Congenital nonprogressive hemangioma: a distinct clinicopathologic entity unlike infantile hemangioma

Is endoscopic resection a useful technique for a cavernous sinus sellar cavernoma? A case report and literature review

BACKGROUND

Cavernous sinus cavernous malformations (CSCMs) is a vascular malformation of the cavernous sinus. Nowadays, there is an increasing preference to withhold using the terms cavernoma or cavernous hemangioma in order to stop considering these lesions as vascular neoplasms. These lesions are highly vascularized making surgical resection a challenge, mainly in endoscopic approaches. We present a case of this tumor treated in our institution with an endoscopic endonasal approach and incomplete resection. Because of the strenuous resection through this approach, we systematically reviewed the reported endoscopic cases of CSCMs to determine their intraoperative complications, results and tumor features.

METHODS

Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, one database (PubMed) and crossed references were queried for CSCMs from 1948 to 2020. Data regarding demographic features, clinical presentation, MRI features, surgical results and overall pathology features extracted.

RESULTS

Eighteen patients were selected (including our case). The mean age was 50.4 ± 14 years. Pituitary dysfunction and cavernous sinus nerve compression were the most reported symptoms. Only five cases (27%) reported a gross total resection (GTR) through endoscopic endonasal approach. Intraoperative bleeding was the most frequent intraoperative complication.

CONCLUSION

We present a comprehensive analysis of every reported CSCM treated through endoscopic approach. Partial or subtotal resection are the most used techniques because of the intraoperative bleeding and the adherence to surrounding structures. Radiotherapy is a very good option for patients with incomplete resections.

Massive spinal epidural infantile hemangioma, image findings, and treatment: a case report and review of literature

Spinal involvement of infantile hemangiomas is rare with the predilection to involve the epidural space. A proper diagnosis might be challenging due to the atypical location and variable/inconsistent use of the International Society for the Study of Vascular Anomalies (ISSVA) classification by radiologists, pathologists, and clinicians. A proper diagnosis of epidural infantile hemangioma is key due to the different aggressiveness of the treatment options with inconstant literature regarding the best available treatment. Herein, we present a case of a massive epidural infantile hemangioma successfully treated with only beta-blocker. We discuss the clinical, MRI, CT, ultrasound, and histological features of this lesion as we review the literature with the objective of addressing some of the confusion surrounding the subject.

Les anomalies vasculaires pendant l'enfance : quand traiter les patients et quand les diriger vers une ressource spécialisée

Les anomalies vasculaires sont des affections hétérogènes qui touchent les vaisseaux sanguins ou lymphatiques. Les enfants atteints peuvent éprouver de la douleur ou une perte fonctionnelle, présenter une infection ou une coagulopathie ou être confrontés à des difficultés psychologiques. Le diagnostic et la prise en charge exigent souvent une approche interdisciplinaire. Sept cliniques d'anomalies vasculaires au Canada offrent des soins interdisciplinaires. Le présent point de pratique propose une approche thérapeutique des anomalies vasculaires pédiatriques les plus fréquentes (hémangiomes). On y passe en revue les indications de diriger les patients vers une clinique spécialisée, en s'attardant sur les anomalies vasculaires complexes, et notamment les hémangiomes infantiles, qui peuvent provoquer des complications.

Vascular anomalies in childhood: When to treat and when to refer

Vascular anomalies are heterogeneous conditions that affect blood and/or lymphatic vessels. Affected children may experience pain, functional loss, infection, coagulopathies, and psychological challenges. Diagnosis and management often warrant an interdisciplinary approach. There are seven vascular anomalies clinics in Canada that offer interdisciplinary care. This practice point outlines a treatment approach for the most common paediatric vascular anomaly (hemangioma). It reviews indications for referral to a specialized clinic, with focus on complex vascular anomalies, specifically infantile hemangioma, which can pose complications.

Infantile hepatic hemangiomas: looking backwards and forwards

Infantile hepatic hemangiomas (IHHs) are common benign tumors seen in the liver of infants. IHHs are true infantile hemangiomas (IHs) and have phases of proliferation and involution parallel to those of cutaneous IHs. The definition and classification of IHH are still confusing in the literature. The mechanisms during the pathogenesis of IHH have yet to be discovered. The clinical manifestations of IHH are heterogeneous. Although most IHH lesions are asymptomatic, some lesions can lead to severe complications, such as hypothyroidism, consumptive coagulopathy, and high-output congestive cardiac failure. Consequently, some patients can possibly encounter a fatal clinical condition. The heterogeneity of the lesions and the occurrence of disease-related comorbidities can make the treatment of IHH challenging. Oral propranolol is emerging as an effective systemic approach to IHH with obvious responses in tumor remission and symptom regression. However, the precise clinical characteristics and treatment strategies for patients with severe IHH have not yet been well established. Here, we summarize the epidemiology, pathogenic mechanism, clinical manifestations, diagnosis, and treatment of IHH. Recent updates and future perspectives for IHH will also be elaborated.

Infantile hemangiomas β3-adrenoceptor overexpression is associated with nonresponse to propranolol

BACKGROUND

Propranolol (antagonist of β₁-/β₂-AR but minimally active against β₃-AR) is currently the first-line treatment for infantile hemangiomas (IH). Its efficacy is attributed to the blockade of β₂-AR. However, its success rate is ~60%. Considering the growing interest in the angiogenic role of β₃-ARs, we evaluated a possible relationship between β₃-AR expression and response to propranolol.

