Efficacy of Bleomycin-Lauromacrogol Foam in Pediatric Macrocystic Lymphatic Malformations With and Without Intracapsular Hemorrhage

BACKGROUND

Sclerotherapy is purportedly less effective in patients with hemorrhagic than with non-hemorrhagic lymphatic malformations (LMs). We aimed to compare the efficacy of bleomycin-lauromacrogol foam (BLF) sclerotherapy in the treatment of macrocystic LMs with and without intralesional hemorrhage.

METHODS

Fifty-five children with macrocystic LMs admitted to the Pediatric Surgery Department were retrospectively included. The patients were allocated into a hemorrhage group (23 cases) or a non-hemorrhage group (32 cases) based on the occurrence of an intracapsular hemorrhage. The diagnosis was confirmed by physical examination, color ultrasound, magnetic resonance imaging, and puncture findings. BLF was injected into the capsule after draining the cystic fluid under color ultrasound guidance. Patients whose lesions were unchanged or showed minor change after 1 month were treated again using the same method. Changes in lesion size and the number of treatments were recorded. Effectiveness was classified as excellent (volume reduction ≥90%), good (50%≤volume reduction<90%), or poor (volume reduction <50%).

RESULTS

In the hemorrhage group, 17, 6, and 0 patients' outcomes were classified as excellent, good, and poor, respectively. The overall efficacy rate was 100%. In the non-hemorrhage group, 23, 7, and 2 patients' outcomes were classified as excellent, good, and poor, respectively. The overall efficacy rate was 93.8%. There was no significant difference in efficacy rate between groups (P = 0.767).

CONCLUSIONS

BLF is an effective and safe treatment for macrocystic LMs with bleeding. The results were similar in patients with and without bleeding.

LEVEL OF EVIDENCE

Treatment, Level III.

Lymphatic malformations: mechanistic insights and evolving therapeutic frontiers

The lymphatic vascular system is gaining recognition for its multifaceted role and broad pathological significance. Once perceived as a mere conduit for interstitial fluid and immune cell transport, recent research has unveiled its active involvement in critical physiological processes and common diseases, including inflammation, autoimmune diseases, and atherosclerosis. Consequently, abnormal development or functionality of lymphatic vessels can result in serious health complications. Here, we discuss lymphatic malformations (LMs), which are localized lesions that manifest as fluid-filled cysts or extensive infiltrative lymphatic vessel overgrowth, often associated with debilitating, even life-threatening, consequences. Genetic causes of LMs have been uncovered, and several promising drug-based therapies are currently under investigation and will be discussed.

Percutaneous sclerotherapy for head and neck lymphatic malformations in neonates and infants ≤12 months of age

BACKGROUND

Percutaneous sclerotherapy is an effective treatment for lymphatic malformations (LM) of the head and neck in adults. The purpose of this study was to examine the indications and efficacy of sclerotherapy for head/neck LM in the neonate and infant population.

METHODS

We retrospectively reviewed patients treated with percutaneous sclerotherapy for LM of the head/neck at age ≤12 months at a single vascular anomalies clinic. The clinical, anatomic, and technical aspects of each treatment, complications, and post-treatment clinical and imaging outcomes were analyzed.

RESULTS

22 patients underwent 36 treatments during the first year of life. Median age at first treatment was 6.2 months (range 2-320 days). Severe airway compromise was the most frequent indication for treatment (31.8%). Sclerosants included doxycycline (80.5%), sodium tetradecyl sulfate (55.5%), bleomycin (11.1%) and ethanol (2.8%). There were no immediate procedure-related complications; sclerosant-related laboratory complications included transient metabolic acidosis (8.3%) and hemolytic anemia (5.5%). Median follow-up was 3.7 years (IQR 0.6-4.8). 47.6% of patients showed >75% lesion size reduction and 19.0% showed minimal response (<25% improvement). At last follow-up, 71.4% of children were developmentally normal and asymptomatic, 23.8% had recurring symptoms, and 4.8% required permanent tracheostomy. Patients with ongoing symptoms or limited response to percutaneous sclerotherapy (33.3%) were treated with long-term sirolimus.

CONCLUSIONS

Percutaneous sclerotherapy is a safe and effective treatment for symptomatic LM of the head and neck in neonates and infants. Treatment strategy and management of recurrent symptoms requires consensus from an experienced, multidisciplinary team.

Dual-agent percutaneous sclerotherapy technique for macrocystic lymphatic malformations

Percutaneous sclerotherapy is an effective technique for treating lymphatic malformations of the head and neck, with clinical success rates exceeding 84%.1 Sodium tetradecyl, which damages lipid membranes and stimulates free radical-induced local damage, and doxycycline, which inhibits angiogenesis, have emerged as the safest and most effective of several available sclerosants.2-4 Although severe periprocedural morbidity is rare, temporary local complications are reported in 14% and skin necrosis or scarring in up to 0.8-5.8% of sclerotherapy procedures.5 As these lesions are frequently located in the face and/or neck, even minor complications can be disfiguring and must be avoided. This technical video describes a 'dual-agent' approach for percutaneous sclerotherapy of macrocystic lymphatic malformations using sodium tetradecyl as a 'primer' followed by doxycycline as a definitive sclerosant (video 1). This technique emphasizes meticulous backtable preparation and effective use of ultrasound and fluoroscopy to minimize complications. neurintsurg;15/9/931/V1F1V1Video 1 .

A case series of fetal lymphatic malformations and a review of the literature

Lymphatic malformations are rare benign developmental anomalies of the lymphatic system that can be diagnosed by prenatal ultrasound. Depending on their anatomical site and size, the lesions can cause a variety of aesthetic and functional deficits. Several treatment options are available, the most suitable is still under debate. The experience gained at our Centre and the review of the literature can be useful to improve prenatal counseling, that is challenging due to the heterogeneity of clinical presentation and treatment.

