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Huerta CT, Beres AL, Englum BR, Gonzalez K, Levene T, Wakeman D, Yousef Y, Gulack BC, Chang HL, Christison-Lagay ER, Ham PB, Mansfield SA, Kulaylat AN, Lucas DJ, Rentea RM, Pennell CP, Sulkowski JP, Russell KW, Ricca RL, Kelley-Quon LI, Tashiro J, Rialon KL. Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee. J Pediatr Surg 2024; 59:161589. [PMID: 38914511 DOI: 10.1016/j.jpedsurg.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | - Alana L Beres
- Division of Pediatric General and Thoracic Surgery, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine Gonzalez
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, University of Rochester, Rochester, NY, USA
| | - Yasmine Yousef
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, Hollywood, FL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Henry L Chang
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Phillip Benson Ham
- Division of Pediatric Surgery, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Sara A Mansfield
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Afif N Kulaylat
- Division on Pediatric Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rebecca M Rentea
- Division of Pediatric Surgery, Children's Mercy- Kansas City, Kansas City, MO, USA; Department of Surgery, University of Missouri- Kansas City, Kansas City, MO, USA
| | | | - Jason P Sulkowski
- Division of Pediatric Surgery, Children's Hospital of Richmond, Richmond, VA, USA
| | - Katie W Russell
- Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, USA
| | - Robert L Ricca
- Division of Pediatric Surgery, University of South Carolina, Greenville, SC, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Kristy L Rialon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
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Alqutub A, Baamir NJ, Mofti Z, Zawawi F, Al-Khatib T. Sclerotherapy vs. surgical excision for lymphatic malformations of the head and neck: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08793-9. [PMID: 38951201 DOI: 10.1007/s00405-024-08793-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 06/16/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES Lymphatic malformations (LMs) are abnormal lymphatic vessels with cystic characteristics, categorized as macrocystic, microcystic, or a combination of both. They represent the second most common vascular malformations, and their management involves multidisciplinary approaches based on clinical assessments and imaging studies. LMs manifest as a challenge to medical professionals in the head and neck, posing functional and aesthetic concerns. Our systematic review aims to compare the efficacy of sclerotherapy and surgery for LMs, identifying optimal treatment modalities for each scenario. METHODS We searched four electronic databases for related studies. Data were extracted from the included studies. We calculated the pooled rate ratios with 95% confidence intervals (CIs). The I2 test was used to detect heterogeneity. The inclusion of the studies required the following prerequisites: 1- Studies focusing on any lymphatic malformations in the head and neck, whether microcystic, macrocystic, or a mix of both; 2- Studies performed on more than ten patients; 3- All interventions used as surgery, sclerotherapy, or both. RESULTS We included 58 studies in our systematic review, of which 45 were eligible for the meta-analysis. For macrocystic LMs, sodium tetradecyl sulfate (STS) mixed with ethanol and excision achieved the highest complete response rates at (92.9%) and (92.5%), respectively. Surgical excision showed the lowest poor response rate. Polidocanol microfoam had the highest poor response rate (11.1%). In microcystic LMs, combining sclerotherapy with excision showed the highest complete response rate (70.3%) and the lowest poor response rate (1.3%). Picibanil had the lowest complete response rate (9.1%) and the highest rate of poor response (61.4%). In mixed LMs, surgical excision had the highest complete response rate (70.3%). CONCLUSION Both surgical excision and STS combined with ethanol are highly effective for treating macrocystic LMs, achieving similar complete response rates. The combination of sclerotherapy and surgical excision demonstrated the best outcomes in microcystic LMs. Surgical excision demonstrates superior efficacy over sclerotherapy for mixed LMs. These findings suggest that excision is generally more effective in achieving complete and excellent responses across all LM subtypes. Further high-quality studies are necessary to standardize and optimize treatment protocols.
