Intralesional bleomycin injection (IBI) treatment for haemangiomas and congenital vascular malformations

Efficacy of Bleomycin Intralesional Injection for Treating Digital Mucous Cysts: A Comparative Study of Corticosteroid Intralesional Injection and Surgical Excision

BACKGROUND

Sclerotherapy has shown superior efficacy among the nonsurgical options for managing digital mucous cysts (DMC). Notably, previous research has indicated that bleomycin offers a more favorable side-effect profile and similar efficacy to conventional sclerosing agents.

OBJECTIVE

This study aimed to assess the efficacy and safety of bleomycin intralesional injection (ILI) for treating DMC through a comparative analysis of corticosteroid ILI and surgical excision.

METHODS

We retrospectively reviewed electronic medical records and clinical photographs. Telephone interviews were conducted to further investigate long-term treatment efficacy, safety, and overall treatment satisfaction.

RESULTS

Ten patients underwent surgical excision, and 13 and 15 patients received bleomycin and corticosteroid ILI, respectively. Both surgical excision and bleomycin ILI demonstrated superior treatment efficacy compared to corticosteroid ILI. No statistically significant difference in the treatment effectiveness between surgical excision and bleomycin ILI was observed. No significant adverse effects were observed. In the survey, the level of satisfaction was the highest for bleomycin ILI, followed by surgical excision and corticosteroid ILI.

CONCLUSION

This study revealed that bleomycin ILI exhibits a treatment efficacy higher than that of corticosteroid ILI and slightly lower than that of surgical excision, without any side effects. Therefore, bleomycin ILI is a safe and effective therapeutic option for the treatment of DMC.

Elucidating the crosstalk between endothelial-to-mesenchymal transition (EndoMT) and endothelial autophagy in the pathogenesis of atherosclerosis

Atherosclerosis, a chronic systemic inflammatory condition, is implicated in most cardiovascular ischemic events. The pathophysiology of atherosclerosis involves various cell types and associated processes, including endothelial cell activation, monocyte recruitment, smooth muscle cell migration, involvement of macrophages and foam cells, and instability of the extracellular matrix. The process of endothelial-to-mesenchymal transition (EndoMT) has recently emerged as a pivotal process in mediating vascular inflammation associated with atherosclerosis. This transition occurs gradually, with a significant portion of endothelial cells adopting an intermediate state, characterized by a partial loss of endothelial-specific gene expression and the acquisition of "mesenchymal" traits. Consequently, this shift disrupts endothelial cell junctions, increases vascular permeability, and exacerbates inflammation, creating a self-perpetuating cycle that drives atherosclerotic progression. While endothelial cell dysfunction initiates the development of atherosclerosis, autophagy, a cellular catabolic process designed to safeguard cells by recycling intracellular molecules, is believed to exert a significant role in plaque development. Identifying the pathological mechanisms and molecular mediators of EndoMT underpinning endothelial autophagy, may be of clinical relevance. Here, we offer new insights into the underlying biology of atherosclerosis and present potential molecular mechanisms of atherosclerotic resistance and highlight potential therapeutic targets.

Percutaneous microwave ablation versus sclerotherapy for large hepatic hemangioma: a multi-center cohort study

OBJECTIVE

The study aimed to compare the effectiveness and safety of ultrasound-guided microwave ablation (MWA) and percutaneous sclerotherapy (PS) for the treatment of large hepatic hemangioma (LHH).

METHODS

This retrospective study included 96 patients who underwent MWA (n = 54) and PS (n = 42) as first-line treatment for LHH in three tertiary hospitals from January 2016 to December 2021. Primary outcomes were technique efficacy rate (volume reduction rate [VRR] > 50% at 12 months), symptom relief rate at 12 months and local tumor progression (LTP). Secondary outcomes included procedure time, major complications, treatment sessions, cost and one-, two-, three-year VRR.

RESULTS

During a median follow-up of 36 months, the MWA group showed a higher technique efficacy rate (100% vs. 90.4%, p = .018) and symptom relief rate (100% vs. 80%, p = .123) than the PS group. The MWA group had fewer treatment sessions, higher one-, two- and three-year VRR, lower LTP rate (all p < .05), longer procedure time and higher treatment costs than the PS group (both p < .001). MWA shared a comparable major complications rate (1.8% vs. 2.4%, p = .432) with PS. After multivariate analysis, the lesion's heterogeneity and maximum diameter >8.1 cm were independent risk factors for LTP (all p < .05). In the PS group, lesions with a cumulative dose of bleomycin > 0.115 mg/cm3 had a lower risk of LTP (p = .006).

CONCLUSIONS

Both MWA and PS treatments for large hepatic hemangioma are safe and effective, with MWA being superior in terms of efficacy.

Percutaneous Sclerotherapy of Large Venous Malformations Using Consecutive Polidocanol and Bleomycin Foam: MR Imaging Volumetric and Quality-of-Life Assessment

PURPOSE

To retrospectively evaluate sclerotherapy using consecutive polidocanol and bleomycin foam (CPBF) for large untreated venous malformations (VMs) and/or those resistant to prior treatment.

MATERIALS AND METHODS

This retrospective study included all patients treated with CPBF for untreated VMs larger than 10 mL and/or refractory to treatment between May 2016 and October 2019. Baseline and follow-up VM volumes were measured on fat-suppressed T2-weighted magnetic resonance (MR) imaging. Outcome was evaluated on postprocedural MR imaging volumetry and by a retrospective survey assessing clinical response and adverse events. Imaging response was considered good for volume reduction from 50% to 70% and excellent for volume reduction ≥70%. Symptoms and quality-of-life (QoL) scores were compared before and after CPBF sclerotherapy.

RESULTS

Forty-five patients (mean age, 16 years; range, 1-63 years; 25 males) with 57 VMs were analyzed and treated by 80 sclerotherapy. Sixty percent (27 of 45) of patients had undergone prior treatment for VM. Median VM volume was 36.7 mL (interquartile range, 84 mL) on pretherapy MR imaging. Good and excellent results after the last sclerotherapy were achieved in 36% (16 of 45) and 29% (13 of 45) of patients, respectively, corresponding to a decrease of >50% in 60% (34 of 57) of VMs. QoL score increased by at least 3 points, regardless of initial symptoms. Most patients did not desire additional sclerotherapy owing to near complete symptomatic relief, even for patients who did not achieve a good response. Swelling, pain, and motor impairment scores significantly improved after CPBF. Adverse events included fever (44%, 15 of 34) and nausea/vomiting (29%, 10 of 34).

CONCLUSIONS

CPBF sclerotherapy represents an effective therapy for large and/or refractory VMs with minimal adverse events.

