complete response rates. The combination of sclerotherapy and surgical excision demonstrated the best outcomes in microcystic LMs. Surgical excision demonstrates superior efficacy over sclerotherapy for mixed LMs. These findings suggest that excision is generally more effective in achieving complete and excellent responses across all LM subtypes. Further high-quality studies are necessary to standardize and optimize treatment protocols.

Bleomycin for Head and Neck Venolymphatic Malformations: A Systematic Review

BACKGROUND

Venolymphatic malformations are rare benign vascular lesions of the head and neck. Sclerotherapy has become the first-line therapy of these lesions with bleomycin being a sclerosing agent commonly used.

PURPOSE

To perform a systematic review of the published literature to synthesize evidence on the safety and efficacy of bleomycin for the treatment of head and neck venolymphatic malformations.

DATA SOURCES

A systematic review of the literature (January 1995-May 2019) was performed in PubMed, Embase, and Cochrane Library databases to identify studies on sclerotherapy of venolymphatic malformations of the head and neck.

STUDY SELECTION

A total of 32 studies with participants met the inclusion criteria among which 1121 patients were included in the systematic review.

DATA ANALYSIS

Two reviewers independently screened and extracted data and assessed the risk of bias. The primary outcome was the subjective or objective reduction of lesion size as well as minor and major complications.

DATA SYNTHESIS

The bleomycin/pingyangmycin sclerotherapy achieved subjective or objective lesion size reduction in 96.3% (95% CI 94.1%-98.5%) of patients. Minor complications were observed in 16.2% and major complications in 1.1%.

CONCLUSION

Bleomycin is a highly effective treatment of venolymphatic malformations of the head and neck with a low rate of major adverse events. This study represents an update on the "available" evidence, but only low-to-moderate quality studies were available.

LIMITATIONS

This study reviewed 32 studies performed in different parts of the world, but there was heterogeneity of the study designs and interventions.

Outcome measurement instruments for peripheral vascular malformations and an assessment of the measurement properties: a systematic review

Purpose

The Outcome measures for vascular malformation (OVAMA) group reached consensus on the core outcome domains for the core outcome set (COS) for peripheral vascular malformations (venous, lymphatic and arteriovenous malformations). However, it is unclear which instruments should be used to measure these domains. Therefore, our aims were to identify all outcome measurement instruments available for vascular malformations, and to evaluate their measurement properties.

Methods

With the first literature search, we identified outcomes and instruments previously used in prospective studies on vascular malformations. A second search yielded studies on measurement properties of patient- and physician-reported instruments that were either developed for vascular malformations, or used in prospective studies. If the latter instruments were not specifically validated for vascular malformations, we performed a third search for studies on measurement properties in clinically similar diseases (vascular or lymphatic diseases and benign tumors). We assessed the methodological quality of these studies following the Consensus-based Standards for the selection of health Measurement Instruments methodology, and evaluated the quality of the measurement properties.

Results

The first search yielded 27 studies, none using disease-specific instruments. The second and third search included 22 development and/or validation studies, concerning six instruments. Only the Lymphatic Malformation Function Instrument was developed specifically for vascular malformations. Other instruments were generic QoL instruments developed and/or partly validated for clinically similar diseases.

Conclusions

Additional research on measurement properties is needed to assess which instruments may be included in the COS. This review informs the instrument selection and/or the development of new instruments.

Systematic review registration

PROSPERO, 42017056242.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02301-x) contains supplementary material, which is available to authorized users.

Is multiple session of intralesional bleomycin mandatory for complete resolution of macrocystic lymphatic malformation?

Background

Intralesional bleomycin scelro-therapy has become a favored line of treatment for macrocystic lymphatic malformations. However the need for multiple sessions is a drawback associated with this treatment modality. Our aim is to document whether multiple session of intra- lesional sclero-therapy is necessary for complete resolution of cystic lymphatic malformation.

Method

Intralesional bleomycin under Ultrasound guidance was used for macrocystic lymphangioma at concentration of 3mg/ml but not exceeding the total dose (1mg/kg) body weight for single session or cumulative dose of 5mg/kg. In all cases intralesional sclerosant (ILS) was installed under proper aseptic precaution in operation theatre in general anesthesia or sedation depending on the site or size of lesion and age of the patient. Age of patients at the time of enrolment in study ranged from 3 months to 18 years. Clinical examination was the main stay of diagnosis which was supplemented by USG and/or computed tomography. Compression of the lesion site was done for few hours wherever it was possible after the ILS session.

Result

A total of 21 patients included in our study. The age ranged from 3 months to 18 years. Male to female ratio was 8:13. The most common site of involvement was neck and axilla followed by anterior chest wall and nape of the neck. Complete resolution after single session was observed in 90.5% cases where as surgery was required in 9.5% case. Major complication was observed in one patient, who had intralesional bleeding which was managed conservatively. Transient pain and fever was observed in 23.8% of cases. Only two patient required surgical intervention where one had persistent subcutaneous fibrotic nodule and other one did not respond to ILS.

Conclusion

Intralesional bleomycin is an effective treatment for macrocystic lesion, and complete resolution may be achieved by single session of ILS if proper principle are followed.

Acute Lung Toxicity After Intralesional Bleomycin Sclerotherapy

Bleomycin has progressively been used to treat low-flow vascular malformations in children. No significant systemic side effects have been reported in large series after low doses, but some authors are still concerned about its use. We report a case of a severe acute lung toxicity after a low dose of a second bleomycin intralesional injection in a 5-year-old girl. She had no risk factors and presented a cervical low-flow venous malformation. Twenty-four hours after this second administration, she presented with fever and respiratory distress. A chest radiograph showed bilateral opacities and computerized tomography revealed extensive and diffuse lung ground-glass opacities. The patient started to receive intravenous methylprednisolone, but she experienced progressively increased dyspnea, and montelukast was added. She improved and was discharged from the hospital without oxygen support, with montelukast and prednisolone for tapering doses during months. Five months after onset, the patient is developing well, is active, and walks and talks without dyspnea. A new low-dose computed tomography shows improvement in radiologic findings. This is the second case of pulmonary toxicity observed in a child after bleomycin intralesional administration, and the first reported after the lowest dose of this drug to date (7 mg: 0.28 mg/kg; 10 U: 0.4 U/kg). A delay in the diagnosis and treatment of this complication can be fatal. Any physician who treats these patients must be alert and consider this complication in children with respiratory symptoms after bleomycin sclerotherapy. Early detection of pulmonary toxicity would allow prompt therapy and could avoid pulmonary damage.

Treatment of Xanthelasma Palpebrarum With Intralesional Pingyangmycin

BACKGROUND

Xanthelasma palpebrarum (xanthelasma) is the most common type of cutaneous xanthoma, and many patients tend to seek medical treatments for cosmetic reasons. Many methods treating xanthelasma have been proposed, but none of these options can be regarded as a perfect solution.

OBJECTIVE

To study and evaluate the intralesional injection treatment of xanthelasma with pingyangmycin, which has been widely used as a broad-spectrum antitumor antibiotic.

MATERIALS AND METHODS

21 lesions in 12 patients were treated by intralesional pingyangmycin. Photographs were taken before and after each treatment session. Patients were followed up for 7 to 36 months.

RESULTS

All patients except one received satisfactory results after up to 2 sessions. Only 1 patient had a local recurrence 1 year after the treatment. No severe complications such as infection, atrophy, ulceration, or scar were noticed.

CONCLUSION

Intralesional pingyangmycin is a cheap, effective, and safe treatment for xanthelasma, which has been well accepted by patients.