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Affiliation(s)
- Abdulsalam Alqutub
- Department of Otolaryngology-Head and Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Noor J Baamir
- Department of Otolaryngology-Head and Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zainab Mofti
- Department of Family and Community Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Faisal Zawawi
- Department of Otolaryngology-Head and Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talal Al-Khatib
- Department of Otolaryngology-Head and Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
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Moreno-Alfonso JC, Triana P, Miguel Ferrero M, Díaz González M, López Gutiérrez JC. Risk factors for sequelae after surgery for lymphatic malformations in children. J Vasc Surg Venous Lymphat Disord 2024; 12:101730. [PMID: 38070670 DOI: 10.1016/j.jvsv.2023.101730] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/22/2023] [Accepted: 11/30/2023] [Indexed: 01/01/2024]
Abstract
OBJECTIVE The first-line treatment of lymphatic malformations (LMs) is pharmacological or interventional; however, surgery is still necessary in selected cases. Our aim was to identify factors associated with the occurrence of permanent postoperative complications. METHODS This was a case series study of children operated on for LMs between 2001 and 2021 and followed-up in our institution. Patients who presented sequelae derived from surgical treatment (cases) and those who did not (controls) were compared. RESULTS We included 112 children who underwent surgery for LMs in different centers. Forty-nine cases and 63 controls were included (58% male), with a mean age of 34 months. Patients younger than 1 year presented more complications than older children, 59% (n = 29/49) vs 41% (n = 24/49), respectively (P = .02). LMs were in the cervicofacial region in seven patients in the control group compared with 30 of the cases (P ≤ .001), with microcystic malformations the most associated with sequelae (n = 11/15; P = .019). Concerning permanent complications, 88% were neurological (n = 43/49), mainly peripheral facial palsy (n = 17). There was greater postoperative residual disease in controls compared with cases (65% vs 14%, respectively; P ≤ .0001). However, following a second procedure in the control group, there was no significant difference in long-term cure rates (P = .38). CONCLUSIONS The risk of sequelae following surgery for LM increases significantly in patients younger than 12 months in cervicofacial and microcystic malformations. Because non-radical resections are associated with fewer complications and an optimal long-term cure rate, we consider that aggressive surgical approaches should be avoided if the absence of sequelae is not guaranteed.
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Affiliation(s)
- Julio César Moreno-Alfonso
- Doctoral School, Universidad Pública de Navarra (UPNA), Campus de Arrosadia, Pamplona, Navarra, Spain; Department of Pediatric Surgery, Hospital Universitario de Navarra, Pamplona, Navarra, Spain.
| | - Paloma Triana
- Department of Pediatric Surgery, Division of Pediatric Plastic Surgery and Vascular Anomalies, Hospital Universitario La Paz, Madrid, Spain
| | - Miriam Miguel Ferrero
- Department of Pediatric Surgery, Division of Pediatric Plastic Surgery and Vascular Anomalies, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Díaz González
- Department of Pediatric Surgery, Division of Pediatric Plastic Surgery and Vascular Anomalies, Hospital Universitario La Paz, Madrid, Spain
| | - Juan Carlos López Gutiérrez
- Department of Pediatric Surgery, Division of Pediatric Plastic Surgery and Vascular Anomalies, Hospital Universitario La Paz, Madrid, Spain
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Lin SN, Wu YM, Siow TY, Yeh CH, Toh CH, Tseng TY, Wong HF. Sclerotherapy with intralesional bleomycin injection under guidance of multi-slice CT for retrobulbar orbital low-flow vascular lesions-single-center experience. Br J Radiol 2024; 97:186-194. [PMID: 38263834 PMCID: PMC11027304 DOI: 10.1093/bjr/tqad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/02/2023] [Accepted: 10/22/2023] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVE This study investigated the safety and efficacy of sclerotherapy with intralesional bleomycin injection (IBI) for retrobulbar orbital low-flow vascular lesions under multi-slice computed tomography (CT) guidance. METHODS Between January 2010 and September 2021, consecutive patients with retrobulbar orbital low-flow vascular lesions who underwent CT-guided IBI at a tertiary centre in Taiwan were enrolled. Their medical records and imaging data were retrospectively collected. RESULTS This study enrolled 13 patients (7 male and 6 female patients; age range: 1-57 years; mean age: 25.9 years) with lymphatic malformation (LM, n = 4), venolymphatic malformation (n = 1), and venous malformation (VM, n = 8). The overall radiological response rate was 76.9% (10 of 13); the radiological response rate was 75.0% in the VM group (6 of 8) and 75.0% in the LM group (3 of 4). Moreover, 3 patients (23.1%) had minor complications and 1 (7.7%) had a major complication. The mean clinical and radiological follow-up was 8.3 months and no recurrence or progression was reported. CONCLUSION CT-guided IBI is an effective and relatively safe minimally invasive treatment for retrobulbar orbital low-flow vascular lesions, with an overall radiological response rate of 76.9% in a mean of 1.5 sessions and a low complication rate. ADVANCES IN KNOWLEDGE CT-guided sclerotherapy with IBI is a relatively safe, effective, and feasible alternative treatment option for retrobulbar orbital low-flow vascular lesions.