Clinical outcomes and predictors of bleomycin polidocanol foam sclerotherapy treatment response in venous malformations

OBJECTIVE

To evaluate the safety and efficacy of bleomycin polidocanol foam (BPF) sclerotherapy for venous malformations (VMs) and analyze the associated clinical outcomes and predictors.

METHODS

We retrospectively assessed BPF sclerotherapy outcomes in 138 patients with VMs. We analyzed pain levels, lesion volume reduction, and subjective perception of response. Logistic regression analysis was performed to identify potential predictors of treatment outcome. Additionally, we carefully monitored and recorded complications.

RESULTS

There was a notable average reduction in lesion volume by 78.50% ± 15.71%. The pain numerical rating scale (NRS) score decreased from 4.17 ± 2.63 prior to treatment to 1.05 ± 1.54 afterward, and 70.3% of the patients experienced effective relief after a single BPF treatment. Multivariate analysis revealed that a high baseline NRS (odds ratio [OR]:  4.026) and elevated activated partial thromboplastin time (APTT, OR: 1.200) were positive predictors of pain reduction. Additionally, a high baseline NRS score (OR: 1.992) and elevated thrombocytocrit (PCT, OR: 2.543) were positive predictors of incomplete postoperative pain relief. Minor complications occurred in 31 (22.46%) patients.

CONCLUSION

BPF sclerotherapy is safe and effective for VMs, resulting in significant reduction in lesion volume, improved symptoms, and minimal complications. APTT and PCT levels are important predictors of pain outcomes following BPF treatment.

Evaluation of lung protection of Sanghuangporus sanghuang through TLR4/NF-κB/MAPK, keap1/Nrf2/HO-1, CaMKK/AMPK/Sirt1, and TGF-β/SMAD3 signaling pathways mediating apoptosis and autophagy

Idiopathic pulmonary fibrosis (IPF) is a type of interstitial pneumonia characterized by chronic and progressive fibrosis with an unknown etiology. Previous pharmacological studies have shown that Sanghuangporus sanghuang possesses various beneficial properties including immunomodulatory, hepatoprotective, antitumor, antidiabetic, anti-inflammatory, and neuroprotective effects. This study used a bleomycin (BLM)-induced IPF mouse model to illustrate the possible benefits of SS in ameliorating IPF. BLM was administered on day 1 to establish a pulmonary fibrosis mouse model, and SS was administered through oral gavage for 21 d. Hematoxylin and eosin (H&E) and Masson's trichrome staining results showed that SS significantly reduced tissue damage and decreased fibrosis expression. We observed that SS treatment resulted in a substantial lowering in the level of pro-inflammatory cytokines like TGF-β, TNF-α, IL-1β, and IL-6 as well as MPO. In addition, we observed a notable increase in glutathione (GSH) levels. Western blot analysis of SS showed that it reduces inflammatory factors (TWEAK, iNOS, and COX-2), MAPK (JNK, p-ERK, and p-38), fibrosis-related molecules (TGF-β, SMAD3, fibronectin, collagen, α-SMA, MMP2, and MMP9), apoptosis (p53, p21, and Bax), and autophagy (Beclin-1, LC3A/B-I/II, and p62), and notably increases caspase 3, Bcl-2, and antioxidant (Catalase, GPx3, and SOD-1) levels. SS alleviates IPF by regulating the TLR4/NF-κB/MAPK, Keap1/Nrf2/HO-1, CaMKK/AMPK/Sirt1, and TGF-β/SMAD3 pathways. These results suggest that SS has a pharmacological activity that protects the lungs and has the potential to improve pulmonary fibrosis.

Foam Sclerotherapy in the Treatment of Hemangiomas and Venous Malformations

BACKGROUND

Sclerotherapy has achieved great success in treating most venous malformation (VM) lesions.

OBJECTIVE

To compare the effects of foam sclerotherapy on infantile hemangioma and pyogenic granuloma (PG). In addition, we analyzed the data and outcomes of foam sclerotherapy for the VM.

MATERIALS AND METHODS

Thirty-nine patients with hemangiomas and 83 patients with VMs were treated, and clinical outcomes, resolution, and complication rates were compared. Sclerotherapy data from the VM group were also analyzed.

RESULTS

The average age of the patients and the distribution and tissue involvement of lesions among the 3 groups were significantly different ( p < .001). The average amount of sclerosing foam administered per session in VMs was significantly higher than that in the other 2 groups ( p < .0001) (whereas that in the PG group was lower than that in the infantile hemangioma group [ p < .0001]). However, the overall therapeutic efficacy and side effects in the 3 groups were not significantly different. For VMs, the frequency of ultrasound guided foam sclerotherapy and use of 3% polidocanol increased from superficial to deep lesions, whereas the use of 1% POL decreased ( p < .0001).

CONCLUSION

Infantile hemangioma and PG treatments presented good results and minor adverse reactions comparable with those of VMs.

Sirolimus treatment for paediatric head and neck lymphatic malformations: a systematic review

PURPOSE

This PRISMA-compliant systematic review aimed to assess risks and benefits of sirolimus treatment for paediatric lymphatic malformations by focusing not only on treatment efficacy but also on possible treatment-related adverse events, and treatment combinations with other techniques.

METHODS

Search criteria were applied to MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov databases and included all studies published up to March 2022 reporting paediatric lymphatic malformations treated with sirolimus. We selected all original studies that included treatment outcomes. After the removal of duplicates, selection of abstracts and full-text articles, and quality assessment, we reviewed eligible articles for patient demographics, lymphatic malformation type, size or stage, site, clinical response rates, sirolimus administration route and dose, related adverse events, follow-up time, and concurrent treatments.

RESULTS

Among 153 unique citations, 19 studies were considered eligible, with reported treatment data for 97 paediatric patients. Most studies (n = 9) were case reports. Clinical response was described for 89 patients, in whom 94 mild-to-moderate adverse events were reported. The most frequently administered treatment regimen was oral sirolimus 0.8 mg/m2 twice a day, with the aim of achieving a blood concentration of 10-15 ng/mL.

CONCLUSION

Despite promising results for sirolimus treatment in lymphatic malformation, the efficacy and safety profile of remains unclear due to the lack of high-quality studies. Systematic reporting of known side effects, especially in younger children, should assist clinicians in minimising treatment-associated risks. At the same time, we advocate for prospective multicentre studies with minimum reporting standards to facilitate improved candidate selection.

