Hereditary Vascular Anomalies

Case report of generalized lymphatic dysplasia with PIEZO1 mutation and review of the literature

Background

The newborn malformation of primary lymphatic dysplasia (PLD), developed primarily due to PIEZO1 gene autosomal recessive mutation, is known to hinder with the lymphatic system action, causing chyle or lymph effusion into the peritoneal cavity or pleura.

Case presentation

A 4-years-old male subject presented with a recurrent chylothorax and bilateral lower limb edema that started at age of 6 months. Lymphoscintigraphy showed lymphangiectasia with chylothorax. The whole exome sequence consisted of Pathogenic variants in PIEZO1 gene associated with lymphatic malformation type 6 (LMPHM6).

Conclusion

This is the first reported pediatric case of PIEZO1 gene mutation in Saudi Arabia. This case highlighted the wide differential diagnosis of recurrent chylothorax and lower limb edema, as well as the relative literature on the molecular foundation, clinical scale, pathophysiology, and lymphatic malformation treatment. patients can be improved via application of standardized chylothorax and lymphedema therapies. Overall, awareness of the diseases related to the thoracic lymphatic circulation should be observed as its prognosis may highly promote better approaches for its management.

Palmar Venous Malformation: A Case Report of a Rare Occurrence and a Treatment Algorithm

Palmar venous malformations are not well described in the surgical literature and are a therapeutic challenge due to the intricate anatomy of the hand. We present the case of a 19-year-old right-handed female patient from Mexico who was referred to us with a right palmar lesion present since birth, previously diagnosed as a venous malformation. The patient reported that she had undergone sclerotherapy 10 years before in addition to a prior aborted attempt at excision. Venous palmar malformations are rare occurrences. Although an individualized approach is important, the development of an algorithm may assist in the standardization of the treatment of this pathology to preserve the hand’s functional status.

Arteriovenous malformation on the sole of the foot treated successfully by embolization

Arteriovenous malformations of the sole of the foot are rare and can cause disturbances in normal living activities. We report a case of a plantar arteriovenous malformation in a 24-year-old male with pain and difficulty in walking. The arteriovenous malformation was complex, with a large and poorly marginated nidus, so we considered that with surgical resection, walking disabilities would be inevitable. When surgical removal of vascular mass is difficult, embolization alone can be effective. Therefore, he was treated with 4 therapeutic embolization procedures. Transvenous approaches to the venous sac and direct punctures of the nidus was performed. The nidus was successfully eradicated by embolization using alcohol, resulting in the disappearance of associated symptoms. Appropriate imaging is essential for diagnosis and evaluation of treatment. We were successful in achieving improved quality of life and satisfaction for a rare and difficult case by percutaneous embolization and sclerotherapy.

Circulating Levels of Vascular Endothelial Growth Factor and Basic Fibroblastic Growth Factor in Infantile Hemangioma Versus Vascular Malformations

Few preliminary reports studied the utility of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) for differentiation between infantile hemangiomas (IHs) and vascular malformations. The aim of this study was to investigate the role of serum VEGF and bFGF levels in differentiating IHs from vascular malformations and identifying the stage and clinical course of IHs. Serum levels of VEGF and bFGF were assessed in 60 infants and children with various cutaneous vascular anomalies defined in 3 groups: proliferating IHs (n = 25), involuting IHs (n = 23), and vascular malformations (n = 12), in comparison with their levels in 40 healthy matched control. Serum levels of VEGF and bFGF were significantly elevated in all groups as compared to control ( P < .001, respectively). Both proliferating and involuting IHs had comparable levels of both markers ( P > .05, respectively) that were significantly higher in comparison with vascular malformations ( P < .05, respectively). Significantly lower VEGF levels were found in IHs that had regressed spontaneously (n = 11) compared to those regressed by treatment (n = 37), ( P < .05); meanwhile, bFGF showed no significant difference between both groups ( P > .05). Using receiver operating characteristic curves, a combined use of VGEF and bFGF yielded a sensitivity of 85.42% and a specificity of 100% for differentiating IHs from vascular malformations. Serum VEGF and/or bFGF levels are increased in cutaneous vascular anomalies and can differentiate IHs from vascular malformations. None of these markers could help in identifying the stage of IHs. Low VEGF is associated with spontaneous regression of IHs.

