Infantile Hemangioma: Challenges, New Insights, and Therapeutic Promise

Propranolol in the Management of Infantile Hemangiomas: Clinical Response and Predictors

Background:

Recent data suggest that propranolol is an effective treatment for infantile hemangiomas (IHs). Data on the optimal dose, duration of therapy, and predictors of response are currently lacking.

Objective:

To assess the clinical response to and predictors of propranolol use in the treatment of IH.

Methods:

Retrospective cohort study of 44 patients. Two independent assessors evaluated improvement by comparing serial digital photographs using a 100 mm visual analogue scale (VAS), where 5 mm change represented 10% change in the size or appearance of the IH.

Results:

Propranolol was started at a mean age of 7.8 (SD 8.21) months and was used for 7.3 (SD 4.8) months before weaning. The mean percent improvement compared to baseline (as measured by the VAS) was 78% (SD 23%). Minor adverse events were noted in 32% of patients. The most significant predictor of regrowth after weaning was a IH > 5 cm in size ( p = .017).

Conclusions:

Propranolol is effective in IH, but the side effects and the possibility of regrowth should be considered.

Evaluation of intra-lesional corticosteroids in the treatment of peri-ocular haemangioma of infancy: still an alternative besides propranolol

PURPOSE

Haemangioma of infancy (HOI) is the most frequently occurring benign tumour of infancy. Alarming HOI require treatment. Current therapy is empirically based; corticosteroids are often administered but in recent publications propranolol was reported to be more effective. Peri-ocular HOI are highly sensitive to corticosteroids. Our goal was to evaluate the effectiveness of intra-lesional corticosteroids in the treatment of peri-ocular HOI.

METHODS

We selected all patients with peri-ocular HOI who had only been treated with intra-lesional corticosteroids at our hospital from 1993 until 2009. Treatment was standardized according to a prospective protocol.

RESULTS

A total of n = 34 patients were included. There were no complications at all after therapy. A second intra-lesional injection was necessary in five patients. At follow-up after 6 and 12 months after injection, 94 and 91% of the patients, respectively, had regression of the HOI. Astigmatism, Haemangioma Activity Score and global assessments all had improved after therapy.

CONCLUSIONS

This study shows that intra-lesional therapy with corticosteroids is very safe in the treatment of peri-ocular HOI. It remains a good and safe alternative besides propranolol or when propranolol therapy is not possible (e.g. asthma, PHACE syndrome, and certain cardiac diseases).

Propranolol in the Treatment of Problematic Infantile Hemangioma: Review of 35 Consecutive Patients from a Vascular Anomalies Clinic

Background:

Propranolol, a nonselective β-blocker, has been reported as efficient for controlling the growth of complicated infantile hemangiomas (IHs). No uniformly accepted protocol exists regarding the administration of oral propranolol for IH.

Objective:

We sought to share our experience using propranolol for problematic IH and to evaluate the efficacy of this treatment modality.

Methods:

A retrospective chart review analysis was performed for 35 consecutive children treated with propranolol as an oral solution on an outpatient basis in our dermatology/vascular anomalies clinic. A protocol was established with the help of our pediatric cardiologists, including pretreatment electrocardiography and echocardiography. Medical photographs taken after 2 months of treatment were rated by two independent evaluators.

Results:

We treated 31 girls and 4 boys with a median age of 3.5 months. Rapid improvement was reported in the first days of treatment in 34 patients. Mean improvement after 2 months was 61.5%. No serious adverse effects were reported.

Conclusion:

Propranolol was effective in controlling the proliferative phase of problematic IH. It was well tolerated in our study. Outpatient treatment is possible if parents follow strict guidelines. Propranolol should be a first-line treatment for problematic IH in carefully selected patients.

Propranolol versus prednisone in the treatment of infantile hemangiomas: a retrospective comparative study