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Affiliation(s)
- Shin-Nan Lin
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Yi-Ming Wu
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Tiing-Yee Siow
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Chih-Hua Yeh
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Cheng-Hong Toh
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Ti-Yung Tseng
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Ho-Fai Wong
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
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Sun J, Wang C, Li J, Song D, Guo L. The efficacy of bleomycin sclerotherapy in the treatment of lymphatic malformations: a review and meta-analysis. Braz J Otorhinolaryngol 2023; 89:101285. [PMID: 37423005 PMCID: PMC10344707 DOI: 10.1016/j.bjorl.2023.101285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE At present, bleomycin has been widely used in the treatment of Lymphatic Malformations (LMs). This study aims to perform a meta-analysis to investigate the effectiveness and influencing factors of bleomycin in the treatment of LMs. METHODS We conducted a systematic review and meta-analysis to clarify the relationship between bleomycin and LMs. PubMed, ISI Web of Science and MEDLINE were searched. RESULTS A total of 21 studies (including 428 cases) about bleomycin sclerotherapy for LMs were included in the current meta-analyses. We calculated pooled effective rate and 95% Confidence Interval (95% CI) using random effects model to evaluate the relations between bleomycin and LMs. The results suggested that the effective rate of bleomycin was the combined effective rate was 84.0% (95% CI 0.81‒0.87) and ranged from 39% (95% CI 0.22‒0.56) to 94% (95% CI 0.87-1.02). The heterogeneity among the studies was substantial (I2=61.7%, p= 0.000). In subgroup analyses, it was observed that among retrospective study and prospective study, the estimated effective rate was 80.0% (95% CI 0.76‒0.84) and 91.0% (95% CI 0.85‒0.97), respectively. In terms of the dosage, the combined effective rates of weight-based group and fixed-dose group were 86% (95% CI 0.83‒0.90) and 74.0% (95% CI 0.66‒0.82), respectively. There was no significant publication bias in Egger's test (p=0.059, 95% CI -3.81 to 0.082), but Begg's test did (p=0.023), and the funnel plot is asymmetric. CONCLUSION Our study suggested that bleomycin was safe and effective in the treatment of LMs and was primarily dose dependent.
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Affiliation(s)
- Jiali Sun
- Children's Hospital Affiliated to Shandong University, Department of Vascular anomalies and Interventional Radiology, Shandong, China
| | - Changfeng Wang
- Children's Hospital Affiliated to Shandong University, Department of Vascular anomalies and Interventional Radiology, Shandong, China
| | - Jing Li
- Children's Hospital Affiliated to Shandong University, Department of Vascular anomalies and Interventional Radiology, Shandong, China
| | - Dan Song
- Children's Hospital Affiliated to Shandong University, Department of Vascular anomalies and Interventional Radiology, Shandong, China; Jinan Children's Hospital, Department of Vascular Anomalies and Interventional Radiology, Jinan, China; Shandong Provincial Clinical Research Center for Children's Health and Disease, Shandong, China.
| | - Lei Guo
- Children's Hospital Affiliated to Shandong University, Department of Vascular anomalies and Interventional Radiology, Shandong, China.