METHODS

Fifteen samples of surgical biopsies were collected from patients with IH. Three were taken precociously from infants and then successfully treated with propranolol (responder group). Twelve were taken later, from residual lesions noncompletely responsive to propranolol (nonresponder group). A morphometrical analysis of the percentage of β₁-, β₂-, and β₃-ARs positively stained area was compared between the two groups.

RESULTS

While no difference was found in both β₁- and β₂-AR expression level, a statistically significant increase of β₃-AR positively stained area was observed in the nonresponder group.

CONCLUSIONS

Although the number of biopsies is insufficient to draw definitive conclusions, and the different β-AR pattern may be theoretically explained by the different timing of samplings, this study suggests a possible correlation between β₃-AR expression and the reduced responsiveness to propranolol treatment. This study could pave the way for new therapeutic perspectives to manage IH.

IMPACT

Propranolol (unselective antagonist of β₁ and β₂-ARs) is currently the first-line treatment for IHs, with a success rate of ~60%. Its effectiveness has been attributed to its ability to block β₂-ARs. However, β₃-ARs (on which propranolol is minimally active) were significantly more expressed in hemangioma biopsies taken from patients nonresponsive to propranolol. This study suggests a possible role of β₃-ARs in hemangioma pathogenesis and a possible new therapeutic target.

Intraosseous Venous Malformation of the Zygomatic Bone: Comparison between Virtual Surgical Planning and Standard Surgery with Review of the Literature

Intraosseous venous malformations affecting the zygomatic bone are infrequent. Primary reconstruction is usually accomplished with calvarial grafts, although the use of virtual surgical planning, cutting guides and patient-specific implants (PSI) have had a major development in recent years. A retrospective study was designed and implemented in patients diagnosed with intraosseous venous malformation during 2006–2021, and a review of the scientific literature was also performed to clarify diagnostic terms. Eight patients were treated, differentiating two groups according to the technique: four patients were treated through standard surgery with resection and primary reconstruction of the defect with calvarial graft, and four patients underwent resection and primary reconstruction through virtual surgical planning (VSP), cutting guides, STL models developed with CAD-CAM technology and PSI (titanium or Polyether-ether-ketone). In the group treated with standard surgery, 75% of the patients developed sequelae or morbidity associated with this technique. The operation time ranged from 175 min to 210 min (average 188.7 min), the length of hospital ranged from 4 days to 6 days (average 4.75 days) and the postoperative CT scan showed a defect surface coverage of 79.75%. The aesthetic results were “excellent” in 25% of the patients, “good” in 50% and “poor” in 25%. In the VSP group, 25% presented sequelae associated with surgical treatment. The operation time ranged from 99 min to 143 min (average 121 min), the length of hospital stay ranged from 1 to 2 days (average of 1.75 days) and 75% of the patients reported “excellent” results. Postoperative CT scan showed 100% coverage of the defect surface in the VSP group. The multi-stage implementation of virtual surgical planning with cutting guides, STL models and patient-specific implants increases the reconstructive accuracy in the treatment of patients diagnosed with intraosseous venous malformation of the zygomatic bone, reducing sequelae, operation time and average hospital stay, providing a better cover of the defect, and improving the precision of the reconstruction and the aesthetic results compared to standard technique.

Imaging of benign cervicofacial vascular anomalies and associated syndromes

Cervicofacial vascular anomalies can result in morbidity, pain, and cosmetic concerns in affected individuals. Each anomaly has its own unique natural history, treatment, and associations with underlying genetic syndromes. For optimal patient care, it is important for the neuroradiologist to accurately recognize and characterize these entities to ensure appropriate treatment and management. In this review, we discuss the general characteristics, classifications, and imaging features associated with the most common vascular anomalies such as hemangiomas, arteriovenous malformations and fistulas, capillary malformations, venous malformations, and lymphatic malformations in the context of associated syndromes. Additionally, we discuss novel imaging techniques that aid in identifying these vascular anomalies.

Vascular anomalies of the head and neck: diagnosis and treatment

Vascular malformations and vascular tumors comprise the two specific subsets of vascular anomalies that arise as a result of disorganized angiogenesis and neoplasm, respectively. Malformations are separate entities from vascular tumors (e.g., hemangiomas) and are recognized by the International Society for the Study of Vascular Anomalies (ISSVA) as such. Vascular malformations are classified into four main groups: simple, combined, anomalies of major vessels, and those associated with other vascular anomalies. Vascular tumors are neoplastic growths of blood vessels and are morphologically and molecularly distinct from malformations but can arise in the head and neck and have syndromic association. Head and neck vascular anomalies are not uncommon in the pediatric population and require special care in the workup, diagnostic imaging and clinical care. The purpose of this manuscript is to discuss the diagnosis and management of the most common intracranial and extracranial vascular malformations and tumors in the head and neck in children and adolescents.

