Propranolol for severe infantile hemangiomas: follow-up report

Ocular and orbital tumors in childhood

Pediatric tumors of the eye and orbit can be benign or malignant as well as congenital or acquired and are usually distinctively different than those seen in adults. Although most of these neoplasms are benign (eg, dermoid cyst, chalazion, molluscum), their location near and within a vital organ can result in serious dermatologic and ophthalmologic sequelae. Lesions discussed include vascular lesions, retinoblastomas (the most common primary pediatric intraocular malignancy), rhabdomyosarcoma (the most common primary pediatric orbital malignancy), Langerhans cell histiocytosis, and metastatic lesions to the orbit (neuroblastoma, Ewing sarcoma). Although cysts and ocular melanoma can occur within the pediatric population, these conditions are covered in other contributions in this issue of Clinics in Dermatology.

From Severe Anemia to Intestinal Hemangiomatosis, a Bumpy Road-A Case Report and Literature Review

Gastrointestinal hemangiomas (GIH) are unusual vascular tumors found anywhere alongside the GI tract, the small bowel being the most common site. Diagnosis requires good clinical insight and modern imaging. This is a comprehensive review of the literature, starting from a new pediatric case diagnosed through exploratory laparotomy after complex imaging techniques failed. This research was conducted on published articles from the past 25 years. We identified seventeen original papers (two series of cases with three and two patients, respectively, and fifteen case reports). The female/male ratio was 1.5. The youngest patient was a 3-week-old boy, and the was oldest a 17-year-old girl. The most common localization was the jejunum (eight cases), followed by the ileum (four), colon (three), stomach (two), and rectum (one). Seven children had cavernous and four had capillary hemangiomas. Eight patients presented gastrointestinal bleeding, seven had refractory anemia, such as our index patient, three had recurrent abdominal pain, and two had bowel obstruction. Surgical assessment was successful in fifteen cases; three cases experienced great outcomes with oral propranolol, one child was treated successfully with sirolimus, and for one patient, endoscopic treatment was the best choice. The authors present the case of a female patient admitted to the Pediatrics Department of "Grigore Alexandrescu" Emergency Children's Hospital from 25 February to 28 March 2019 for severe anemia, refractory to oral iron treatment, and recurrent blood infusions. No clear bleeding cause had been found. Although very uncommon, intestinal hemangiomas can express puzzling, life-threatening symptoms. We should keep in mind this disorder in cases of unresponsive chronic anemia.

Cardiac side effects of propranolol in infants treated for infantile haemangiomas

OBJECTIVES

This study aims to add proof to the safety profile of propranolol as first-line choice in treating infantile haemangiomas, in particular related to its cardiac side effects the main hindering reason for parents and physicians to start and comply with treatment.

METHOD

This is a prospective observational and analytic study with a sample of 476 patients diagnosed with infantile haemangioma and treated with systemic propranolol during the time interval January 2011 to December 2021. We studied clinical propranolol adverse events experienced in hospital or outpatient and measured the impact of propranolol on blood pressure and heart rate.

RESULTS

This study showed that symptomatic adverse events caused by propranolol were mild and severe adverse events were rare. The most common clinical side effects were paleness, sweating, reduced feeding, and agitation. Only in 28 (5.9%) cases these symptoms were severe enough to review treatment, 1.8% had severe respiratory symptoms, 2.7% experienced hypoglycaemia, and 1.2% had heart-related symptoms. Mean blood pressure reduction with treatment was statistically significant only after achieving the maintenance dose 2 mg/kg body weight. Blood pressure under the 5th percentile was registered in 2.9% of cases, but only four patients had symptomatic hypotension. While heart rate reduction was noticed with the first dose, only two experienced symptomatic bradycardia.

CONCLUSION

We conclude that propranolol is not only an excellent drug in treating infantile haemangioma, but it has also a very safe profile, with mild side effects and very rare severe cardiac adverse events, easily overcome with treatment interruption.

Global research trends of infantile hemangioma: A bibliometric and visualization analysis from 2000 to 2022

Background

Infantile hemangioma (IH) has received global attention, resulting in a significant volume of literature. However, there is a lack of bibliometric analyses specifically focusing on IH publications. This study aims to fill this gap by conducting a comprehensive analysis of IH publications, investigating their characteristics, contribution distribution, and developmental trends. By enhancing our understanding of IH and identifying potential research topics and collaborators, this study will contribute to the advancement of the field.

Methods

A total of 4333 articles and reviews on IH were collected from the Web of Science (WoS) database, spanning the years 2000-2022. The study encompassed a comprehensive analysis of IH publications, evaluating their quantity and quality. Additionally, we profiled publishing groups based on country, institution, author publication records, and collaboration networks. Lastly, we identified and summarized the prominent research topics.

Results

Annual publications on IH have increased over the past 20 years. The United States has the highest number of publications and the highest total number of citations. Pediatric Dermatology was the most influential journal in the IH field. The citation analysis indicated that the articles published by Léauté-Labrèze in 2008 had the highest number of citations. The articles published by North PE in 2000 and Boye E in 2001 laid a certain research foundation for this field. Concerning institutions, most of the cooperative relationships were established in the same country/region. The United States has the largest number of scientific research institutions and IH researchers, leading most of the cross-country collaboration. The University of California, San Francisco, Medical College of Wisconsin, Harvard University, and Shanghai Jiaotong University were the research centers that published the most IH-related research. Frieden IJ, Mulliken JB, and Drolet BA were the top three most influential authors. Frieden IJ, Garzon MC, and Mulliken JB were the top three authors with the most cited frequency. In addition, keywords and keyword co-occurrence networks prompted that the pathological mechanism of IH, clinical analysis, and other vascular anomalies are research hotspots. Analysis of trending topics suggests that research on IH has evolved from treatment-focused studies towards investigations of other vascular diseases and a series of clinical case studies. Currently, clinical case studies receive the most attention in the field.

Conclusions

This comprehensive bibliometric study provides a thorough analysis of post-2000 publications in the field of IH, offering insights into current research trends for the first time. The findings suggest that future investigations will continue to prioritize understanding IH mechanisms, treatment approaches, and treatment evaluation. Furthermore, the exploration of other vascular diseases and the inclusion of clinical case studies are expected to contribute to advancements in IH clinical practice. By identifying potential collaborators, partner institutions, and new research avenues, this study offers valuable guidance for future in-depth research on IH.

A Pilot Feasibility Study Assessing the Combined Effects of Early Behavioral Intervention and Propranolol on Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD), a neurodevelopmental disorder typified by differences in social communication as well as restricted and repetitive behaviors, is often responsive to early behavioral intervention. However, there is limited information on whether such intervention can be augmented with pharmacological approaches. We conducted a double-blinded, placebo-controlled feasibility trial to examine the effects of the β-adrenergic antagonist propranolol combined with early intensive behavioral intervention (EIBI) for children with ASD. Nine participants with ASD, ages three to ten, undergoing EIBI were enrolled and randomized to a 12-week course of propranolol or placebo. Blinded assessments were conducted at baseline, 6 weeks, and 12 weeks. The primary outcome measures focusing on social interaction were the General Social Outcome Measure-2 (GSOM-2) and Social Responsiveness Scale-Second Edition (SRS-2). Five participants completed the 12-week visit. The sample size was insufficient to evaluate the treatment efficacy. However, side effects were infrequent, and participants were largely able to fully participate in the procedures. Conducting a larger clinical trial to investigate propranolol's effects on core ASD features within the context of behavioral therapy will be beneficial, as this will advance and individualize combined therapeutic approaches to ASD intervention. This initial study helps to understand feasibility constraints on performing such a study.