Effect of Japanese Kampo medicine, eppikajutsuto, in patients with lymphatic malformation: A retrospective observational study

Lymphatic malformations (LMs) are congenital malformations of the lymphatic system that cause considerable cosmetic and functional complications. In this study, we present 8 children with LM who were treated with the Kampo medicine eppikajutsuto (EKJT).Between 2001 and 2020, 8 children (male: 4, female: 4) with LMs who underwent magnetic resonance imaging (MRI) evaluation both before and after treatment or observation were selected for investigating the effect of EKJT. Two patients were observed without any treatment for 24 and 60 months. EKJT was evaluated based on percentage reduction, defined as the percentage of total lesions that decreased in size, confirmed by radiological examination after initiating treatment with EKJT or determined by observation alone. Volumetric analysis of LMs on MRI was performed using the Digital Imaging and Communications in Medicine viewer.Six patients were treated with EKJT. The mean observational period was 13.2 months (range: 6-24 months). The mean reduction in LM volume on MRI was 73.0% in treated patients and -66.3% in observed patients. Two of the 6 lesions exhibited complete reduction, 2 exhibited marked (>90%) reduction, 1 exhibited moderate reduction, and 1 exhibited a small response. The treatment was well-tolerated, with no severe adverse events.This preliminary study demonstrated the beneficial effects of EKJT. Prospective evaluations of this promising therapeutic modality are warranted based on the results of this study.

A Radiologic Grading System for Assessing the Radiographic Outcome of Treatment in Lymphatic and Lymphatic-Venous Malformations of the Head and Neck

BACKGROUND AND PURPOSE

Two-thirds of lymphatic malformations in children are found in the head and neck. Although conventionally managed through surgical resection, percutaneous sclerotherapy has gained popularity. No reproducible grading system has been designed to compare sclerotherapy outcomes on the basis of radiologic findings. We propose an MR imaging-based grading scale to assess the response to sclerotherapy and present an evaluation of its interrater reliability.

MATERIALS AND METHODS

A grading system was developed to stratify treatment outcomes on the basis of interval changes observed on MR imaging. By means of this system, 56 consecutive cases from our institution with formally diagnosed head and neck lymphatic malformations treated by sclerotherapy were retrospectively graded. Each patient underwent pre- and posttreatment MR imaging. Each study was evaluated by 3 experienced neuroradiologists. Interrater reliability was assessed using the Krippendorff α statistic, intraclass coefficient, and 2-way Spearman ρ correlation.

RESULTS

The overall Krippendorff α statistic was 0.93 (95% CI, 0.89-0.95), denoting excellent agreement among raters. Intraclass coefficients with respect to consistency and absolute agreements were both 0.97 (95% CI, 0.96-0.98), illustrating low variability. Every combination of individual rater pairs demonstrated statistically significant (P < .01) linear Spearman ρ correlations, with values ranging from 0.90 to 0.95.

CONCLUSIONS

The proposed radiographic grading scale demonstrates excellent interrater reliability. Adoption of this new scale can standardize reported outcomes following sclerotherapy for head and neck lymphatic malformation and may aid in the investigation of future questions regarding optimal management of these lesions.

Generalized lymphatic anomalies and review of the current management landscape: a case report and review of the literature

BACKGROUND

Generalized lymphatic anomaly previously known as diffuse systemic lymphangiomatosis is a rare multisystem congenital disease arising from the lymphatic system, and it is characterized by abnormal proliferation of the lymphatic channels in osseous and extraosseous tissues. It typically affects children or young adults. Although it is benign, it can be misdiagnosed as malignancy because of its diffuse and debilitating nature depending on the site of involvement. Due to its rarity, diagnosis is often delayed, leading to potential significant morbidity or mortality if vital organs are involved. Furthermore, its potential for multiorgan involvement with no curative treatment makes its management challenging.

CASE PRESENTATION

We describe a case of a 35-year-old Caucasian female, who presented with epigastric pain and was subsequently extensively investigated at multiple tertiary centers by numerous specialists for query malignancy and metabolic bone disorder following incidental computed tomography imaging findings of multiple osteolytic lesions in the axial skeleton, and low-attenuating lesions in the axilla, spleen, and mediastinum. The diagnosis was confirmed with an axillary excisional biopsy. She was clinically stable with no end organ damage. She was monitored conservatively.

CONCLUSIONS

The case illustrates the importance of increased awareness among clinicians for this rare congenital disease to enable earlier diagnosis and to avoid unnecessary invasive investigations. Furthermore, this case highlights the potential need for multiple biopsies of affected sites to confirm diagnosis. We also discuss the emergence of interferon therapy, chemotherapy, immunosuppression, and immunotherapy as medical management for this condition.

Lymphatic malformations: a 20-year single institution experience

PURPOSE

Lymphatic malformations (LMs) are congenital abnormalities which result from disturbances in the embryologic development of the lymphatic system. We sought to determine the characteristics and treatment patterns for LMs in a rural setting, and the effect of a specialized vascular malformations clinic on triage and follow-up.

METHODS

This is a retrospective cohort study at a single tertiary care institution. Sixty-two patients were identified; chart review was completed to obtain demographic, surgery/sclerotherapy session and follow-up information.

RESULTS

The head/neck region was the most predominant LM location (N = 26, 41.9%), followed by trunk (N = 16, 25.8%), extremity (N = 11, 17.7%), and intraabdominal/retroperitoneal (N = 7, 11.3%). Twenty-eight patients were managed non-surgically, while 21, 7 and 6 patients required surgery, sclerotherapy, or both. Head/neck LMs were the most likely to recur (73%, p = 0.028). Patients seen in specialty clinic had similar duration of follow-up and time to intervention, but were more often below 1 year of age (p = 0.030). Average LM volume among patients with available imaging was much larger in those referred to specialty clinic (73.2 cm³ versus 14.8 cm³, p = 0.022).

CONCLUSION

Our experience reiterates not only the wide variety of clinical presentations of lymphatic malformations, but also demonstrates the necessity of multiple subspecialties and their collaboration to achieve prompt and efficacious treatment.

Use of percutaneous bleomycin sclerotherapy for orbital lymphatic malformations

PURPOSE

Bleomycin sclerotherapy has been shown to be a viable treatment for lymphatic malformations. However, its use for these lesions confined to the orbit is becoming increasingly documented in the literature. In this study, we summarize the clinical manifestations and outcomes observed following percutaneous bleomycin sclerotherapy for orbital lymphatic malformation.