PHACES Syndrome and Associated Anomalies: Risk Associated With Small and Large Facial Hemangiomas

OBJECTIVE. PHACES syndrome includes posterior fossa malformations, hemangioma, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities, and sternal defect with or without supraumbilical raphe. Usually, brain imaging is performed when facial hemangiomas are larger than 5 cm. Data on associated anomalies regardless of hemangioma size are sparse. The objective of this study was to determine, first, the prevalence of PHACES-like associated anomalies in a large sample of infants with all sizes of segmental facial or periorbital focal infantile hemangioma and, second, whether the cutaneous localization of the hemangioma correlates with the type of anomalies present. MATERIALS AND METHODS. The records of all patients of a vascular anomalies practice who had a diagnosis of segmental facial or periorbital focal infantile hemangioma and who had clinical photographs and brain MRI available were reviewed. The clinical photographs were reviewed to determine the localization by segment and lateralization. MRI was reviewed by two experienced pediatric radiologists. If present, cardiovascular anomalies, sternal defects, and eye anomalies were recorded. The criteria for definite and possible PHACES were used. RESULTS. The study included 122 children (90 girls, 32 boys; mean age, 16.6 months). Forty-five (36.9%) children had a facial infantile hemangioma larger than 5 cm. Twenty-two patients (18.0%) had PHACES or possible PHACES syndrome. Cerebrovascular structural anomalies were seen in 14 of 22 and brain anomalies in 6 of 22 patients with PHACES syndrome but in none and one of the patients in the group without PHACES (p < .001). Cardiovascular anomalies were seen in six patients and ocular anomalies in eight patients. All but one of them had PHACES syndrome. CONCLUSION. Clinical concern about associated extracutaneous anomalies is warranted for all children with facial segmental or periorbital focal infantile hemangiomas, including those with small hemangiomas. Further studies are needed to correlate cerebrovascular anomalies with the clinical evolution of hemangiomas and their effects on cerebral perfusion.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Congenital Disseminated Pyogenic Granuloma: Characterization of an Aggressive Multisystemic Disorder

OBJECTIVE

To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement.

STUDY DESIGN

We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included.

RESULTS

Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1.

CONCLUSIONS

Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement.

Neurosurgery in paediatric strokes

Paediatric strokes are a different entity owing to the difference in pathological entity causing the stroke as well as difficulty in treatment and management due to the presence of a growing brain and small vascular volume making surgery and endovascular intervention dangerous. Yet, the high neuronal plasticity coupled with unique surgical and endovascular procedures makes surgery in these conditions rewarding with improving morbidity and mortality statistics. The field is young and dynamic leading to constant change and updating. We attempt to review the current recommendations with our own experience in paediatric neurosurgery for paediatric strokes and present an overview of common conditions causing paediatric strokes. A brief review of the literature is also supplied for reference.

Risk factors for infantile hemangioma: a meta-analysis

BACKGROUND

Infantile hemangioma (IH) is one of the most common tumors in infants. Its pathogenesis is complex and poorly understood. The risk factors of IH have been extensively studied from clinical and epidemiological perspectives in recent years, but the conclusions in the literature reports are inconsistent. To provide a reference for the prevention of hemangioma, we conducted a meta-analysis of the published studies of potential risk factors for IH.

METHODS

The Cochrane Library, Ovid, PubMed, and Web of Science databases were searched systematically. Log odds ratios (log ORs), logistic regression standard errors and 95% confidence intervals (CIs) were used to compare the correlation between IH and potential risk factors. Review Manager 5.3.3 was used for the statistical analysis.

RESULTS

Six studies were included and 17 potential risk factors were eventually evaluated. P values < 0.05 were found for female gender (P < 0.01, OR 2.04, 95% CI 1.65-2.51), low birth weight (P < 0.01, OR 4.39, 95% CI 3.05-6.31), multiple gestation (P = 0.01, OR 2.39, 95% CI 1.21-4.71), preterm birth (P = 0.03, OR 2.37, 95% CI 1.07-5.23), progesterone therapy (P < 0.01, OR 2.73, 95% CI 2.12-3.51), and family history (P = 0.01, OR 1.98, 95% CI 1.16-3.38).

CONCLUSIONS

This meta-analysis revealed that risk factors, including female gender, low birth weight, multiple gestation, preterm birth, progesterone therapy, and family history may affect the occurrence of IH.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence‐based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence‐based guidelines for the management of vascular anomalies.

Benign vascular anomalies: A transition from morphological to etiological classification

The International Society for the Study of Vascular Anomalies (ISSVA) devised a multidisciplinary etiopathogenesis based approach to classify benign vascular anomalies into tumors and malformations. This classification scheme has major therapeutic and prognostic implications as treatment modalities differ for both the categories. Inappropriate usage of the term "hemangioma" for etiopathogenetically distinct entities is commonly seen in clinical practice leading to delivery of incorrect treatment to the patients. We aimed to study the histomorphological and immunohistochemical features of benign vascular anomalies for their precise histopathological classification. A total of 48 cases diagnosed over a period of 3.5 years were reviewed and reclassified into vascular tumors and malformations based on ISSVA classification and prototypical histopathological features. Biopsies were reviewed based on 5 histopathological criteria viz. endothelial morphology, mitotic activity, intralesional nerve bundles, intralesional inflammation, and prominent vessel type. A panel of GLUT-1, WT-1, and Ki-67 was performed in each case. Seven cases of infantile hemangioma, 4 cases each of non-involuting congenital hemangioma and pyogenic granuloma, and 33 cases of vascular malformations were diagnosed. Endothelial cell morphology (p < 0.001), mitotic activity (p < 0.001), and intralesional nerve bundles (p < 0.001) were found to be statistically significant in differentiating hemangioma from malformations. GLUT-1 (p < 0.001) and Ki-67 labeling index (p < 0.001) were useful to distinguish infantile hemangioma from vascular malformations. To conclude, the ISSVA classification of benign vascular anomalies can be reliably done on histopathology. However, every case must be interpreted in the light of clinical and radiological features.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Conventional ultrasonography and elastography for the diagnosis of congenital and infantile hemangiomas

