Efficacy and safety of propranolol in the treatment of parotid hemangioma

Propranolol for infantile hepatic hemangioendothelioma: Clinical evaluation of drug efficacy and safety using a single-center patient cohort

INTRODUCTION AND OBJECTIVES

Infantile hepatic hemangioendothelioma (IHHE) is a benign liver tumor, associated with hypothyroidism and vascular malformations along the skin, brain, digestive tract and other organs. Here, we determined a single-center patient cohort by evaluating the effectiveness and safety of propranolol and sirolimus for the treatment of IHHE.

PATIENTS AND METHODS

We performed a monocentric and observational study, based on clinical data obtained from 20 cases of IHHE treated with oral propranolol and sirolimus at the Shanghai Children's Medical Center (SCMC), between December 2017 and April 2019. All cases were confirmed by abdominal enhanced CT examination (18/20, 90%) and sustained decrease of alpha fetoprotein (AFP) (2/20, 10%). Propranolol treatment was standardized as once a day at 1.0mg/kg for patients younger than 2 months, and twice a day at 1.0mg/kg (per dose) for patients older than 2 months. Sirolimus was used to treat refractory IHHE patients after 6 months of propranolol treatment, and initial dosing was at 0.8mg/m² body surface per dose, administered every 12h. Upon treatment, abdominal ultrasound scanning was regularly performed to evaluate any therapeutic effects. All children were followed up for 6-22 months (mean value of 12.75 months). The clinical manifestations and therapeutic effects, including complications during drug management, were reviewed after periodic follow-up.

RESULTS

The effective rate of propranolol for the treatment of children with IHHE was 85% (17/20). In most cases, the AFP levels gradually decreased into the normal range. A complete response (CR) was achieved in 3 cases, partial response (PR) for 14 cases, progressive disease (PD) for 2 cases and stable disease (SD) was only detected once. Lesions decreased in two PD patients after administration of oral sirolimus. No serious adverse reactions were observed.

CONCLUSION

This study indicates that both propranolol and sirolimus were effective drugs for the treatment of children with IHHE at SCMC.

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.

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.

Medical, Surgical, and Wound Care Management of Ulcerated Infantile Hemangiomas: A Systematic Review [Formula: see text]

Ulcerated infantile hemangiomas may present a therapeutic challenge, especially if there is concurrent hemorrhage or infection. The aim of this study was to systematically review the published evidence on the treatment of ulcerated hemangiomas, focusing on wound healing as the outcome of interest. We searched MEDLINE, Embase, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science from inception to July 2016. Seventy-seven studies met our inclusion criteria. One study was a randomized controlled trial, 30 were observational studies, and 46 were case reports or case series. There is significant heterogeneity among the methods used. We reviewed 1239 patients in total. Of the 197 treated with oral propranolol, 191 (97.0%) achieved complete ulcer healing. Thirty-one patients failed corticosteroid therapy (oral, intralesional, or topical) and were subsequently successfully treated with other therapies. Surgical resections were typically performed for larger hemangiomas and those causing complications. None of the therapies discussed appear to offer significant advantages over others. Therefore, treatment decisions should be individualized based on location of disease, extent, symptoms, feasibility, cost, and parental preference.

Systematic Review of the Toxicity of Long-Course Oral Corticosteroids in Children

Background

Long courses of oral corticosteroids are commonly used in children in the management of chronic conditions. Various adverse drug reactions (ADRs) are known to occur with their use. This systematic review aimed to identify the most common and serious ADRs and to determine their relative risk levels.

Methods

A literature search of Embase, Medline, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions in order to identify studies where oral corticosteroids were administered to patients aged 28 days to 18 years of age for at least 15 days of treatment. Each database was searched from their earliest dates to January 2016. All studies providing clear information on ADRs were included.

Results

One hundred and one studies including 33 prospective cohort studies; 21 randomised controlled trials; 21 case series and 26 case reports met the inclusion criteria. These involved 6817 children and reported 4321 ADRs. The three ADRs experienced by the highest number of patients were weight gain, growth retardation and Cushingoid features with respective incidence rates of 21.1%, 18.1% and 19.4% of patients assessed for these ADRs. 21.5% of patients measured showed decreased bone density and 0.8% of patients showed osteoporosis. Biochemical HPA axis suppression was detected in 269 of 487 patients where it was measured. Infection was the most serious ADR, with twenty one deaths. Varicella zoster was the most frequent infection (9 deaths).

Conclusions

Weight gain, growth retardation and Cushingoid features were the most frequent ADRs seen when long-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR.

Treatment of infantile subglottic hemangioma with oral propranolol

Infantile subglottic hemangioma (SH) can cause biphasic stridor, respiratory distress and even life-threatening airway compromise. Treatment of SH in infants has traditionally been characterized as a challenging situation with multiple therapeutic options without consensus as to which one is the best and with risks of severe side-effects. Four infants with SH were treated with propranolol. Treatment with oral propranolol resulted in resolution of symptoms within 2 days, followed by complete recovery. Propranolol appears to be an effective treatment for SH and should be used as a first-line treatment for SH when intervention is required.

Targeting of beta adrenergic receptors results in therapeutic efficacy against models of hemangioendothelioma and angiosarcoma

Therapeutic targeting of the beta-adrenergic receptors has recently shown remarkable efficacy in the treatment of benign vascular tumors such as infantile hemangiomas. As infantile hemangiomas are reported to express high levels of beta adrenergic receptors, we examined the expression of these receptors on more aggressive vascular tumors such as hemangioendotheliomas and angiosarcomas, revealing beta 1, 2, and 3 receptors were indeed present and therefore aggressive vascular tumors may similarly show increased susceptibility to the inhibitory effects of beta blockade. Using a panel of hemangioendothelioma and angiosarcoma cell lines, we demonstrate that beta adrenergic inhibition blocks cell proliferation and induces apoptosis in a dose dependent manner. Beta blockade is selective for vascular tumor cells over normal endothelial cells and synergistically effective when combined with standard chemotherapeutic or cytotoxic agents. We demonstrate that inhibition of beta adrenergic signaling induces large scale changes in the global gene expression patterns of vascular tumors, including alterations in the expression of established cell cycle and apoptotic regulators. Using in vivo tumor models we demonstrate that beta blockade shows remarkable efficacy as a single agent in reducing the growth of angiosarcoma tumors. In summary, these experiments demonstrate the selective cytotoxicity and tumor suppressive ability of beta adrenergic inhibition on malignant vascular tumors and have laid the groundwork for a promising treatment of angiosarcomas in humans.

Renal and hepatic tumors in the neonatal period

Renal and hepatic tumors in neonates are extremely rare. Nevertheless it is important for clinicians to be familiar with them. Both renal and hepatic neonatal tumors are heterogeneous collections of several tumor types. Some renal and hepatic tumors are benign and may require no interventions whereas others can be associated with significant morbidity and even mortality and may require multimodality treatment. Early diagnosis and initiation of the proper treatment plan is crucial for achieving the best outcomes for these rare tumors in this vulnerable population.