Transcriptional activation of Hedgehog pathway components in aggressive haemangioma

Infantile hemangioma is a vascular neoplasm and is one of the most common tumors diagnosed in young children. Although most hemangiomas are harmless and involute spontaneously, some show severe progression, leading to serious complications, such as high-output cardiac failure, ulcerations, compression of the trachea or deprivation amblyopia, depending on their size and localization. However, the pathogenesis and cause of hemangioma are largely unknown to date. The goal of this study was to identify markers that could predict hemangiomas with aggressive growth and severe progression that would benefit from early intervention. By using a PCR-based screening approach, we first confirmed that previously known markers of hemangioma, namely FGF2 and GLUT1, are highly expressed in hemangioma. Nevertheless, these genes did not show any differential expression between severely progressing tumors and mild tumors. However, transcriptional upregulation of several Hedgehog signalling components, comprising the ligand Sonic Hedgehog (SHH), the transcription factor GLI2 and its target gene FOXA2 were detected in extremely aggressive hemangioma specimens during the proliferation phase. Notably, GLI2 was even overexpressed in involuting hemangiomas if they showed an aggressive growth pattern. In conclusion, our data suggest that overexpression of the Hedgehog components SHH, GLI2 and FOXA2 might be used as markers of an aggressive hemangioma that would benefit from too early intervention, while FGF2 and GLUT1 are more general markers of hemangiomas.

Understanding venous malformations of the head and neck: a comprehensive insight

Venous malformations (VMs) are congenital vascular malformations. They are very often misnamed and thus incorrectly managed. The aim of the present paper is to provide the reader with the most updated literature available and to offer a detailed description of each single aspect of this disease. In detail, the paper discusses the epidemiology, the embryological origins and the physiopathology of VMs. Then, the clinical features of sporadic, inherited and syndromic VMs are discussed. The instrumental diagnosis is presented, and the role of US, CT, MRI and phlebography is pointed out. Differential diagnoses with other vascular malformations and tumors are described. The clinical session ends with the staging of VMs relying on MRI and rheological features. All aspects of treatment are described: conservative measures, medical treatment, sclerotherapy, laser and surgery are thoroughly discussed. A section is reserved to bony VMs. Their clinical aspects and the appropriate treatment are presented.

Differential regulation of angiogenesis using degradable VEGF-binding microspheres

Vascular endothelial growth factor (VEGF) spatial and temporal activity must be tightly controlled during angiogenesis to form perfusable vasculature in a healing wound. The native extracellular matrix (ECM) regulates growth factor activity locally via sequestering, and researchers have used ECM-mimicking approaches to regulate the activity of VEGF in cell culture and in vivo. However, the impact of dynamic, affinity-mediated growth factor sequestering has not been explored in detail with biomaterials. Here, we sought to modulate VEGF activity dynamically over time using poly(ethylene glycol) microspheres containing VEGF-binding peptides (VBPs) and exhibiting varying degradation rates. The degradation rate of VBP microspheres conferred a differential ability to up- or down-regulate VEGF activity in culture with primary human endothelial cells. VBP microspheres with fast-degrading crosslinks reduced VEGF activity and signaling, while VBP microspheres with no inherent degradability sequestered and promoted VEGF activity in culture with endothelial cells. VBP microspheres with degradable crosslinks significantly reduced neovascularization in vivo, but neither non-degradable VBP microspheres nor bolus delivery of soluble VBP reduced neovascularization. The covalent incorporation of VBP to degradable microspheres was required to reduce neovascularization in a mouse model of choroidal neovascularization in vivo, which demonstrates a potential clinical application of degradable VBP microspheres to reduce pathological angiogenesis. The results herein highlight the ability to modulate the activity of a sequestered growth factor by changing the crosslinker identity within PEG hydrogel microspheres. The insights gained here may instruct the design and translation of affinity-based growth factor sequestering biomaterials for regenerative medicine applications.

