A randomized, controlled trial of oral propranolol in infantile hemangioma

BACKGROUND

Oral propranolol has been used to treat complicated infantile hemangiomas, although data from randomized, controlled trials to inform its use are limited.

METHODS

We performed a multicenter, randomized, double-blind, adaptive, phase 2-3 trial assessing the efficacy and safety of a pediatric-specific oral propranolol solution in infants 1 to 5 months of age with proliferating infantile hemangioma requiring systemic therapy. Infants were randomly assigned to receive placebo or one of four propranolol regimens (1 or 3 mg of propranolol base per kilogram of body weight per day for 3 or 6 months). A preplanned interim analysis was conducted to identify the regimen to study for the final efficacy analysis. The primary end point was success (complete or nearly complete resolution of the target hemangioma) or failure of trial treatment at week 24, as assessed by independent, centralized, blinded evaluations of standardized photographs.

RESULTS

Of 460 infants who underwent randomization, 456 received treatment. On the basis of an interim analysis of the first 188 patients who completed 24 weeks of trial treatment, the regimen of 3 mg of propranolol per kilogram per day for 6 months was selected for the final efficacy analysis. The frequency of successful treatment was higher with this regimen than with placebo (60% vs. 4%, P<0.001). A total of 88% of patients who received the selected propranolol regimen showed improvement by week 5, versus 5% of patients who received placebo. A total of 10% of patients in whom treatment with propranolol was successful required systemic retreatment during follow-up. Known adverse events associated with propranolol (hypoglycemia, hypotension, bradycardia, and bronchospasm) occurred infrequently, with no significant difference in frequency between the placebo group and the groups receiving propranolol.

CONCLUSIONS

This trial showed that propranolol was effective at a dose of 3 mg per kilogram per day for 6 months in the treatment of infantile hemangioma. (Funded by Pierre Fabre Dermatologie; ClinicalTrials.gov number, NCT01056341.).

Serum levels of vascular endothelial growth factor and basic fibroblastic growth factor in children with hemangiomas and vascular malformations--preliminary report

Impaired balance between proangiogenic and antiangiogenic factors has been implicated in the development of hemangiomas. Elevated vascular endothelial growth factor serum levels and basic fibroblastic growth factor urine levels in patients with proliferating hemangiomas were reported. However, whether these growth factors can be used for the differential diagnosis of vascular anomalies or assessment of the clinical course of hemangiomas has yet to be determined. We report here our preliminary results of serum vascular endothelial growth factor and basic fibroblastic growth factor levels as an aid in the diagnosis of hemangiomas and in the follow up of patients with this lesion. Twenty two children with infantile hemangioma (13 with proliferating hemangiomas, nine with involuting lesions), five children with vascular malformations, and 25 healthy children study group. Vascular endothelial growth factor and basic fibroblastic growth factor serum levels were analyzed by an ELISA assay. The serum vascular endothelial growth factor concentrations in children with proliferating hemangiomas were significantly higher than in patients with involuting hemangiomas, vascular malformations and healthy patients. The serum basic fibroblastic growth factor concentrations were low and similar in all patients with no statistical correlation between study groups. We concluded that (i) ELISA can easily determine vascular endothelial growth factor concentrations in different phases of hemangioma growth and help distinguishing them from vascular malformations. (ii) A potential role for vascular endothelial growth factor in the pathophysiology of hemangiomas is probable.

Single-nucleotide polymorphisms of VEGF-A and VEGFR-2 genes and risk of infantile hemangioma

BACKGROUND

Infantile hemangioma (IH) is the most common vascular tumor of childhood and infancy. It is distinguished by rapid proliferation of endothelial cells during the first year of life followed by spontaneous regression thereafter. One of the possible factors responsible for the IH development is vascular endothelial grow factor (VEGF). The purpose of this study was to evaluate the influence of selected polymorphisms in the genes coding for VEGF-A (+405 G/C, rs2010963; +936 C/T, rs3025039) and its receptor VEGFR-2 (+1416 T/A, rs1870377; -271 G/A, rs7667298) on the susceptibility to infantile hemangioma.

METHODS

We performed a case-control study of 99 Polish children hospitalized due to IH and compared them with matched healthy control subjects. The polymorphisms were ascertained through genotyping by PCR-RFLP assay, PCR-HRM, or the allelic discrimination method.