METHODS

A 5-year retrospective chart review of patients with clinical, radiographic, and/or biopsy-confirmed diagnoses of orbital lymphatic malformation that received bleomycin sclerotherapy was conducted at the Emory Hospital and Clinics. Data examined included patient demographics, patient history and symptoms, clinical findings, radiographic findings, route of bleomycin delivery, and outcome.

RESULTS

Of the 10 patients who met inclusion criteria, the median age of treatment was 7 years. The most common presenting symptoms included vision change and proptosis. Nine of 10 patients demonstrated macrocysts (>1 cm) on imaging. Seven of 10 patients had histories of prior interventions including resections, cyst drainage, and debulking. Because 2 of these 10 patients were lost to follow-up, 8 patients remained for post-procedural evaluation. Four of these eight showed improvement of visual acuity after post-bleomycin sclerotherapy. In seven of eight patients, extraocular motility either improved or remained stable. Pretreatment and posttreatment exophthalmometer measurements obtained in four patients revealed an average improvement in proptosis of 65% from their average pretreatment measurements.

CONCLUSIONS

Our findings suggest that percutaneous bleomycin sclerotherapy is a viable option for treatment of orbital lymphatic malformations, with potentially greater benefit to those with macrocystic features.

Current status, pitfalls and future directions in the diagnosis and therapy of lymphatic malformation

Lymphatic malformations are complex congenital vascular lesions composed of dilated, abnormal lymphatic channels of varying size that can result in significant esthetic and physical impairment due to relentless growth. Lymphatic malformations comprised of micro-lymphatic channels (microcystic) integrate and infiltrate normal soft tissue, leading to a locally invasive mass. Ultrasonography and magnetic resonance imaging assist in the diagnosis but are unable to detect microvasculature present in microcystic lymphatic malformations. In this review, we examine existing tools and elaborate on alternative diagnostic methods in assessing lymphatic malformations. In particular, photoacoustics, low-toxicity nanoparticles and optical clearing can overcome existing challenges in the examination of lymphatic channels in vivo. In combination with photothermal scanning and flow cytometry, Photoacoustic techniques may provide a versatile tool for lymphatic-related clinical applications, potentially leading to a single diagnostic and therapeutic platform to overcome limitations in current imaging techniques and permit targeted theranostics of microcystic lymphatic malformations.

Treatment of giant cervico-mediastinal lymphatic malformations: a case series

BACKGROUND

Lymphatic malformations are histologically benign vascular structures that vary in anatomic lesion and size. Extensive head and neck lymphatic malformations may be life-threatening. In the present study, we described three difficult-to-treat infants with giant cervico-mediastinal lymphatic malformations accompanied by severe respiratory distress.

CASE PRESENTATIONS

Case 1. A Korean girl born at a gestational age of 37 weeks and weighing 2920 g had a large cervical mass compressing the trachea. Despite initial OK-432 sclerotherapy, the mass extended over the contralateral retropharyngeal space and mediastinum. Although the cervical mass was completely excised, our patient was not weaned off the ventilator. The mediastinal lymphatic malformation was excised, and our patient underwent continued intensive respiratory care with nasal continuous positive airway pressure for 6 months. She is now 5 years old and doing well without any sequelae. Case 2. A 5-month-old Korean boy showed respiratory difficulty with feeding intolerance after partial excision of a neck lymphatic malformation. We found that the remnant cervical mass had grown into the retropharyngeal space and mediastinum. After a second operation for the cervico-mediastinal mass, he experienced severe respiratory difficulty requiring ventilator care for 6 months. However, he died from central-line fungal sepsis. Case 3. A 30-day-old Korean girl was referred for remnant lymphatic malformation after partial excision. The cervical mass extended to the mediastinum and occupied half of the thoracic cavity, encasing all of the major vessels. After surgical excision, she underwent ventilator care and pleurodesis three times with doxycycline for recurrent pleural effusion. At the age of 26 months, she was weaned off supplementary oxygen and she showed normal development without any sequelae.

CONCLUSIONS

Despite difficulties in the treatment process, combinations of delicate surgical treatment, appropriate adjuvant sclerotherapy, and intensive respiratory supportive care could result in a good outcome. However, complications due to long-term intensive care could still be considered.

Percutaneous Drainage and Povidone-Iodine Sclerotherapy of Cervical Lymphatic Malformation

Lymphatic malformations in cases with macrocystic lesions can be treated with surgical excision or sclerotherapy using alcohol, bleomycin, doxycycline, or OK-432. We report a case of a 24-year-old woman who underwent percutaneous drainage and povidone-iodine sclerotherapy as primary treatment for cervical lymphatic malformation. The patient underwent povidone-iodine sclerotherapy for 3 consecutive days. After 8 months, ultrasonography of the lesion in the neck revealed complete resolution of the cervical lymphatic malformation without any complication. Povidone-iodine sclerotherapy can be a safe and cost-effective treatment option for cervical lymphatic malformation.

Congenital Venous Lymphatic Malformation as an Unusual Source of Premenarchal Vaginal Bleeding

BACKGROUND

Premenarchal vaginal bleeding can present a diagnostic challenge and has not been previously reported in association with congenital venous lymphatic malformation.

CASE

A 3-year-old girl presented with intermittent vaginal bleeding since birth. Evaluation showed premenarchal estradiol and gonadotropin hormones, a normal pelvic ultrasound and normal colonoscopy. Examination under anesthesia and vaginoscopy showed a congested appearance of the hymen and vaginal petechiae. Sudden development of a vulvar cyst led to a pelvic magnetic resonance imaging scan, which revealed a venous malformation of the pelvis and vulvar lymphatic cyst. Vaginal bleeding stopped for approximately 6 months after sclerotherapy with doxycycline and ethanol, however recurred and required repeat sclerotherapy.

SUMMARY AND CONCLUSION

Congenital venous lymphatic malformations can rarely be associated with premenarchal vaginal bleeding and should be considered when all more common etiologies have been ruled out. Diagnosis is made using magnetic resonance imaging, and treatment might include doxycycline and ethanol sclerotherapy.

[A neonate with a mass on the upper back]

Immediately after birth, a skin-covered mass with weak consistency was noted on the back of a full-term newborn boy. Ultrasound and MRI (performed to exclude spina bifida occulta) showed a multicystic venolymphatic malformation. Sclerotherapy or surgical excision are possible treatments. In asymptomatic patients, however, a watchful waiting approach is used.