Infantile and congenital hemangiomas are difficult to distinguish in infants. The aim of this study was to compare the conventional ultrasonographic (US) and elastographic features of infantile and congenital hemangiomas. The US findings in 118 patients with congenital hemangioma (58 non-involuting, 36 rapidly involuting, 24 partially involuting) and 111 with 120 infantile hemangioma were retrospectively evaluated. On US imaging, 31.7% of infantile hemangiomas were hyperechoic, 31.7% hypoechoic and 36.6% mixed-echoic with hyperechoic and hypoechoic areas; 57.6% of congenital hemangiomas were mixed-echoic with a hypoechoic area and many vessels visible, 39.0% hypoechoic and 3.4% were mixed-echoic with hyperechoic and hypoechoic area. Calcifications were present in 6.8% and visible vessels involving muscle in 24.6% of congenital hemangiomas. All infantile hemangiomas and 82.2% of congenital hemangiomas were well-defined. All congenital hemangiomas were subcutaneous whereas 17.5% of the infantile hemangiomas were superficial. The maximum diameter and vascular density were greater in congenital hemangiomas. Elastography demonstrated that the congenital hemangiomas were softer than the infantile hemangiomas. The maximum diameter (including of visible vessels), thickness, vascular density, venous blood flow velocity and elasticity scores were greater for rapidly and partially involuting congenital hemangiomas than for non-involuting ones. The density of visible vessels in congenital hemangiomas decreased in the order of non-involuting, partially involuting and rapidly involuting. In conclusion, congenital hemangiomas have distinctive US imaging characteristics, including a greater maximum diameter, vascular density, number of visible vessels, visible vessels involving muscle, calcifications and elasticity score.

A case series of tardive expansion congenital hemangioma: A variation of noninvoluting congenital hemangioma or a new hemangiomatous entity?

BACKGROUND

Congenital hemangiomas present fully grown at birth and share a remarkably similar lack of disproportionate or accelerated postnatal proliferation.

OBJECTIVE

We report a series of unusual congenital hemangiomas that arise prenatally and initially exhibit a proportional growth pattern similar to that of noninvoluting congenital hemangioma. However, a tardive expansion of the lesion, similar to the proliferation phase of infantile hemangioma, occurs later during childhood.

METHODS

A total of 11 unusual congenital hemangiomas were reviewed in regard to clinical presentation, imaging, and pathologic characteristics.

RESULTS

The infants included 9 boys and 2 girls. The tumors were located in the head and neck (n=10) and abdominal wall (n=1). Spontaneous expansion began at the age of 12 months to 61 months, as determined from clinic notes and paired follow-up photographs. Uniform parenchymal masses and fast-flow vessels were confirmed by imaging examination. There are both histopathological overlap and distinction between these lesions and other congenital hemangiomas.

LIMITATIONS

Only a small number of cases were identified.

CONCLUSION

We propose that these lesions be denominated "tardive expansion congenital hemangioma (TECH)" to indicate their specific clinical and histological distinctiveness. Recognition of these distinct lesions will contribute to a better understanding of congenital hemangiomas.

Childhood Vascular Tumors

Vascular tumors in pediatric patients are an important entity for the clinician to recognize and correctly diagnose. They may present at birth or develop at any point during infancy, childhood, or adolescence. Most are benign, but even benign lesions may have significant morbidity without proper intervention. Malignant vascular tumors are also rarely seen in the pediatric population, and may be associated with various syndromes.

Elevated eosinophil levels observed in infantile hemangioma patients from Kaifeng, China

Infantile hemangioma (IH) is one of the most common soft-tissue neoplasms of infancy. Although clinical diagnosis for IH is well-established, the haematological parameters associated with IH are not well explored. In this short study, we observed significantly higher eosinophil (EO) numbers in IH patient blood compared to healthy controls. This contributed to the observed higher EO % in the peripheral blood of IH patients and was irrespective of age. This new haematological finding could carry a potential diagnostic/prognostic relevance for IH.

Management of a Large Congenital Hemangioma Obstructing Visual Axis: A Case Report and Review of Literature

Congenital hemangiomas comprise a subset of vascular tumors with clinicopathologic features that are distinct from the more common infantile hemangioma. The authors present a patient with a large congenital hemangioma involving the forehead and brow which obstructed the visual axis and created significant risk for deprivational amblyopia. Management of the congenital hemangioma involved customized headgear to clear the visual axis and early vascular embolization of feeder vessels with the subsequent successful surgical resection at 23 days of life.A large amblyogenic congenital hemangioma required a multidisciplinary approach involving early vascular embolization of feeder vessels and subsequent surgical resection at 23 days of life.

