Intralesional bleomycin in lymphangioma: an effective and safe non-operative modality of treatment

Sclerotherapy vs. surgical excision for lymphatic malformations of the head and neck: a systematic review and meta-analysis

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.

A rare pediatric case: Mesenteric cystic hygroma in a 5-year-old child

INTRODUCTION AND SIGNIFICANCE

Lymphangiomas are benign vascular malformations commonly found in the head and neck region, although they can occur elsewhere. Clinical manifestations vary based on location and size. Surgical resection remains the primary treatment modality.

CASE PRESENTATION

A male child presented with progressive abdominal distension without associated symptoms. Emergency department evaluation revealed a palpable abdominal mass. Abdominal ultrasound and computed tomography (CT) scans confirmed a large abdominal cyst. The cyst was surgically removed, and pathological examination diagnosed mesenteric lymphangioma.

CLINICAL DISCUSSION

Despite their infrequent occurrence, mesenteric cysts should be included in the differential diagnosis of pediatric abdominal masses.

CONCLUSION

Complete surgical resection is essential for the definitive management of mesenteric lymphangioma. Partial resection or aspiration should be avoided due to the risk of complications and potential recurrence.

A rare case of a large mesenteric lymphangioma in a 2-year-old child: Case report and review of the literature

INTRODUCTION AND SIGNIFICANCE

Lymphangiomas are benign tumors that are typically found in the neck and armpit region but can also occur in other locations. The clinical presentation varies depending on their location and size, and surgical resection is the primary treatment option.

CASE PRESENTATION

We present the case of a child who presented with a painless and non-obstructing abdominal mass. The mass was diagnosed and underwent complete surgical resection. Subsequent tissue analysis confirmed that the cyst was a lymphangioma.

CLINICAL DISCUSSION

These tumors should be considered in the differential diagnosis of cystic lesions in the abdomen, and the importance of performing complete surgical resection is emphasized.

CONCLUSION

The importance of complete surgical resection for mesenteric lymphangioma must be emphasized. Partial resection or aspiration should not be performed due to the risk of complications associated with these procedures and the increased risk of recurrence.

The efficacy of bleomycin sclerotherapy in the treatment of lymphatic malformations: a review and meta-analysis

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.

Management of prenatally diagnosed multiple giant cystic lymphangioma with combination of surgery and intralesional bleomycin injection: A case report

INTRODUCTION AND IMPORTANCE

Giant cystic lymphangioma was a congenital lymphatic system malformation. Although it is benign, it can cause some complications requiring prompt treatment. The selection of therapy was challenging because none of them is perfect. In this report, we presented a case of multiple giant cystic lymphangiomas in an infant treated with stepwise surgeries combined with intralesional bleomycin injection.

CASE PRESENTATION

A two-day-old infant presented with multiple, soft, skin-colored tumors on the right side of the neck, thoracoabdominal region, axilla, and upper extremity which on pre-natal MRI appeared as heterogeneous masses with septate cystic components infiltrating upper chest cavity and compressing subclavian and carotid arteries. The patient was treated successfully with stepwise surgeries followed by intralesional bleomycin injections.

CLINICAL DISCUSSION

Cystic lymphangioma is a benign malformation of lymphatic vessels with the neck and axillar region being the most common site. There are several options for treatment modalities. Surgery has been the mainstay of treatment, but other treatment modes are getting more popular. A combination of surgery and sclerotherapy has shown satisfying results.

CONCLUSION

In large and infiltrative lymphangioma cases, staged surgery followed by intralesional bleomycin injection can be a treatment approach to minimize morbidity and mortality.

Role of Bleomycin Sclerotherapy as a Non-surgical Method for the Treatment of Cystic Hygroma of Head and Neck Region-an Institutional Study

Cystic hygroma is a benign congenital tumor of lymphatic origin. Most common location is head and neck region. Bleomycin is an antineoplastic glycopeptide antibiotic agent with sclerosing property. In our present study, we used bleomycin for intralesional sclerotherapy for cystic hygromas of head neck region, as an alternative to surgical excision. We also statistically analyzed the pattern of cystic hygroma in head and neck region. Our present study was a prospective observational study of 40 patients. The study period was 18 months. All patients were given intralesional bleomycin at the dose of 0.5 mg /kg body weight, not exceeding 10 units at a time. The injection was repeated if required, at an interval of 4 weeks up to 4-5 times. Each patient was followed up at regular interval up to 1 year. Most common age group was found to be between 0-7 years (55%). Mean age was 6.9 years. Posterior triangle of neck was the commonest site (35%). Excellent response was noted in 24 patients (60%) while good response was noticed in 11 patients (27.5%). Poor response in 5 patients (12.5%). No major side effects noted with bleomycin sclerotherapy. No recurrence was noticed in our study. Intralesional bleomycin is a safe, simple, relatively cheaper and effective nonsurgical treatment method for cystic hygroma of head and neck region. It can be used as a first line treatment modality. Still, a lot of research is needed to establish it as a gold standard treatment modality for cystic hygroma.