Treatment of deep-seated facial microcystic lymphatic malformations with intralesional injection of pingyangmycin

Treatment of microcystic lymphatic malformations (LMs) is still a great challenge to physicians in the field of managing vascular anomalies. Several kinds of treatment have been proposed for microcystic LMs, but the responses to these treatment modalities vary considerably among individuals. The aim of the study was to investigate the safety and efficacy of intralesional injection of pingyangmycin for microcystic LMs located in the deep facial region.Twenty-one consecutive patients with deep-seated facial microcystic LMs were treated with intralesional injection of pingyangmycin between March 2010 and April 2015. The patients received 2 to 8 injections, and the average session was 3.7. The therapeutic efficacy was accessed on the basis of the imaging findings and clinical measurements.Among the 21 patients, the clinical responses were excellent in 7 patients (33.33%), good in 9 patients (42.86%), fair in 3 patients (14.29%), and poor in 2 patients (9.52%). No severe side effects were encountered. Furthermore, therapeutic outcomes were significantly associated with lesion location (P = 0.006) and number of injections (P = 0.003).Our study supports that sclerotherapy with pingyangmycin is safe and effective for the treatment of deep-seated facial microcystic LMs.

Management of the critical airway when an EXIT procedure is not an option: A case report

Perinatal imaging facilitates detection of congenital head and neck masses to plan fetal procedures which secure the airway. Ex utero intrapartum therapy (EXIT) procedures are preferred to protect the neonatal airway. Herein we present a case in which a neonate with a large oropharyngeal lymphovascular malformation was delivered and the airway successfully managed without an EXIT procedure using a multidisciplinary approach. Preparations for the non-EXIT delivery and critical airway management are described.

[The diagnosis and treatment progress of lymphatic malformations of the head and neck in children]

Lymphatic malformations including macrocystic and microcystic malformation are congenital benign vascular disease. The incidence in children is much higher than adults and they most often occur in head and neck. There are a variety of diagnosis and treatment methods in lymphatic malformations. This paper reviewed the recent literatures with respect to the pathology, imaging and treatment of the lymphatic malformations in children. And we detailed the advantage and disadvantage of surgical excision, sclerotherapy, laser ablation and drug treatment of lymphatic malformations particularly in children. Surgical excision continues to be integral to treat in many cases when the lesions involve the eye socket or are large enough to affect breathing, but it should not be overused without consideration of the histologic types and extent. In addition, cervicofacial macrocystic lesions tend to sclerotherapy while superficial mucosal microsystic lesions are amenable to laser therapy. In order to obtain the best treatment outcomes, the treatment protocol should be individualized and comprehensive.

[Mixed facial lymphatic malformation: case report]

Lymphangiomas are a common form of vascular malformation of the lymphatic vessels, mainly in the head and neck region. Most cases are progressive evolution and require a multidisciplinary approach. Currently, the first therapeutic option is sclerotherapy, leaving surgery for the treatment of remaining lesions.

OBJECTIVE

To present a case of facial lymphatic malformation (LM) treated with sclerotherapy, surgery and orthodontics in a 15-year follow up.

CASE REPORT

A one-year-old female patient who consulted health professionals due to a progressive volume increase of the soft parts of her right cheek. The imaging study confirmed the diagnosis of microcystic lymphatic malformation. It was managed with OK-432 sclerotherapy and Bleomycin. At 2 years of age, the patient response was considered adequate; an intralesional submandibular surgical excision was then performed, with partial resection of the lesion. The biopsy confirmed the diagnosis of microcystic LM. Six months after, a re-resection was planned using the same approach and removing the remaining lesion, with favorable development until the age of 9 years when the patient required surgery and orthodontic management due to intraoral recurrence. No major developments until the age of 13 when a new orthodontic surgery and handling are planned to perform right oral commissure suspension.

CONCLUSION

LM management by sclerotherapy, surgery, and orthodontics has shown the advantages of a multidisciplinary long-term treatment in this case.

[Diagnosis and treatment of faciocervical lymphatic malformations in infant]

OBJECTIVE

To discuss the treatment effect of infant lymphatic malformations (LMs) located in the head and neck.

METHODS

Fourty-six LMs located in the head and neck between 2009 and 2013 were retrospectively analyzed. There were 26 males and 20 females, aged from 9 months to 4 years, with a median age of 1.8 years.

RESULTS

Phase Isurgical resection was performed in 28 cases. The low concentrations of pingyangmycin was injected in 18 cases, and Phase II surgical resection was performed in 6 cases after 6 months, because of the large tumors and a wide range of invasion. Two post-operative complications were found, one was minor paralyses of mandibular branch of facial nerve, manifestied as mouth askew. Another was injured accessory nerve, manifestied as right upper limb lifting weakness, which improved after rehabilitation treatment.

CONCLUSIONS

Surgical treatment is effective to LMs. In order to avoid serious complications, the huge LMs and microcystic LMs may be given local injection of pingyangmycin after puncture fluid, and phase II surgical resection secondly if necessary.

OK-432 sclerotherapy of lymphatic malformation in the head and neck: factors related to outcome

BACKGROUND

No previous study to the best of our knowledge has examined the multiple factors related to the outcome of OK-432 sclerotherapy of lymphatic malformations.

OBJECTIVE

This study aimed to assess factors related to the successful outcome of OK-432 sclerotherapy for lymphatic malformations in the head and neck region.

MATERIALS AND METHODS

During a 6-year period, OK-432 sclerotherapy was performed in 26 patients with lymphatic malformations. Several factors related to the efficacy of OK-432 sclerotherapy were evaluated, including the type (macrocystic or microcystic), the maximum lesion diameter, amount and hemorrhagic cytology of the aspirate, degree of aspiration, injected dose of OK-432 and post-therapy inflammation-related symptom. In all cases, ultrasound (US) follow-up was performed.

RESULTS

Of the 26 cases, 13 (50%) showed successful elimination of the lymphatic malformations in the follow-up US after the initial session, and all successful cases were of the macrocystic type. The type of lymphatic malformation and the success of OK-432 sclerotherapy were significantly related (P = 0.0149). Of the 16 cases of complete aspiration, 11 (68.8%) showed a successful outcome. Further, of the 17 cases with inflammation-related symptom, 13 (76.5%) showed a successful outcome. While the degree of aspiration and presence of inflammation-related symptom showed a significant relationship with the success of OK-432 sclerotherapy (P < 0.05), no other factors showed a significant relationship.