Infantile Haemangioma in the Romanian Paediatric Population-Characteristics and Therapeutic Approaches

Infantile haemangioma (IH) is the most common benign tumour in childhood, with an incidence of 4% to 12%. Aim: to describe the characteristics of infantile haemangioma in a sample of Romanian children <2 years old at diagnosis, types of treatment applied, recorded complications and the response to the therapeutic approach. A two-year prospective case series study (August 2019 to August 2021) was carried out. Sample: 117 patients <24 months of age diagnosed with IH at the Emergency Hospital for Children "Marie Sklodowska Curie", in Bucharest, Romania. Five therapeutic approaches were used: oral treatment with propranolol, local treatment with timolol, surgical treatment, topical treatment with steroids and no treatment ("wait and see"). Recorded factors mentioned in the literature were also present in this study population: female patients-68.4%; phototype I-58%. In 53% of cases, IHs had a head and neck location and 10% developed local complications (traumatic bleeding). The majority of patients (86%) required one type of therapy: oral propranolol (51%). A low relapse rate was recorded (4%). We consider that any child with a vascular anomaly should be referred to a highly specialised medical service for therapeutic approach.

Laser treatment of infantile hemangioma

BACK GROUNDS AND OBJECTIVE

Infantile hemangiomas (IH) are common benign tumors of infancy. Most IH either involute spontaneously or respond to treatment with systemic Beta- blockers, but unfortunately not in all cases. In poor responses or in cases of contra indications for pharmacological treatment, laser treatment poses a very good solution.

METHODS

As a search strategy and study selection we searched the MEDLINE database via PubMed starting 1982 to June 2022 using a key terms related to interventions for IH (e.g., infantile hemangioma, laser, Beta blockers).

RESULTS

In this article, we reviewed the published data regarding the use of energy-based devices in treatment of children with IH, and noted our experience over the course of treating dozens of cases over the years.

CONCLUSION

There are many laser systems used for the treatment of hemangioma and vascular tumors. These laser systems are of different wavelengths and penetration depths, however, they operate by similar mechanisms and in some cases two or more lasers can be applied during the course of treating these lesions.

CircRNA-miRNA-VEGFA: an important pathway to regulate cancer pathogenesis

Cancers, especially malignant tumors, contribute to high global mortality rates, resulting in great economic burden to society. Many factors are associated with cancer pathogenesis, including vascular endothelial growth factor-A (VEGFA) and circular RNAs (circRNA). VEGFA is a pivotal regulator of vascular development such as angiogenesis, which is an important process in cancer development. CircRNAs have covalently closed structures, making them highly stable. CircRNAs are widely distributed and participate in many physiological and pathological processes, including modulating cancer pathogenesis. CircRNAs act as transcriptional regulators of parental genes, microRNA (miRNA)/RNA binding protein (RBP) sponges, protein templates. CircRNAs mainly function via binding to miRNAs. CircRNAs have been shown to influence different diseases such as coronary artery diseases and cancers by regulating VEGFA levels via binding to miRNAs. In this paper, we explored the origin and functional pathways of VEGFA, reviewed the current understanding of circRNA properties and action mechanisms, and summarized the role of circRNAs in regulating VEGFA during cancer pathogenesis.

Our experience with propranolol for infantile hemangioma

BACKGROUND/OBJECTIVES

The most frequent benign vascular tumor in children is infantile hemangioma (IH). For severe IHs, propranolol has become the first-line Treatment. Despite the fact that several studies have comprehensive therapy regimens, including the best time to start Treatment, dosage, visit frequency, and treatment duration, there is still controversy about the best time to start and stop propranolol medication.

METHODS

Between January 2016 and February 2019, dermatologists experienced hemangioma treatment and recommended propranolol treatment for 232 IHs. A total of 90 patients completed the treatment process after undergoing a color Doppler ultrasound test.

RESULTS

Propranolol uniquely affects each IH. Ninety patients were divided into two groups in this study: entire regression (n = 40) and partial regression (n = 50). The entire regression group's initial treatment period (4.3 ± 2.97 months) was substantially shorter than the partial regression group's (5.2 ± 4.57 months) (p < 0.05). Between the entire regression group (23.4 ± 12.8 months) and the partial regression group (24.5 ± 16.6 months), there was no significant difference in time to reduce propranolol. The partial regression group (32.9 ± 25.3month) had a lengthier treatment course than the entire regression group (23.4 ± 13.7 months) (p < 0.05). The partial regression group (22%), like the entire regression group, had a higher recurrence rate (5%). The overall proportion of hemangiomas on the face (particularly periocular hemangioma) in the regression group was greater than in the control group.

CONCLUSION

The entire regression group's initial treatment time was significantly shorter than the partial regression group's. As a result, as soon as a hemangioma is discovered, it should be treated. To determine the appropriate time to reduce propranolol, we must evaluate the patient's age and the percentage of tumor regression. Periocular hemangioma may have a better prognosis than other types. Given the small number of patients in our study, we will need to do more research in the future to confirm our findings.

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.

KIAA1429 promotes infantile hemangioma regression by facilitating the stemness of hemangioma endothelial cells

Infantile hemangiomas are common vascular tumors with a specific natural history. The proliferation and regression mechanism of infantile hemangiomas may be related to the multilineage differentiation ability of hemangioma stem cells, but the specific mechanism is not well elucidated. KIAA1429 is an N⁶ -methyladenosine methylation-related protein that can also exert its role in a methylation-independent manner. This study aims to explore the function of KIAA1429 in infantile hemangiomas. qRT-PCR, western blotting, and immunostaining were performed to verify the expression of KIAA1429. The endothelial and fibroblast-like phenotypes of hemangioma endothelial cells were detected after KIAA1429 knockdown and overexpression. The stemness properties of hemangioma endothelial cells and the underlying mechanism of KIAA1429 in hemangiomas were also investigated. Nude mouse models of infantile hemangiomas were conducted to ascertain the effects of KIAA1429 in vivo. The results showed that KIAA1429 was highly expressed in infantile hemangiomas, particularly in involuting hemangiomas. In vitro experiments confirmed that KIAA1429 inhibited the endothelial phenotype, enhanced the differentiation ability, and promoted the fibroblast-like phenotype of hemangioma endothelial cells by inducing endothelial cell transition to facultative stem cells. However, the effect of KIAA1429 on the potential target was shown to be independent of N⁶ -methyladenosine methylation modification. Mouse models further revealed that KIAA1429 could inhibit the proliferation and promote the regression of hemangiomas. In conclusion, this study found that KIAA1429 played an important role in the regression of infantile hemangiomas by enhancing the stemness of hemangioma endothelial cells and could be a potential treatment target for infantile hemangiomas.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RATIONALE

Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management.

