Efficacy of propranolol treatment in infantile hepatic haemangioma

Diffuse infantile hepatic hemangioma successfully treated with propranolol orally: a case report and literature review

Background

Infantile hepatic hemangioma (IHH) is a common vascular, fast-growing hepatic tumor that is usually accompanied by multiple cutaneous hemangiomas. Diffuse IHH (DIHH) is a rare type of IHH that exhibits many tumors with nearly complete hepatic parenchymal replacement. At present, there is no specific standardized treatment plan for DIHH. Herein, we present the case of a 2-month-old girl with DIHH and without cutaneous hemangioma who achieved complete remission after undergoing propranolol monotherapy.

Case presentation

The infant with low birth weight was presented to the pediatric department with a 2-month history of persistent vomiting and feeding difficulty. Ultrasonography and abdominal magnetic resonance imaging revealed hepatomegaly and diffused intrahepatic lesions. A computed tomography-guided percutaneous liver biopsy was performed, and the pathological examination suggested the diagnosis was DIHH. The patient exhibited remarkably response to an increasing dose of oral propranolol, from 0.5 mg/kg to 2 mg/kg every day. The intrahepatic lesions were almost completely regressed after one year of treatment and no distinct adverse reaction was observed.

Conclusion

DIHH can induce life-threatening complications that require prompt interventions. Propranolol monotherapy can be an effective and safe first-line treatment strategy for DIHH.

Clinical features of cutaneous infantile hemangioma combined with asymptomatic infantile hepatic hemangioma and efficacy of propranolol treatment

INTRODUCTION

Infantile hepatic hemangioma (IHH) is a common liver tumor in infants and shares the same characteristics as cutaneous infantile hemangioma (IH). Propranolol is effective for symptomatic IHH. The clinical features between cutaneous IH and IHH, and treatment efficacy of IHH (smaller than 4 cm) is unclear. To evaluate the correlation of clinical features between cutaneous IH and IHH, as well as efficacy of systemic propranolol in the treatment of cutaneous IH combined with IHH.

MATERIALS AND METHODS

The clinical data of infants with complicated cutaneous IH combined with IHH treated with systemic propranolol (1.5 ~ 2 mg/(kg d)) from January 2011 to October 2020 were retrospectively analyzed.

RESULTS

Forty-five cases with IHH combined with complicated cutaneous IH were reviewed. Single cutaneous IH is more likely to be combined with focal IHH, cutaneous IH greater than 5, more likely to be combined with multiple IHH (Pearson = 0.546, p < 0.01). The mean age of focal and multiple IHH regression was 11.93 ± 14.42 months and 10.20 ± 9.15 months, respectively.

CONCLUSIONS

The number of cutaneous IH were correlated with the number of IHH. There was no difference in the age of complete remission for focal and multiple IHH.

Propranolol Monotherapy in Multifocal/Diffuse Infantile Hepatic Hemangiomas in Indian Children: A Case Series

Introduction

Infantile hepatic hemangioma (IHH) is the most common benign liver tumor in children, and multifocal and diffuse tumors often become life-threatening, necessitating therapy. Propranolol is now considered the first choice of therapy with ample data in Caucasian children. We present a series of nine Indian children with multifocal (n = 5) and diffuse (n = 4) IHH treated with propranolol monotherapy.

Methods

This was a retrospective clinical data-based single-center study. Propranolol was used at a median dose of 3.2 mg/kg/day (range 3-3.3 mg/kg/day) for a median duration of 12 months (range 6-32 months).

Results

The presentations of IHH (either in isolation or combination) were hypothyroidism in six patients (diagnosed by elevated serum TSH levels), heart failure in three (diagnosed based on clinical and echocardiographic features), and imaging evidence of macrovascular shunting in two patients. A good response to propranolol monotherapy (with a median dose of 3.2 mg/kg/day for a median duration of 12 months) was observed in eight patients, with a poor response in one. One patient experienced recurrence but responded adequately to propranolol retreatment.

Conclusions

Our data reiterate the excellent response (88.9% responded) and safety profile with propranolol monotherapy in complicated IHH and strengthen the data in Asian (Indian) children. It includes the maximum proportion of complicated IHH treated with propranolol in East and South Asia, and the largest series from India.

Case reports of large and symptomatic abdominal tumors in newborns: Pitfalls, difficulties in management, and surgical decision making

BACKGROUND

Large and rapidly growing abdominal tumors may result in fatal outcomes in newborns. In some cases, a rapidly worsening clinical condition requires surgical decision-making despite the absence of a precise histological diagnosis. In these situations, there is neither a guide nor consensus.