Integrative meta-analysis identifies microRNA-regulated networks in infantile hemangioma

BACKGROUND

Hemangioma is a common benign tumor in the childhood; however our knowledge about the molecular mechanisms of hemangioma development and progression are still limited. Currently, microRNAs (miRNAs) have been shown as gene expression regulators with an important role in disease pathogenesis. Our goals were to identify miRNA-mRNA expression networks associated with infantile hemangioma.

METHODS

We performed a meta-analysis of previously published gene expression datasets including 98 hemangioma samples. Deregulated genes were further used to identify microRNAs as potential regulators of gene expression in infantile hemangioma. Data were integrated using bioinformatics methods, and genes were mapped in proteins, which were then used to construct protein-protein interaction networks.

RESULTS

Deregulated genes play roles in cell growth and differentiation, cell signaling, angiogenesis and vasculogenesis. Regulatory networks identified included microRNAs miR-9, miR-939 and let-7 family; these microRNAs showed the most number of interactions with deregulated genes in infantile hemangioma, suggesting that they may have an important role in the molecular mechanisms of disease. Additionally, results were used to identify drug-gene interactions and druggable gene categories using Drug-Gene Interaction Database. We show that microRNAs and microRNA-target genes may be useful biomarkers for the development of novel therapeutic strategies for patients with infantile hemangioma.

CONCLUSIONS

microRNA-regulated pathways may play a role in infantile hemangioma development and progression and may be potentially useful for future development of novel therapeutic strategies for patients with infantile hemangioma.

Mosaic Neurocutaneous Disorders and Their Causes

Neurocutaneous disorders are a heterogeneous group of conditions (mainly) affecting the skin [with pigmentary/vascular abnormalities and/or cutaneous tumours] and the central and peripheral nervous system [with congenital abnormalities and/or tumours]. In a number of such disorders, the skin abnormalities can assume a mosaic patterning (usually arranged in archetypical patterns). Alternating segments of affected and unaffected skin or segmentally arranged patterns of abnormal skin often mirror similar phenomena occurring in extra-cutaneous organs/tissues [eg, eye, bone, heart/vessels, lung, kidney and gut]. In some neurocutaneous syndromes the abnormal mosaic patterning involve mainly the skin and the nervous system configuring a (true) mosaic neurocutaneous disorder; or an ordinary trait of a neurocutaneous disorder is sometimes superimposed by a pronounced linear or otherwise segmental involvement; or, lastly, a neurocutaneous disorder can occur solely in a mosaic pattern. Recently, the molecular genetic and cellular bases of an increasing number of neurocutaneous disorders have been unravelled, shedding light on the interplays between common intra- and extra-neuronal signalling pathways encompassing receptor-protein and protein-to-protein cascades (eg, RAS, MAPK, mTOR, PI3K/AKT and GNAQ pathways), which are often responsible of the mosaic distribution of cutaneous and extra-cutaneous features. In this article we will focus on the well known, and less defined mosaic neurocutaneous phenotypes and their related molecular/genetic bases, including the mosaic neurofibromatoses and their related forms (ie, spinal neurofibromatosis and schwannomatosis); Legius syndrome; segmental arrangements in tuberous sclerosis; Sturge-Weber and Klippel-Trenaunay syndromes; microcephaly/megalencephaly-capillary malformation; blue rubber bleb nevus syndrome; Wyburn-Mason syndrome; mixed vascular nevus syndrome; PHACE syndrome; Incontinentia pigmenti; pigmentary mosaicism of the Ito type; neurocutaneous melanosis; cutis tricolor; speckled lentiginous syndrome; epidermal nevus syndromes; Becker's nevus syndrome; phacomatosis pigmentovascularis and pigmentokeratotica; Proteus syndrome; and encephalocraniocutaneous lipomatosis.

Vascular anomalies of the upper extremity

The topic of vascular anomalies is uncommon in the hand surgery literature, but hand surgeons do diagnose and treat patients with hemangiomas and vascular malformations. These are separate entities and require different treatment strategies. Proper diagnosis will lead to timely and appropriate treatment.

