Infantile hemangioendothelioma treated with high dose methylprednisolone pulse therapy

Current concepts in pediatric liver tumors

Liver tumors in children can be classified into benign or malignant; some of the benign lesions can have the potential of malignant transformation, and therefore the therapeutic approach may change. These neoplasms account for nearly 1-2% of all pediatric tumors and they have gained significant attention in the last decades due to data suggesting that the incidence may be increasing 5% annually. We know that with new and improved imaging modalities some of these lesions may be detected more often than before. Recent studies showed that liver cancer represented 2% of malignancies in infants by 1980s and this was doubled in incidence to 4% in the following 10 yr. In this review our aim is to discuss all primary liver tumors in children with attention to their clinicopathological and immunohistochemical features followed by the current standard of care.

Clinical features of infantile hepatic hemangioendothelioma

Purpose

Infantile hepatic hemangioendothelioma (IHHE) is the most common type of hepatic vascular tumor in infancy. We conducted this study to review our clinical experience of patients with IHHE and to suggest management strategies.

Methods

We retrospectively analyzed the medical records of 23 IHHE patients (10 males, 13 females) treated at the Asan Medical Center between 1996 and 2009.

Results

Median age at diagnosis was 38 days (range, 1 to 381 days). Seven patients (30%) were diagnosed with IHHE based on sonographically detected fetal liver masses, 5 (22%) were diagnosed incidentally in the absence of symptoms, 5 (22%) had congestive heart failure, 3 (13%) had skin hemangiomas, 2 (9%) had abnormal liver function tests, and 1 (4%) had hepatomegaly. All diagnoses were based on imaging results, and were confirmed in three patients by histopathology analysis. Six patients were observed without receiving any treatment, whereas 12 received corticosteroids and/or interferon-alpha. One patient with congestive heart failure and a resectable unilobar tumor underwent surgical resection. Three patients with congestive heart failure and unresectable tumors were managed by hepatic artery embolization with/without medical treatment. At a median follow-up of 29 months (range, 1 to 156 months), 21 (91%) patients showed complete tumor disappearance or >50% decrease in tumor size. One patient died due to tumor-related causes.

Conclusion

IHHE generally has a benign clinical course with low morbidity and mortality rates. Clinical course and treatment outcome did not differ significantly between medically treated and non-treated groups. Surgically unresectable patients with significant symptoms may be treated medically or with hepatic artery embolization.

CT and MR imaging characteristics of infantile hepatic hemangioendothelioma

AIM

This study aims to analyze computed tomography (CT) and magnetic resonance (MR) imaging features of infantile hepatic hemangioendotheliomas before and after treatment.

MATERIALS AND METHODS

CT and MR examinations of seven infants with biopsy proven hepatic hemangioendotheliomas were retrospectively analyzed. The distribution, number, size, imaging appearance, enhancement pattern and post-treatment changes of the tumors were evaluated.

RESULTS

A total of 153 hepatic hemangioendotheliomas were detected on CT (111) and MR (42) imaging. In six infants, 109/111 (98.2%) tumors were hypodense and 2/111 (1.8%) lesions contained calcification on unenhanced CT. On MR imaging, all 42 lesions in one infant were heterogeneously T1-hypointense and T2-hyperintense compared to the normal liver parenchyma. Contrast-enhanced CT and MRI showed peripheral rim (51.6%), uniform (48.4%), fibrillary (33.3%), and nodular (28.8%) contrast enhancement in the hepatic arterial phase. Homogeneous (100%), rim (98.2%) and mixed enhancement patterns were noted in tumors <1.0cm, >2.0cm and 1.0-2.0cm in diameter respectively in the hepatic arterial phase. In three patients who underwent steroid therapy, follow-up CT examination demonstrated tumor size reduction and increased intra-tumoral calcification in two patients.

CONCLUSION

Infantile hepatic hemangioendotheliomas show some typical imaging features and size-dependent pattern of contrast enhancement on CT and MR imaging, which allow accurate imaging diagnosis and post-treatment evaluation.

The steroid benefit in treating complicated haemangioma

The clinical study included 30 patients with complicated cutaneous haemangioma (ulceration, bleeding, obstruction of anatomical orifices, and interference with function or movement). The patients were studied regarding the age group, sex, site of lesion, size of lesion, and the percentage of regression after treatment with steroid.

The age ranged from three months to six years, there were 20 female patients and 10 male patients. We used local injection of diluted triamcinolone 4 mg with 5 ml. 0.9% NACI (normal saline), injected through 23-guage syringe under local or general anaesthesia every two weeks for six to eight sessions depending on the severity of the case, followed by a local pressure dressing. We measured the size of the lesion before each session and recorded the regression of the lesion. The patients were followed up for two years. Haemangioma commonly presents in infants and children, most commonly in females, especially in the head and neck and are usually of a small size. It regresses if the treatment is started earlier.

Clinical experience with infantile hepatic hemangioendothelioma

BACKGROUND

Infantile hepatic hemangioendothelioma (IHHE) is a rare disorder with only a few series reported in the medical literature. We reviewed our treatment experience with IHHE over 17 years.

METHODS

A retrospective analysis of patients with IHHE between 1991 and 2008 was performed.

RESULTS

Sixteen patients (median age 30 days) with IHHE were identified. A palpable abdominal mass was the most common presentation. All except two cases could be diagnosed radiologically. Thirteen patients had a unilobar single tumor and three patients had bilobar disease. Nine patients with symptoms and a resectable tumor underwent complete resection. Three patients with symptoms and unresectable tumor underwent medical treatment with steroids and interferon. Four asymptomatic patients were closely observed. Overall, 14 patients were cured and 1 patient died of postoperative bleeding. One patient is still on medication, and the tumor has greatly decreased in size. Two patients with bilobar disease showed elevated levels of serum alpha-fetoprotein at presentation. Histopathology confirmed type 1 IHHE in all of the 10 specimens.

CONCLUSIONS

The presence of clinical symptoms is a key element determining the treatment options. In symptomatic patients, primary surgical resection should be considered whenever feasible.

Infantile hepatic hemangioendothelioma with elevated serum alpha-fetoprotein

Infantile hemangioendothelioma is the most common hepatic vascular tumor in infants less than 6 months of age, with a prevalence of 1%. Serum alpha-fetoprotein levels have been used as an important tumor marker for hepatoblastoma, hepatocellular carcinoma, and germ cell tumors. It is rarely elevated in hepatic hemangioendothelioma. The authors report an infant with a hepatic hemangioendothelioma associated with elevation of serum alpha-fetoprotein who was treated with corticosteroids. In young infants, a solitary hepatic mass and elevated serum AFP level may not always be associated with hepatoblastoma. Infantile hemangioendothelioma must be differentiated by MRI or other radiological techniques before performing invasive procedures.