Cervicofacial cystic lymphangiomas in 17 childrens: A case series

Introduction

Cystic lymphangiomas are rare dysembrioplasias that occur mostly in children. Although benign, these tumors remain potentially life-threatening, due to the possible compression of the upper airway. The management of cystic lymphangiomas is still somewhat controversial, with surgery generally being the first-line treatment.

Patients and methods

17 patients were included in this retrospective study, all aged less than 18 years old and treated for head and neck cystic lymphangiomas at our department between 2007 and 2017. All these patients had received surgical treatment alone. The relevant data were analyzed with SPSS software.

Results

17 patients were included, with a sex ratio M/F of 1,4, and an average age of 4 years old. Complete resection of the tumor could only be completed in 12 patients. No postoperative complications were observed in our series. All the patients were followed for a minimum of 2 years after treatment.

Conclusion

Cystic lymphangiomas are rare tumors of mysterious origins. The main symptom is swelling of the affected area. In our series, the results of the surgery were promising and consistent with results reported in the literature. A follow-up study with a larger population could be interesting, to further examine potential prognostic factors.

Sclerosing agents in the management of lymphatic malformations in children: A systematic review

PURPOSE

Sclerotherapy is frequently employed in treating lymphatic malformations (LMs), and multiple agents, practitioners and strategies exist. This review investigates the reported efficacy and safety of sclerosants in the pediatric population.

METHODS

Adhering to PRISMA guidelines, multiple databases were queried without linguistic or temporal restriction. Inclusion criteria were patients aged 0-18 exclusively receiving injection sclerotherapy for the treatment of LMs with follow-up data. Data abstracted included agent, dose, anatomic site and key outcome measures including complications (major/minor) and resolution rates (>95% reduction in volume). Critical appraisal was undertaken using the MINORS tool.

RESULTS

Forty-eight studies met the inclusion criteria with a mean MINORS score of 0.65 ± 0.08. Included studies yielded 886 patients, across nearly 30 years. The overall observed rate of success was 89%, with variable follow-up across publications (6 weeks - 10 years). Most reported LMs were macrocystic (82%) and had a higher resolution rate than mixed/microcytic variants (89%, 71%, 34%, p<0.01) For head/neck LMs, rates of complete regression for OK-432, bleomycin, and doxycycline were 67% ± 27% (n = 26), 91% ± 53% (n = 34) and 85% ± 16% (n = 52) respectively. Major complications were most commonly reported with OK-432, including airway compromise or subsequent operation.

CONCLUSIONS

In pediatric patients treated for LM by sclerotherapy, complication rates were low. Macrocystic lesions respond well but success rates were modest at best for microcystic disease. Differences in agent utilization were noted between high and low resourced contexts; despite its lack of federal approval, OK-432 was the most reported agent. Further prospective research is warranted. LOE: 3a.

Long term outcomes of transcutaneous non-image guided bleomycin sclerotherapy in orbital/adnexal lymphatic malformations: a protocol-based management in 69 eyes

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.

Intralesional Agents in Dermatology: Pros and Cons

Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.

Results of Injection Sclerotherapy with Bleomycin in Pediatric Lymphatic Malformations

Aim:

The aim of the study was to evaluate the results of injection sclerotherapy with bleomycin in pediatric patients with lymphatic malformations.

Materials and Methods:

In this prospective cohort study, all consenting pediatric patients with macrocystic lymphatic malformations were managed with injection bleomycin sclerotherapy (0.5 mg/kg, not exceeding 5 mg at a time) under ultrasound (US) guidance. After aspirating the cyst fluid bleomycin was instilled intralesionally in a ratio of 5:1 (aspirated cyst fluid volume: diluted bleomycin solution volume). Patients were reassessed at three weekly intervals. The response to therapy was assessed clinically as well as by size and volume on ultrasound Doppler study. The response was classified as excellent response, i.e., complete regression, good response >50% regression, and poor response <50% regression.