CASE

We highlight our experience with five patients with large abdominal tumors and assess the available literature for the best possible management of a rare condition.

CONCLUSION

In these cases, laparostomy should be considered as a life-saving procedure. If the liver is involved and coagulopathy is present, prognosis is often compromised.

Clinical evaluation of transcatheter arterial embolization combined with propranolol orally treatment of infantile hepatic hemangioma

PURPOSE

To assess the efficacy of transcatheter arterial embolization (TAE) plus propranolol treatment for infantile hepatic hemangioma (IHH).

METHODS

A retrospective study of symptomatic IHH and hemodynamic changes in IHH was conducted between 2016 and 2019.

RESULTS

There were five boys and seven girls with diffuse lesions (n = 7) and multifocal lesions (n = 5). Hepatomegaly and abdominal distension (n = 6) were the predominant clinical presentations. Seven patients (58.3%) had multiple cutaneous hemangiomas. Pulmonary arterial hypertension, heart failure (n = 4), and hypothyroidism (n = 4) were observed. A total of 17 TAE procedures were performed in 12 IHH cases, with a technical success rate of 100%. All patients received standard propranolol orally, and one patient was orally administered metacortandracin. Two patients died of heart failure and multiple organ dysfunction caused by an enlarged liver. In addition, one patient was not reexamined after discharge. Of the remaining nine children, the average follow-up time was 10.78 months (range 2-28 months), and they all responded well to TAE combined with oral propranolol.

CONCLUSION

TAE combined with propranolol is safe and effective for the treatment of IHH, demonstrating low complication rates.

Infantile hepatic hemangiomas: looking backwards and forwards

Infantile hepatic hemangiomas (IHHs) are common benign tumors seen in the liver of infants. IHHs are true infantile hemangiomas (IHs) and have phases of proliferation and involution parallel to those of cutaneous IHs. The definition and classification of IHH are still confusing in the literature. The mechanisms during the pathogenesis of IHH have yet to be discovered. The clinical manifestations of IHH are heterogeneous. Although most IHH lesions are asymptomatic, some lesions can lead to severe complications, such as hypothyroidism, consumptive coagulopathy, and high-output congestive cardiac failure. Consequently, some patients can possibly encounter a fatal clinical condition. The heterogeneity of the lesions and the occurrence of disease-related comorbidities can make the treatment of IHH challenging. Oral propranolol is emerging as an effective systemic approach to IHH with obvious responses in tumor remission and symptom regression. However, the precise clinical characteristics and treatment strategies for patients with severe IHH have not yet been well established. Here, we summarize the epidemiology, pathogenic mechanism, clinical manifestations, diagnosis, and treatment of IHH. Recent updates and future perspectives for IHH will also be elaborated.

Application value of computer-assisted surgery system in pediatric hepatic hemangioma

PURPOSE

To explore the treatment of pediatric hepatic hemangioma and the role of the Hisense computer-assisted surgery (Hisense CAS) system in diagnosis and treatment.

METHODS

We collected the clinical and follow-up data of all pediatric hepatic hemangioma cases in our pediatric surgery department from March 2008 to March 2021 for retrospective analysis. The Hisense CAS system was used to create three-dimensional (3D) reconstructions based on computed tomography data.

RESULTS

There were 71 patients, mainly infants (prenatal to 39 months). There were more males than females (42 vs. 29), and the alpha-fetoprotein level was significantly increased in 8 cases. 3D reconstruction by the Hisense CAS system showed that hepatic artery tracking was helpful for the differential diagnosis of pediatric hepatic hemangioma. Twenty-three children treated with propranolol showed significant differences in the tumour diameter, volume, and tumour-to-liver volume ratio after treatment (all P < 0.05). Compared with early surgical treatment, the curative effect of this approach was obvious.

CONCLUSION

As a non-surgical treatment for symptomatic pediatric hepatic hemangioma, propranolol can replace surgical resection to a certain extent and reduce the proportion of children who need surgical intervention. Hisense CAS has advantages in evaluating the tumour volume before and after propranolol treatment. The liver volume and the liver tumour volume percentage provide new perspectives for evaluating the tumour outcome.

Utility of the Infantile Hemangioma Referral Score (IHReS) as a decision-making tool for referral to treatment

BACKGROUND

The general paediatricians and primary care physicians sometimes face immense difficulty in referral judgements regarding which infantile hemangiomas (IHs) require referrals and when is the appropriate time to refer IHs for treatment. This resulted in the treatment being delayed beyond IHs' critical timeframe. The Infantile Hemangioma Referral Score (IHReS) has been recently developed, with the aim to solve this problem.

OBJECTIVES

The objective of the present study is to evaluate the reliability of IHReS and to assess the possibility of using this instrument in our country where a similar problem of delaying treatment of IHs is currently existing.