Cytological and Biochemical Analyses of Lymphatic Fluid from Patients with Lymphatic Malformations

Background: Intracystic hemorrhage from lymphangiomas is a common phenomenon in lymphatic malformations (LMs); however, little is known about the associated compositional changes in the lymphatic fluid. Materials and Methods: We prospectively collected lymphatic fluid from children with LMs. Lymphatic fluid was divided depending on the bleeding status into the bleeding and nonbleeding groups. The fluid was subjected to cytological and biochemical analyses to determine protein and cytokine levels. The Mann-Whitney U test was used to compare the two groups. Results: There were significant differences in the levels of interleukin (IL)-6, IL-10, and glucose, and the percentage of white blood cells between the bleeding and nonbleeding groups. There was no significant difference in chlorine and protein content; white blood cell count; and IL-2, IL-4, tumor necrosis factor α, and interferon γ levels between the two groups. Conclusion: Lymphatic fluid is less stable in bleeding LMs than in non-bleeding LMs and is prone to inflammatory reactions. The inflammatory reaction in lymphatic fluid does not stimulate the cytokine storm in blood. The inflammatory reaction due to LMs does not affect the contents of protein and chlorine in lymphatic cyst fluid.

The Treatment of Adult Laryngeal Hemangiomas Located on the Arytenoids: Excision vs. Chemotherapy

OBJECTIVE

To evaluate and compare the results of the excision and bleomycin injection treatment methods for adult laryngeal hemangiomas (ALHs) located on the arytenoids.

METHODS

Twenty-six ALH patients in 29 different cases were enrolled in the study at our department between June 2012 and March 2021. Some patients were treated more than once. Twenty-nine cases of ALH treated with either bleomycin injection or excision were studied to assess the efficacy of both treatments. A lumen constriction score (from 1 to 4) was used to evaluate the therapeutic effect three months later.

RESULTS

The ALHs in the ALH excision group were resected successfully, and the ALHs did not recur. The mean lumen constriction score for the bleomycin injection group was 2.95. The lumen constriction score for the ALH excision group was higher than that of the bleomycin injection group.

CONCLUSIONS

Both bleomycin injection and excision are safe and effective treatments for ALHs located on the arytenoids. On the condition that the ALH is well exposed and can be completely removed, ALH excision surgery is the preferable method to treat ALHs located on the arytenoids.

Bleomycin-triamcinolone sclerotherapy in the management of propranolol resistant infantile hemangioma of the maxillofacial region: A single arm prospective evaluation of clinical outcome and Doppler ultrasound parameters

INTRODUCTION

Propranolol has emerged as a first line agent in the management of hemangiomas. With increased use of propranolol, studies have also focused on relapses following propranolol therapy. Our current study evaluates the role of bleomycin triamcinolone sclerotherapy for the management of propranolol resistant Infantile Hemangioma (IH). We also evaluated the role color Doppler USG for response assessment of sclerotherapy.

METHODS

Patients with Propranolol resistant (Non- responders/ Partial responders) IHs were included in the study. Patients received intralesional bleomycin at a dose of 0.5 IU/kg followed by intralesional injection of triamcinolone at a dose of 2mg/kg body weight. Clinically patients were grouped into excellent, partial and non responders. Doppler parameters; Resistivity index (RI), Pulsatility index(PI) and Peak systolic velocity (PSV) were used to evaluate the response to sclerotherapy. These parameters were evaluated prior to sclerotherapy and 3 months following completion of therapy. The clinical responses of the patients were compared with the change in Doppler parameters before and after treatment.

RESULTS

A total of 115 participants were considered for analysis; 60.86% had excellent response, 32.17% had partial response and 6.95% had poor response. There was a significant change in terms of RI, PI and PSV in patients who were either excellent or partial responders. Poor responders did not have a significant change in Doppler parameters.

CONCLUSION

Combined bleomycin- triamcinolone sclerotherapy is an effective therapy for the management of propranolol resistant IHs. Doppler parameters RI, PI and PSV are reliable indicators of response in the management of IH.

A systematic review and network meta-analysis of the effectiveness of sclerotherapy for venous malformation

OBJECTIVE

Sclerotherapy for venous malformation has been widely used; however, no guidelines are available to assess the effectiveness of different sclerotherapy agents. We conducted a systematic review and network meta-analysis to investigate the effectiveness of sclerotherapy agents for venous malformations.

METHODS

Three electronic databases were searched from their inception (1950) to April 29, 2021. Studies comparing the effectiveness of different sclerotherapy agents were included. The risk of bias within and across studies was assessed. Pairwise meta-analyses were conducted, followed by a network meta-analysis. We also assessed inconsistency and publishing bias using various approaches.

RESULTS

Seven studies with 547 patients in six arms were included in the present study. We defined the response and complete response as two separate outcomes. Significant differences were observed in four comparisons with respect to the response (ethanol vs bleomycin, ethanol vs polidocanol, ethanol vs sodium tetradecyl sulfate, polidocanol vs sodium tetradecyl sulfate). No statistically significant differences were found in the other comparisons. The evidence network revealed that for the response outcome, ethanol ranked first, followed by pingyangmycin, polidocanol, sodium morrhuate, bleomycin, and, finally, sodium tetradecyl sulfate. For the complete response outcome, pingyangmycin had the best results, followed by sodium morrhuate, polidocanol, ethanol, bleomycin, and, finally, sodium tetradecyl sulfate. Major complications, such as facial nerve palsy, serious local swelling, and necrosis, had occurred mostly in the ethanol group and rarely in the other groups. Because of the limited data, no further analysis of major complications was conducted. Our confidence in the comparisons and rankings was low. We found no verified inconsistency or publishing bias in the present study using the existing approaches.

CONCLUSIONS

Ethanol showed a significantly better response statistically compared with the other agents. However, ethanol had also resulted in the highest incidence of complications. Pingyangmycin showed the second-best response, best complete response, and a low rate of complications, respectively. Overall, pingyangmycin achieved excellent performance and balance in terms of the different outcomes. However, they could not be adequately recommended from the available data. More superior trials, especially randomized controlled trials, are needed in the future.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip

RATIONALE

Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management.

METHODS

Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value &lt;0.05 was taken as significant.

RESULTS

In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049).

CONCLUSION

Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Safety and Efficacy of Bleomycin Slow Infusion Sclerotherapy Using a Syringe Pump for Microcystic and Mixed Lymphatic Malformations

PURPOSE

To evaluate the safety and efficacy of bleomycin infusion sclerotherapy using a syringe pump in microcystic and mixed (microcystic components with the presence of a cyst over 1 cm) lymphatic malformations (LMs).

MATERIALS AND METHODS

Patients who received bleomycin sclerotherapy with a syringe pump for microcystic or mixed LMs were reviewed. Cystic components of LMs were accessed under sonographic guidance, followed by injection of an opacified bleomycin solution using a syringe pump (infusion rate, 10-20 mL/h) under fluoroscopic guidance. Imaging outcomes were graded as complete (> 90% size reduction), partial (25-90%), or no response (< 25%). Clinical outcomes and procedure-related complications were also reviewed.