Expression of (pro)renin receptor and its effect on endothelial cell proliferation in infantile hemangioma

BACKGROUND

Propranolol is the preferred treatment for problematic proliferating infantile hemangioma (IH) by targeting the renin-angiotensin system (RAS) expressed by IH endothelium. (Pro)renin receptor (PRR) is a major component of the RAS associated with the canonical wnt signaling pathway. We proposed that activation of PRR by renin causes proliferation of IH.

METHODS

The expression of PRR in IH tissue samples was investigated using immunohistochemical (IHC) staining and NanoString analysis. NanoString analysis was also used to confirm transcriptional expression of PRR in CD34-sorted proliferating IH-derived primary cell lines. MTT assay was utilized to determine the effect of exogenous renin on the number of viable IH cells. RT-qPCR was used to determine the effect of renin on the stem cell gene expression.

RESULTS

NanoString analysis and IHC staining confirmed transcriptional and translational expression of PRR, which was localized to the non-endothelial and the endothelial IH cell populations. MTT assay demonstrated an increased number of viable IH cells by administration of renin and the effect was negated by the wnt receptor blocker dickkopf-1.

CONCLUSION

Our results present a model for renin-induced increased proliferation of IH cells through PRR acting via the wnt signaling pathway, which may account for accumulation of cells in IH during the proliferative phase of the tumor.

Non-involuting congenital hemangiomas (NICH) with postnatal atypical growth: A case series

BACKGROUND

Non-involuting congenital hemangiomas (NICH) are fully formed vascular tumors at birth, with a distinctive clinical, radiologic, and histopathological profile, and classically lack expansion or involution over time. We describe a series of NICH cases with atypical postnatal growth.

METHODS

The authors retrospectively analyzed all NICH cases diagnosed from 2007 to 2017. We reviewed charts and photographic databases from our Vascular Anomalies Clinic. We included in the study all NICH with an atypical postnatal growth. Clinical data, imaging, and histopathology were analyzed.

RESULTS

Eighty cases of NICH were identified. Nine presented with atypical postnatal growth after a stable period, at ages from 2 to 10 years (mean: 5.3 years). Two patients had associated pain; 5 patients showed new red papules on the surface of the lesion; 2 reported bleeding from the papules; and 1 developed a pyogenic granuloma. All patients had Doppler ultrasound and/or MRI compatible with NICH, and a confirmatory biopsy was performed in 4 cases. In treatment, 2 patients received endovascular embolization, and one required further surgery.

CONCLUSIONS

Non-involuting congenital hemangiomas (NICH) may develop significant postnatal growth over time (10% in our series), requiring closer follow-up for longer periods. The development of red papules, pyogenic granulomas, and superficial bleeding may be observed. Since this is a small series, we were not able to establish risk factors for NICH with postnatal growth.

Abnormal hemostasis in children with vascular anomalies, part I: Thrombocytopenias among different vascular anomalies

Long before the classification of vascular anomalies from the International Society for the Study of Vascular Anomalies (ISSVA) provided a framework to differentiate vascular anomalies, otherwise known as vascular birthmarks, it was recognized that patients with such lesions can present with acute life-threatening hemostatic and/or thrombotic complications, as well as chronic long-standing bleeding or thrombotic issues. Scenarios such as a rapidly growing vascular lesion with severe acute thrombocytopenia, a visceral hemorrhagic lesion, a lesion associated with repetitive and painful superficial thrombosis, and cases of unprovoked or post-procedural fatal pulmonary embolism highlight the wide spectrum of manifestations of abnormal coagulation in patients with vascular anomalies. The separation of vascular anomalies into two distinct groups, vascular tumors and vascular malformations, was followed by the characterization that their respective coagulopathies were due to either a derangement of platelets or to a disequilibrium of the patient's coagulation/fibrinolytic process. This configuration of coagulopathies will be the foundation for this two-chapter review series. In the initial review, coagulopathies where thrombocytopenia is the main feature will be characterized, whereas the second review will focus on vascular malformations that have a coagulation disorder secondary to some degree of coagulation consumption and/or fibrinolytic pathway derangement.

[Infantile haemangioma: an update]

Infantile haemangioma (IH) are the most frequent skin tumors in childhood. The diagnosis is usually established from the clinical picture and typical course of growth. Sectional imaging procedures are indicated in segmental, especially facial haemangiomas. The vast majority of IH are uncomplicated and do not require any treatment. In complicated IH, treatment should be initiated as soon as possible in order to avoid permanent damage. Propranolol is the treatment of choice for complicated IH.

Congenital cutaneous pyogenic granuloma: Report of two cases and review of the literature

Congenital cutaneous pyogenic granuloma is a rare benign vascular tumor with clinical and histopathological features similar to infantile hemangioma. It usually presents as a red, pedunculated and highly friable papule. On histopathological analysis, one can see a capillary vessel proliferation with lobular pattern and endothelial proliferation. The differential diagnosis is based on negativity of glucose transporter 1 (GLUT1) immunochemistry studies. We report two infants with congenital pyogenic granuloma, one with a unique cutaneous lesion and the other with multiple lesions affecting both skin and mucosal surfaces. These two cases highlight the importance of the differential diagnosis based on the GLUT1 immunochemistry analysis considering the distinct treatments required to these infant vascular tumors.