METHODS

Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value &lt;0.05 was taken as significant.

RESULTS

In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049).

CONCLUSION

Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Gene expression profiles of beta-adrenergic receptors in canine vascular tumors: a preliminary study

Beta adrenergic receptors (β-AR) play a key role in regulating several hallmark pathways of both benign and malignant human and canine tumors. There is scarce information on the expression of β-AR in canine vascular tumors. Therefore, the purpose of the present research work was to study the mRNA expression levels of the three subtypes of the β-AR genes (ADRB1, ADRB2, ADRB3) in hemangiosarcoma (HSA) and hemangioma (HA), as well as in vascular hamartomas (VH) from dogs.Fifty samples (n = 50) were obtained from 38 dogs. Twenty-three animals had HSA, eight animals HA and seven animals VH. HSA were auricular (n = 8), splenic (n = 5), cutaneous (n = 6), auricular and splenic (n = 2), cutaneous-muscular (n = 1) and disseminated (n = 1). There were seven cases of HSA that were divided into primary tumor and secondary (metastatic) tumor. Skin and muscle samples with a normal histological study were used as control group. ADRB gene expression was determinate in all samples by real-time quantitative PCR. Results showed that ADRB1, ADRB2 and ADRB3 were overexpressed in HSA when compared to the control group. ADRB2 was overexpressed in HA when compared to the control group. HSA express higher values of ADBR1 (p = 0.0178) compared to VH. There was a high inter-individual variability in the expression of the three subtypes of ADBR. No statistically significant difference in the expression of ADBR genes were observed between HSA primary when compared to metastatic or in different anatomical locations. In conclusion, canine HSA overexpress the three β-AR subtypes and canine HA β2-AR. High variability was observed in β-AR mRNA levels amongst HSA cases.

Does Oral Propranolol Improve the Final Outcome of All Involuted Infantile Hemangiomas? A Matched Retrospective Comparative Study

BACKGROUND

Oral propranolol can effectively activate and accelerate infantile hemangioma (IH) involution; however, could the final outcome of oral propranolol treatment for IHs commensurate that of spontaneous involution?

OBJECTIVE

This study aimed to investigate the long-term therapeutic effect of oral propranolol for IHs.

METHODS

We present an individual matching comparative study with (1) oral propranolol therapy for mixed and deep IHs on the lips, nose, and parotid and (2) lesion type- and lesion location-matched untreated IHs as controls. Patients' follow-up photographs were assessed by 3 surgeons blinded of their treatment. Outcome measures were the quantification of the degree of sequelae ranging from 1 to 4 and the age at which IH achieved involution arrest.

RESULTS

Ten groups of oral propranolol and untreated patients with matched lesions were assessed. Average age at which lesions stabilized and reached no change in appearance was 1.7 years old and 6.3 years old for propranolol group and untreated group (t = 5.663, P < 0.001). There was no significant difference in the quantified degree of sequelae for oral propranolol group and untreated group upon follow-up (1.60 vs 1.40, respectively; t = 1.259, P = 0.240).

CONCLUSIONS

Oral propranolol therapy accelerates IH involution but does not have a superior effect than spontaneous involution on the overall outcome of problematic IHs.

Nasal Obstruction in the Infant

Neonatal nasal obstruction is common in both the hospital and clinic settings. Causes can range from rhinitis to congenital masses, with a wide variety of congenital nasal masses described. A complete history and physical examination are necessary for correct diagnosis and management. Arhinia and bilateral choanal atresia will present with complete obstruction leading to forced mouth breathing. Partial obstruction will require assessment of nasal patency with possible nasal endoscopy and imaging. Medical and surgical options for treatment are discussed.

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.

Expression of β1 adrenergic receptor in vascular anomalies in children

OBJECTIVE

Controversial, heterogeneous, and inconsistent responses to beta-blockers have been reported in some cases of infantile proliferative hemangiomas. On the basis of these clinical observations, we aimed to examine the β1 adrenergic receptor (β1-AR) protein expression distribution among different types of pediatric vascular anomalies.

METHODS

Immunohistochemistry (IHC) was performed for β1-AR on 43 surgical specimens.

RESULTS

We found positive β1-AR IHC staining in all intramuscular hemangiomas, capillary-lymphatic, lymphatic, venous, and combined malformations, and Masson's tumor cases, as well as in 7 of 10 cases of proliferative infantile hemangiomas.

CONCLUSIONS

Our research demonstrates, for the first time, the degree of heterogeneous expression of β1-AR among pediatric vascular malformations. Our results support the need for β1-AR assessment in pediatric vascular anomalies to select cases with a robust response to β1-selective blockers. β1-AR assessment may have a strong impact on therapeutic refinement for pediatric vascular anomalies by selecting cases with a stronger response to beta-blockers.

Propranolol Therapy in Infantile Hemangioma: It Is Not Just About the Beta

BACKGROUND

Propranolol, a nonselective β-adrenergic receptor antagonist, is approved by the U.S. Food and Drug Administration to treat problematic infantile hemangiomas, but a subset of patients experience treatment complications. Parents wary of long-term use and side effects consult plastic surgeons on surgical options or as a second opinion. Understanding the mechanism(s) of action of propranolol will allow plastic surgeons to better inform parents.

METHODS

A systemic literature search was performed to query published translational and basic science studies on propranolol effects on infantile hemangiomas and cells derived from these lesions.

RESULTS

In experimental studies, propranolol was antiproliferative and cytotoxic against hemangioma endothelial and stem cells and affected infantile hemangioma perivascular cell contractility. Propranolol inhibited migration, network formation, vascular endothelial growth factor A production, and vascular endothelial growth factor receptor 2 activation and down-regulated PI3K/AKT and mitogen-activated protein kinase signaling in hemangioma endothelial cells, but it increased ERK1/2 activity in hemangioma stem cells. At effective clinical doses, measured propranolol plasma concentration is 100 times higher than necessary for complete β-adrenergic receptor blockade, yet was 10 to 100 times less than required to induce hemangioma stem cell death.

CONCLUSIONS

Propranolol targets multiple cell types in infantile hemangiomas by means of β-adrenergic receptor-dependent and -independent mechanisms. Plasma concentration played a significant role. At clinically relevant doses, incomplete infantile hemangioma suppression may explain the rebound phenomenon and worsening ulceration, and propranolol off target effects may lead to commonly reported adverse effects, such as sleep and gastrointestinal disturbances. Propranolol limitations and complications underscore the importance of surgical treatment options in cases of rebound and severe adverse effects. Surgical intervention remains an important treatment choice when parents are hesitant to use propranolol.

Infantile Hemangiomas Cleared by Combined Therapy With Pulsed Dye Laser and Propranolol

BACKGROUND

Oral propranolol is the first-line therapy for infantile hemangioma. Combining it with pulse dye laser (PDL) (595nm-long PDL) could reduce treatment duration and sequelae incidence and severity.