RESULTS

Forty-nine patients with 81 sclerotherapies were analyzed. The mean age was 17 years (range 0.1-65 y). Thirty-one (63%) patients had microcystic LMs, and 18 (37%) had mixed. A mean of 1.7 sessions (range 1-4) of sclerotherapy was performed using a mean cumulative dose of bleomycin of 10.8 U (range 1.5-39 U). The mean infusion time was 39 min (range 14-130 min). Regarding imaging outcomes, there was a complete response in 29% (n = 14), a partial response in 57% (n = 28), and no response in 14% (n = 7). Regarding clinical outcomes, there was a complete response in 39% (n = 19), a partial response in 51% (n = 25), and no response in 10% (n = 5). According to the CIRSE classification, no major complications were identified.

CONCLUSIONS

Bleomycin slow infusion sclerotherapy provides gradual filling of sclerosant to target microcystic components. This technique is safe and feasible for the management of microcystic or mixed LMs.

LEVEL OF EVIDENCE

Level 4, Case series.

Therapeutic Effects of Intralesional Bleomycin Sclerotherapy for Non-Invasive Management of Low Flow Vascular Malformations - A Prospective Clinical Study

Introduction

Bleomycin, a cytotoxic and antitumour drug, is safe and effective in the management of vascular anomalies prevalent in the head and neck region. The aim of our study was to evaluate the effect of intralesional bleomycin injection in vascular malformations (VMs), especially venous and lymphatic malformations present extracranially on the face, lips and intraorally.

Subjects and Methods

This prospective clinical study was conducted in the Department of Oral and Maxillofacial Surgery, Government Dental College, Srinagar. The study included 30 patients with low-flow VMs (LFVMs) wherein the effectiveness of intralesional bleomycin sclerotherapy was evaluated. The recorded data was compiled and continuous variables were expressed as mean ± standard deviation and categorical variables were summarised as frequency and percentages.

Results

Complete resolution (cure) was observed in 11 patients (36.66%), marked improvement in 17 patients (56.66%) and mild improvement in two patients (6.66%). Local complications were superficial ulcerations in 14 patients (46.66%) and hyperpigmentation in one patient (3.33%). Systemic complications in the form of flu like symptoms, nausea or vomiting were not reported in any of the above-mentioned patients. Signs of pulmonary fibrosis and/or hypertension were also not reported in any of the above cases.

Conclusion

Intralesional bleomycin injection is a potent and safe therapeutic alternative for the treatment of haemangiomas and LFVMs. Such patients can be managed on an outpatient basis without the need of any extensive surgery, expensive armamentarium and with only minor complications.

Management of Macrocystic Lymphatic Malformation in the Cervicofacial Region: Ultrasound-Guided Iodine Tincture Cauterization Combined With Intralesional Negative Pressure

PURPOSE

The purpose of our study was to evaluate the efficacy and safety of ultrasound-guided iodine tincture cauterization combined with postoperative intralesional negative pressure in the management of cervicofacial cystic lymphatic malformation (cLM).

METHOD

From January 2019 to July 2021, indocyanine green lymphography was performed preoperatively to confirm the lymph inflow, and this treatment was administered in 71 patients with cervicofacial cLM in our center. All cases were evaluated by curative effects, treatment frequency, and adverse events. The duration of posttreatment follow-up was from 12 to 14 months.

RESULTS

Indocyanine green lymphography indicated at least one lymphatic inflow in each cLM lesion. Excellent resolution was observed in 87.3% of cases, and good improvement of the treated cLM occurred in 9.9% of cases, and 2 cases with fair outcomes required subsequent treatment. It is noteworthy that no case was treated more than 3 times. Some minor adverse effects, including localized itch and scar, were managed by symptomatic treatment.

CONCLUSIONS

Because of satisfactory outcomes and low treatment frequency, ultrasound-guided iodine tincture cauterization combined with intralesional negative pressure represents an efficacious, safe, and feasible method for the management of macro-cLM in the cervicofacial region.

Percutaneous Sclerotherapy with Bleomycin and Ethiodized Oil: A Promising Treatment in Symptomatic Giant Liver Hemangioma

Background Percutaneous sclerotherapy with bleomycin has been proven to have a potential benefit in the management of low-flow venous malformations. Liver hemangiomas are considered low-flow venous malformations. Thus, percutaneous sclerotherapy could potentially have a promising result in their management. Purpose To investigate the feasibility, efficacy, and safety of percutaneous sclerotherapy with bleomycin in the management of symptomatic giant liver hemangioma (GLH). Materials and Methods This single-institute prospective study was conducted between September 2018 and July 2020. Percutaneous sclerotherapy was performed using a mixture of bleomycin and ethiodized oil under guidance of US and fluoroscopy in participants with GLH who were experiencing related abdominal pain or fullness. Technical success was recorded. Change in symptom severity, according to visual analog scale (VAS), was considered the primary outcome of the study. Volume change, based on the lesion volume at CT, and complications, based on the classification of the Society of Interventional Radiology, were regarded as secondary outcomes. The primary and secondary outcomes were recorded 6 and 12 months after the procedure. Comparison was performed by using the Wilcoxon signed-rank test or paired t test. Results Twenty-eight participants (mean age, 45 years ± 9; 25 women) were evaluated. Technical success was 100%. The mean VAS score was 8.3 before the procedure, which decreased to 1.4 (84.7% reduction) and 1.5 (83.5% reduction) at 6- and 12-month follow-ups, respectively (P < .001 for both). All participants reported relief of symptoms (17 of 28 participants [61%] with complete relief; 11 [39%] with partial relief) at 12-month follow-up. Mean GLH volumes dropped from 856.3 cm³ to 309.8 cm³ (65.7% reduction) and 206.0 cm³ (76% reduction) at 6- and 12-month follow-ups, respectively (P < .001 for both). No major complications were detected. Conclusion Percutaneous sclerotherapy is a safe and feasible method with promising results in the treatment of patients with symptomatic giant liver hemangioma. Clinical trial registration no. NCT03649113 © RSNA, 2021 See also the editorial by McGahan and Goldman in this issue.

Lymphatic Malformations: Genetics, Mechanisms and Therapeutic Strategies

Lymphatic vessels maintain tissue fluid homeostasis by returning to blood circulation interstitial fluid that has extravasated from the blood capillaries. They provide a trafficking route for cells of the immune system, thus critically contributing to immune surveillance. Developmental or functional defects in the lymphatic vessels, their obstruction or damage, lead to accumulation of fluid in tissues, resulting in lymphedema. Here we discuss developmental lymphatic anomalies called lymphatic malformations and complex lymphatic anomalies that manifest as localized or multifocal lesions of the lymphatic vasculature, respectively. They are rare diseases that are caused mostly by somatic mutations and can present with variable symptoms based upon the size and location of the lesions composed of fluid-filled cisterns or channels. Substantial progress has been made recently in understanding the molecular basis of their pathogenesis through the identification of their genetic causes, combined with the elucidation of the underlying mechanisms in animal disease models and patient-derived lymphatic endothelial cells. Most of the solitary somatic mutations that cause lymphatic malformations and complex lymphatic anomalies occur in genes that encode components of oncogenic growth factor signal transduction pathways. This has led to successful repurposing of some targeted cancer therapeutics to the treatment of lymphatic malformations and complex lymphatic anomalies. Apart from the mutations that act as lymphatic endothelial cell-autonomous drivers of these anomalies, current evidence points to superimposed paracrine mechanisms that critically contribute to disease pathogenesis and thus provide additional targets for therapeutic intervention. Here, we review these advances and discuss new treatment strategies that are based on the recently identified molecular pathways.