Vascular tumors in infants and adolescents

Malignant vascular tumors as part of the vascular anomalies spectrum are extremely rare in children and young adults. Instead, benign vascular neoplasias are frequently encountered in the pediatric patient population. While vascular malformations are congenital vascular lesions, originating from a mesenchymal stem cell defect, vascular tumors are neoplastic transformations of endothelial and other vascular cells. The appropriate differential diagnosis and nomenclature according to the classification of the International Society for the Study of Vascular Anomalies (ISSVA) is decisive to initiate correct therapy. While infantile hemangioma can be routinely diagnosed by clinical means and rarely require therapy, more rare vascular tumors are frequently difficult to diagnose, require dedicated cross-sectional imaging, and benefit from an interdisciplinary treatment approach. The focus of this review is to provide an overview over the spectrum of vascular tumors, typical imaging characteristics, and summarize treatment options including interventional radiology approaches.

Multifocal congenital pyogenic granuloma successfully treated with oral propranolol

Disseminated congenital pyogenic granuloma (DCPG) is an uncommon condition. Individual lesions of DCPG share clinical and histologic similarities with infantile hemangioma (IH); endothelial glucose transporter 1 (GLUT-1), which is highly expressed in IH but generally not in pyogenic granulomas (PG), is an important diagnostic tool. Treatment for DCPG remains difficult. We describe a case of DCPG effectively treated with propranolol.

Guidance Document for Hepatic Hemangioma (Infantile and Congenital) Evaluation and Monitoring

OBJECTIVE

To define the types of hepatic hemangiomas using the updated International Society for the Study of Vascular Anomalies classification and to create a set of guidelines for their diagnostic evaluation and monitoring.

STUDY DESIGN

We used a rigorous, transparent consensus protocol defined by an approved methodology, with input from multiple pediatric experts in vascular anomalies from hematology-oncology, surgery, pathology, radiology, and gastroenterology.

RESULTS

In the first section, we define the subtypes of hepatic hemangiomas based on the clinical course, histology, and radiologic characteristics. We recommend against using the term "hemangioma" for any vascular malformations affecting the liver or any hypervascular tumors that are not characterized by the approved definitions. We recommend against using the term "hemangioendothelioma" for infantile or congenital hemangioma. The following 2 sections dedicated to infantile hepatic hemangioma and to congenital hepatic hemangioma individually describe these subtypes in further detail, including complications to be considered during monitoring and respectively recommended screening evaluations.

CONCLUSIONS

Although institutional variations may exist for specific clinical details, a clear understanding of the diagnosis of hepatic hemangiomas affecting children and the possible complications that require screening during the monitoring period should be standard. As children with hepatic hemangiomas are managed by different medical and surgical specialties, we offer an expert opinion multidisciplinary consensus based on current literature and on data extracted from the liver hemangioma registry.

Classification and Pathology of Congenital and Perinatal Vascular Anomalies of the Head and Neck

Accurate histopathologic description in correlation with clinical and radiological evaluation is required for treatment of vascular anomalies, both neoplastic and malformative. It is important to examine current clinical, histologic, and immunophenotypical features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck. General discussions of pathogenesis and molecular diagnosis must also be taken into account. This article provides an overview of the features that distinguish the major types of congenital and perinatal vascular anomalies affecting the head and neck, and summarizes the diagnostic histopathologic criteria and nomenclature currently applied to these lesions.

Classification of Vascular Anomalies: An Update

Vascular anomalies present both a diagnostic and therapeutic challenge to physicians. Identification of these lesions is difficult due to their immense phenotypic variability, and naming conventions for vascular anomalies have historically been inconsistent. Terms such as "hemangioma" are informative when used correctly, but can cause confusion and miscommunication if applied indiscriminately to all vascular anomalies. Accuracy in classification is essential, as both disease course and therapeutic options differ greatly depending on the particular vascular anomaly present. In order for clinicians to properly diagnose and treat patients with these diseases, a unified nomenclature must be employed. This section provides an update on the current classification of vascular anomalies, with clinical descriptions of the most commonly encountered lesions, and clarifies the ambiguous nomenclature present in the existing literature.

The expression of renin-angiotensin-aldosterone axis components in infantile hemangioma tissue and the impact of propranolol treatment

BackgroundPropranolol's mechanism of action for controlling infantile hemangioma (IH) remains unclear. We hypothesize that this nonselective beta antagonist downregulates renin-angiotensin-aldosterone (RAA) axis components, preventing angiogenic substrate induction of IH.MethodsIH tissue and serum were collected from children with propranolol-treated or -untreated IH during surgery. Normal skin and serum from demographically matched children were used as controls. Real-time PCR and western blot quantified RAA components in proliferative (n=10), involuting (n=10), propranolol-treated (n=12) IH, and normal specimens (n=11). Serum was analyzed by enzyme-linked immunosorbent assay (ELISA).ResultsThere were significantly greater messenger RNA (mRNA) levels of angiotensinogen (AGT) in proliferating IH, but not in involuting or treated IH, when compared with controls (P<0.05). Angiotensin-converting enzyme (ACE) and angiotensin II receptor 1 (AGTR1) mRNA expression was higher in all IH specimens when comparedwith controls (P<0.05). ACE and AGTR1 protein expression was greater in proliferating IH tissue compared with that in controls and in involuting and treated IH tissue (P<0.05). ELISA showed no significant difference in ACE serum levels but did show a significant reduction in renin in involuting compared with proliferating IH (P<0.05).ConclusionsThe protein and mRNA expression of several RAA pathway constituents is elevated in IH tissue when compared with that in normal tissue. The action of propranolol on IH may be the result of reductions in ACE and AGTR1.