RESULTS

The study revealed a lower odds of infantile hemangioma in individuals with GG genotype or G allele for +405 G/C VEGF-A polymorphism (OR_dis = 0.52, P = 0.023 and OR_dis  = 0.63, P = 0.025, respectively). No association was observed for the remaining VEGF and VEGFR-2 polymorphisms and IH risk.

CONCLUSIONS

In our study, none of the investigated VEGF-A and VEGFR-2 genes polymorphisms was found to be an independent prognostic marker for infantile hemangioma. However, there is evidence that individuals carrying at least one G allele of +405 G/C VEGF-A polymorphism have significantly lower risk of IH.

Soluble receptors for vascular endothelial growth factor (sVEGFR1/sVEGFR2) in infantile hemangioma

Vascular endothelial growth factor (VEGF) and its receptors were postulated to be involved in pathogenesis of infantile hemangioma. The aim of this study was to determine the serum levels of VEGF and soluble VEGF receptors (sVEGFR1/sVEGFR2) in children with hemangiomas.

MATERIALS AND METHODS

Thirty-eight children with infantile hemangiomas (25 proliferating, 13 involuting) and 34 healthy children were included in the study. sVEGFR1 and sVEGFR2 serum levels in peripheral blood and in vascular tumors were determined with ELISA test.

RESULTS

sVEGFR1 serum levels were slightly lower in hemangioma patients (p = 0.049). No significant differences in sVEGFR2 levels were observed in any study group. VEGF levels did differ significantly, with median level being 364.05 pg/ml in hemangioma patients and 107.40 pg/ml in the control group (p < 0.0001).

CONCLUSIONS

The obtained results suggest that VEGF is involved in hemangioma angiogenesis but that soluble VEGFRs marginally influence this process. Lower serum levels of sVEGFR1 in hemangioma patients indicate the possible dysregulation between VEGFR1 and VEGFR2 receptors.

EXPRESSION OF ESTROGEN RECEPTOR α AND PROGESTERONE RECEPTOR IN CHILDREN WITH UNDESCENDED TESTICLE PREVIOUSLY TREATED WITH HUMAN CHORIONIC GONADOTROPIN

PURPOSE

The aim of this study was to investigate expression of estrogen receptor alpha (ERalpha) and progesterone receptor (PR) in paratesticular tissues obtained from boys with undescended testes.

MATERIALS AND METHODS

A total of 65 boys with unilateral cryptorchidism and failed human chorionic gonadotropion treatment underwent orchiopexy. A small sample of gubernaculum, cremasteric muscle and processus vaginalis was obtained. A total of 57 boys who underwent inguinal hernia repair served as the control group. All boys in the control group had testes in the scrotum. The expression of estrogen receptor alpha and progesterone receptor was measured by counting the number of ERalpha or PR positive cells detected by immunohistochemical analysis.

RESULTS

ERalpha and PR density was higher in cremasteric muscle and processus vaginalis obtained from boys with undescended testes than in the control group. Density of progesterone receptor in the examined groups was lower than the density of estrogen receptor.

CONCLUSIONS

ERalpha and PR are expressed in paratesticular tissues important for normal testicular descent. ERalpha was over expressed in cremasteric muscle and processus vaginalis in boys with undescended testes previously treated with human chorionic gonadotropin.

The usefulness of testicular atrophy index in the assessment of undescended testicle--preliminary report

PURPOSE

Cryptorchidism affects 2-8% of male newborns. There is a controversy regarding timing of surgery as well as indications for orchiopexy in boys with retractile testicle. The aim of this study was to evaluate the clinical usefulness of testicular atrophy index (TAI) as a criterion of qualifying patients with undescended testes for surgery as well as of monitoring the results of treatment.

MATERIAL AND METHODS

In 1999-2000, 105 cryptorchid boys, aged 1 to 15 years (mean 4.8) underwent unilateral orchiopexy. Dimensions and volume of testes were measured by means of scrotal US and TAI was calculated before and 1 year after surgery.

RESULTS

Pre- and postoperative scrotal US measurements were analyzed in 35 boys divided into five age dependent groups. The preoperative TAI values ranged from 27.1% to 52.8%. The biggest loss in volume of affected testis was found in boys aged 4 to 10 years (35.4% to 52.8%). The TAI values measured one year after orchiopexy were lower than preoperative ones. Significant difference in TAI values, ranging from 18.16% to 36.43% were observed in boys between 2 and 10 years (p < 0.001). In the youngest (0-2 yrs) and the oldest boys (> 10 yrs) the difference was not statistically significant.