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Poget M, Fresa M, El Ezzi O, Saliou G, Doan MT, de Buys Roessingh A. Lymphatic malformations in children: retrospective review of surgical and interventional management. Pediatr Surg Int 2022; 39:36. [PMID: 36469112 PMCID: PMC9722885 DOI: 10.1007/s00383-022-05320-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Lymphatic malformations (LMs) are classified as macrocystic, microcystic or mixed. Treatment depends on their characteristics: surgery, sclerotherapy, both combined, systemic treatment or observation. This study aims to analyze the surgical and interventional management of LMs in children over the last two decades in our university hospital. METHODS Management of children born with LMs between 2000 and 2019 was reviewed. Parameters collected were: malformation characteristics, type of treatment, symptoms, imaging, timing of diagnosis and first treatment, number of interventions, recovery rate, complications and length of stay. RESULTS Files of 48 children were reviewed: 27 with macrocystic and 21 with microcystic LMs. There was no statistically significant difference in type of treatment except for combined treatment, more performed in microcystic LMs (p = 0.04). Symptoms, imaging, timing of diagnosis and first treatment, number of interventions and complications were not statistically significant. Overall, the number of surgeries was lower than sclerotherapies (p = 0.04). Recovery rate after surgery was higher in macrocystic LMs (p = 0.01). Complications and length of stay were not statistically significant. CONCLUSION A good rate of recovery was observed when surgery was performed, with no significant increase in complications and length of stay. A prospective study will be determinant to create a decisional algorithm for children with LMs.
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Affiliation(s)
- Marion Poget
- Department of Pediatric, Children and Adolescent Surgery Service, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland
- Visceral Surgery Department, Neuchâtel Hospital, Rue de la Maladière 45, 2000, Neuchâtel, Switzerland
| | - Marco Fresa
- Department of Heart and Vascular Disease, Angiology Service, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland
| | - Oumama El Ezzi
- Department of Pediatric, Children and Adolescent Surgery Service, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Radiology, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland
| | - Marie-Thérèse Doan
- Department of Pediatric, Children and Adolescent Surgery Service, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland
| | - Anthony de Buys Roessingh
- Department of Pediatric, Children and Adolescent Surgery Service, Lausanne University Hospital (CHUV), Rue du Bugnon 21, 1011, Lausanne, Switzerland.
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Safety and Efficacy of Bleomycin Slow Infusion Sclerotherapy Using a Syringe Pump for Microcystic and Mixed Lymphatic Malformations. Cardiovasc Intervent Radiol 2022; 45:1288-1294. [PMID: 35864208 DOI: 10.1007/s00270-022-03224-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/05/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of bleomycin infusion sclerotherapy using a syringe pump in microcystic and mixed (microcystic components with the presence of a cyst over 1 cm) lymphatic malformations (LMs). MATERIALS AND METHODS Patients who received bleomycin sclerotherapy with a syringe pump for microcystic or mixed LMs were reviewed. Cystic components of LMs were accessed under sonographic guidance, followed by injection of an opacified bleomycin solution using a syringe pump (infusion rate, 10-20 mL/h) under fluoroscopic guidance. Imaging outcomes were graded as complete (> 90% size reduction), partial (25-90%), or no response (< 25%). Clinical outcomes and procedure-related complications were also reviewed. RESULTS Forty-nine patients with 81 sclerotherapies were analyzed. The mean age was 17 years (range 0.1-65 y). Thirty-one (63%) patients had microcystic LMs, and 18 (37%) had mixed. A mean of 1.7 sessions (range 1-4) of sclerotherapy was performed using a mean cumulative dose of bleomycin of 10.8 U (range 1.5-39 U). The mean infusion time was 39 min (range 14-130 min). Regarding imaging outcomes, there was a complete response in 29% (n = 14), a partial response in 57% (n = 28), and no response in 14% (n = 7). Regarding clinical outcomes, there was a complete response in 39% (n = 19), a partial response in 51% (n = 25), and no response in 10% (n = 5). According to the CIRSE classification, no major complications were identified. CONCLUSIONS Bleomycin slow infusion sclerotherapy provides gradual filling of sclerosant to target microcystic components. This technique is safe and feasible for the management of microcystic or mixed LMs. LEVEL OF EVIDENCE Level 4, Case series.