METHODS

The present study was a prospective, cross-sectional study. Thirteen selected clinical cases were used to assess the reliability of IHReS among physicians who may have had the chance to deal with patients with IHs. The target physicians across the country were asked to participate in the study via an online platform (Google Forms) to decide whether to refer patients with IHs for treatment or observe. There were 3 steps of assessment: step 1, usual practice evaluation; step 2, using IHReS; step 3, retesting by using IHReS.

RESULTS

Substantial agreement was observed after using IHReS (step 2) for interrater reliability, with Fleiss' Kappa values of 0.80 and 0.78 among IH experts and non-expert physicians, respectively. Regarding repeatability, in the test-retest assessments, Cohen's Kappa coefficient values revealed almost perfect agreement in intrarater repeatability for both experts and non-expert physicians (1.00).

CONCLUSION

IHReS is a simple, easy-to-assess tool for non-expert physicians. The benefit in the increase of interrater agreement was found in both IH experts and non-expert physicians. It has had the reliability to be used in making referral decisions regarding patients with IH for treatment among Thai physicians. Using IHReS can improve clinical outcomes by identifying which patient needs early intervention to minimise the possible complications.

Screening for infantile hepatic hemangioma in patients with cutaneous infantile hemangioma: A multicenter prospective study

BACKGROUND

Abdominal ultrasonography has been proposed to screen for infantile hepatic hemangioma (IHH) in patients with multiple cutaneous infantile hemangiomas (IHs).

OBJECTIVES

The aim of this study was to establish the optimal cutoff point for the number of cutaneous IHs needed to screen for IHH.

METHODS

We performed a prospective, multicenter study to screen for IHH in patients younger than 9 months who had multiple cutaneous IHs (n ≥ 3) on ultrasonography. For comparison, a group of patients with 1 or 2 focal cutaneous IHs was also recruited.

RESULTS

In total, 676 patients with at least 3 cutaneous IHs and 980 patients with 1 or 2 focal cutaneous IHs were enrolled. Thirty-one patients were found to have IHH. A higher number of cutaneous IHs was associated with an increased risk of IHH (R = 0.973; P < .001). Receiver operating characteristic curve analysis showed that 5 cutaneous IHs was the optimal cutoff point to screen for IHH, with an area under the curve of 0.872 (P < .001; 95% confidence interval, 0.789-0.955).

LIMITATIONS

This was an uncontrolled study.

CONCLUSIONS

Screening for IHH is recommended in patients younger than 9 months who present with 5 or more cutaneous IHs.

Historical and Contemporary Management of Infantile Hepatic Hemangioma: A 30-year Single-center Experience

OBJECTIVE

To describe outcome of infants with hemangioma(s) of the liver.

SUMMARY OF BACKGROUND DATA

Infantile hepatic hemangiomas exhibit a diverse phenotype. We report our 30-year experience and describe optimal management based on precise radiological classification.

METHODS

Retrospective review of 124 infants (66 female) 1986-2016. Categorical analysis with Chi and nonparametric comparison. Data expressed as median (range) and P < 0.05 considered significant.

RESULTS

Lesions classified as focal (n = 70, 56%); multifocal (n = 47, 38%) or diffuse (n = 7, 6%) and of these 80(65%) were symptomatic (eg, cardiac failure n = 39, 31%; thrombocytopenia n = 12, 10%).Increased hepatic artery velocity was seen in 63 (56%). Median hepatic artery velocity was greatest in diffuse lesions [245 (175-376) cm/s vs focal 120 (34-242) cm/s vs multifocal 93 (36-313) cm/s; P = 0.0001]. Expectant management alone was followed in 55 (44%). Medical therapy was utilised in 57(46%) and sufficient for symptom control in 29/57 (51%). Propranolol therapy (from 2008) was sufficient for symptom control in 22/28 (79%). Surgery (hepatic artery ligation n = 26; resection n = 13; embolization n = 1) was required in 40 (32%). Median maximal lesion diameter was 3 (0.5-17.1) cm and greater in those requiring surgery (7 cm vs 4.9 cm; P = 0.04). The proportion requiring surgery decreased markedly in the propranolol era [pre-propranolol 25/48 (52%) vs post-propranolol 16/76 (21%) (P = 0.0003)]. Systematic follow-up with ultrasound to a median of 2.6 (0.02-16) years.

CONCLUSIONS

A proportion of infantile hepatic hemangiomas remain asymptomatic permitting observation until resolution but the majority require complex multi-modal therapy. First-line pharmacotherapy with propranolol has reduced but not abolished the need for surgery.