The goal of the current study was to compare the clinical effectiveness of oral propranolol with that of oral prednisone in the treatment of infantile hemangiomas (IH). Patients treated for IH with oral propranolol were retrospectively matched with patients treated with oral prednisone according to type, location, and size of the IH and age at start of treatment. Response to treatment was evaluated by rating serial medical photographs taken 1, 2, and 6 months after initiation of treatment. Degree of clinical improvement in overall appearance (including color and size) was rated as follows: worse or stable (0), slight (<25%), moderate (25-50%), good (50-75%), or excellent (>75%). A second assessment was done using a 100-mm visual analog scale to rate improvement at 6 months. Pre and post-treatment imaging was available for several patients. Twelve pairs of infants with IH were analyzed. At 1 month, clinical improvement in the propranolol group was moderate to good in all patients. In the prednisone group, only one patient had moderate improvement, with others showing slight (7/12) or no improvement or stabilization (3/12) from baseline and one case worsening. At 6 months, the propranolol group showed good to excellent response in all cases, whereas nine in the prednisone group showed slight to moderate response. Doppler ultrasound and magnetic resonance imaging correlated with the clinical improvement in the cases in which it was performed. No major side effects were observed in either group. Propranolol appears superior to oral prednisone in inducing more-rapid and greater clinical improvement in this study. A larger prospective study comparing these two treatment modalities is warranted.

A prospective study of infantile hemangiomas with a focus on incidence and risk factors

Infantile hemangiomas (IHs) are the most common tumor of infancy and have been estimated to occur in 4% of infants. Only two previous incidence studies of IH in a healthy population have been published, and both of these were performed in the first week of life. The objective was to identify the incidence of IH in an Australian neonatal population and characterize the risk factors. All women who presented to the postnatal ward in a 200-bed maternity hospital were asked to complete a questionnaire. Details of maternal history and birth details were recorded. Two follow-up emails 3 and 6 weeks after discharge were sent to all mothers who consented, asking if their baby had developed an IH. Babies reported to have an IH were seen in clinic to confirm the diagnosis. Details were collected from 1,034 mothers of 1,065 babies; 28 (2.6%) of the infants developed IH. Babies that developed IH were more likely to be female (p < 0.001), have a low birth weight (p = 0.020), be born at a gestational age of <37 weeks (p = 0.005), and be conceived through in vitro fertilization (IVF) (p = 0.001) than those who did not. The incidence of IH at 6 weeks of life was 2.6%.

The use of propranolol in the management of periocular capillary haemangioma--a systematic review

Capillary haemangioma or infantile haemangioma (IH) is the most common congenital vascular tumour in the periocular region. Several treatment modalities have been documented, with variable degree of success. Propranolol has recently been reported to be an effective and safe alternative. The aim of this systematic review is to examine the evidence base for the use of propranolol administered orally in the management of periocular capillary haemangioma, and use this information to guide future research. A systematic review of literature was carried out by two independent reviewers using the search strategies highlighted below. A total of 100 cases of oral propranolol use in periorbital or orbital capillary haemangiomas have been documented in the literature. Of the 85 cases that had details of previous treatment, it was used as first-line treatment in 50 (58.8%). The commonest dose used was 2 mg/kg/day. Adverse events were documented in one-third of cases; in most cases these were minor. Improvement or complete resolution of the lesions occurred in 96% of cases. Recurrence was noted in one-fifth of cases. Propranolol has shown a lot of promise in the therapy of IH and further research in the form of properly designed randomized trials is certainly warranted. Treatment guidelines based on literature available to date is included in this review.

Hemangiomas revisited: the useful, the unusual and the new. Part 1: overview and clinical and imaging characteristics

Hemangiomas are common vascular tumors occurring in children. Though most of the lesions present in infants and young children with a typical appearance, it is important to understand that they all do not behave in the same way. Rather, they are a group of vascular lesions with different clinico-pathological subtypes, with their clinical behavior varying with the stage of the tumor as well. As such, they can and do have a varied clinical, imaging and pathological appearance according to the location of the tumor and also the stage at which the patient is seen. In this pictorial essay, the classification, pathogenesis, clinical appearance, natural history and imaging characteristics of hemangiomas are reviewed and illustrated.

Vascular wall of head-facial hemangioma

BACKGROUND

The aim of this work was to study some morphologic and histochemical characteristics of the wall of blood vessels in the hemangioma of the head and/or face. This disease represents a most frequent vascular pathology, consisting of an embryonic display involving the cranial-facial vascular network.

METHODS

The clinical characteristics of head-facial hemangioma were studied in 28 individuals (9 males and 19 females) admitted in our hospital. Some of these patients (n = 16) were subjected to the surgical therapy for the removal of the hemangioma. During surgical therapy, all the removed tissues were transferred in our experimental laboratories for the staining of microanatomic details and for immune-chemical demonstration of some specific substances enclosed in the wall of the hemangioma vessels (proteoglycans, collagen type IV, and laminin). All results were submitted to the quantitative analysis of images and statistical evaluation of the data.

