Involution Of Hemangioma Research Articles

Treatment of massive or life-threatening hemangiomas with recombinant α 2a-interferon

OBJECTIVE: To assess the response of massive, life-threatening, or function-impairing hemangiomas in pediatric patients receiving daily α 2a-interferon subcutaneously. METHODS: The effect of 3 or more months of subcutaneous α 2a-interferon (3 mU/m 2) was prospectively evaluated in 10 patients with hemangiomas necessitating medical intervention. Hemangioma characteristics and extent were initially assessed by radiographic imaging in all but one patient. α 2a-Interferon tolerance was monitored, and reduction in hemangioma size was recorded as marked (>50%), moderate (25% to 50%), or minimal (<25%). RESULTS: Hemangiomas were apparent at birth in 8 of 10 patients, and α 2a-interferon was initiated at a median age of 4.5 months. Symptoms necessitating therapeutic intervention included congestive heart failure, airway obstruction, dysphagia, infection, failure to thrive, external auditory canal occlusion, visual axis impairment, and severe facial deformity. Four patients received treatment before referral that included systemic steroids ( n = 2), intralesional steroids ( n = l), or surgical/laser excision ( n = 2). α 2a-Interferon therapy was well tolerated. Most patients had a temporary elevation in body temperature during the first month of therapy. One patient with anorexia required nasogastric feedings and a temporary reduction in her α 2a-interferon dose. An additional patient with irritability was withdrawn from the study at his parents’ request even though this symptom persisted after drug cessation. Hemangioma response to α 2a-interferon was marked in six patients, moderate in two, and minimal in one whose lesion had features suggestive of a vascular malformation. Early signs of involution were usually evident within 6 weeks and often heralded by cutaneous blanching. α 2a-Interferon therapy was concluded in four patients after a mean duration of 20 months. CONCLUSIONS: Daily subcutaneous α 2a-interferon is well tolerated in pediatric patients and appears effective in hastening involution of symptomatic hemangiomas. A significant response is unlikely in lesions with features suggestive of a vascular malformation. (Otolaryngol Head Neck Surg 1997;117:99-110.)

Surgical treatment of hemangiomas and vascular malformations in functional areas

Hemangiomas and vascular malformations (VM) in functional areas can be treated by a variety of methods. Because of the natural involution of hemangiomas, a non-agressive approach is recommended. Active therapy is necessary only in cases where a function is affected such as vision, respiration, hearing, and feeding. Psychological problems can be an indication for early excision, and psychological/cosmetic reasons in the presence of fibrofatty tissue residues when the hemangioma has been involuted for late excision. In contrast to hemangiomas, no involution is to be expected for VMs, so that therapy depends mainly on the occurrence of functional problems and/or serious complications. Surgical excision still has a place, however, the indications are limited.

A new protocol for the management of Hemangiomas in infants and children. 806

Contrary to the standard teaching promulgated by Lister in 1938 for the management of hemangiomas in infants and children, we propose proactive early interventional therapy to arrest the growth of these often disfiguring lesions. Previous approaches emphasize the spontaneous involution of hemangiomas in late childhood and adolescence, a policy that basically ignored the psychosocial effect of these lesions on patient and family. Early intervention was reserved for those lesions that were life threatening.

Treatment of cutaneous hemangiomas by the flashlamp-pumped pulsed dye laser: Prospective analysis

Thirty-three cutaneous capillary and mixed hemangiomas in 24 patients were treated prospectively with the flashlamp-pumped pulsed dye laser. Patients ranged in age from 2 weeks to 7 months; the follow-up period was up to 22 months. Some patients received therapy until the lesion was almost clear or until the lesion failed to respond; others received treatment only until active capillary lesional proliferation abated. In the first group of patients, 18 of 25 lesions that were 3 mm or less in elevation lightened with therapy (93.9% +/- 4.6% in 4.1 +/- 1.6 treatment sessions) and flattened to 0.3 +/- 0.4 mm in thickness. The seven lesions that were 4 mm or more in thickness lightened 85.7% +/- 7.3% in 7.0 +/- 2.0 treatment sessions but showed less diminution in thickness (to 3.4 +/- 3.6 mm; p less than 0.01). The second group of patients, who received therapy until proliferation ceased, required just one to three therapeutic sessions. Three of the four lesions that showed residual atrophy were 4 mm or greater in thickness; the fourth lesion was ulcerated on presentation. None of the lesions had residual induration or scarring. We conclude that the flashlamp-pumped pulsed dye laser may successfully prevent enlargement and promote involution of capillary hemangiomas with minimal adverse effects. Therapy is most appropriate for patients with hemangiomas at sites of potential functional impairment, of maceration or ulceration, and of significant cosmetic disfigurement. Therapy should be initiated as early as possible, when lesions are relatively flat, for optimal results.