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Long term outcomes of transcutaneous non-image guided bleomycin sclerotherapy in orbital/adnexal lymphatic malformations: a protocol-based management in 69 eyes. Eye (Lond) 2022; 36:789-799. [PMID: 33879854 PMCID: PMC8956730 DOI: 10.1038/s41433-021-01527-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 02/09/2021] [Accepted: 03/31/2021] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To study the efficacy and the long-term outcomes of treating micro and macrocystic orbital and/or adnexal lymphatic malformations (OA-LM) with protocol-based bleomycin sclerotherapy. METHODS A retrospective interventional study of 69 eyes having OA-LM treated with non-image guided transcutaneous or transconjunctival bleomycin sclerotherapy (1IU/ml aqueous solution) between December 2014 and December 2018. Based on clinical regression, the outcomes were classified as excellent, good, fair and poor. RESULTS The mean age at presentation was 20 ± 16 years (median 16; range 1 month to 70 years). The orbital-palpebral variant was the most common presentation, seen in 29 patients (42%). Microcystic morphology was seen in 34(49%), macrocystic in 22 (32%) and mixed cyst in 13 (19%) patients. Mean units of bleomycin injected per patient were 9 ± 8 IU (median 5.5 IU, range 1-38 IU). Mean number of treatment sessions required were 2 ± 1 (median 2, range 1-6). The response was excellent in 43 (62%), good in 12 (17%), fair in 9 (13%) and poor in 5 (7%) patients. These responses were comparable across the morphological subgroups (p = 0.24, chi-square test). Adverse reactions noted were inflammation in 11 eyes (16%) and peri-ocular pigmentation in 15 (22%). There was a sustained tumour regression over a mean follow-up duration of 3.5 years (median 3; range 1.5-5 years). CONCLUSIONS Seventy-nine percent of eyes with OA-LM showed a good outcome with transcutaneous and/or transconjunctival non-image guided bleomycin sclerotherapy with no serious adverse events. The results were promising over long-term follow-up.
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Wang H, Xie C, Lin W, Zhou J, Yang W, Guo Z. Liposuction-Like Sclerotherapy Technique for Microcystic Lymphatic Malformation. Cureus 2022; 14:e22795. [PMID: 35291728 PMCID: PMC8896249 DOI: 10.7759/cureus.22795] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 11/09/2022] Open
Abstract
Background The treatment for microcystic lymphatic malformation (LM) remains challenging. We describe the liposuction-like sclerotherapy technique, a new treatment for extensive microcystic LM. Methods LM data was retrospectively reviewed. This study included patients with a microcystic LM component treated by liposuction-like technique with bleomycin sclerotherapy. Results Between June 2016 and October 2019, 39 consecutive patients (male/female ratio: 21:18; mean age, 33.6 months; range: 5 months to 15 years) with microcystic LM were treated by liposuction-like sclerotherapy (LS-LS) technique. Fifty-six sessions of LS-LS were performed (mean of 1.44 sessions per patient; range: one to four sessions). Follow-up ranged 6-30 months (mean of 21 months). We observed no major complications. Transient minor complications included: postoperative noninfectious fever, vomiting, temporary skin edema, pigmentation, mild local depressions, and/or irregularities, and a small hyperpigmented scar at the incision. No postoperative infection, skin ulcer, or necrosis occurred. The patients’ symptoms were successfully resolved or stable. A sub-complete response and partial response were observed for 26 (76%) and 13 patients (33%), respectively. Conclusion The LS-LS technique for microcystic LMs is safe, feasible, and effective. This technique is an effective intervention with which it is possible to manage and potentially cure microcystic LM clinically.
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Zhang YT, Zhang C, Wang Y, Chang J. Efficacy and safety of ultrasound-guided bleomycin combined with dexamethasone in the treatment of pediatric lymphangiomas. Front Pediatr 2022; 10:935470. [PMID: 35928682 PMCID: PMC9343682 DOI: 10.3389/fped.2022.935470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE This work aimed to report our experience with ultrasound-guided instillation for the treatment of lymphangiomas in children, so as to determine whether the combined use of bleomycin and dexamethasone achieved a higher response rate and a lower side effect rate. METHODS The medical records from patients with lymphangiomas between January 1st, 2013 and September 31st, 2020, were reviewed. Patients who received bleomycin combined with dexamethasone sclerotherapy were classified as the dexamethasone group, while those receiving bleomycin without dexamethasone were classified as the control group. RESULTS Altogether one hundred and twenty-seven patients were diagnosed with lymphangiomas. Among them, one hundred and five patients received bleomycin combined with dexamethasone injection, while the remaining twenty-two received bleomycin injection alone. The excellent rates were 89.52% [95% confidence interval (CI), 81.64-94.40%] in the dexamethasone group and 72.73% (95% CI, 52.51-92.94%) in the control group (p < 0.05). Additionally, the recurrence rates were 3.81% (95% CI, 1.22-10.03%) in the dexamethasone group and 13.64% (95% CI, 3.6-36.0%) in the control group (p > 0.05). After comparison between the two groups, the following risk factors were identified. These include >10 sacs at the initial stage of diagnosis, larger size after all injections, and response to the first injection. CONCLUSIONS Although there was no significant difference in the recurrence rate between the two groups, this retrospective study demonstrated that the excellent response rates were dramatically improved between the two groups, suggesting that bleomycin combined with DEX was an effective and highly safe treatment for all types of pediatric lymphangiomas. Moreover, this study also identified three novel features as the significant risk factors for recurrence.