OBJECTIVE

To determine the effect of PDL-propranolol treatment on duration to cure and sequelae.

METHODS

All consecutive patients with infantile hemangioma who were cured by PDL-propranolol treatment were identified.

RESULTS

In the 27 cases, average age at treatment start was 4.3 ± 3.8 months, mean tumor diameter was 11.1 ± 14.0 cm2, and tumor-type was most common (72.4% of lesions). The patients received 9.8 ± 10.5 PDL sessions. After ensuring patients had no physical contraindications, including heart disease, oral propranolol was started at 1 mg/kg/d, increased up to 3 mg/kg/d as a maintenance dose. Mean propranolol treatment duration was 11.1 ± 4.9 months. Total treatment duration was 15.3 ± 10.8 months.

CONCLUSION

Our data in the context of recent literature suggest combining propranolol with PDL may reduce propranolol duration without increasing harms.

Effect of Oral Propranolol on Periocular Infantile Capillary Hemangioma: Outcomes Based on Extent of Involvement

PURPOSE

To evaluate the efficacy of oral propranolol in the treatment of periocular infantile capillary hemangioma (CHI) based on the involvement of embryological facial placodes and their extent of anatomical involvement.

METHODS

Retrospective study of 27 patients.

RESULTS

The mean age at the presentation of periocular CHI was 4 months (median, 3 months; range, <1-14 months). There were 11 (41%) males and 16 (59%) females. Based on embryological facial placodes, the involvement was focal in 16 (59%) cases and segmental in 11 (41%) cases. Based on the anatomical distribution, the lesions were preseptal in 4 (15%), postseptal in 13 (48%), and combined in 10 (37%) cases. The duration of use of oral propranolol was 10 months (median, 10 months; range, 4-16 months). Overall, the mean % resolution of periocular CHI was 78% (median, 90%; range, 20%-100%). The mean percentage resolution of focal lesions was 69% (median, 83%; range, 20%-100%), and segmental lesions were 92% (median, 95%; range, 70%-100%). The mean percentage resolution of preseptal component of lesions was 94% (median, 95%; range, 80%-100%) and postseptal component was 74% (median, 85%; range, 20%-100%) over a mean follow-up period of 16 months (median, 15 months; range, 4-37 months). Four (15%) patients exhibited flare-up of lesion after tapering oral propranolol.

CONCLUSION

Oral propranolol is effective in the treatment of periocular CHI. Segmental and preseptal lesions respond better to the treatment compared to focal and postseptal lesions.

Value of Doppler ultrasound scans in deciding whether to treat infantile haemangioma with oral propranolol

BACKGROUND

Oral propranolol (Pr) must be administered until the end of the proliferation phase of infantile haemangioma (IH). This phase may be difficult to assess, particularly where a deep component is involved. Doppler ultrasound scans (DUS), which identify vascular activity (VA), could assist the clinician in making the correct therapeutic decision (CTD).

PATIENTS AND METHODS

All children with IH treated with Pr for at least 3 months and up to the age of 9 months, and who also underwent DUS, were enrolled in this retrospective, single-centre, observational study. The quality of DUS as a binary diagnostic test for IH proliferation was assessed, together with its value in deciding whether to discontinue Pr (at the end of the presumed proliferation phase) or resume this drug (in the case of suspected recurrence).

RESULTS

A total of 29 children were enrolled and 45 DUS were performed. Thirty-nine (87%) DUS were of high quality (80% sensitivity, 95% specificity) and made a major, moderate, or minimal contribution to the CTD in respectively 20%, 60% and 7% of cases.

DISCUSSION

DUS proved to be a high-value tool. They were essential in some cases of IH, mainly periocular and localised forms, and those involving deep components, in which the question of discontinuing Pr arose (age>1 year) and where clinical examination had not been sufficient to make the CTD. Furthermore, in the vast majority of cases, they provide a helpful examination and complement clinical findings in terms of patient follow-up and reaching a CTD.

CONCLUSION

DUS is an effective and complementary tool to clinical investigation.

Efficacy and Safety of Propranolol vs Atenolol in Infants With Problematic Infantile Hemangiomas: A Randomized Clinical Trial

Importance

Propranolol has become the first-line therapy for problematic infantile hemangiomas (IHs) that require systemic therapy. However, different adverse events have been reported during propranolol treatment. The positive efficacy and safety of atenolol raise the question of whether it could be used as a promising therapy for IH.

Objective

To compare the efficacy and safety of propranolol vs atenolol in infants (between age 5 and 20 weeks) with problematic IHs who required systemic therapy.

Design, Setting, and Participants

This was a prospective, multicenter, randomized, controlled, open-label clinical trial conducted in collaboration among 6 separate investigation sites in China from February 1, 2015, to December 31, 2018. A total of 377 patients met the criteria for inclusion and were randomized to the propranolol (190 [50.4%]) and atenolol (187 [49.6%]) groups. Data were analyzed in June 2020.

Interventions

Participants were randomized to receive either propranolol or atenolol for at least 6 months. They completed efficacy assessments at 2 years after the initial treatment.

Main Outcomes and Measures

The primary outcome was any response or nonresponse at 6 months. The key secondary outcome was changes in the hemangioma activity score.

Results

Of 377 participants, 287 (76.1%) were female, and the mean (SD) age was 10.2 (4.0) weeks in the propranolol group and 9.8 (4.1) weeks in the atenolol group. After 6 months of treatment, in the propranolol and atenolol groups, the overall response rates were 93.7% and 92.5%, respectively (difference, 1.2%; 95% CI, -4.1% to 6.6%). At 1 and 4 weeks after treatment, and thereafter, the hemangioma activity score in the atenolol group aligned with the propranolol group (odds ratio, 1.034; 95% CI, 0.886-1.206). No differences between the propranolol group and atenolol group were observed in successful initial responses, quality of life scores, complete ulceration healing times, or the rebound rate. Both groups presented a similar percentage of complete/nearly complete responses at 2 years (82.1% vs 79.7%; difference, 2.4%; 95% CI, -5.9% to 10.7%). Adverse events were more common in the propranolol group (70.0% vs 44.4%; difference, 25.6%; 95% CI, 15.7%-34.8%), but the frequency of severe adverse events did not differ meaningfully between the groups.

Conclusions and Relevance

In this randomized clinical trial, when compared with propranolol, atenolol had similar efficacy and fewer adverse events in the treatment of infants with problematic IHs. The results suggest that oral atenolol can be used as an alternative treatment option for patients with IH who require systemic therapy.

Trial Registration

ClinicalTrial.gov Identifier: NCT02342275.

Clinical Application of High-frequency Ultrasound in Treatment of Infantile Hemangiomas

OBJECTIVE

To study the clinical application of high-frequency ultrasound in the treatment of infantile hemangiomas.