Hemangiomas and Spitz Nevi

Hemangiomas are, with the exception of warts, the most common benign tumors found in infants and children. A great many lesions are in this general category. The three most common types are capillary (strawberry) hemangiomas, cavernous hemangiomas, and port wine stains. In the majority of patients, these lesions cause no significant morbidity or mortality. Important exceptions to this general rule will be highlighted. GENERAL CONSIDERATIONS Hemangiomas are benign blood vessel tumors with a greatly variable capacity for growth and involution. Histologically, strawberry hemangiomas are proliferations of endothelial cells with small capillary-sized lumina. Cavernous lesions have larger, more mature vessels. Proliferation of endothehial cells is absent in port wine stains, in which dilated, thin-walled, mature capillaries are found in the upper and lower dermis. The origin of congenital vascular lesions in unknown. The question remains whether hemangiomas are true congenital benign neoplasms or hamartomas of primitive mesenchymal tissue. The factors responsible for growth and involution of hemangiomas are also unknown. Mast cells, found in abundance in actively enlarging lesions, may play an important role. With the exception of a few rare syndromes, there is no known genetic inheritance os hemangiomas, although familial cases have been reported in as many as 10% of patients.

An ultrastructural study of mast cell interactions in hemangiomas.

Hemangiomas, the most common tumors of infancy, are characterized by a postnatal period of rapid growth, followed by a phase of gradual involution. The proliferative phase is characterized by increased numbers of endothelial and mast cells and thickened basement membrane. Ultrastructural analysis of hemangiomas in the late proliferative phase showed that mast cells had numerous fingerlike processes aligned parallel to the outer lamina of the thickened basement membranes surrounding the vessels and to the surfaces of opposing cell membranes. We found evidence of different types of interactions between mast cells and adjacent connective tissue cells (fibroblasts, macrophages, multinucleated giant cells, and plasma cells) in the perivascular regions of the lesions. Intercellular contacts were observed in areas where these mast cell processes were in close association to the opposing cell membrane. Areas of membrane fusions were seen between cell types. Coated vesicles and pinocytotic vesicles were present along the periphery of cells adjacent to mast cells. Occasionally, cytoplasmic bridges were found between mast cells and fibroblasts. These ultrastructural findings suggest the proliferation and involution of hemangiomas are determined by interactions between the various types of cells found in the lesions.

Quantitative evaluation of mast cells in cellularly dynamic and adynamic vascular malformations.

Mast cells were counted in 78 histologic specimens from 70 patients with various vascular malformations showing cellularly dynamic and cellularly adynamic lesions. In growing stages of strawberry hemangiomas, there was an increased number of mast cells (mean 11.0 cells per high-power field in stage III and 23.7 in stage IV), as well as a high number of mast cells in the initial involution of strawberry hemangiomas (stage V, mean 21.0 cells per high-power field). In later involuting stages (stages VI and VII), the number of mast cells decreased (mean 9.3 in stage VI; mean 4.7 in stage VII). In cellularly adynamic lesions, i.e., port wine stains, the mean number of mast cells was 4.8, and in congenital arteriovenous malformations, it was 3.6. In normal skin, the mean number of mast cells was 3.2. In cellular hemangiomas that showed active growth (stages III to IV), the number of mast cells was strikingly low (mean 1.3). It seems that the mast cells are not responsible for the proliferation of the endothelium or for growth of the hemangioma. The markedly increased number of mast cells in the growing stages and initial involuting stage of strawberry hemangiomas parallels the gradual growth of fibrous connective tissue inside the tumor. Mast cells may thus be a precursor of the beginning of the involution of a strawberry hemangioma.

Spontaneous involution of capillary hemangiomas of the integument in children. (Russian)

Spontaneous involution of capillary hemangiomas of the integument in children. (Russian)

Underdevelopment of the Human Breast After Radiotherapy

Gamma or x-radiation applied to the region of the female breast in the early years of life may result in underdevelopment of the mammae. Two patients are reported who were treated with radium emanation for cutaneous hemangiomas and suffered subsequent failure of proper development of breasts. Since spontaneous involution of such hemangiomas does not result in breast atrophy, radiation therapy is of necessity implicated as the causative factor in this anatomical area and, therefore, should be avoided as a modality of treatment.

Cutaneous Hemangiomas in Children

Hemangiomas in infants and children are managed best by intelligent neglect. Other entities in this category are umbilical hernia, lingua fraenata (tonguetie) and the small ventricular septal defect. Vascular birthmarks pose a common management problem to physicians of almost every speciality because parents frequently seek treatment for such lesions. Although the phenomenon of spontaneous involution of hemangiomas in children was reported 77 years ago and further emphasized in recent articles,^1-6many authors^7-10continue to advocate or discuss active treatment. During the past seven years we have followed the course of 210 patients will 336 hemangiomas. Active treatment was not used in our patients. Some of the unfortunate complications of active treatment which occurred in children who received therapy elsewhere will be noted. We wish to reemphasize that progressive involution does occur with eventual complete regression in the majority of cutaneous hemangiomas. <h3>Description of Hemangiomas</h3> The subjects comprised 210