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Affiliation(s)
- Yu-Tong Zhang
- Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, China
| | - Chao Zhang
- Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, China
| | - Yu Wang
- Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, China
| | - Jian Chang
- Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, China
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Sheng L, Yu Z, Li S, Cao W, Jiang Z. Bleomycin sclerotherapy for large diffuse microcystic lymphatic malformations. Gland Surg 2021; 10:1865-1873. [PMID: 34268071 DOI: 10.21037/gs-21-70] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/07/2021] [Indexed: 12/16/2022]
Abstract
Background Microcystic lymphatic malformations (LMs) are congenital lesions with the diameter of the majority of cysts <1 cm. Bleomycin sclerotherapy has been shown to yield beneficial results for macrocystic LMs. This study aims to evaluate the safety and efficacy of consecutive bleomycin sclerotherapy for large diffuse microcystic LMs. Methods The location and size of the lesions were detected by ultrasound for the 46 patients included in this study. Bleomycin lavage was performed in larger cysts and intradermal injection for the superficial lesion. The outcome and complications were assessed for its efficacy and safety. Results The large diffuse microcystic LMs mainly located in the neck, abdominal wall and axilla/lateral chest wall. The average lesion size was 10.6 cm × 7.2 cm. The mean number of treatment sessions was 4.5 with 7.3 mg bleomycin for per session averagely. Excellent (69.6%) and moderate (23.9%) responses were obtained. There was no recurrence for the 6 patients (13%) who received a long follow-up. Obvious local swelling, slight intralesional hemorrhage and low-grade fever were the most commonly occurred complications. No lung fibrosis was identified for the patients who received more than 6 sessions. Conclusions Local lavage combined with intradermal injection of bleomycin is effective and safe for large diffuse microcystic LMs with good therapeutic effect and low complication rates, and can be regarded as the mainstay of therapy for microcystic LMs.
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Affiliation(s)
- Lingling Sheng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ziyou Yu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shengli Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weigang Cao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaohua Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Rootman DB, Diniz SB, Cohen LM. Clinical Assessment and Lesion-Specific Management of Orbital Vascular Malformations. J Neurol Surg B Skull Base 2021; 82:116-128. [PMID: 33777625 DOI: 10.1055/s-0040-1722702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The systematic classification of vascular disease as proposed and refined by the International Society for the Study of Vascular Anomalies (ISSVA) divides vascular pathology first into tumors and malformations. Malformations are described as simple and complex, where simple malformations contain a single vascular system and complex malformations comprised of multiple vascular systems. Arteriovenous malformations are considered in terms of inflow characteristics which are primarily responsible for the key management challenges. Management utilizing endovascular embolization and/or surgical resection is often employed; however, recurrence can occur, particularly in diffuse cases. There may be an increasing role for systemic antiangiogenic therapy in such cases. Lymphaticovenous malformations are divided into the principle components on the lymphatic and venous sides for clarity of discussion. Lymphatic malformations are described morphologically as macrocystic and microcystic, and physiologically in terms of the processes responsible for growth. In both cases, surgical options are challenging and local therapeutics intended to close large luminal spaces in the case of macrocystic and to slow biological signaling for growth in microcystic. Venous malformations are described physiologically in terms of flow and distensibility, as volume plays a critical role in the limited space of the orbital cavity. Combined embolic-surgical approaches can be effective for management. More complicated, combined lesions can be managed by dividing the lesion into principal components and treating each appropriately.