Results:

Sixty patients with lymphatic malformations were enrolled in the study, the mean age was 3.22 years, and the male-to-female was 2.5:1. The most common site of lesion was in the neck (43.3%), followed by the axilla (15%) and flank (8.3%). The responses were excellent, good, and poor in 43 (71.6%), 12 (20%), and five (8.3%) patients, respectively. Two patients underwent surgical excision of the residual lesion. Complications noted were fever in six, local pain in five, and residual lesion in three patients.

Conclusion:

Sclerotherapy with bleomycin is simple, safe, and effective in the first line of management for macrocystic lymphatic malformations in children.

Musculoskeletal Interventional Radiology in the Pediatric Population: State of the Art

Interventional radiology procedures have been proven to be as effective as traditional surgery but usually are characterized by lower morbidity rates. In this article, the most diffuse IR treatments for pediatric lesions are reviewed with the aim of describing main advantages and drawbacks. Ablation procedures (in particular RFA and MRgFUS) are widely used for the management of osteoid osteoma and osteoblastoma whereas intracystic injection of methylprednisolone acetate is performed for simple bone cysts. Sclerosing agents and where possible, selective arterial embolization are used for treatment of aneurysmal bone cysts and other vascular malformations. In the management of malignant muscoloskeletal tumors, the role interventional radiology is mainly represented by percutaneous biopsies, and by adiuvant selective embolizations in presence of hypervascular lesions to be submitted to surgery.

Bleomycin for Percutaneous Sclerotherapy of Venous and Lymphatic Malformations: A Retrospective Study of Safety, Efficacy and Mid-Term Outcomes in 26 Patients

Percutaneous sclerotherapy is used to treat venous and lymphatic vascular malformations, which can cause significant discomfort and/or disfigurement. The purpose of this study is to describe the bleomycin sclerotherapy technique and to evaluate its clinical and radiological efficacy and safety. We retrospectively identified consecutive patients with venous malformations (VMs) and lymphatic malformations (LMs) who underwent bleomycin sclerotherapy in 2011–2020 at our institution. We collected the clinical and radiological success rates, complications and recurrences separately in the VM and LM groups. We identified 26 patients, 15 with VMs and 11 with LMs. The significant volume reductions obtained were 45% in the VM group and 76% in the LM group (p = 0.003 and p = 0.009, respectively). Significant reductions in discomfort/pain and in cosmetic disfigurement were obtained in both groups. An overall improvement was reported by 69% and 82% of patients in the VM and LM groups, respectively. No major complications occurred during the mean follow-up of 51 ± 34 months in the VM group and 29 ± 18 months in the LM group. A recurrence developed within 2 years in 23% of patients. Bleomycin is clinically and radiologically effective for the treatment of venous and lymphatic malformations, with a high level of patient safety.

Percutaneous sclerotherapy for mediastinal cyst resulting in dyspnea due to tracheal compression in an elderly patient: A case report

Surgical resection is usually indicated for symptomatic mediastinal tumors. However, surgery potentially increases postoperative complications and hospitalization length in patients who are elderly, in poor general condition, or have tumors located in the thoracic inlet. We present an 84-year-old female with progressive cough and dyspnea for 1 week. Simple radiogram and computed tomography scan showed a large superior mediastinal cyst, sized 8.3 × 6.1 × 4.6 cm, narrowing the trachea. Ultrasonography- and fluoroscopy-guided percutaneous sclerotherapy using alcohol and bleomycin was applied a single time. The patient was discharged 2 days later without complication, and she did not develop symptoms over a 6-year period. Percutaneous sclerotherapy, especially in patients who are elderly or in poor general condition, could be an effective and reliable tool for cyst management.

The Curious Case of Fibrofatty Conversion of Cystic Hygroma Treated with Bleomycin Sclerotherapy

Cystic hygroma is a congenital malformation of the lymphatic system that mostly presents at birth. Though the classic treatment of this condition is surgical excision, recent alternative treatment modalities such as injection of sclerotherapeutic agents (e.g., bleomycin and OK-432) into the lesion has gained popularity due to its safe and effective response profile with minimal side effects. We report a rare complication of repeated bleomycin sclerotherapy in a follow-up patient of cystic hygroma, where the lesion underwent fibrolipomatous conversion with insinuation into multiple fascial planes, causing mass effect by encasement and compression of major vascular and airway structures. This is the first time such a complication of bleomycin sclerotherapy has been reported in literature. Such an unusual presentation reminds us that, in any patient presenting with recurrent gradually increasing swelling with worsening of symptoms following bleomycin sclerotherapy, a possibility of fibrolipomatous conversion of cystic hygroma should be borne in mind.