Arrested Development: Infantile Hemangioma and the Stem Cell Teratogenic Hypothesis

BACKGROUND

Early-life programming is defined by the adaptive changes made by the fetus in response to an adverse in utero environment. Infantile hemangioma (IH), a vascular anomaly, is the most common tumor of infancy. Here we take IH as the tumor model to propose the stem cell teratogenic hypothesis of tumorigenesis and the potential involvement of the immune system.

OBJECTIVES

Teratogenic agents include chemicals, heavy metals, pathogens, and ionizing radiation. To investigate the etiology and pathogenesis of IH, we hypothesized that they result from a teratogenic mechanism. Immature, incompletely differentiated, dysregulated progenitor cells (multipotential stem cells) are arrested in development with vasculogenic, angiogenic, and tumorigenic potential due to exposure to teratogenic agents such as extrinsic factors that disrupt intrinsic factors via molecular mimicry. During the critical period of immunological tolerance, environmental exposure to immunotoxic agents may harness the teratogenic potential in the developing embryo or fetus and modify the early-life programming algorithm by altering normal fetal development, causing malformations, and inducing tumorigenesis. Specifically, exposure to environmental agents may interfere with physiological signaling pathways and contribute to the generation of IH, by several mechanisms.

DISCUSSION

An adverse in utero environment no longer serves as a sustainable environment for proper embryogenesis and normal development. Targeted disruption of stem cells by extrinsic factors can alter the genetic program.

CONCLUSIONS

This article offers new perspectives to stimulate discussion, explore novel experimental approaches (such as immunotoxicity/vasculotoxicity assays and novel isogenic models), and to address the questions raised to convert the hypotheses into nontoxic, noninvasive treatments.

Up-To-Date Practical Imaging Evaluation of Neonatal Soft-Tissue Tumors: What Radiologists Need to Know

OBJECTIVE

The purposes of this article are to provide an up-to-date overview of neonatal soft-tissue tumors, including information regarding their unique nature, and to present practical imaging techniques and characteristic imaging findings.

CONCLUSION

Neonatal soft-tissue tumors are a unique set of neoplasms that often have characteristic clinical and imaging findings. Imaging evaluation, mainly with ultrasound and MRI, plays an important role in the initial diagnosis, staging, preoperative assessment, and follow-up evaluation. Clear understanding of practical imaging techniques combined with up-to-date knowledge of characteristic imaging findings can help the radiologist provide a timely and accurate diagnosis of these neoplasms and can lead to optimal neonatal patient care.

Immunolocalization of substance P and NK-1 receptor in vascular anomalies

The peptide substance P (SP) shows a widespread distribution in both the central and peripheral nervous systems, but it is also ubiquitous in the human body. After binding to the neurokinin-1 (NK-1) receptor, SP regulates tumoral angiogenesis and proliferation. Thus, knowledge of this system is the key for a better understanding and, hence, a better management of many human diseases, including vascular anomalies (VA). This study aims to examine the expression and localization of both SP and the NK-1 receptor in different vascular anomalies using an immunohistochemical technique. Our results demonstrated predominantly nuclear localization of SP in venous malformations and in one haemangioma sample, in contrast with cytoplasmic expression in capillary malformations and rapidly involuting congenital hemangioma (RICH). NK-1 receptor showed a cytoplasmic localization in all VA. In summary, all these findings demonstrate that SP and NK-1 receptor are expressed in VA, with different expression patterns depending on the nature of the anomaly, suggesting that they could play an important role in the pathogenesis of VA.

Phosphoinositide 3-kinase: a new kid on the block in vascular anomalies

Vascular anomalies are broadly divided into vascular tumours and malformations. These lesions are composed of abnormal vascular elements of various types, and mainly affect infants, children, and young adults. Vascular anomalies may be painful, may be complicated by bleeding, infection, or organ dysfunction, and can have secondary effects on other tissues. Current treatment strategies include surgical excision, pulsed laser, and sclerotherapy, which are invasive, with risks of recurrence. There are growing pharmacological options for these vascular anomalies, but, to date, no specific targeted therapies have been developed. Phosphoinositide 3-kinases (PI3Ks) constitute a family of lipid kinases that are involved in signal transduction and vesicular traffic, and that modulate important cellular processes such as proliferation, growth, and migration. Recent findings have indicated that the PI3K signalling pathway is important in the pathogenesis of vascular anomalies. This provides an opportunity to use PI3K inhibitors, which are in clinical trials for cancer treatment, for such lesions. Here, we provide an update on the classification of vascular anomalies, with their major features, and discuss the role of the PI3K signalling pathway in the pathogenesis of vascular anomalies, and their clinical implications and therapeutic opportunities. Copyright © 2016 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Management of Orbital and Periocular Vascular Anomalies

PURPOSE

To review the treatment modalities available to clinicians who treat orbital and periocular vascular anomalies, with a focus on newer approaches.

