Intralesional bleomycin injection for localized verrucous venous malformations

Abstract

To the Editor: Verrucous venous malformation (VVM) is a form of vascular proliferation that usually presents at birth or in early childhood. Surgical resection is considered the first-line treatment for VVM, but recurrence is common1Calduch L. Ortega C. Navarro V. et al.Verrucous hemangioma: report of two cases and review of the literature.Pediatr Dermatol. 2000; 17: 213-217Crossref PubMed Scopus (40) Google Scholar; therefore, we explore the safety and efficacy of bleomycin injection2Yura J. Hashimoto T. Tsuruga N. et al.Bleomycin treatment for cystic hygroma in children.Nihon Geka Hokan. 1977; 46: 607-614PubMed Google Scholar in treating the tenacious VVM. A prospective cohort study (Chinese Clinical Trial Registry: ChiCTR-OPh-17012006) was performed on 15 patients with VVM. Bleomycin was intralesionally injected and terminated when the injected part of the lesion became hard. Patients were discharged after 30 minutes of observation after the injection. Apart from mild swelling, no procedural complications were noted. Injection intervals were 2 to 4 months, depending on clinical status and response. The patients were evaluated for any procedure-related complications at every follow-up. Treatment was terminated if the lesion shrunk to less than 25% or had no response after as many as 3 injections. Treatment outcomes were assessed according to before and after photographs (primary outcome) and magnetic resonance imaging or Doppler ultrasonography examinations (secondary outcome). The response rate was graded as excellent response if the lesion achieved more than 50% regression, partial response for 25% to 50% regression, and no response if the lesion regressed less than 25%.3Pandey V. Tiwari P. Sharma S.P. Kumar R. Singh O.P. Role of intralesional bleomycin and intralesional triamcinolone therapy in residual haemangioma following propranolol.Int J Oral Maxillofac Surg. 2018; 47: 908-912Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The average follow-up was 12.3 months (range, 2-32 months; standard deviation, 9.2 months). Thirteen VVMs were localized lesions, and 2 were diffuse. One patient experienced occasional tolerable pain with her lesion. The rest experienced no symptoms, such as pain or dysfunction, relating to their lesion. No abnormalities were found in blood routine examination, liver and kidney function, or chest x-ray imaging before the treatment. The average number of injections was 2.2 (range, 1-5). Each treatment dose of bleomycin ranged from 3 to 15 mg, and the cumulative dose ranged from 9 to 54 mg. Among the 15 patients with VVMs, 12 achieved excellent response (Fig 1), none had partial response, and 3 had no response. The 2 diffuse VVM lesions both had no response to the injection, and 12 of 13 localized VVM lesions achieved an excellent response. We performed physical examination, routine blood tests, liver and kidney function blood tests and chest x-ray imaging before every treatment to monitor possible adverse events. The patient who experienced occasional pain with her lesion before treatment reported an improvement in the level of discomfort after treatment. No adverse events were found in any of the patients. There were no joint dysfunctions observed during follow-up. Most patients had local swelling after treatment, which gradually subsided in less than 2 months without intervention. Two patients experienced tolerable local pain after treatment that subsided spontaneously. Five patients developed superficial ulcers that could be cured by dressing change. Two patients developed superficial scarring, 4 hyperpigmentation and 2 depigmentation. For patients with localized VVM lesions, intralesional bleomycin treatment could delay its progression or reduce lesion volume, although further follow-up is necessary to evaluate the duration of its efficacy. For patients who have concerns about postsurgical recurrence, intralesional bleomycin is an effective modality to terminate lesion progression.