Intralesional bleomycin: A treatment modality for conjunctival lymphangioma

Lymphangioma is a benign hamartomatous lesion of vascular system which frequently involves orbit and ocular adnexa. A 35-year-old male patient presented with a subconjunctival mass extending from limbus to fornices. There was a history of recurrent swellings following episodes of upper respiratory tract infection. Bleomycin is an antineoplastic agent which acts on endothelial cells of the vascular channels, helps in collapsing the cystic cavity, and prevents its recurrence. We report a case where only bleomycin injection has been used intralesionally at multiple spots and patients have shown good cosmetic outcome without any recurrence noted after 1 year of follow-up.

Outcome measurement instruments for peripheral vascular malformations and an assessment of the measurement properties: a systematic review

Purpose

The Outcome measures for vascular malformation (OVAMA) group reached consensus on the core outcome domains for the core outcome set (COS) for peripheral vascular malformations (venous, lymphatic and arteriovenous malformations). However, it is unclear which instruments should be used to measure these domains. Therefore, our aims were to identify all outcome measurement instruments available for vascular malformations, and to evaluate their measurement properties.

Methods

With the first literature search, we identified outcomes and instruments previously used in prospective studies on vascular malformations. A second search yielded studies on measurement properties of patient- and physician-reported instruments that were either developed for vascular malformations, or used in prospective studies. If the latter instruments were not specifically validated for vascular malformations, we performed a third search for studies on measurement properties in clinically similar diseases (vascular or lymphatic diseases and benign tumors). We assessed the methodological quality of these studies following the Consensus-based Standards for the selection of health Measurement Instruments methodology, and evaluated the quality of the measurement properties.

Results

The first search yielded 27 studies, none using disease-specific instruments. The second and third search included 22 development and/or validation studies, concerning six instruments. Only the Lymphatic Malformation Function Instrument was developed specifically for vascular malformations. Other instruments were generic QoL instruments developed and/or partly validated for clinically similar diseases.

Conclusions

Additional research on measurement properties is needed to assess which instruments may be included in the COS. This review informs the instrument selection and/or the development of new instruments.

Systematic review registration

PROSPERO, 42017056242.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02301-x) contains supplementary material, which is available to authorized users.

Results of Intralesional Bleomycin Sclerotherapy for Treatment of Orbital Lymphangiomas at a Tertiary Eye Care Centre in Bangladesh

Purpose

The purpose of our study was to evaluate the role of intralesional bleomycin injection for the treatment of orbital lymphangiomas.

Methods

This was a prospective interventional case study. Twelve patients diagnosed with orbital lymphangiomas received intralesional bleomycin injection at a dose of 0.5 mg/kg body weight (maximum 15 mg) along with lignocaine 2%. Those who required retreatment were injected at intervals of 4 weeks. The outcome was reviewed radiologically and using serial photographic comparison.

Result

Proptosis and lid swelling were the most frequent presentations. The number of injections ranged from 1 to 3. Fifty percent of our patients showed complete resolution, and the other 50% showed more than 70% resolution as evidenced radiologically and on digital photography.

Conclusion

No significant ophthalmic or systemic side effect was noticed in our study group. Therefore, intralesional bleomycin injection can be considered as first-line therapy for treatment of orbital lymphangiomas.

Diagnosis and surgical treatment of cervical macrocystic lymphatic malformations in infants

The treatment of lymphatic malformations (LMs) represents a great clinical challenge. The present study reported on the treatment of 68 infants with cervical macrocystic LMs using surgical resection. The cases were retrospectively analyzed. All patients underwent pre-operative ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) examinations. The surgery was performed under general anesthesia with endotracheal intubation. Ultrasonograms showed that 24 cases were monolocular, 44 were multilocular, 16 had no echo, 20 had a uniform low-level echo and 32 had a non-uniform low-level echo. CT showed non-enhancing low-attenuating cystic lesions and attenuation values of 10–45 HU. The magnetic resonance images of the LMs showed a low signal intensity on T1-weighted imaging (WI) and a high signal intensity on T2-WI. Complete resection was achieved in 56 patients, subtotal resection in eight and partial resection in four. Two complications were noted, including reversible paresis of the marginal mandibular branch of the facial nerve and a surgical-site infection. One patient in whom partial resection was achieved had recurrence at ~2 months after the surgery. Ultrasonography, CT and MRI clearly demonstrated the size, shape, extent and adjacent structures of LMs, which aided in surgical planning and assessment of potential risks. Surgical excision increased the chances of cure and was relatively safe for infants aged <1 year. Location and extent, rather than age, were determined to be the most important factors for successful surgical treatment.