CONCLUSION

The study results suggest that the macrocystic type and complete aspiration of cystic contents were important factors for the success of OK-432 sclerotherapy of lymphatic malformations, and that inflammation-related symptom was a predictor of a successful outcome.

Efficacy of ultrasonography in lymphatic malformations: diagnosis, treatment and follow-up: a case report

Lymphatic malformation (LM) is a localized and rare benign anomaly of the lymphatic system. Surgery is the primary form of treatment, but total resection is difficult and generally not possible. The least invasive and most effective form of treatment is injection sclerotherapy with sclerosing agents. Here, we report a case of LM in a baby, detected at prenatal ultrasound. The aim of this report is to assess the importance of ultrasonography in the prenatal diagnosis, therapy and follow-up of LM's.

Unusual regression of severe recurrent lymphatic malformation of a face after contraception and pregnancy

We report the case of a female who had suffered from progressive lymphatic malformation in the orbito-temporal region since childhood. Many surgical interventions were performed, including radical excision and shunt drainage. Despite aggressive surgical treatment, recurrence was observed after every intervention. Eventually, the condition regressed after the patient began taking a contraceptive. Moreover, it virtually disappeared after pregnancy.

[Lymphatic malformations in the head and neck: experiences with sclerotherapy]

BACKGROUND

Lymphatic malformations are rare tumors of the head and neck region. Complete resection is the mainstay of treatment in these cases. Surgery of lymphatic malformations is accompanied by various complications because of the adjacency to neurovascular structures and the infiltrative nature of these masses.

PATIENTS AND METHODS

Between March 2008 and April 2010 three patients with lymphatic malformations of the head and neck region were treated by sclerotherapy with OK-432 (Picibanil). Two young children and a male adult with a late relapse were enrolled. The children were treated under general anesthesia.

RESULTS

A complete remission of lymphangiomas of the external nose as well of the lateral neck could be observed after a single sclerotherapy with OK-432. No response was seen after multiple injections of OK-432 into the orbital lymphangioma and treatment was finally successful after resection.

CONCLUSIONS

Today sclerotherapy has to be considered in the planning of the treatment of lymphatic malformations. Intralesional treatment of lymphangiomas in the head and neck with OK-432 shows good clinical response. Sclerotherapy with OK-432 is safe, effective and associated with few side-effects. After sclerotherapy a surgical resection can be carried out without any problems.

Vascular malformations

Vascular malformations are rare but important skin disorders in children, which often require multidisciplinary care. The goal of this article is to orient pediatricians to the various types of vascular malformations. We discuss the clinical characteristics, diagnostic criteria, and management of capillary, venous, arteriovenous, and lymphatic malformations. Associated findings and syndromes are also discussed briefly.

Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2009

Primary lymphedema can be managed safely as one of the chronic lymphedemas by a proper combination of DLT with compression therapy. Treatment in the maintenance phase should include compression garments, self management including the compression therapy, self massage and meticulous personal hygiene and skin care in addition to lymph-transport promoting excercises. The management of primary lymphedema can be further improved with proper addition of surgical therapy either reconstructive or ablative. These two surgical therapies can be effective only when fully integrated with MLD-based DLT postoperatively. Compliance with a long-term commitment of DLT postoperatively is the most critical factor determining the success of any new treatment strategy with either reconstructive or palliative surgery. The future of management of primary lymphedema caused by truncular lymphatic malformation has never been brighter with the new prospect of gene-oriented management.

Orbital and periorbital vascular anomalies--an approach to diagnosis and therapeutic concepts

CONCLUSION

A correct and universally accepted terminology based on the biologic behavior of orbital vascular anomalies is essential to avoid misleading diagnoses, to choose an adequate therapy regimen, and to compare different therapeutic approaches. The management of these diseases is multi-modal and an interdisciplinary challenge.

BACKGROUND

There is persisting terminological and clinical confusion about vascular anomalies involving the orbit. Review of the literature reveals a diverse or misleading terminology and a lack of consensus for the treatment of vascular malformations or vascular tumors of the orbit.

METHODS

This study comprised a detailed analysis of cases presenting with orbital vascular anomalies followed by an extensive review of the literature.

RESULTS

Thirty-six patients were analyzed, among them 19 patients with peri- and/or intraorbital hemangiomas, 3 with intraorbital and 2 with periorbital venous malformations, 2 with orbital involvement of complex vascular malformations, and 10 with lymphatic malformations involving the orbit.

Treatment of lymphatic malformations of head and neck with OK-432 sclerotherapy induce systemic inflammatory response

Systemic immune responses after OK-432 (Picibanil) sclerotherapy in patients with head and neck lymphatic malformations (LM) were examined to achieve a better understanding of the mechanism of OK-432 sclerotherapy and to evaluate the long-term treatment outcome. Serum samples from 17 consecutive patients with head and neck LMs were collected during a total of 26 OK-432 treatment episodes. Serum C-reactive protein (CRP), interleukins (IL) 1β, 6, 8, 10, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, RANTES, immune protein (IP)-10 and macrophage chemoattractant protein (MCP)-1 as well as blood leukocyte counts were determined. Clinical outcome of the treatment was evaluated at the last visit and from patient files. Elevated serum levels of IP-10 (means at baseline 702 ng/L, after 1 day 1180 ng/L, after 4 weeks 691 ng/L) were seen on day one after OK-432 sclerotherapy (p < 0.05). C-reactive protein and leukocyte counts 1 day after treatment differed statistically significantly (p < 0.05) from the baseline. No significant differences with other cytokines investigated were observed. Patients with macrocystic LM responded better than patients with microcystic LM (p = 0.01). The elevated levels of IP-10, C-reactive protein and leukocyte levels indicate that OK-432 sclerotherapy induces systemic immune responses in patients with LM. The mechanisms of OK-432 sclerotherapy are still not precisely understood, but the IP-10 elevation may reflect local antiangiogenetic properties of immunoactivation induced by OK-432.

Doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations in children

PURPOSE

The authors report their experience with doxycycline sclerotherapy as primary treatment of head and neck lymphatic malformations (LMs) in children.

METHODS

A retrospective chart review was used to collect data on 11 patients treated with doxycycline sclerotherapy for LMs of the head and neck at our institution since 2003. Radiographic imaging allowed classification of patient LM as macrocystic, microcystic, or mixed according to previously published guidelines. Only patients with macrocystic or mixed lesions were offered doxycycline sclerotherapy. Radiographic imaging and physical examination were used to determine efficacy of treatment. After each treatment, the clinical and radiographic response was characterized as excellent (> or = 95% decrease in lesion size), satisfactory (> or = 50% decrease in volume and asymptomatic), or poor (< 50% decrease in volume or symptomatic).

RESULTS

Eleven patients underwent a total of 23 sclerotherapies with an average of 2 treatments per patient (range, 1-4). All 7 patients with macrocystic lesions achieved complete clinical resolution with an average radiographic resolution of 93%. The 4 patients with mixed lesions achieved only partial clinical resolution and an average of 73% radiographic resolution. No patient experienced any adverse effects related to the treatment. At a median follow-up of 8 months, 2 patients (18%) experienced lesion recurrence in the setting of concomitant infection.

CONCLUSION

Doxycycline sclerotherapy is safe and effective as a primary treatment modality for macrocystic and mixed LMs of the head and neck in the pediatric population.

Extensive venous/lymphatic malformations causing life-threatening haematological complications

BACKGROUND

Large venous/lymphatic slow-flow malformations (SFM) can be associated with a coagulopathy resulting in thrombosis and haemorrhage. Such potentially life-threatening complications of SFM have been reported only rarely.

OBJECTIVES

To better define the clinical characteristics of haematological complications associated with SFM, to highlight the importance of recognition and to discuss the management of these difficult-to-treat patients.

PATIENTS AND METHODS

A cohort of six children who presented with massive SFM associated with serious haematological complications was seen between January 1980 and June 2005 in the Department of Paediatric Dermatology, Great Ormond Street Hospital for Children, London, U.K. (tertiary referral centre for vascular anomalies). Clinical and haematological characteristics were recorded.

RESULTS

Patients were aged 1-20 years. All suffered with recurrent episodes of pain, localized skin necrosis and bleeding. All had intravascular coagulopathy and life-threatening complications. These included brain haemorrhage, massive bleeding from the uterus and colon, large and extensive thromboses of the deep vessels in the abdomen and pelvis and severe haemoptysis. One patient died suddenly at the age of 20 years from pulmonary thromboembolism and thrombosis within the deep vessels of the vascular malformation. The youngest patient underwent a leg amputation to remove the huge vascular malformation due to the major risk of complications and lack of limb function. Three of the patients underwent anticoagulation treatment and showed improvement in their coagulopathy.

CONCLUSIONS

It is essential that patients with extensive SFM have their coagulation screened regularly to detect intravascular coagulopathy. This may progress to disseminated vascular coagulopathy and a serious risk of thrombosis and haemorrhage. Such patients require early anticoagulation in an attempt to prevent these secondary complications.

Pediatric gastrointestinal vascular anomalies: imaging and therapeutic issues

Vascular anomalies are an uncommon cause of gastrointestinal bleeding. Imaging plays an important role in the diagnosis and therapy of these anomalies. Accurate diagnosis, classification and awareness of associated syndromes are mandatory for applying the appropriate management. In this pictorial essay we review the classification, imaging characteristics and treatment of gastrointestinal vascular anomalies.

Site-specific induction of lymphatic malformations in a rat model for image-guided therapy

BACKGROUND

Lymphatic malformation is a common benign mass in children and adults and is representative of a derangement in lymphangiogenesis. These lesions have high recurrence rates and significant morbidity associated with surgery. Several sclerotherapy regimens have been developed clinically to treat lymphatic malformations; however, an animal model has not been developed that is adequate to test the efficacy of image-guided therapeutic interventions.

OBJECTIVE

To develop an animal model suitable for evaluation of percutaneous treatments of lymphatic malformations.

MATERIALS AND METHODS

Male Harlan Sprague-Dawley rats (n = 9) received two US-guided injections of Incomplete Freund's Adjuvant (IFA) over a 2-week period. All nine rats were injected twice into the peritoneum (IP); a subgroup (n = 3) received additional injections into the neck. Three animals that received IP injections of saline were used as controls. The injection sites were monitored for the development of lesions by high-resolution ultrasonography at 2-week intervals for 100 days. High-resolution (4.7 Tesla) magnetic resonance imaging was then performed on two animals noted to have developed masses. The rats were sacrificed and histologic examination of the identified lesions was performed, including immunohistochemical staining for vascular (CD31) and lymphatic (Flt-4 and Prox-1) endothelium.

RESULTS

All animals injected with IFA developed cystic lesions. The three animals injected at dual sites were noted to have both microcystic and macrocystic malformations in the neck and microcystic plaque-like lesions in the peritoneum. The macrocystic malformations (> or =5 mm) in the neck were detected by ultrasonography and grossly later during necropsy. Histopathologic analysis revealed the cystic spaces to be lined by lymphatic endothelium supported by a connective tissue stroma. Control animals did not exhibit detectable lesions with either ultrasonography or necropsy.

CONCLUSION

This model represents a promising tool for translational development of image-guided interventions for lymphatic malformations. It may also serve as a model for the study of lymphangiogenesis and the development of anti-lymphangiogenic therapies.

Treatment of Cystic Lymphatic Vascular Malformations with OK-432 Sclerotherapy

BACKGROUND

Cystic lymphatic vascular malformations are benign lesions that can cause disfigurement and functional impairment. Complete surgical resection is often difficult, and clinical recurrence is common. Sclerotherapy has been used as an alternative to excision. OK-432 is a lyophilized mixture of Streptococcus pyogenes and benzylpenicillin which, when injected into a lesion, has shown significant ability to reduce its size or obliterate it completely.