Recent progress in studies of infantile hemangioma

A hallmark of infantile hemangioma, the most common tumor of infancy, is its dramatic growth after birth, by diffuse proliferation of immature endothelial cells, followed by spontaneous regression. The growth and involution of infantile hemangioma is quite different from other vascular anomalies, which do not regress and can occur at any time during life. Some hemangioma lesions can be extremely disfiguring and destructive to normal tissue and may even be life-threatening. Unfortunately, existing therapeutic approaches have limited success and significant adverse effects of some treatment modalities limit their use. Better understanding of the pathogenesis of hemangioma will enable the development of better therapeutic strategies. Here, we review recent studies and new hypotheses on the pathogenesis of the tumor. Detailed mechanisms of activated vascular endothelial growth factor signaling in tumor cells, identification of their origin and characterization of multipotent stem cells that can give rise to infantile hemangioma are shedding new light on this intriguing vascular tumor.

Update on vascular tumors of infancy

PURPOSE OF REVIEW

Advances have been made in the pathogenesis, diagnosis and management of vascular tumors of infancy in the past year. Propranolol therapy for infantile hemangiomas (IH) is now being used widely, and case reports, series, and adverse effects are reviewed. Kaposiform hemangioendothelioma and tufted angioma are less common than IH but more often associated with coagulopathy (Kasabach-Merritt phenomenon).

RECENT FINDINGS

Recent work suggests that stem cells, mediated by the Notch signaling pathway, may become proliferating endothelial cells that comprise IH. Large, segmental IH are more likely to develop complications that can include life-threatening bleeds; however, solitary large IH do not appear to increase the risk of hepatic IH. Segmental IH may herald underlying structural anomalies of the brain, cerebral, and cardiac vessels (PHACE syndrome--Posterior fossa defects, Hemangiomas, Arterial anomalies, Cardiac defects and Coarctation of the aorta, Eye anomalies), and new criteria aid in diagnosis. Propranolol therapy is effective in life-threatening IH and appears to stop growth and hasten involution in proliferative and plateau phase IH. Adverse effects include bradycardia, hypotension, hypoglycemia, and bronchospasm. A recent review of kaposiform hemangioendothelioma finds that an associated coagulopathy (Kasabach-Merritt phenomenon) occurs in 72%.

SUMMARY

Propranolol appears to be tremendously efficacious with fewer side effects than systemic corticosteroids, but its proper place in the therapeutic algorithm for IH and other vascular tumors awaits controlled study.

Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action

Infantile haemangiomas (IH) are the most common benign tumours of infancy. Although most IH are innocuous and 85-90% regress spontaneously, some may become life- or function-threatening and require immediate treatment. Previous standard therapeutic options include physical measures (laser surgery, cryosurgery) and systemic corticosteroids, in severe cases also vincristine, alpha-interferon or cyclophosphamide, all bearing the risk of serious side-effects. Oral propranolol is a very recent therapeutic option for complicated IH with impressive efficacy and generally good tolerance. The effects of propranolol on IH were discovered by chance, and very little is known about its mechanisms of action in IH. Here we present a summary of current knowledge of how propranolol interferes with endothelial cells, vascular tone, angiogenesis and apoptosis. Early, intermediate and long-term effects of propranolol on IH can be attributed to three different pharmacological targets. Early effects (brightening of the haemangioma surface within 1-3 days after start of therapy) are attributable to vasoconstriction due to decreased release of nitric oxide. Intermediate effects are due to the blocking of proangiogenic signals (vascular endothelial growth factor, basic fibroblast growth factor, matrix metalloproteinase 2/9) and result in growth arrest. Long-term effects of propranolol are characterized by induction of apoptosis in proliferating endothelial cells, and result in tumour regression.

Propranolol treatment for hemangioma of infancy: risks and recommendations

Hemangioma of infancy is a condition that may be associated with significant morbidity. While evidence most supports the use of corticosteroids, there is no well-defined or Federal Drug Administration (FDA)-approved systemic therapy for hemangioma of infancy. All currently used treatments have significant risks. Dramatic improvement of complicated hemangioma of infancy to propranolol was recently reported, but details for initiating therapy, monitoring, and potential risks were not included. We present two infants treated with propranolol, who suffered complications and propose a treatment protocol to minimize potential adverse events.