Non-surgical treatment of a relapsed cystic hygroma in an adult

Lymphatic malformations, also known as lymphangiomas or cystic hygromas, are benign masses that typically affect newborns and infants and involve the head and neck regions. They are, however, rare in adults and even rarer in the axillary region. Although surgery is considered to be the treatment of choice, we present a rare case of a recurrent cystic hygroma 32 years after the first surgical operation. Due to the cosmetic concerns and the risks of a surgical approach, non-surgical therapy with percutaneous sclerosants was performed, with a good outcome after a 2-year follow-up period.

A prospective study of the role of intralesional bleomycin in orbital lymphangioma

PURPOSE

To evaluate the efficacy of intralesional bleomycin injection in the management of lymphangiomas of the orbit.

METHODS

This prospective noncomparative interventional case study included 13 patients with orbital lymphangiomas. Reconstituted bleomycin 1-5 ml (0.5 IU/kg body weight; maximum, 15 IU/ml) was injected with 2% lignocaine in the lesion as seen on imaging or, in deeper lesions, under ultrasound guidance. Repeat injections were administered when required after every 4 weeks. The decision to retreat was based on clinical and radiological evidence of response.

RESULTS

Patients were treated with 1-6 injections of bleomycin 0.5 IU/kg body weight. Dramatic response was achieved in all cases. During the mean follow-up period of 19.69 months (range, 7-26 months) none of the patients experienced recurrence or significant complication.

CONCLUSIONS

In this patient cohort lymphangiomas of the orbit showed favorable and promising results with intralesional injections of bleomycin. This treatment should be considered as a first-line therapy for lymphangiomas of the orbit.

Aqueous intralesional bleomycin sclerotherapy in lymphatic malformation: Our experience with children and adult

Objectives:

Lymphatic malformations (LMs) are aberrant proliferation of sequestrated lymphatic vessels during early embryogenesis and do not communicate directly with the general lymphatic system. The absence of vascular flow is the hallmark of LMs and is usually symptomless apart from painless disfiguring mass with concerns regarding cosmesis.

Design:

Sclerotherapy has gained prominence as a preferred treatment modality for macrocystic lesions. Here, we present our experience with use of aqueous bleomycin as intralesional sclerosing agent, an economical first-line treatment for macrocystic variant of LMs in children and adults. While bleomycin microsphere in oil has been commonly used in many previous studies, we have used aqueous bleomycin solution as the sclerosing modality which is easily available and economical.

Materials and Methods:

Twenty-seven patients of macrocystic LM including adults and children underwent bleomycin sclerotherapy under ultrasonography guidance. Number of sessions, dose administered, and the response to therapy along with all side effects were noted.

Results:

Sixteen patients received 3 or less sessions while rest needed 4–6 sessions of sclerotherapy for desired response. The response was excellent in 22 patients while 5 patients showed good response. Eleven patients developed minor side effects in form of fever, local infection, intracystic bleed, and local skin discoloration. Postsclerotherapy, surgery was performed in two patients.

Conclusion:

The better response in the present study can be attributed to targeting of individual cysts in multiloculated lesion, ultrasound-guided aspiration of the cysts content before drug delivery, and postprocedure compression which increases the contact time between cyst wall and bleomycin reducing the chances of postprocedure seroma formation. Since the drug acts on the endothelial lining of the cyst, volume of the cyst is the major determinant in response. Aqueous bleomycin had comparable results with oil-based microsphere establishing it as an economical alternative treatment modality.

Nursing Implications for the Management of Lymphatic Malformation in Children [Formula: see text]

Lymphatic malformation (LM) is a benign congenital childhood growth that presents primarily at birth, with the remainder becoming evident by age 2 years. LM can cause devastating complications such as respiratory failure, dyspnea, dysphagia, organ compression, and nerve compression. Surgery is the preferred treatment option, although resection is not always an option due to the anatomic location of the malformation. Other treatments that have been tried with success include sclerotherapy, radiofrequency ablation, propranolol, and sirolimus. Nurses have an important role in caring for the child with LM, as with any complex disease. Nurses provide care at the bedside, education to the family, case coordination, and psychosocial support. LM is a rare disease in infancy necessitating pediatric nurses to support families through prolonged treatments and potential complications.