METHODS

Ultrasonographic data before and after treatment for 1 month, 3 months and 5 months were recorded from 80 patients with infantile hemangioma. The hemangioma was monitored dynamically with relevant indexes before and after treatment, and the treatment results were divided into 2 groups: the treatment-effective group of 70 cases and the treatment-ineffective group of 10 cases. The differences of tumor size, internal echo and hemodynamic parameters (peak arterial systolic flow velocity, resistance index and venous velocity) were compared before and after treatment, and reliable ultrasound observation indexes were summarized.

RESULTS

After treatment, in the treatment-effective group, the thickness of tumor was reduced in all cases, the blood flow signals decreased in 55 cases, the peak systolic velocity decreased in 55 cases, resistance index increased in 55 cases, and venous flow velocity decreased in 53 cases; the differences were statistically significant compared with those before treatment (P < 0.05). The thickness of tumors was significantly decreased after 5 months of treatment compared with 1 month and 2 month treatment (P < 0.05). There was no significant difference in the longitudinal and transverse diameter of tumors after treatment (P > 0.05). In the treatment-ineffective group, there was no significant difference in the above indexes before and after treatment (P > 0.05).

CONCLUSION

High-frequency ultrasound had primary application value in the treatment of infantile hemangiomas, where the change of tumor thickness provided the most important observational indicator.

Anti-Angiogenic Therapy: Current Challenges and Future Perspectives

Anti-angiogenic therapy is an old method to fight cancer that aims to abolish the nutrient and oxygen supply to the tumor cells through the decrease of the vascular network and the avoidance of new blood vessels formation. Most of the anti-angiogenic agents approved for cancer treatment rely on targeting vascular endothelial growth factor (VEGF) actions, as VEGF signaling is considered the main angiogenesis promotor. In addition to the control of angiogenesis, these drugs can potentiate immune therapy as VEGF also exhibits immunosuppressive functions. Despite the mechanistic rational that strongly supports the benefit of drugs to stop cancer progression, they revealed to be insufficient in most cases. We hypothesize that the rehabilitation of old drugs that interfere with mechanisms of angiogenesis related to tumor microenvironment might represent a promising strategy. In this review, we deepened research on the molecular mechanisms underlying anti-angiogenic strategies and their failure and went further into the alternative mechanisms that impact angiogenesis. We concluded that the combinatory targeting of alternative effectors of angiogenic pathways might be a putative solution for anti-angiogenic therapies.

Morphological, genetic and clinical correlations in infantile hemangiomas and their mimics

Infantile hemangiomas (IHs) are the most frequent pediatric benign vascular tumors, with a reported incidence of 5% to 10%. They have self-limiting evolution pattern divided into a growth phase in the first 12 months and a regression one, that may take up to 10 years. Occasionally, hemangiomas might lead to local or systemic complications, depending on their morphological characteristics. The first line of treatment is β-blockers, such as Propranolol, Timolol, Nadolol, administered either locally or systemically. Newer therapeutic strategies involving laser therapy and angiotensin-converting enzyme inhibitors are being studied, while older treatment modalities like corticosteroids, Imiquimod, Vincristine, Bleomycin and Interferon-α have become second line therapy options. Before establishing the appropriate treatment, clinical, histological, and imaging investigations are required.

Propranolol for infantile hemangioma: Evaluating efficacy and predictors of response and rebound growth

Propranolol emerged as the first-line therapy for infantile hemangioma (IH). Determinants of interindividual variation in drug response and predictors of rebound growth after drug discontinuation are yet to be firmly established. We aimed to evaluate the outcomes of a relatively large cohort of patients with IH treated by propranolol and to determine predictors of (a) an excellent response to treatment (≥90 improvement) and (b) of rebound growth after drug cessation. A retrospective cohort study was conducted to follow all patients with IH receiving systemic propranolol in a referral center-based specialized clinic. Multivariate logistic regression analysis was performed to identify predictors of excellent response and rebound growth. The study included 206 patients who completed oral propranolol treatment. The mean (SD) age in which the drug was initiated was 4.8 (3.1) months. The average improvement rate was estimated at 85.5 (13.8)%. Initiation of propranolol at the age of 0 to 3 (adjusted odds ratio [OR], 3.43; 95% confidence interval [CI], 1.25-9.40; P = .016) and 3 to 6 (adjusted OR, 3.71; 95% CI, 1.50-9.19; P = .005) months was associated with an increased likelihood of excellent response. Twenty-four (11.7%) patients developed rebound growth following cessation of propranolol. No significant predictors of rebound were identified in the multivariate analysis. Eleven (5.3%) patients experienced mild adverse events, which necessitated drug discontinuation in only two (1.0%) patients. Propranolol is highly effective and safe based on the real-life experience of a referral center for IH. The current study supports early initiation of propranolol.

Oral propranolol therapy in parotid hemangiomas: A retrospective comparison with other infantile hemangiomas

BACKGROUND

The outcomes of propranolol treatment remain controversial for parotid hemangiomas, which may be inferior to outcomes for infantile hemangiomas (IHs) at other sites.

METHODS

Patients with IHs treated with oral propranolol were retrospectively reviewed. Outcomes of propranolol therapy for parotid hemangiomas and other IHs were examined. Regression models were conducted to analyze the factors associated with the outcomes for parotid hemangiomas.

RESULTS

Longer treatment duration was needed for parotid hemangiomas (p = 0.012) at a comparable efficacy and relapse rate as those of IHs at other sites. The higher efficacy was associated with early intervention before 4 months of age (OR = 5.2, p = 0.011), while, the lower relapse rate was associated with adequate treatment duration over 6 months (OR = 9.2, p = 0.010).

CONCLUSIONS

With a longer propranolol treatment duration, parotid hemangiomas could achieve a comparable efficacy and relapse rate as other IHs. Early treatment initiation and adequate treatment duration benefited the outcomes.

Oral atenolol treatment for infantile hemangiomas: clinical analysis of 133 consecutive patients

Background

Infantile hemangiomas (IHs) are the most frequently occurring pediatric lesions. Oral propranolol has been shown to be safe and effective in infants with IHs. Side effects such as sleep disturbances have been associated with propranolol. Atenolol is a hydrophilic, selective β1-blocker and therefore may be not associated with side effects attributable to β2-adrenergic receptor blockade and lipophilicity. However, the efficacy of atenolol in the treatment of IHs is poorly understood. The aim of this study was to evaluate the efficacy of atenolol in the treatment of proliferating IHs in a clinical cohort including 133 consecutive patients.

Methods

In this study, we enrolled 133 patients diagnosed as proliferating IHs from the routine clinical and referral practices of the authors. The procedures followed were in accordance with the ethical standards of the Institute Review Board of Shanghai Ninth People's Hospital and Helsinki Declaration. Clinical characteristics, including demographic data and clinical morphology, were collated. Responses to oral atenolol therapy were graded as: excellent, good, fair and poor. According to the reaction to atenolol treatment, additional medications or therapy were used for IH patients to achieve satisfactory clinical results.