The shunt problem: control of functional shunting in normal and tumour vasculature

Networks of blood vessels in normal and tumour tissues have heterogeneous structures, with widely varying blood flow pathway lengths. To achieve efficient blood flow distribution, mechanisms for the structural adaptation of vessel diameters must be able to inhibit the formation of functional shunts (whereby short pathways become enlarged and flow bypasses long pathways). Such adaptation requires information about tissue metabolic status to be communicated upstream to feeding vessels, through conducted responses. We propose that impaired vascular communication in tumour microvascular networks, leading to functional shunting, is a primary cause of dysfunctional microcirculation and local hypoxia in cancer. We suggest that anti-angiogenic treatment of tumours may restore vascular communication and thereby improve or normalize flow distribution in tumour vasculature.

Facial Nerve Hemangiomas: Vascular Tumors or Malformations?

OBJECTIVE: To reclassify facial nerve hemangiomas in the context of presently accepted vascular lesion nomenclature by examining histology and immunohistochemical markers.

STUDY DESIGN: Cohort analysis of patients diagnosed with a facial nerve hemangioma between 1990 and 2008.

SETTING: Collaborative analysis at a specialty hospital and a major academic hospital.

SUBJECTS AND METHODS: Seven subjects were identified on composite review of office charts, a pathology database spanning both institutions, and an encrypted patient registry. Clinical data were compiled, and hematoxylin-eosin–stained specimens were reviewed. For six patients, archived pathological tissue was available for immunohistochemical evaluation of markers specific for infantile hemangioma (glucose transporter protein isoform 1 [GLUT1] and Lewis Y antigen) and for lymphatic endothelial cells (podoplanin).

RESULTS: All patients clinically presented with slowly progressive facial weakness at a mean age of 45 years without prior symptomatology. Hemotoxylin-eosin–stained histopathological slides showed irregularly shaped, dilated lesional vessels with flattened endothelial cells, scant smooth muscle, and no internal elastic lamina. Both podoplanin staining for lymphatic endothelial cells and GLUT1 and LewisY antigen staining for infantile hemangioma endothelial cells were negative in lesional vessels in all specimens for which immunohistochemical analysis was performed.

CONCLUSION: Lesions of the geniculate ganglion historically referred to as “hemangiomas” do not demonstrate clinical, histopathological, or immunohistochemical features consistent with a benign vascular tumor, but instead are consistent with venous malformation. We propose that these lesions be classified as “venous vascular malformations of the facial nerve.” This nomenclature should more accurately predict clinical behavior and guide therapeutic interventions.

Ultrastructural characteristics of peripheral arteriovenous and venous angiodysplasias

Comparative histological and electron microscopic study of arteriovenous and venous angiodysplasias revealed specific features of their structure, presumably reflecting differences in their morphogenesis. Specific ultrastructural characteristics of angiodysplasias are modified shape of endotheliocytes, impaired structure of the basal membrane, and reduced count of pericytes.

Phenotypic categorization of genetic skin diseases reveals new relations between phenotypes, genes and pathways

Motivation: Systematic analysis of connection between proteins, their cellular function and phenotypic manifestations in disease is a central problem of biological and clinical research. The solution to this problem requires the development of new approaches to link the rapidly growing dataset of gene–disease associations with the many complex and overlapping phenotypes of human disease.

Results: We analyze genetic skin disorders and suggest a manually designed set of elementary phenotypes whose combinations define diseases as points in a multidimensional space, providing a basis for phenotypic disease clustering. Placing the known gene–disease associations in the context of this space reveals new patterns that suggest previously unknown functional links between proteins, signaling pathways and disease phenotypes. For example, analysis of telangiectasias (spider vein diseases) reveals a previously unrecognized interplay between the TGF-β signaling pathway and pentose phosphate pathway. This interaction may mediate glucose-dependent regulation of TGF-β signaling, providing a clue to the known association between angiopathies and diabetes and implying new gene candidates for mutational analysis and drug targeting.

Contact:grishin@chop.swmed.edu

Supplementary information:Supplementary data are available at Bioinformatics online.

Expression of growth factors in endotheliocytes in vascular malformations

The expression of growth factors and proliferation of endotheliocytes in vascular malformations were studied by immunohistochemical methods. The detected specific features of growth factor expression in the endothelium of venous and arteriovenous malformations seem to reflect the differences in the pathogenesis of these formations. High proliferative activity of the endothelium in angiodysplasias of both types can underlie the disease relapsing.