Management of Venous Malformations

Venous malformations (VMs) are slow-flow, congenital vascular anomalies that are a result of vascular dysgenesis. Clinical presentation and morbidity depend on size, location, and association with other syndromes. VMs are the most common symptomatic vascular anomaly referred for intervention, usually due to thrombosis, swelling, mass effect, functional compromise, or cosmetic concerns. Treatment for larger lesions can be challenging and a multidisciplinary approach involving medical, interventional, and surgical input is critical for comprehensive care. This article will assist the interventional radiologist in patient assessment and will discuss current techniques for treatment, means to minimize adverse events, and expected outcomes.

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.

Bleomycin sclerotherapy for large diffuse microcystic lymphatic malformations

Background

Microcystic lymphatic malformations (LMs) are congenital lesions with the diameter of the majority of cysts <1 cm. Bleomycin sclerotherapy has been shown to yield beneficial results for macrocystic LMs. This study aims to evaluate the safety and efficacy of consecutive bleomycin sclerotherapy for large diffuse microcystic LMs.

Methods

The location and size of the lesions were detected by ultrasound for the 46 patients included in this study. Bleomycin lavage was performed in larger cysts and intradermal injection for the superficial lesion. The outcome and complications were assessed for its efficacy and safety.

Results

The large diffuse microcystic LMs mainly located in the neck, abdominal wall and axilla/lateral chest wall. The average lesion size was 10.6 cm × 7.2 cm. The mean number of treatment sessions was 4.5 with 7.3 mg bleomycin for per session averagely. Excellent (69.6%) and moderate (23.9%) responses were obtained. There was no recurrence for the 6 patients (13%) who received a long follow-up. Obvious local swelling, slight intralesional hemorrhage and low-grade fever were the most commonly occurred complications. No lung fibrosis was identified for the patients who received more than 6 sessions.

Conclusions

Local lavage combined with intradermal injection of bleomycin is effective and safe for large diffuse microcystic LMs with good therapeutic effect and low complication rates, and can be regarded as the mainstay of therapy for microcystic LMs.

Clinical course of pediatric large vascular anomalies located in the extremities

Objective

Difficulties encountered in the diagnosis and treatment of vascular anomalies located in the extremities of the children. The most common vascular lesions are hemangiomas and venous malformations. The complex malformations, such as, Klippel-Trenaunay Syndrome are much less commonly encountered lesions. Treatment of vascular malformations are variable based on the etiology of the lesion and clinical presentation. In this study, we aimed to share our experience on the clinical features of vascular lesions in the extremities of the children.

Material and Methods

The demographic, clinical and prognostic features of 330 children with vascular anomalies followed at IUC, Cerrahpasa Medical Faculty, Department of Pediatric Hematology and Oncology were retrospectively reviewed. Fifty-one patients with lesions >5 cm in diameter were included into the study. The diagnosis, age, sex, history of prematurity, lesion type and location, imaging and biopsy findings, complications, details of treatment, and follow-up were evaluated.

Results

Twenty-nine (57%) of patients were female and 22 (43%) were male. The female to male ratio was 1.3:1. The median age at admission was 15 months (10 days-180 months). Eight patients (16%) had a history of premature birth. Thirty-one patients (61%) had lesions since birth, eight lesions (8%) appeared in the first month of life and 6 (12%) occurred after 1 year of age. Sixteen of the patients (31%) had hemangioma, 11 (22%) had lymphangioma, 19 (37%) had venous malformation and 5 (10%) were diagnosed as Klippel Trenaunay Syndrome. The lesions were in the upper extremity in 21 patients (41%), in the lower extremity in 27 patients (53%), and both lower and upper extremities were affected in 3 patients (6%). Of all patients, six had intramuscular and two had intraarticular lesions. The diagnosis was made on clinical grounds in most of the cases. In 22 children Magnetic Resonance Imaging was performed for differential diagnosis and to demonstrate the infrastructure of the lesion and the extent of local infiltration. Histopathologic examination by biopsy was done in four patients. Complications developed in 19 patients as follows: Disseminated intravascular coagulation in 6, bleeding in 4, thrombosis in 3, and soft tissue infection in 6. Twenty-one patients were not given any treatment. Medical treatments were propranolol in 14 patients, sirolimus in 4 patients, propranolol and sirolimus in 5 patients. Intralesional bleomycin injection was performed in 3 children.

Conclusion

The diagnosis, classification and treatment of extremity located vascular malformations in children are complex. Treatment strategy should be defined as in accordance with a combination of the type of the vascular malformation, the age of the patient and the clinical picture.

Morphological, genetic and clinical correlations in infantile hemangiomas and their mimics

Infantile hemangiomas (IHs) are the most frequent pediatric benign vascular tumors, with a reported incidence of 5% to 10%. They have self-limiting evolution pattern divided into a growth phase in the first 12 months and a regression one, that may take up to 10 years. Occasionally, hemangiomas might lead to local or systemic complications, depending on their morphological characteristics. The first line of treatment is β-blockers, such as Propranolol, Timolol, Nadolol, administered either locally or systemically. Newer therapeutic strategies involving laser therapy and angiotensin-converting enzyme inhibitors are being studied, while older treatment modalities like corticosteroids, Imiquimod, Vincristine, Bleomycin and Interferon-α have become second line therapy options. Before establishing the appropriate treatment, clinical, histological, and imaging investigations are required.

Bleomycin for Percutaneous Sclerotherapy of Venous and Lymphatic Malformations: A Retrospective Study of Safety, Efficacy and Mid-Term Outcomes in 26 Patients

Percutaneous sclerotherapy is used to treat venous and lymphatic vascular malformations, which can cause significant discomfort and/or disfigurement. The purpose of this study is to describe the bleomycin sclerotherapy technique and to evaluate its clinical and radiological efficacy and safety. We retrospectively identified consecutive patients with venous malformations (VMs) and lymphatic malformations (LMs) who underwent bleomycin sclerotherapy in 2011–2020 at our institution. We collected the clinical and radiological success rates, complications and recurrences separately in the VM and LM groups. We identified 26 patients, 15 with VMs and 11 with LMs. The significant volume reductions obtained were 45% in the VM group and 76% in the LM group (p = 0.003 and p = 0.009, respectively). Significant reductions in discomfort/pain and in cosmetic disfigurement were obtained in both groups. An overall improvement was reported by 69% and 82% of patients in the VM and LM groups, respectively. No major complications occurred during the mean follow-up of 51 ± 34 months in the VM group and 29 ± 18 months in the LM group. A recurrence developed within 2 years in 23% of patients. Bleomycin is clinically and radiologically effective for the treatment of venous and lymphatic malformations, with a high level of patient safety.