Results

In this study, 128 (96.2%) of 133 IH patients responded to oral atenolol, and the response rate (RR) was significantly different for different ages of patients (P<0.05), with the youngest patients having the highest RR. The mean time of treatment was 4.9 months. Forty-one patients who exhibited residual hyperpigmentation or telangiectasia were further treated with timolol maleate cream (n=32) or pulsed dye laser (n=9). All the 41 patients showed positive response. No life-threatening complications were noted during and after oral atenolol. Only 4 (3.0%) of 133 patients developed minor complications including diarrhea. No agitation and bronchospasm were noted in our study.

Conclusions

This study demonstrated that atenolol was effective in the treatment of IHs. Compared to propranolol, atenolol seems to have a similar effect on IHs. Furthermore, atenolol seems to be less frequently associated with potentially life-threatening side effects.

A new clinical and dermoscopic monitoring of infantile hemangiomas treated with oral propranolol

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

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.

CircAP2A2 acts as a ceRNA to participate in infantile hemangiomas progression by sponging miR-382-5p via regulating the expression of VEGFA

Background

Increasing evidences reveal that circular RNAs (circRNAs) play crucial functions in cancer development. However, the expression pattern and roles of circRNAs in infantile hemangiomas (IH) remain unclear.

Methods

In this study, qRT‐PCR was performed to determine the expression of circAP2A2, miR‐382‐5p, and VEGFA in IH tissues and cell lines. Moreover, MTT assay, colony formation, transwell assay, and Western blot analysis were conducted to assess the function of circAP2A2 or miR‐382‐5p on cell proliferation, and migration in vitro, respectively. Also, dual luciferase assay was used to confirm the interactions among circAP2A2, miR‐382‐5p, and VEGFA.

Results

CircAP2A2 was confirmed to be highly expressed in IH. CircAP2A2 knockdown or miR‐382‐5p overexpression decreased the proliferation, colony formation, migration, and invasion of HemECs and HUVEC cells.

Conclusion

CircAP2A2 could promote proliferation and invasion of IH by regulating miR‐382‐5p/VEGFA axis.

Oral propranolol for the treatment of infantile haemangiomas in Singapore

INTRODUCTION

Infantile haemangiomas (IH) are the most common vascular tumours in childhood. Over the past decade, treatment of IH has been revolutionised by the discovery of the effectiveness of beta-blockers in its treatment. We review our hospital's experience with oral propranolol in the treatment of IH in an Asian population.

METHODS

We performed a retrospective review of the medical records and clinical photos of paediatric patients with IH treated with propranolol in a tertiary paediatric hospital in Singapore from January 2010 to February 2015.

RESULTS

A total of 88 patients with IH treated with propranolol were identified over a five-year period, with 79 patients included in the final analysis. There was a predominance of female patients (75.9%) and preterm infants (41.8%) in our study population. The head and neck (65.8%), especially the orbital or preorbital region (45.6%), were the most common lesion sites in our cohort of patients. Mean age of onset was 2.3 ± 4.5 weeks of age, and mean age of starting propranolol treatment was 7.7 ± 10.5 weeks of age. 44.3% of patients experienced > 75% improvement, while 29.1% experienced improvement of 50%-75%. Response to treatment was influenced by the age of starting treatment.

CONCLUSION

Our study provides further evidence of the efficacy and safety of propranolol in the treatment of IH in an Asian population. Early treatment is recommended for optimal results.

Success in the use of oral propranolol in the treatment of infantile hemangioma in nasal tip - Report of two cases

Infantile hemangioma is the most common pediatric vascular tumor, with the following risk factors: low birth weight, prematurity, white skin, female gender, multiparity and advanced maternal age. The use of oral and topical beta-blockers, although recent, has emerged as the first line of treatment, with superior safety and efficacy to previously used therapies, such as corticosteroids and surgeries. This report describes two cases of nasal tip infantile hemangioma, treated with oral propranolol. Both presented excellent therapeutic responses.

Cutaneous ultrasound and its utility in Pediatric Dermatology: Part II-Developmental anomalies and vascular lesions

High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a noninvasive and harmless diagnostic technique that is especially appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and aids our understanding of cutaneous pathology. In this second part, we describe the ultrasonographic findings of developmental anomalies and vascular lesions.

Residual Lesions After Pharmacological and Dye-Laser Treatment of Infantile Hemangiomas: Critical Review of 432 Cases

BACKGROUND AND OBJECTIVES

Infantile hemangiomas (IHs) are the most common benign tumors in infanthood. Although they are often self-limiting, management of IHs is still controversial because residual lesions may persist in some cases. The aim of this study is to report our experience with patients affected with IH and investigate the frequency of residual lesions in treated versus untreated patients.

STUDY DESIGN/MATERIALS AND METHODS

This retrospective observational study enrolled patients with IHs evaluated over the past 10 years. Patients were managed with systemic or local pharmacotherapy, laser therapy, a combination of them, or with observation only.

RESULTS

A total of 432 patients were included: 71% received one or more therapies for IHs; 75.2% of untreated patients had at least one residual lesion compared with 41.4% of treated patients (P < 0.001). Patients treated with laser therapy or topical timolol had the lowest rate of residual lesions.

CONCLUSIONS

This rather large case series suggests that IHs management with pharmacotherapy and especially laser therapy is associated with a lower number of residual lesions than observation only. Although propranolol can be very useful to avoid life-threatening complications and severe tissue impairment, laser therapy and topical timolol are potential effective treatments to decrease the incidence of residual lesions, mostly associated with superficial IHs. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Taste masking of propranolol hydrochloride by microbeads of EUDRAGIT® E PO obtained with prilling technique for paediatric oral administration

The purpose of this study was to develop a new solid paediatric formulation for propranolol hydrochloride (PR). This drug is used to treat various paediatric diseases, and recently received clearance to treat haemangioma. However, PR has a bitter salty taste that does not facilitate high rates of compliance among children, especially in liquid formulations. In addition, the solid formulations are designed for adults and often their dosage is not suitable for children that require a flexible dose based on their weight. Therefore, matrix microbeads of EUDRAGIT® E PO containing PR were manufactured to overcome these limitations. Nine different samples were prepared using the prilling-congealing technique with high yield. Using 2 nozzles, 300 and 450 μm (code n), the diameters obtained of microbeads (from 333 to 699 μm) were homogenous and appropriate to be swallowed by children. In this study, the ratio drug:matrix for the microbeads was also examined in detail: 1:25 (F₁), 1:15 (F₂) and 1:10 (F₃) in aqueous and tert-butyl alcohol/aqueous (code t) media. Most of the examined microbeads were characterized by high percentage of encapsulation efficiency (22-100%) and drug loading (22-77 mg of drug per g of matrix) effective for the administration of low and high doses of PR. SEM analysis revealed a matrix with a radial or a spongy structure, with numerous pores that generated soft floating microbeads in aqueous solution. Release studies confirmed a low release and dissolution of the drug in artificial saliva, mainly F_1n > F₁ > F_2nt, and a prompt dissolution in simulated gastric media. Finally, electronic tongue measurements revealed the ability of these formulations to mask the bitter drug taste, especially for the sample with a ratio 1:25 (F_1n and F₁). These samples were chemically and physically stable for six months. In conclusion, the projected microbeads F₁, and F_1n reached the goal of the study, and could be proposed as new solid oral formulations dedicated to use by children.