CURRENT CONCEPTS IN DIAGNOSIS AND MANAGEMENT OF CONGENITAL CUTANEOUS HEMANGIOMAS

SPONTANEOUS involution of hemangiomas in children was reported nearly 80 years ago and was further emphasized by Lister in 1938. However, among physicians considerable diversity of opinion still prevails regarding management of these lesions. Recent articles and texts continue to advocate or discuss therapy (surgery, radiation, dry ice, or injections of sclerosing agents) even though these authors mention that many hemangiomas will spontaneously subside. Our experience has shown that very few hemangiomas require any type of active therapy and that children in whom these lesions were treated had more complications than those managed conservatively. Our current approach to management is based on a seven-year experience with over 200 children who had 340 hemangiomas. The seven common types encountered are listed (Table 1) in the practical classification used by most authors. Since the outcome of the tumorous types (strawberry, cavernous, and mixed) and erythema nuchae is one of gradual regression and involution whereas the course of many spider nevi and most port wine stains is lack of regression, a brief description of each type follows to facilitate diagnosis. The common strawberry hemangioma or hemangioma simplex (Fig. 1) is a capillary hemangioma, usually bright red or purlish red with well-defined margins. It consists of myriads of tiny capillaries protruding above the skin surface. The strawberry [SEE TABLE I., FIG. 1A. and FIG. 1B. IN SOURCE PDF.] lesion blanches incompletely with pressure, and on palpation is a firm rubbery mass which compresses minimally if at all. The cavernous hemangioma (Fig. 2) usually has poorly defined borders arising underneath the skin surface (hypodermal) or it may be well circumscribed and elevated above the surface (dermal). [SEE FIG. 2A. IN SOURCE PDF]

Spontaneous involution of giant hemangioma. Simultaneous regression of tumor and thrombocytopenia in newborn.

Association of hemangioendothelioma with thrombocytopenic purpura has been described repeatedly. 1,2 The tumor is usually obvious at birth. Radiation therapy has been thought to be of value; surgical removal of the tumor has been performed 3 ; splenectomy is apparently not beneficial. As the tumor shrinks, purpura ceases, and platelet counts return to normal. There are a few reports of spontaneous involution of cavernous hemangioma. 4 The interest in the following case revolves about the spontaneous regression of a huge hemangioma with thrombocytopenic purpura in the first 6 months of life. Case History The patient, a boy, was admitted to Children's Hospital, at the age of 3 days, because of jaundice, hematemesis, and a large tumor on the left leg. He was born of a full-term pregnancy; normal delivery. His birth weight was 3175 gm. (7 lb.); there was no neonatal distress. Jaundice was noticed at 12 hours. The patient vomited

The Management of Visible Hemangioma

Abstract We believe that spontaneous involution of the most common hemangiomas of infancy and childhood must be accepted as a fact. However, in some cases involution progresses slowly, while in a small percentage regression does not occur. When surgery is forced by parental pressure (Fig. 6) and is attempted during the growing phase of the large involuting type of hemangioma, it can rarely be completely excised and growth will continue in the residual vascular tissue until the latent period is reached. If operation is delayed until involution has started, then one may perform a more conservative excision, as the residual vascular tissue will involute spontaneously. If early therapy is required to placate the parents, some homeopathic method of treatment at infrequent intervals should be carried out. It is also recognized that plastic surgery is necessary to remove the residual cosmetic disfigurements of the large hemangioma in the preschool period. However, surgery which is performed after a number of years following the involution of large hemangiomas is much simpler and less dangerous than when attempted in infancy. Furthermore, we believe that radical methods of treatment which may damage or prevent the growth of normal tissues are contraindicated. A discussion of the treatment for the non-involuting types of hemangiomas is presented.

The management of visible hemangiomas

We believe that spontaneous involution of the most common hemangiomas of infancy and childhood must be accepted as a fact. However, in some cases involution progresses slowly, while in a small percentage regression does not occur. When surgery is forced by parental pressure (Fig. 6) and is attempted during the growing phase of the large involuting type of hemangioma, it can rarely be completely excised and growth will continue in the residual vascular tissue until the latent period is reached. If operation is delayed until involution has started, then one may perform a more conservative excision, as the residual vascular tissue will involute spontaneously. If early therapy is required to placate the parents, some homeopathic method of treatment at infrequent intervals should be carried out. It is also recognized that plastic surgery is necessary to remove the residual cosmetic disfigurements of the large hemangioma in the preschool period. However, surgery which is performed after a number of years following the involution of large hemangiomas is much simpler and less dangerous than when attempted in infancy. Furthermore, we believe that radical methods of treatment which may damage or prevent the growth of normal tissues are contraindicated. A discussion of the treatment for the non-involuting types of hemangiomas is presented.