Serum levels of vascular endothelial growth factor and basic fibroblastic growth factor in children with hemangiomas and vascular malformations--preliminary report

Impaired balance between proangiogenic and antiangiogenic factors has been implicated in the development of hemangiomas. Elevated vascular endothelial growth factor serum levels and basic fibroblastic growth factor urine levels in patients with proliferating hemangiomas were reported. However, whether these growth factors can be used for the differential diagnosis of vascular anomalies or assessment of the clinical course of hemangiomas has yet to be determined. We report here our preliminary results of serum vascular endothelial growth factor and basic fibroblastic growth factor levels as an aid in the diagnosis of hemangiomas and in the follow up of patients with this lesion. Twenty two children with infantile hemangioma (13 with proliferating hemangiomas, nine with involuting lesions), five children with vascular malformations, and 25 healthy children study group. Vascular endothelial growth factor and basic fibroblastic growth factor serum levels were analyzed by an ELISA assay. The serum vascular endothelial growth factor concentrations in children with proliferating hemangiomas were significantly higher than in patients with involuting hemangiomas, vascular malformations and healthy patients. The serum basic fibroblastic growth factor concentrations were low and similar in all patients with no statistical correlation between study groups. We concluded that (i) ELISA can easily determine vascular endothelial growth factor concentrations in different phases of hemangioma growth and help distinguishing them from vascular malformations. (ii) A potential role for vascular endothelial growth factor in the pathophysiology of hemangiomas is probable.

An infant with a segmental hemangioma: Sturge-Weber?

A 6-week-old infant was referred for possible Sturge-Weber syndrome. The patient had a segmental hemangioma primarily involving the left eye. Subsequent evaluation suggested the diagnosis of PHACES syndrome, which is discussed. The risks to vision presented by the orbital involvement of the hemangioma should be noted.

Venous malformations: classification, development, diagnosis, and interventional radiologic management

Venous malformations are categorized as low-flow vascular malformations within the domain of vascular anomalies and are the most common vascular malformation encountered clinically. Venous malformations are by definition present at birth, undergo pari passu growth, and present clinically because of symptoms related to mass effect or stasis. Although diagnosis can usually be made by clinical history and examination, differentiation from other vascular and nonvascular entities often requires an imaging work-up that includes ultrasound, CT, MR imaging, and diagnostic phlebography. All decisions regarding imaging work-up and decision to treat must be coordinated though referral and discussions with a multidisciplinary team and be based on clearly defined clinical indications. Percutaneous image-guided sclerotherapy has become the mainstay of treatment for venous malformations and involves the introduction of any one of a number of endothelial-cidal sclerosants into the vascular spaces of the lesion, with each sclerosant possessing its own unique spectrum of advantages and disadvantages.

Linfangiogênese e genética dos linfedemas: revisão da literatura

O estudo do genoma humano propiciou recentes descobertas de genes e de complexos mecanismos de controle da linfangiogênese. Neste artigo esses conhecimentos são revistos, com suas implicações na embriogênese e desenvolvimento do sistema linfático e na etiopatogenia de diferentes formas e síndromes de linfedema hereditário. Algumas doenças linfáticas de transmissão genética e síndromes de aneuploidia são descritas nas suas características genotípicas e fenotípicas. Os avanços na compreensão do crescimento e desenvolvimento dos vasos linfáticos devem trazer novas alternativas terapêuticas nas linfangiodisplasias e no controle da disseminação linfática dos tumores.

Left coronary artery arteriovenous malformation presenting as a diastolic murmur with exercise intolerance in a child with a suspected familial vascular malformation syndrome

OBJECTIVE

Intracardiac arteriovenous malformations are rare and may be associated with sudden death in adults. This case report describes an intracardiac left coronary arteriovenous malformation in a 7-year-old boy with a suspected familial cutaneous vascular malformation syndrome. The patient presented with a diastolic murmur, exercise intolerance, chest pain, and a left ventricular mass.