METHODS

The authors report a series of 12 patients treated in this fashion at the Vascular Anomalies Clinic, British Columbia Children's Hospital, between 1999 and 2004. All patients underwent imaging of the lesion: 10 had magnetic resonance imaging, one had a computed tomographic scan, and one had ultrasound examination. Six patients had macrocystic malformations (cysts > or = 2 cm) and six had microcystic or combined lymphaticovenous malformations. Patients were treated with intralesional injection of OK-432. The position of the injection was confirmed by angiography and/or ultrasound in 10 cases. Response to treatment was assessed clinically.

RESULTS

All patients with macrocystic malformations had complete resolution or good response to treatment. None required any additional treatment. In contrast, those with microcystic or combined malformations responded poorly. All of these patients underwent subsequent excision without adverse consequences. The size and location of the lesion did not correlate with response to treatment. Seventy-five percent of patients experienced pyrexia. Local swelling is an expected phenomenon and must be anticipated, particularly for lesions near the airway.

CONCLUSIONS

OK-432 is an excellent treatment for patients with macrocystic lymphatic malformations. However, it is ineffective for microcystic lesions.

[Percutaneous treatment of cystic lymphangiomas]

Management of cystic lymphangioma necessitate for optimal diagnosis and treatment the expertise of a trained multidisciplinary team including dermatologists, radiologists, plastic and vascular surgeons. An initial imaging work-up of these lesions by ultrasound Doppler examination and MR imaging are necessary before treatment planning. Depending of the size, the location, the risk for the adjacent organs, a therapeutic decision may be mandatory. Percutaneous sclerotherapy is a safe and efficient treatment. It is the treatment of choice that must be proposed in first intention.

Percutaneous Sclerotherapy for Lymphatic Malformations: A Retrospective Analysis of Patient-evaluated Improvement

PURPOSE

To evaluate the midterm outcomes of percutaneous sclerotherapy of lymphatic malformations (LMs) as judged by patients.

MATERIALS AND METHODS

A 13-item survey questionnaire was sent to 74 patients who had undergone at least one sclerotherapy procedure in our hospital from January 1997 through January 2003. Information regarding the anatomic location, specific symptoms reported, history, treatment satisfaction, postprocedural complications, and number of treatment sessions was elicited. Four sclerosing agents (as single agents or in combination with other agents) were used: ethanol, sodium tetradecyl sulfate 3% (STS), OK-432, and doxycycline.

RESULTS

Fifty-five patients or their caregivers completed the survey. The patients' ages ranged from 6 months to 48 years at the time of the first procedure (mean, 12 y; median, 4 y). A majority of LMs were located in the cervicofacial region. The size and location of the lesion, recurrent infection, and pain were the most frequent indications for treatment. Fifty-one percent of these patients received sclerotherapy alone or in conjunction with surgery as primary treatment. Ethanol was the most common sclerosing agent used, followed by doxycycline, STS, and OK-432. Response varied with the type of LM, with 100%, 86%, and 43% of the patients reporting good to complete response for macrocystic, microcystic, and combined-type LMs, respectively. Skin blistering and ulcers were the most common complications. Permanent complications were uncommon and were largely related to ethanol use.

CONCLUSIONS

Percutaneous sclerotherapy provides effective midterm primary treatment for LMs. Treatment outcomes appear to vary according to the morphology of the malformation.

Lymphatic malformations of the tongue base

PURPOSE

In light of the paucity of literature on lymphatic malformations of the tongue base, our aim was to present our experience and long-term outcomes of patients with this rare and challenging pathologic entity.

METHODS

Medical records of 25 patients treated by the 3 senior authors (RGA, MTC, and RTC) between 1974 and 2003 were retrospectively reviewed, and comprehensive clinical data were collected and analyzed.

RESULTS

Twenty-one patients (13 female and 12 male infants) were diagnosed either prenatally or at birth. Of these patients, 18 required early airway stabilization; 17 required tracheotomy. Four patients were diagnosed after 1 year of age and had no airway problems. Follow-up ranged from 2 days (owing to death) to 28 years, with a mean of 10 years. In 21 patients, pathology was extensive, involving contiguous anatomical areas such as the anterior tongue, larynx, pharynx, and floor of mouth. Multiple resections and debulking procedures were performed to restore function and improve cosmesis. Four patients died, all with laryngeal involvement. Of the 14 survivors who had tracheotomies, only 5 are decannulated. Normal oral feeding has been achieved in 14 patients and normal speech, in 8 patients. Cosmesis has improved with time. Orthodontic and dental problems are common, and 9 patients have significant macrognathia.

CONCLUSIONS

Although most patients with lymphatic malformations of the tongue base achieve normal oral feeding, airway, speech, and cosmesis issues remain problematic throughout life. Laryngeal involvement signifies extensive disease and is the most significant risk factor for serious complications and death.

[Management of lymphatic malformations in oral and maxillofacial regions: the rationale according to the new classification]

According to the classification of ISSVA, Waner and Suen, the traditionally called lymphangiomas are now referred to as lymphatic malformations, including both macrocystic and microcystic lesions. They are commonly seen vascular anomalies, and most frequently diagnosed at birth and most often occur in the head and neck area. The etiology of lymphatic malformations is still unknown, resulting in a variety of treatment modalities. This paper reviewed the recent literatures with respect to the indications, contraindications, advantages and disadvantages of surgical excision, sclerotherapy and laser ablation of lymphatic malformations of the head and neck, with detailed discussion of the advances in molecular biology and clinical treatment prospects. It is concluded that although lymphatic malformations are benign lesions, they seldom involute spontaneously. Of all vascular malformations, lymphatic malformations are the most difficult to be eradicated. Their infiltrating nature coupled with the difficulty in distinguishing involved important structures of the head and neck from adjacent normal tissues makes complete surgical extirpation even more difficult. The likelihood of postsurgical recurrence and complications is thus higher than other vascular lesions. Although many treatment protocols are available in clinic, indications, contraindications, advantages and disadvantages exist in each modality. The selection of treatment modalities should depend on the patients' status and techniques available. The treatment protocol should be individualized and comprehensive as well as sequential, in order to obtain the best treatment outcomes. In general, treatment will vary according to the depth and the extent of the lesions. Superficial mucosal microcystic lesions and cervicofacial macrocystic lesions are amenable to ablation with sclerotherapy using Bleomycin and OK-432 with the advantages of the absence of a surgical scar. The sclerosing agent OK-432 is effective for macrocystic lymphatic malformations but showed less promise for microcystic lesions, mixed lesions, and lesions outside the head and neck region. In addition, superficial mucosal microcystic lesions are also amenable to CO2 laser therapy. Deeper microcystic lesions are still challenging head and neck surgeons, which are usually extensive and sometimes need to be resected in stages, and even may be impossible to be completely removed. Somnoplasty shows promise for reduction of tongue lymphatic malformations. Surgical excision, staged when necessary, continues to be integral to management in many cases, but should not be overused without consideration of the histologic types and extent. Localized mucosal microcystic lesions and major cervicofacial macrocystic lesions are amenable to primary excision. Care should be exercised in identifying and preserving important cervical and facial structures because anatomical planes are often distorted. Combined sequential approach is recommended for mixed lesions as well as extensive lesions involving both the mucosa and soft tissues.