Intralesional Bleomycin Injections for Vascular Malformations: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular malformations are congenital anomalies of the vascular system. Intralesional bleomycin injections are commonly used to treat vascular malformations. However, pulmonary fibrosis could potentially be a severe complication, known from systemic bleomycin therapy for malignancies. In this study, the authors investigate the effectiveness and safety of bleomycin (A2, B2, and A5) injections for vascular malformations, when possible relative to other sclerosants.

METHODS

The authors performed a PubMed, Embase, Cochrane Central Register of Controlled Trials, and gray literature search for studies (1995 to the present) reporting outcome of intralesional bleomycin injections in patients with vascular malformations (n ≥ 10). Predefined outcome measures of interest were size reduction, symptom relief, quality of life, adverse events (including pulmonary fibrosis), and patient satisfaction.

RESULTS

Twenty-seven studies enrolling 1325 patients were included. Quality of evidence was generally low. Good to excellent size reduction was reported in 84 percent of lymphatic and 87 percent of venous malformations. Pulmonary fibrosis was never encountered. Meta-analysis of four studies on venous malformations treated with bleomycin versus other sclerosants showed similar size reduction (OR, 0.67; 95 percent CI, 0.24 to 1.88) but a significantly lower adverse event rate (OR, 0.1; 95 percent CI, 0.03 to 0.39) and fewer severe complications after bleomycin. Symptom relief, quality of life, and patient satisfaction were reported inadequately.

CONCLUSIONS

The authors' data suggest that bleomycin is effective in reducing the size of lymphatic and venous malformations, and leads to a lower adverse event rate and fewer severe complications than other sclerosants. The included literature does not provide evidence that pulmonary fibrosis is a complication of intralesional bleomycin injections. This study represents the "best available" evidence; however, only low- to moderate-quality studies were available.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Paediatric musculoskeletal interventional radiology

Interventional radiology technique is now well established and widely used in the adult population. Through minimally invasive procedures, it increasingly replaces surgical interventions that involve higher percentages of invasiveness and, consequently, of morbidity and mortality. For these advantageous reasons, interventional radiology in recent years has spread to the paediatric age as well. The aim of this study was to review the literature on the development, use and perspectives of these procedures in the paediatric musculoskeletal field. Several topics are covered: osteomuscle neoplastic malignant and benign pathologies treated with invasive diagnostic and/or therapeutic procedures such as radiofrequency ablation in the osteoid osteoma; invasive and non-invasive procedures in vascular malformations; treatment of aneurysmal bone cysts; and role of interventional radiology in paediatric inflammatory and rheumatic inflammations. The positive results that have been generated with interventional radiology procedures in the paediatric field highly encourage both the development of new ad hoc materials, obviously adapted to young patients, as well as the improvement of such techniques, in consideration of the fact that childrens' pathologies do not always correspond to those of adults. In conclusion, as these interventional procedures have proven to be less invasive, with lower morbidity and mortality rates as well, they are becoming a viable and valid alternative to surgery in the paediatric population.

Laparoscopic segmental colectomy for colonic lymphangiomas: A definitive, minimally invasive surgical option

Colonic lymphangioma is an unusual benign malformation. We herein describe two cases. A 36-year-old woman was admitted with one year of intermittent abdominal pain; colonoscopy, abdominopelvic computed tomography and endoscopic ultrasonography (EUS) revealed enlarged cystic masses at the ascending colon. In another 40-year-old man, colonoscopy and EUS revealed an asymptomatic lobulated cystic mass with four small sessile polyps at the sigmoid colon. Both patients underwent laparoscopic segmental colectomy. Both masses were histologically confirmed as cystic lymphangiomas, and the patients were discharged without complications. The management of colonic lymphangioma depends on the individual situation; close surveillance or endoscopic therapy may be appropriate for asymptomatic lesions smaller than 2.5 cm in diameter. Surgical intervention can be considered for larger lesions or in patients who develop complication risks. Laparoscopic segmental colon resection may be recommended to excise relatively large submucosal lesions because it is a definitive, minimally invasive intervention with a fast postoperative recovery.