METHODS

The left ventricular mass was initially identified by echocardiography. Subsequently, a computed tomography scan revealed the vascular nature of the lesion. We hypothesized that the lesion represented either an arteriovenous malformation (AVM) or a hemangioma. These lesions are thought to cause coronary steal and myocardial dysfunction. Skin biopsies of the patient's cutaneous lesions revealed capillary hyperplasia, which was not consistent with either hemangioma or AVM. Thus, a surgical biopsy and partial resection of the mass was performed.

RESULTS

The surgical pathology of the cardiac mass was consistent with an AVM. Within 6 months following partial resection of the mass, the patient unexpectedly developed a left ventricular pseudoaneurysm at the resection site and required re-operation. Although a portion of the mass remains, both the patient's chest pain and exercise tolerance have improved subjectively.

CONCLUSION

Patients with cutaneous vascular malformations and diastolic murmurs, as well as cardiac symptoms, should undergo echocardiography or alternative imaging modalities to screen for treatable pathological myocardial vascular malformations.

Evaluation of plasma tissue factor and tissue factor pathway inhibitor levels in childhood hemangiomas

BACKGROUND

The purpose of the study was to evaluate the plasma levels of tissue factor (TF), an angiogenic marker, and tissue factor pathway inhibitor (TFPI), an antiproliferative protein, in the childhood hemangiomas at proliferative and regressive stages.

PROCEDURE

The study included 30 patients with hemangiomas and 30 healthy children. Localization, number, stage, type, duration of growth, and complications of the hemangiomas were determined. Venous blood samples from all individuals were collected into citrated tubes and centrifuged. Supernatant plasma was separated, aliquated, and stored at -70 degrees C until samples could be assayed. Plasma levels of TF and TFPI were measured with quantitative ELISA kits.

RESULTS

Plasma TF and TFPI levels did not show any significant difference between the study and control groups. When plasma TF and TFPI levels of the children in the control group and in the study group who were in proliferative and regressive stage were compared to each other, no statistically significant difference could be detected.

CONCLUSIONS

Plasma TF and TFPI levels of our patients with hemangiomas were not different from healthy children and they did not show any significant difference in proliferative and regressive stages.

Classification, diagnosis, and interventional radiologic management of vascular malformations

Vascular anomalies are comprised of either hemangiomas or vascular malformations.Low-flow vascular malformations can be divided into capillary, venous, and lymphatic types and are usually present at birth, undergo pari passu growth, and produce symptoms related to mass effect or stasis. High-flow malformations are comprised pre-dominantly of arteriovenous malformations that follow a more aggressive clinical course of hyperemia, adjacent mass effect, steal phenomenon, tissue destruction, and ultimately high output failure. Ultrasound, CT, nuclear medicine, angiography, and particularly MRI have greatly enhanced diagnostic accuracy and provide detailed information for percutaneous and surgical treatment planning and an objective means of following therapeutic efficacy. Interventional radiologic percutaneous sclerotherapy for low-flow lesions and embolosclerotherapy for high-flow lesions with or without adjunctive surgical intervention have become the mainstay of therapy.

Basic science and clinical aspects of vascular anomalies

PURPOSE OF REVIEW

Patients with vascular and lymphatic anomalies are often 'medical orphans' ascertained through distinct medical specialists. Multidisciplinary vascular anomalies programs provide focused expertise in diagnosis and treatment for patients. National and international workshops on vascular anomalies are fostering clinical and basic science research to enhance our understanding of vascular development and vascular anomalies. Herewith is presented an update of recent advances in the study of vascular/lymphatic anomalies.

RECENT FINDINGS

New original findings include (1) the identification of distinct cell surface markers and other cellular properties in hemangiomas and vascular malformations relevant to vascular development, (2) the discovery of novel genetic mutations and susceptibility genes in patients with vascular anomalies, (3) recognition of new risk stratifications and clinical issues for patients with hemangiomas and vascular malformations, and (4) the elucidation of sequelae from the disorders as well as side effects of recent and previous therapies for vascular anomalies.

SUMMARY

Vascular anomalies are an attractive model for the study of human disorders of vasculogenesis and angiogenesis. The etiology of these disorders is unclear and likely represents a multifactorial process. Clinical clues are leading to scientific investigations that may enable targeted therapies, prevention strategies, or both.