Surgical Intervention of Periocular Infantile Hemangiomas in the Era of β-Blockers

PURPOSE

To examine the role of adjuvant surgical resection of infantile hemangiomas after systemic β-blocker therapy.

METHODS

This is a multicentered retrospective study. Standard protocol for oral propranolol was employed by the referring physicians. Ocular indications for surgery included ptosis obstructing the visual axis, high degrees of astigmatism causing amblyopia, or disfigurement from residual tumor. Patients underwent complete excision or debulking.

RESULTS

Eleven girls and 4 boys were surgically treated with mean operative age of 34.4 months. Patients were followed for a mean of 19.6 months after surgery. Four patients required surgical treatment due to an inability to tolerate medical therapy secondary to drug-related side effects (including bradycardia). The other 11 patients proceeded to surgery due to residual eyelid and orbital lesions despite medical treatment. All 15 patients underwent orbitotomy for residual hemangioma excision. Four patients also underwent simultaneous levator advancement at the time of excision. In all cases, there was resolution of ptosis with clearing of the visual axis. No complications were incurred during the surgical treatment and there were no hemangioma recurrences.

CONCLUSIONS

This is the first study to report surgical management of periocular infantile hemangiomas recalcitrant to standard therapy in the β-blocker era. In patients with infantile hemangioma who have failed medical therapy, adjuvant surgical treatment still plays an important role. For patients with persistent tumor causing ocular sequelae, surgical intervention aimed at soft tissue debulking and ptosis repair can be successful in achieving excellent functional and aesthetic outcomes with minimal side effects.For patients with periocular infantile hemangiomas with residual soft tissue deformity following propranolol therapy, surgical treatment plays an important role in improving functional and cosmetic outcomes with minimal side effects.

To compare intralesional and oral propranolol for treating periorbital and eyelid capillary hemangiomas

Purpose:

A pilot randomized control trial to compare the efficacy and side effects of intralesional and oral propranolol in periorbital and eyelid capillary hemangiomas.

Methods:

Twenty patients were prospectively randomized to two groups of ten each. Group 1 was initiated on oral propranolol 1 mg/kg/day titrated to final dose of 3 mg/kg/day over 1 week which was continued for 6 months and then tapered over 1 week; Group 2 received 3 doses of direct intralesional propranolol hydrochloride 1 mg/ml; 0.2 ml/cm 4–6 weeks apart. Hemangioma area and corneal astigmatism were measured.

Results:

Within each group at 6 months there was a significant reduction in area (group 1: 83.48 ± 11.67%, P = 0.0019; group 2: 67.78 ± 21.71%, P = 0.0019) and improvement in astigmatism (pre, post: group 1: 2.98D @ 179.8°, 1.13D @ 179.8°, P = 0.0045; group 2: 1.62D @ 90.16°, 0.75D @ 179.9°, P = 0.0001). There was no difference in area reduction (P = 0.056), change in appearance (P = 0.085), ptosis (P = 0.23) and side effects (lethargy, poor feeding; P = 0.171) between the two groups.

Conclusion:

Efficacy and side effects with intralesional propranolol are comparable to oral propranolol for periorbital and eyelid lesions.

Management of Head and Neck Hemangiomas in Adults: Oral Propranolol Versus Oral Itraconazole in Conjugation with Injection Sodium Tetra Decyl Sulphate

Management of head and neck hemangiomas with oral propranolol versus oral itraconazole in conjugation with injection sodium tetra decyl sulphate. This prospective parallel clinical trial was done to check for the effectiveness of oral propranolol and oral itraconazole when used in conjugation with inj. sodium tetra decyl sulphate in treatment of head and neck haemangiomas in adult patients visiting department of ENT and head and neck surgery, VIMSAR, Burla. All the patients visiting the department with hemangioma (diagnosed clinically and by FNAC) were considered and only those who gave written informed consent and were according to our inclusion and exclusion criteria were included into the study as subjects. Dimension (length, width and hemi-circumference) of the haemangiomas were measured using disposable paper taper measures. Depth of the hemangioma was calculated based on formula and using that volume was calculated both at baseline and after 8 weeks of drug administration. Data so collected was entered into Microsoft Office Excel 2013 and statistical analysis was performed using SPSS Version 20.0. Descriptive statistics was calculated and student's t test (paired and unpaired) was used to compare within the group (before and after) and between the groups respectively. Statistical significance was set at p ≤ 0.05. Both the groups showed statistically significant volume reduction in the lesions [p < 0.018 (propranolo + sodium tetra decyl sulphate), p < 0.025 (itraconazole + sodium tetra decyl sulphate)]. The mean decrease in volume in propranolol group was 91.92% and that in itraconazole group was 88.97%. There was no statistical difference between the final outcome of both the groups (p < 0.766) but 3 patients on propranolol had complete resolution while 1 patient on itraconazole had complete resolution of the lesion. Oral propranolol and itraconazole are both effective and safe in hemangioma in adults. The combination with inj. sodium tetra decyl sulphate has a (1) favorable impact on decreasing the overall duration of treatment. (2) Aiding in complete resolution of lesions (especially < 3 cm). Propranolol has an edge over itraconazole (more no of tumors had complete resolution).

Lip Infantile Hemangiomas Involving the Vermillion Border Have Worse Outcomes and Prognosis to Oral Propranolol Than Lesions Confined to One Side of the Vermillion

PURPOSE

Oral propranolol has been widely used for problematic infantile hemangiomas (IHs). Lip IHs present a high risk of disfigurement and associated psychosocial dysfunction and require early treatment. Lips are compound parts that consist of the upper and lower lips and include the mucosal and cutaneous lips histologically. The present retrospective study aimed to determine the response and prognosis of different subtypes of lip IHs to the use of systemic propranolol.

PATIENTS AND METHODS

The data from 81 patients with lip IHs treated with systemic propranolol (2 mg/kg/day) were reviewed. Localized and segmental lip IHs were evaluated separately. The outcomes and prognosis of localized hemangiomas were further evaluated stratified by different features: 1) upper and lower lip; and 2) crossing the vermilion border.

RESULTS

The lesions involving the upper lips and those involving the lower lips had the same outcomes and prognosis. Lesions involving the vermillion border required longer treatment and had poorer outcomes and prognosis compared with lesions confined to 1 side of the vermilion.

CONCLUSIONS

After oral propranolol treatment, IHs localized to upper lip had the same outcomes and prognosis as IHs localized to the lower lip. Lip IHs involving the vermillion border had worse outcomes and prognosis than lesions confined to 1 side of the vermillion.

Anorectal malformations and perineal hemangiomas: The Arm-Net Consortium experience

AIM

Perineal hemangiomas rarely occur in patients with anorectal malformations (ARMs), but they can pose a significant challenge and warrant special attention. Surgical incision of posterior sagittal anorectoplasty (PSARP) may involve the hemangioma site resulting in hemorrhage, damage to blood supply, leading to complications and adversely affecting outcome. The aim of this study was to review the experience of the ARM-Net Consortium in the management of perineal hemangioma associated with ARM and evaluate treatment strategies.