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Affiliation(s)
- Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California, Los Angeles, United States
| | - Stefania B Diniz
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California, Los Angeles, United States
| | - Liza M Cohen
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California, Los Angeles, United States
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MRI for Response Assessment of Extensive Lymphatic Malformations in Children Treated With Sirolimus. AJR Am J Roentgenol 2021; 217:741-752. [PMID: 33405944 DOI: 10.2214/ajr.20.24378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND. Extensive lymphatic malformations (LMs) may cause substantial morbidity. The mammalian target of rapamycin (mTOR) inhibitor sirolimus shows promise for treating vascular anomalies, although response assessment is not standardized. OBJECTIVE. The purpose of this study was to retrospectively characterize changes seen on MRI of children with extensive LMs treated with sirolimus. METHODS. Twenty-five children treated with sirolimus for extensive LMs were included. Baseline MRI was defined as the MRI examination performed closest to therapy initiation; follow-up MRI was defined as the most recent MRI examination performed while the patient was receiving therapy. Two pediatric radiologists independently determined MRI lesion volume by tracing lesion contours on all slices (normalized to patient body surface area expressed in square meters) and determined signal by placing an ROI on the dominant portion of the lesions (normalized to CSF signal) on baseline and follow-up T2-weighted MRI sequences. Interreader agreement was determined, and values were averaged for further analysis. Volume and signal changes were compared with patient, lesion, and treatment characteristics. RESULTS. The mean (± SD) interval between initiation of sirolimus treatment and follow-up MRI was 22.1 ± 13.8 months. The mean lesion volume index on baseline and follow-up MRI was 728 ± 970 and 345 ± 501 mL/m2, respectively (p < .001). Ninety-two percent of children showed a decrease in lesion volume index that was greater than 10% (mean volume change, -46.4% ± 28.2%). Volume change was inversely correlated with age (r = -0.466; p = .02). The mean volume change was -64.7% ± 25.4% in children younger than 2 years old versus -32.0% ± 21.6% in children 2 years old or older (p = .008). The mean volume change was -58.1% ± 24.0% for craniocervical lesions versus -35.5% ± 28.2% for lesions involving the trunk and/or extremities (p = .03). Mean lesion signal ratio on baseline and follow-up MRI was 0.81 ± 0.29 and 0.59 ± 0.26, respectively (p < .001). Mean signal ratio change was -23.8% ± 22.7%. Volume and signal changes were moderately correlated (r = 0.469; p = .02). Volume and signal changes were not associated with sex, lesion subtype, serum concentration of sirolimus, or the interval between sirolimus initiation and follow-up MRI (p > .05). Interreader agreement for volume index change was excellent (intraclass correlation coefficient, 0.983), and that for signal ratio change was moderate to good (intraclass correlation coefficient, 0.764). CONCLUSION. Sirolimus treatment of extensive LMs in children is associated with significant reductions in volume and signal on T2-weighted MRI. The decrease in volume is greater in younger children and craniocervical lesions. CLINICAL IMPACT. The results may facilitate development of standardized MRI-based criteria for assessing the response of vascular malformations to pharmacotherapy.
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Narsinh KH, Gautam A, Baker A, Cooke DL, Dowd CF. Vascular anomalies: Classification and management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:345-360. [PMID: 33272404 DOI: 10.1016/b978-0-444-64034-5.00003-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Vascular anomalies are broadly classified into two major categories: vascular tumors and vascular malformations. Most vascular anomalies are caused by sporadic mosaic gene mutations, and recent genetic studies have advanced our understanding of the molecular pathways involved in their pathogenesis. These findings have suggested new therapeutic approaches to vascular anomalies, focusing on their pathogenetic mechanism. This chapter seeks to integrate an improved molecular understanding within the updated classification system of the International Society for Study of Vascular Anomalies. We emphasize the genetic, radiologic, and interventional aspects of diagnosis and management in hopes of allowing improved multidisciplinary collaboration surrounding these complex and interesting anomalies.
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Affiliation(s)
- Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Ayushi Gautam
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States
| | - Christopher F Dowd
- Departments of Radiology and Biomedical Imaging, Neurological Surgery, Neurology, and Anesthesia and Perioperative Care, University of California San Francisco, School of Medicine, San Francisco, CA, United States.