CONCLUSIONS

The testicular atrophy index (TAI) proved to be a valuable and objective tool for qualifying patients with undescended testes for surgery as well as for monitoring the results of treatment. Its value of 20% and more should be considered an indication for surgery in boys with retractile testes.

The role of MRI in diagnostic algorithm of cervicofacial vascular anomalies in children

Background:

Vascular anomalies are usually diagnosed through their clinical picture and history. The purpose of this study was to assess the role of MR imaging in initial assessment of cervicofacial vascular anomalies in children.

Material/Methods:

Twenty pediatric patients with vascular anomalies located in the cervicofacial region underwent MRI examination in our department. Images were evaluated for lesion detectability and its signal characteristics (on T1w, T2w images with fat suppression and contrast enhanced T1w sequences); the extent of the lesions and surrounding tissue involvement were also assessed.

Results:

In the studied group MR images revealed all anomalies and provided information of their anatomic extent and invasion of surrounding anatomic structures. Nine hemangiomas and six venous malformations were found among studied patients. Two children had multiloculated lesions corresponding to lymphatic malformations. One examination visualized a lesion consisting mainly of dilated vascular channels with an apparent feeding artery, which was consistent with arteriovenous malformation. Two remaining lesions were mixed malformations. Nine patients had lesions limited to subcutaneous tissue. Two masses infiltrated bone structures. There was muscle involvement found in nine cases.

Conclusions:

MR imaging is a well-established method for detection and monitoring of vascular anomalies in children. With ultrasound used mostly for initial diagnosis and additional flow assessment, angiography viewed as an invasive therapeutic method and computed tomography used only in specific situations due to its high irradiation dose, magnetic resonance is the best imaging method used in differential diagnosis and topographical characterization of vascular malformations and tumors of cervicofacial area in pediatric patients. Noninvasively and without irradiation, it enables evaluation of the extent and characteristics of lesions and planning proper therapeutic strategy.

Sequential, ultrasound-guided, minimally invasive pit-picking procedure with Nd:YAG laser epilation treatment for pilonidal disease

<b><br>Aim:</b> The aim of this retrospective study was to evaluate our treatment for pilonidal disease in adolescent patients, which uses ultrasonography, minimally invasive pit-picking, and Nd:YAG laser therapy.</br> <b><br>Material and methods:</b> We included 52 of 147 patients treated between June 2017 and December 2020. The patients underwent pit-picking procedures and 6-10 Nd:YAG treatments. The remnants of the cysts were removed by laser therapy, which provided easy epilation. Each patient underwent multiple ultrasound examinations during the therapy to uncover any potential newly formed asymptomatic sinuses. When such issues were identified, the pit-picking procedure was repeated on those sinuses.</br> <b><br>Results:</b> A total of 52 patients were included in this study with a 1-year follow-up following the procedure. There were 49 symptom-free patients (96%). One patient underwent surgery in another hospital because of a recurrence and 1 had a pilonidal disease relapse (4%). In the follow-up period, asymptomatic cysts were found in 2 other patients by ultrasound examination. They were all treated with a pit-picking procedure in the outpatient department with good results.</br> <b><br>Conclusions:</b> Combining sequentially repeated pit-picking procedures and Nd:YAG laser therapy is an effective treatment method for adolescent pilonidal disease. Simultaneous Nd:YAG laser therapy enables efficacious epilation of the intergluteal cleft. Repeatable ultrasonography examinations allow for early diagnosis of possible pilonidal sinus relapse.</br>.

[Eyelid surgery in children with Down's syndrome]

PURPOSE

To establish the best method of surgical correction of epicanthus in children with Down's syndrome.

MATERIAL AND METHODS

18 patients underwent eyelid surgery. In 2 cases Spaeth's technique was used, in 5 cases-Blair-Brown's technique, and in 11 cases-Mustarde's technique. In 10 patients the correction of oblique position of palpebral fissure was additionally carried out.

RESULTS

Comparative analysis showed that postoperative effects were good or excellent, and that Mustarde's technique seemed the best method for correction of epicanthus. The optimal time for this procedure was also assigned (3-6 years of age). Eyelid surgery connected with other plastic operations performed in children with Down's syndrome ensures blurring of mongoloid features. It has an advantageous effect on child's acceptation by others and on the results of psychosomatic rehabilitation as well.