MATERIALS AND METHODS

Data on all patients with ARM and a perineal hemangioma located in the planes of the PSARP dissection who were managed at participating ARM-Net centers were collected retrospectively by questionnaire, as follows: ARM type, hemangioma distribution and penetration, imaging findings, medical/surgical management, timing of definitive repair, complications and outcome.

RESULTS

Ten patients from eight centers were included. Three patients each had a rectobulbar or rectovestibular fistula, 2 had a rectoperineal fistula, and one had a rectoprostatic fistula; in one patient, the hemangioma was too disfiguring to determine malformation type. Mean follow-up time was 36.6 months (median 29 months). Colostomies were performed before definitive repair in 8 patients. Five patients received systemic beta-blockers before PSARP: 3 were operated uneventfully following partial/complete involution of the hemangioma, and 2 are awaiting surgery. The two patients with rectoperineal fistula were managed expectantly. The remaining 3 patients underwent surgery with no preoperative medical treatment, and all had complications: mislocated neoanus in three and complete perineal dehiscence in one.

CONCLUSION

Attempting PSARP in the presence of a perineal hemangioma may lead to complications and adversely affect outcome. This study confirms the benefits of beta blocker treatment before surgical reconstruction.

LEVEL OF EVIDENCE

Treatment study, level III.

Infantile hemangioma: Efficacy of low-dose propranolol and of intralesional bleomycin injection for propranolol non-response

BACKGROUND

Infantile hemangioma (IH) is the most common form of benign childhood vascular tumor. Most resolve spontaneously, but treatment is recommended in patients who develop complication. Propranolol is recommended as the first-line therapy, while the treatment in the case of non-response to first-line therapy depends on the clinical experiences of each center. The aim of this study was to investigate the efficacy of low-dose propranolol in the treatment of IH, and the outcomes of percutaneous intralesional bleomycin injection (IBI) in patients unresponsive to propranolol.

METHODS

Medical records of 104 children diagnosed with IH between June 2014 and June 2017 were reviewed retrospectively.

RESULTS

Median patient age was 6 months (range, 3-12 months). Forty-five patients (43.3%) received therapy: 18 (40%) for cosmetic problems and 27 (60%) for lesion-related complications. The most common complications were hemorrhage (15.6%) and impairment in visual function (15.6%). All of the patients received propranolol 1 mg/kg/day as the first-line therapy. Response to treatment was excellent in 35 patients, good in four and poor in one, while five patients did not respond to therapy. The five unresponsive patients received percutaneous IBI at 0.3-0.5 mg/kg/dose as second-line therapy. The response to treatment was excellent in four patients, good in one.

CONCLUSIONS

The majority of IH resolved spontaneously. In the patients who required treatment, low-dose propranolol was successful in most, and IBI was effective and safe in the remaining five patients who did not respond to propranolol.

Surgical resection of infantile hemangiomas following medical treatment with propranolol versus corticosteroids

PURPOSE

There has been a paradigm shift from corticosteroid to propranolol treatment for infantile hemangiomas (IHs), with surgical resection reserved for complicated or persistent IHs. The purpose of this study was to determine if propranolol treatment was associated with decreased utilization of surgical resection compared to corticosteroids.

METHODS

A single center retrospective chart review of all corticosteroid or propranolol treated IHs between 2005 and 2014 was performed. Demographic and clinical data were collected. Both univariate and multivariate analyses were performed with the primary outcome of requiring surgical intervention.

RESULTS

Of 652 patients with IH, 52 were treated with oral corticosteroids and 195 with propranolol only. Surgical intervention was required in 14 (27%) of steroid patients vs 18 (9%) of propranolol patients (p < .001). On multivariable analysis patients treated with steroids had 3.3 the odds of requiring surgery when compared to propranolol patients (p = .001). Prematurity (<37 weeks) was also associated with increased odds of surgery (OR = 2.8, p = .003).

CONCLUSION

Patients treated with propranolol required significantly fewer surgical interventions than those treated with corticosteroids suggesting a more efficacious treatment paradigm. Prematurity increases the need for surgical intervention regardless of the modality of medical treatment.

LEVEL OF EVIDENCE

Level III, treatment study.

Clinical and radiological outcomes of infantile hemangioma treated with oral propranolol: A long-term follow-up study

Infantile hemangiomas (IH) undergo rapid growth during early infancy followed by gradual involution. After involution, a part of IH remain as residual lesions. Since 2008, oral propranolol has been widely used in the treatment of IH. However, long-term outcome of IH treated with propranolol remains unknown. This study aimed to investigate the sequelae of IH treated with propranolol. In this study, propranolol was given at a dose of 2 mg/kg per day at the age of 3.8 ± 2.5 months and follow-up visits were arranged to continue at least through the age of 4 years. Types of sequela were recorded and classified as four degrees ("none", "minimal", "significant" and "severe" at last visit), then subsequent therapy was evaluated with the help of magnetic resonance imaging (MRI). A total of 73 patients with complete follow up were enrolled in the study. The most common types of sequela were telangiectasia, fibrofatty tissue and erythema. Significant and severe sequelae were observed in 72.4% of treated IH; superficial IH led to more but not significantly significant and severe sequelae than mixed IH (P > 0.05). Despite propranolol treatment, surgery was still needed in 37.5% of IH at a mean age of 70.3 months, and for the main reason of surgery, fibrofatty or hemangioma residua, MRI was useful for us to choose an appropriate surgical procedure.

Clinical and Ultrasonographic Evaluation of Infantile Periocular Hemangioma Treated With Oral Propranolol

PURPOSE

To evaluate the clinical and ultrasonographic response of periocular infantile capillary hemangioma during treatment with oral propranolol.

METHODS

Patients with infantile periocular hemangioma and visual or cosmetic concerns were enrolled in this prospective interventional case series. Propranolol was given at a dose of 2 mg/kg per day for at least 6 months. Evaluation of treatment response was performed at month 3 (time point 1) and month 6 (time point 2). Gray scale ultrasonography and color Doppler imaging were performed at baseline and month 3.

RESULTS

Thirty-one patients with mean age of 4.1 ± 2.3 months were eligible for analysis. Complete or near complete clinical resolution was observed in 4 patients (12.9%) at time point 1 and 21 patients (67.7%) at time point 2. Longitudinal diameter, transverse diameter, thickness, arterial peak systolic velocity, and end diastolic velocity reduced significantly from baseline to 3-month follow up. Complete clinical response at time point 2 was significantly higher in patients with peak systolic velocity reduction >50% from baseline to month 3 than patients with peak systolic velocity reduction of 10% to 50% and <10%.

CONCLUSIONS

Propranolol is safe and effective for infantile periocular hemangioma. Ultrasonography and color Doppler imaging are useful modalities to monitor and predict the treatment response.

Current treatment and management of infantile hemangiomas

Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.

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.