Treatment of deep-seated palatal vascular malformations by bleomycin sclerotherapy

BACKGROUND

Vascular malformations of the head and neck are common. The management of these lesions is complex and challenging due to the high complication rate and recurrence following treatment. Palatal vascular malformations (PVMs) are infrequent and present as slow growing lesions in the palate with recurrent bleeding and pain. These lesions are best managed by sclerotherapy due to their posterior location and risk of bleeding if surgery is attempted. Many sclerosants have been used for treating PVMs but the use of intralesional bleomycin for these lesions has not been reported at length. This paper describes the use of intralesional bleomycin injections for the treatment of deep-seated palatal vascular malformations.

METHODS

Intralesional bleomycin injections were given directly into the lesion with the patients under short general anaesthesia. The total dose of bleomycin ranged between 8 and 15 IU, which depends upon the body weight and was repeated every four weeks till the resolution of lesion was observed.

RESULTS

All the lesions in 12 patients regressed significantly with serial bleomycin injections. Clinically, the involved palatal mucosa became normal and magnetic resonance imaging demonstrated the significant regression of the lesion in all the cases. No complications were encountered with the use of intralesional bleomycin.

CONCLUSIONS

Intralesional bleomycin injections have proved to be an emerging modality in the management of remotely situated palatal vascular malformations. Their rapid regressive effect on the lesion coupled with a high safety margin makes bleomycin sclerotherapy the first choice of treatment for palatal vascular malformations.

The Role of Interventional Radiologists in the Treatment of Congenital Lymphatic Malformations

Lymphatic malformations are low-flow vascular malformations that are typically apparent in the pediatric population and can cause significant functional limitations and effects on quality of life. While surgical resection has historically been the mainstay of therapy, percutaneous sclerotherapy has garnered increasing popularity due to its efficacy and low complication rates. The role of interventional radiology in the multidisciplinary management of these often complex malformations requires thorough understanding of the disease process. This article will review the pathophysiology, clinical presentation, imaging workup, and management options of lymphatic malformations. Special attention will be devoted to available sclerosants, the mammalian target of rapamycin inhibitor sirolimus, and complex lymphatic anomalies.

Sclerotherapy for atypical oral manifestation of Cowden syndrome

Cowden syndrome is an autosomal dominant disorder characterized by hamartomas, as well as benign and malignant neoplasms that may present in organ systems throughout the body. It also poses an increased lifetime cancer risk in those with the disorder. Its clinical presentation is often variable, and diagnosis can be challenging. In the head and neck region, it can present as thyroid enlargement or mass formation, cutaneous and mucocutaneous lesions of the skin and the oral cavity. The most typical oral manifestations of Cowden syndrome are oral papillomatosis and a cobblestone appearance of the mucosa. We present a case of vascular malformation of the tongue in a patient with Cowden syndrome. This lesion was similar in appearance to a cutaneous hamartoma on the patient's upper extremity. He had received prior surgical intervention for this tongue mass, and complete resection was recommended subsequently. However, in search of a less invasive treatment to minimize impact on speech and oral function, sclerotherapy was performed, resulting in resolution of the lesion. Sclerotherapy is a well-documented treatment for head and neck vascular malformations, but it is not universally employed. In our patient with atypical oral manifestation of Cowden syndrome, bleomycin sclerotherapy was employed, resulting in resolution of the lesion, as well as preservation of speech articulation and oral function.

The Curious Case of Fibrofatty Conversion of Cystic Hygroma Treated with Bleomycin Sclerotherapy

Cystic hygroma is a congenital malformation of the lymphatic system that mostly presents at birth. Though the classic treatment of this condition is surgical excision, recent alternative treatment modalities such as injection of sclerotherapeutic agents (e.g., bleomycin and OK-432) into the lesion has gained popularity due to its safe and effective response profile with minimal side effects. We report a rare complication of repeated bleomycin sclerotherapy in a follow-up patient of cystic hygroma, where the lesion underwent fibrolipomatous conversion with insinuation into multiple fascial planes, causing mass effect by encasement and compression of major vascular and airway structures. This is the first time such a complication of bleomycin sclerotherapy has been reported in literature. Such an unusual presentation reminds us that, in any patient presenting with recurrent gradually increasing swelling with worsening of symptoms following bleomycin sclerotherapy, a possibility of fibrolipomatous conversion of cystic hygroma should be borne in mind.

Does using outpatient room air for bleomycin foam preparation increase the risk of infection?

OBJECTIVE

To evaluate whether the risk of infections is increased with the use of air from outpatient rooms to prepare bleomycin foam.

METHODS

Settling plates were adopted to collect bacteria from outpatient room air, operating theatre air, human serum albumin, bleomycin solution and bleomycin foam prepared with both outpatient room and operating theatre air. The plates were placed in an incubator at 37°C for 48 h, and the number of bacterial colonies was recorded using colony-forming units. The results were analysed by the t-test. A retrospective study was then performed to evaluate the outpatient safety of bleomycin foam.

RESULTS

The number of colony-forming units in the bleomycin foam produced using both operating and outpatient room air was very low, with no statistic difference. No infection cases were reported in clinical evaluation.

CONCLUSION

Using the air from outpatient treatment rooms for bleomycin foam preparation does not increase the risk of infections.

Interim results of bleomycin-polidocanol foam sclerotherapy as a highly efficient technique for venous malformations

OBJECTIVE

The objective of this study was to retrospectively review the clinical and radiographic outcomes of patients with venous malformations (VMs) treated with bleomycin-polidocanol foam (BPF) sclerotherapy.

METHODS

The Institutional Review Board waived ethical approval for this retrospective review in which 55 patients (31 female and 24 male patients; mean age, 18.8 years; range, 2-60 years) were treated with BPF sclerotherapy. The stability (half-life) of BPF compared with polidocanol foam was studied. Standard sclerotherapy techniques were used. A total of 111 sclerotherapy sessions were performed, with a mean of 2.0 treatments per patient (range, 1-6). An average of 10 mL of BPF was used per procedure, with the total amount ranging from 2.5 to 30 mL. Symptoms before and after treatment, follow-up time, complications, and volume reduction on magnetic resonance imaging were recorded.