Haemangiomas and vascular malformations of the maxillofacial region--a review

Congenital vascular anomalies have been and remain poorly understood. Since 1982 haemangiomas and vascular malformations have been recognised as distinct entities that exhibit unique characteristics and demand appropriately tailored treatment plans. However, "haemangioma" still continues to be used as a clinical and pathological description of many different types of vascular anomalies, which complicates both the care of patients and the interpretation of reports in journals. In this review we summarise the current classification, terminology, and the pathological basis of these lesions and discuss their management. The various therapeutic options available and their outcome will be discussed in addition to the recent advances in the psychosocial aspects of care, interventional radiology, laser and pharmacological therapy.

Lymphatic Malformation of the Lingual Base and Oral Floor

BACKGROUND

Lymphatic malformation of the tongue and floor of the mouth is associated with chronic airway problems, recurrent infection, and functional issues related to speech, oral hygiene, and malocclusion. There are no accepted anatomic guidelines or treatment protocols.

METHODS

This retrospective review focused on anatomic extent, treatment, complications, and airway management in 31 patients with lymphatic malformation of the lingual base and oral floor.

RESULTS

Involved adjacent structures included the neck (77 percent), mandible (41 percent), face (42 percent), lips (10 percent), pharynx (45 percent), and larynx (26 percent). Fifty-eight percent of patients required tracheostomy during infancy; decannulation was possible in two-thirds of these patients. Management included resection alone (42 percent), resection and sclerotherapy (26 percent), resection and laser coagulation (16 percent), sclerotherapy and laser coagulation (16 percent), and resection and radiofrequency ablation (3 percent). Resection involved the neck (58 percent), floor of the mouth (52 percent), and tongue (42 percent); there were often multiple procedures. Aspiration was tried with little success in 10 percent of patients. Virtually all patients had residual abnormal lymphatic tissue. Complications and posttherapeutic problems included infection (81 percent), neural damage (27 percent), difficulty in speech (23 percent), feeding problems (10 percent), and seroma or hematoma (6 percent). Associated dental/orthognathic conditions, particularly prognathism and anterior open bite, were documented in one-third of patients.

CONCLUSIONS

The initial step in the protocol is control of the neonatal airway. Staged cervical resection is undertaken in late infancy to early childhood; resection should also include abnormal tissue in the oral floor. Sclerotherapy is primarily for macrocystic disease or secondarily for recurrent cysts following partial extirpation. Vesicles of the mucous membranes and dorsal tongue are treated either by sclerotherapy, laser (carbon dioxide, yttrium-aluminum-garnet, or potassium-titanyl-phosphate), or radiofrequency ablation. Reduction for macroglossia is indicated for persistent protrusion or to allow correction of malocclusion. Embolization controls lingual bleeding. Orthognathic procedures are undertaken at the appropriate age, only after lingual size and position are acceptable.

Periorbital lymphatic malformation: clinical course and management in 42 patients

Lymphatic malformation in the orbital cavity and surrounding region often causes disfigurement and visual problems. To better clarify the evolution and treatment of this condition, the authors studied a retrospective cohort of 42 consecutive patients seen between 1971 and 2003 and analyzed anatomic features, complications, and management. The ratio of female to male patients was 1:1. Most periorbital lymphatic malformations were noted at birth (59 percent), presenting as either unilateral swelling (60 percent) or a periorbital mass (24 percent). Sixty-two percent of lesions were on the left side. The ipsilateral cheek, temple, and forehead also were involved in 57 percent of patients. Twenty-two percent of lesions were intraconal, 30 percent were extraconal, and 48 percent were in both spaces. Forty-five percent of children had an associated cerebral developmental venous anomaly. Periorbital lymphatic malformation caused major morbidity; 52 percent of patients had intralesional bleeding and 26 percent of patients had a history of infection. Other common complications included intermittent swelling (76 percent), blepharoptosis (52 percent), proptosis (45 percent), pain (21 percent), amblyopia (33 percent), chemosis (19 percent), astigmatism (17 percent), and strabismus (7 percent). Ultimately, 40 percent of children had diminished vision and 7 percent became blind in the affected eye. Management of periorbital lymphatic malformation involved an interdisciplinary team that included an interventional radiologist, a craniofacial surgeon, and an ophthalmologist. The two therapeutic strategies were sclerotherapy (40 percent) and resection (57 percent); most patients required several interventions. A coronal approach was used for subtotal excision of fronto-temporal-orbital lymphatic malformation in 13 patients, whereas a tarsal incision was used for lesions isolated to the eyelid (n = 14). Ocular proptosis was temporarily managed by tarsorrhaphy (n = 9), but expansion of the bony orbit was needed to correct persistent proptosis (n = 8). Orbital exenteration was necessary in two patients.

Vascular anomalies (birthmarks) of the foot and ankle

Vascular anomalies (birthmarks) commonly involve the feet and ankles. Little is known about these anomalies among practicing physicians. In this article, vascular anomalies are described, and detailed information is presented regarding appropriate diagnostic work-up and treatment strategies.

[Vascular malformations]

Aneurysms, hemangiomas, congenital arteriovascular and lymphatic fistulas often formed as a result of genetically determined defects in the vessel wall structure. They contribute to the development of sysytemic diseases like hypertension or circulatory failure. The author concentrates on the definition of malformation and its types, the review of clinical studies and guidelines for diagnosis and treatment.