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Faiz K, Finitsis S, Linton J, Shankar JJS. Bleomycin for orbital and peri-orbital veno-lymphatic malformations - A systematic review. Interv Neuroradiol 2020; 27:291-297. [PMID: 33175616 DOI: 10.1177/1591019920972514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Orbital and peri-orbital venolymphatic malformations (VLM) are low flow vascular malformations. Intralesional bleomycin is now commonly being used to treat such malformations. OBJECTIVE The purpose of this systematic review is to synthesize evidence on the safety and efficacy of bleomycin/pingyangmycin sclerotherapy for the treatment of orbital and peri-orbital VLM. METHODS We searched Medline, Embase, Scopus and Cochrane database for studies reporting outcomes of bleomycin/pingyangmycin sclerotherapy for orbital and peri-orbital VLM between 1974 to April 5th, 2019. Nine retrospective cohort studies enrolling 132 patients were included. Two reviewers independently screened and extracted data and assessed the risk of bias. Predefined outcome measures were subjective and objective reduction of the lesion and associated complications. RESULTS Subjective reduction of the lesions was seen in 96.2% of the studies. Objective reduction of the lesion and symptomatic improvement were reported in 91.6 and 95% of the studies respectively. Non responders were 9.0%. Minor adverse events were reported in 18.1% of the studies. Major complications like pulmonary toxicity or pulmonary fibrosis was not encountered in any of the included studies. Quality of evidence was generally low. CONCLUSION Bleomycin/pingyangmycin sclerotherapy is very effective and relatively safe for the treatment of orbital and periorbital VLM and is not associated with any major side effects including pulmonary fibrosis.Limitations: The systematic review is limited mainly due to low quality of the included studies with retrospective design.
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Affiliation(s)
- Khunsa Faiz
- Department of Radiology, University of Manitoba, Winnipeg, Canada
| | - Stephanos Finitsis
- AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Janice Linton
- Indigenous Health Librarian & Liaison Librarian for Community Health Sciences, Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Canada
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Abstract
BACKGROUND Venolymphatic malformations are rare benign vascular lesions of the head and neck. Sclerotherapy has become the first-line therapy of these lesions with bleomycin being a sclerosing agent commonly used. PURPOSE To perform a systematic review of the published literature to synthesize evidence on the safety and efficacy of bleomycin for the treatment of head and neck venolymphatic malformations. DATA SOURCES A systematic review of the literature (January 1995-May 2019) was performed in PubMed, Embase, and Cochrane Library databases to identify studies on sclerotherapy of venolymphatic malformations of the head and neck. STUDY SELECTION A total of 32 studies with participants met the inclusion criteria among which 1121 patients were included in the systematic review. DATA ANALYSIS Two reviewers independently screened and extracted data and assessed the risk of bias. The primary outcome was the subjective or objective reduction of lesion size as well as minor and major complications. DATA SYNTHESIS The bleomycin/pingyangmycin sclerotherapy achieved subjective or objective lesion size reduction in 96.3% (95% CI 94.1%-98.5%) of patients. Minor complications were observed in 16.2% and major complications in 1.1%. CONCLUSION Bleomycin is a highly effective treatment of venolymphatic malformations of the head and neck with a low rate of major adverse events. This study represents an update on the "available" evidence, but only low-to-moderate quality studies were available. LIMITATIONS This study reviewed 32 studies performed in different parts of the world, but there was heterogeneity of the study designs and interventions.
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Pediatric Tongue Lesions: An Often-Overlooked but Important Collection of Diagnoses. AJR Am J Roentgenol 2020; 214:1008-1018. [DOI: 10.2214/ajr.19.22121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sclerotherapy for lymphatic malformations of head and neck: Systematic review and meta-analysis. J Vasc Surg Venous Lymphat Disord 2020; 8:154-164. [DOI: 10.1016/j.jvsv.2019.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/11/2019] [Indexed: 11/23/2022]
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Abstract
The approach to treating common (cystic) lymphatic malformations (LMs) has evolved significantly over the last decade due to clinical research and recent developments in molecular biology. Surgery, sclerosing agents, and medical drugs with specific targets for biological therapy have been reported for the management of LMs. We will discuss the importance to standardize the location and imaging characterization of LMs to improve the knowledge about the outcome of the different therapeutic options. Our goal is to help the reader understand the different options for the management of LMs with the balance between risk and benefit for the patients.
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