RESULTS

The median half-lives of the BPF and polidocanol foam were 238.25 ± 3.86 seconds and 194.33 ± 3.5 seconds, respectively. A t-test indicated significant differences between the groups (P < .01). The mean follow-up was 14 months (range, 6-24 months). All 55 patients (100%) reported improvement in symptoms. The total excellent and good response rate was 94.6%. An excellent response was achieved in 32 cases (58.2% [32/55]), a good response in 20 cases (36.4% [20/55]), and a poor response in 3 cases (5.4% [3/55]). Postprocedural magnetic resonance imaging demonstrated volume reduction of treated lesions in 54 of 55 patients (98%), with a mean lesion volume reduction of 84.6%. Postprocedure complications were minor in 13 of 111 procedures (12%) that were performed on 10 of 55 patients (18.2%), and no major complications occurred.

CONCLUSIONS

BPF sclerotherapy of VMs is safe and effective. BPF sclerotherapy can be a promising first-line treatment of VMs.

Management of massive venous malformations by percutaneous injection of bleomycin combined with fibrin glue in the head and neck

PURPOSE

The aim of this study was to evaluate the effectiveness of percutaneous injection of bleomycin combined with fibrin glue in treating massive venous malformations (MVMs) in the head and neck region.

MATERIALS AND METHODS

A retrospective case series analysis of 22 patients who underwent percutaneous sclerotherapy between June 2015 and December 2018 was performed. All the patients were examined by comparing the size of the venous malformations (VMs) and their responses to treatment including complications in the follow-up.

RESULTS

The follow-up period ranged from 6 to 24 months. Ten patients (10/22) were completely cured and 10 patients (10/22) exhibited excellent size reduction of their VMs. Two patients (2/22) exhibited reasonable size reduction and were recommended to undergo a second sclerotherapy procedure. However, both patients were satisfied with the outcomes and refused subsequent treatment. Neither systemic nor local complications occurred in this study. All the patients were satisfied with their significant size reductions and symptom improvements without recurrences during follow-up.

CONCLUSION

Percutaneous injection of bleomycin combined with fibrin glue is a promising treatment option that yielded excellent size reduction with a low risk of complications on MVMs in the head and neck region.

Bleomycin Polidocanol Foam (BPF) Stability - In Vitro Evidence for the Effectiveness of a Novel Sclerosant for Venous Malformations

OBJECTIVE

This study investigated the in vitro stability of a novel sclerosant, bleomycin polidocanol foam (BPF), for venous malformation (VM) sclerotherapy.

METHODS

The study was designed with control groups treated with polidocanol (0.5%, 1%, and 3%) only. The experimental groups included 21 BPFs, which was made by dissolving bleomycin at seven different concentrations (0.1%-1.5%) in polidocanol (0.5%, 1%, and 3%). The Tessari method was used to prepare sclerosant foam with a liquid:gas ratio of 1:4 at room temperature in vitro. The foam stability was measured for each group. The decay process, one component of foam stability, was recorded with a camera. Foam decay process experiments were performed 10 times per group. The stability indices included drainage rate, drainage time, half life, and microscopic measurement of the foams (mean bubble diameter, minimum and maximum bubble diameters, wall thickness, and bubble diameter distribution).

RESULTS

Compared with the control groups, the half lives of BPFs mainly increased significantly with the addition of bleomycin (p < .001). BPF with 3% polidocanol and 0.1% bleomycin recorded the highest half life (246 ± 1.6 sec), and this group also achieved the smallest bubble diameter and wall thickness (69.9 μm and 5.80 μm) among the experimental groups. For the same polidocanol concentration, the bubble diameter and wall thickness increased when bleomycin was added.

CONCLUSION

Bleomycin concentrations account for different BPF stability. BPF stability mainly increased significantly with the addition of a small amount of bleomycin but this advantage was no longer apparent with increasing bleomycin dose.

Safety and efficacy of surgery combined with bleomycin irrigation for complex cervical-facial lymphatic malformations of children

BACKGROUND

In this retrospective study, we compare the safety and efficacy of surgery combined with bleomycin intra-operatively with intralesional sclerotherapy alone for the management of head and neck lymphatic malformations in children.

MATERIALS AND METHODS

The patients with cervical-facial lymphatic malformations were reviewed in Shanghai Children's Hospital from August 2014 to August 2018. Data analysis was performed using SPSS17.0. Pearson X² test and t-test were used, and the significance level was fixed at 5%.

RESULTS

72 patients in all of which 63 patients underwent surgical excision combined with bleomycin irrigation and 9 patients underwent sclerotherapy alone as the primary treatment. The surgical excision group had a significantly higher rate of an excellent response compare to the sclerotherapy group (P < 0.05). In regards to postoperative complications, the surgical group had no higher rate of temporal facial paralysis and other nerve injures compare to the sclerotherapy group (P = 0.624).

CONCLUSIONS

we recommend surgery combined with Bleomycin for microcystic disease with focal and less infiltrative lesions and for lesions located in the oropharynx, parapharynx, retropharynx, or hypopharynx.

Five years’ experience of combined intralesional therapy in infantile hemangioma

Background

Infantile hemangiomas (IHs) are common vascular tumors. Although it involutes spontaneously, outcomes are unpredictable. Intralesional therapy is one of its treatment modality. We present our experience with combined intralesional therapy for IHs over a 5-year duration. A total of 427 patients were treated and followed at Al-Azhar University Hospitals during the study period of 5 years. All patients were treated by intralesional therapy in the form of combined injection of triamcinolone and bleomycin. All patients were followed for the response. Response to the treatment was graded as marked, partial, and poor improvement.

Results

IHs were noticed within the first month of life in 90.2% of patients. The commonest site of involvement was head and neck in 90% of patients. The commonest clinical presentation was swelling with discoloration. Mean age was 7.43 ± 6.04 months and mean IHs size was 15.54 ± 11.13 cm2. The response to the treatment was highest for patients below 1 year of age. The reported complications were ulceration, scarring, and subcutaneous atrophy in some cases.

Conclusion

Combined intralesional therapy in IHs showed good efficacy in most patients. It is a reliable and safe treatment modality with clear curative effects and minimal complications. If IHs treatment is indicated, combined intralesional therapy should be considered as an alternative effective treatment modality.

Clinical Course of Extracranial Arteriovenous Malformations

PURPOSE

Despite many advances in the knowledge of vascular malformations, extracranial arteriovenous malformations (AVMs) remain an enigma and are usually misdiagnosed and mismanaged due to their associated rare morbidity. This study aimed to describe the clinical course and emphasize the progressive nature of AVMs through a retrospective study of 446 patients.

METHODS

Patients with cutaneous and soft-tissue AVMs presenting to our Vascular Anomalies Center between March 2011 and March 2017 were reviewed. Medical records were examined for disease course, age at first presentation at our institution, distributions and locations of lesions, clinical staging, progression, and previous treatments. Progression was defined as advancement to a higher Schobinger stage from a lower stage.