METHODS

The authors' experience, along with a literature review, was used to provide a concise summary of the available approaches to the treatment of periocular vascular anomalies. Emerging diagnostic tools and therapies are highlighted.

RESULTS

The treatment of orbital and periocular vascular anomalies, including vascular malformations and tumors, increasingly utilizes a multidisciplinary team and a combination of endovascular, percutaneous, and open surgical techniques.

CONCLUSIONS

A growing reliance on new instrumentation and tools in a team-oriented approach to treatment may lead to better results with improved visual function and cosmesis and with reduced risk of complications.

Does hypoxia play a role in infantile hemangioma?

Infantile hemangioma (IH), the most common tumor of infancy, is characterized by rapid growth during infancy, followed by spontaneous involution over 5-10 years. Certain clinical observations have led to the suggestion that IH is triggered and maintained by hypoxia. We review the literature on the possible role of hypoxia in the etiology of IH, in particular, (1) the role of hypoxia inducible factor-1α (HIF-1α) and its downstream targets including GLUT-1 and VEGF; (2) the pathophysiological link between IH and retinopathy of prematurity; (3) hypoxic events in the early life including placental insufficiency, pre-eclampsia and low birthweight that have the potential to promote hypoxic stress; and (4) the evidence supporting the development of IH independent of HIF-1α. We also discuss these observations in the context of recent evidence of the crucial role of stem cells and the cytokines niche that governs their proliferation and inevitable differentiation, offering novel insights into the biology of IH. We propose that various triggers may simultaneously up-regulate HIF-1α, which is downstream of the renin-angiotensin system, specifically angiotensin II, which promotes production of HIF-1α. These developments shed light to the understanding of this enigmatic condition.

Elevated Serum Levels of Alpha-Fetoprotein in Patients with Infantile Hemangioma Are Not Derived from within the Tumor

Aims

The embryonic-like stem cell origin of infantile hemangioma (IH) and the observed elevated serum levels of alpha-fetoprotein (AFP) in patients with hepatic IH led us to investigate if this tumor was the source of AFP.

Materials and methods

We measured serial serum levels of AFP in patients with problematic proliferating IH treated with surgical excision or propranolol treatment. We also investigated the expression of AFP in extrahepatic IH samples using immunohistochemical staining, mass spectrometry, NanoString gene expression analysis, and in situ hybridization.

Results

Serum levels of AFP normalized following surgical excision or propranolol treatment. Multiple regression analysis for curve fittings revealed a different curve compared to reported normal values in the general populations. AFP was not detected in any of the IH samples examined at either the transcriptional or translational levels.

Conclusion

This study demonstrates the association of proliferating IH with elevated serum levels of AFP, which normalized following surgical excision or propranolol treatment. We have shown that IH is not the direct source of AFP. An interaction between the primitive mesoderm-derived IH and the endogenous endodermal tissues, such as the liver, via an intermediary, may explain the elevated serum levels of AFP in infants with extrahepatic IH.

Pulsed dye laser and topical timolol gel versus pulse dye laser in treatment of infantile hemangioma: A double-blind randomized controlled trial

Background:

Infantile hemangioma (IH) is the most common tumor during infancy that usually appears as macular and gradually becomes a plaque or tumor. Approximately, 20% of all IH cases results in adverse effects and the Pulsed dye laser (PDL) 585 nm is a vascular laser leading to selective the micro vascular damage. Results of studies on non-selective B-blockers (e.g., timolol) indicate their effectiveness in preventing hemangioma growth. The aim of this study is a comparison of PDL plus timolol and PDL in the treatment of IH.

Materials and Methods:

This double-blind study was carried out on 30 infants (1-12 months old) and the patients were divided into two groups. Group A was treated with the four sessions PDL and the timolol gel 0.05% and Group B with PDL.

Results:

There were no differences in the mean age of patients for the diagnosis of hemangioma (Group A: 32.69 ± 24.64 days, Group B: 25.69 ± 21.16 days, P = 0.39) and the mean age at the start of the treatment (Group A: 148.125 ± 85.88 days, Group B: 146.25 ± 60.87 days, P = 0.94). There were a statistical difference in the mean of lesion size reduction (Group A: 17.62 ± 6.97 cm and Group B: 12 ± 5.71 cm, P = 0.018), mean percentage change in size mean (Group A: 71079 ± 23.41% and Group B: 54.59 ± 25.46%, P = 0.050) visual analog scale (Group A: 7.19 ± 1.51, Group B: 5.62 ± 1.78, P = 0.012) after treatment. There was no correlation between the time of beginning the treatment and the results (P = 0.857).

Conclusions:

Application of timolol with PDL is accompanied by the highest efficacy, cost benefits and the short time of treatment.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Vascular Anomalies in Pediatrics

A standardized classification system allows improvements in diagnostic accuracy. Multidisciplinary vascular anomaly centers combine medical, surgical, radiologic, and pathologic expertise. This collaborative approach tailors treatment and management of vascular anomalies for affected individuals.