RESULTS

A total of 446 patients (mean age, 25.6 ± 14.0 years) were enrolled in this study, including 232 (52.0%) males (gender ratio, 1.08:1). Arteriovenous malformations lesions in 76.7% (342/446) of the patients were located in the head and neck. Children with Stage I AVMs had a 41.9% risk of progression before adolescence and an 80.0% risk of progression before adulthood. Nearly all patients (96.2%) showed progression in adulthood. Diffuse lesions were more likely to progress than localized lesions (P < 0.05) in childhood and adolescence. Lesions in the head and neck regions were less likely to progress than those in other regions in childhood (P = 0.005). A total of 216 (48.4%) patients had undergone previous treatments. Among these patients, bleomycin showed an unintentional positive effect in the treatment of AVMs.

CONCLUSIONS

Extracranial AVMs have a continuously progressive nature. A full understanding regarding the progressive course of AVMs can lead patients and physicians to attach importance to early diagnosis and management. Meanwhile exploring innovative treatments should be focused in the future to prevent potential destructive progression.

Outcome measurement instruments for peripheral vascular malformations and an assessment of the measurement properties: a systematic review

Purpose

The Outcome measures for vascular malformation (OVAMA) group reached consensus on the core outcome domains for the core outcome set (COS) for peripheral vascular malformations (venous, lymphatic and arteriovenous malformations). However, it is unclear which instruments should be used to measure these domains. Therefore, our aims were to identify all outcome measurement instruments available for vascular malformations, and to evaluate their measurement properties.

Methods

With the first literature search, we identified outcomes and instruments previously used in prospective studies on vascular malformations. A second search yielded studies on measurement properties of patient- and physician-reported instruments that were either developed for vascular malformations, or used in prospective studies. If the latter instruments were not specifically validated for vascular malformations, we performed a third search for studies on measurement properties in clinically similar diseases (vascular or lymphatic diseases and benign tumors). We assessed the methodological quality of these studies following the Consensus-based Standards for the selection of health Measurement Instruments methodology, and evaluated the quality of the measurement properties.

Results

The first search yielded 27 studies, none using disease-specific instruments. The second and third search included 22 development and/or validation studies, concerning six instruments. Only the Lymphatic Malformation Function Instrument was developed specifically for vascular malformations. Other instruments were generic QoL instruments developed and/or partly validated for clinically similar diseases.

Conclusions

Additional research on measurement properties is needed to assess which instruments may be included in the COS. This review informs the instrument selection and/or the development of new instruments.

Systematic review registration

PROSPERO, 42017056242.

Electronic supplementary material

The online version of this article (10.1007/s11136-019-02301-x) contains supplementary material, which is available to authorized users.

Effect of foam and liquid bleomycin in the management of venous malformations in head and neck region: A comparative study

BACKGROUND

Many treatment options for venous malformations (VMs) have been documented in the literature, but injection sclerotherapy has been considered a current mainstay for their treatment. We conducted this study to determine the efficacy and durability of injection of different forms of bleomycin sclerotherapy in the treatment of VMs in the cervico-facial region.

PATIENTS AND METHODS

Thirty patients with clinically diagnosed VMs of the head and neck region, confirmed by magnetic resonance imaging, had been injected with the bleomycin sclerosing material. They were divided into 2 groups according to the form of bleomycin injected: in Group A, the foam form was injected, and in Group B, the liquid form was injected. Data of patients' demographics, anatomical sites, type and volume of the VMs, number of injection sessions and the average dose of injected agents were documented and statistically compared between the 2 groups.

RESULTS

MRI showed a decline of more than 90% from the initial size of the lesions in 66.7% of the cases and considerable decline (60-90%) in 33.3% of the cases. In Group A, the number of sessions and the amount of sclerosant material injected were lower than those in Group B. The cumulative dose in the equal-sized lesions was lower in the foam form than in the liquid form.

CONCLUSION

We recommend using bleomycin in its foam form on a greater number of patients with larger VMs and in different sites, as the results are more promising in this form than in the liquid form.

Percutaneous treatment of orofacial vascular malformations

The aim of this study was to evaluate the efficacy of fluoroscopy-guided percutaneous injection of bleomycin as the primary treatment for low-flow vascular malformations. A total of 34 patients (mean (range) age 24 (8-51) years) with orofacial vascular lesions were treated in the Department of Interventional Radiology and Maxillofacial Surgery. There were 20 low-flow venous malformations, 11 lymphatic malformations, and three of mixed type. All patients were treated by fluoroscopy-guided percutaneous injection of a mixture of bleomycin (mean (range) 15 (5-15)mg) and a radio-opaque agent (Ultravist^® (iopromide), Bayer)/session. The number of sessions ranged from one to six. The clinical response was complete in 21 patients, obvious in nine, and of clinical benefit in four. Patients were reviewed within the first week, third week, and at three-month periods until 24 months. There were no serious complications such as pulmonary fibrosis. Fluoroscopy-guided intralesional injection of bleomycin should be considered as the first-line treatment for lymphatic malformations because it is effective and reliable with few complications.

Infantile hemangioma: Efficacy of low-dose propranolol and of intralesional bleomycin injection for propranolol non-response

BACKGROUND

Infantile hemangioma (IH) is the most common form of benign childhood vascular tumor. Most resolve spontaneously, but treatment is recommended in patients who develop complication. Propranolol is recommended as the first-line therapy, while the treatment in the case of non-response to first-line therapy depends on the clinical experiences of each center. The aim of this study was to investigate the efficacy of low-dose propranolol in the treatment of IH, and the outcomes of percutaneous intralesional bleomycin injection (IBI) in patients unresponsive to propranolol.

METHODS

Medical records of 104 children diagnosed with IH between June 2014 and June 2017 were reviewed retrospectively.

RESULTS

Median patient age was 6 months (range, 3-12 months). Forty-five patients (43.3%) received therapy: 18 (40%) for cosmetic problems and 27 (60%) for lesion-related complications. The most common complications were hemorrhage (15.6%) and impairment in visual function (15.6%). All of the patients received propranolol 1 mg/kg/day as the first-line therapy. Response to treatment was excellent in 35 patients, good in four and poor in one, while five patients did not respond to therapy. The five unresponsive patients received percutaneous IBI at 0.3-0.5 mg/kg/dose as second-line therapy. The response to treatment was excellent in four patients, good in one.

CONCLUSIONS

The majority of IH resolved spontaneously. In the patients who required treatment, low-dose propranolol was successful in most, and IBI was effective and safe in the remaining five patients who did not respond to propranolol.

Efficacy of Percutaneous Sclerotherapy in Low Flow Venous Malformations - A Single Center Series

Purpose

We analyzed results of percutaneous sclerotherapy for venous malformations (VMs) in head, neck and extremities.

Materials and Methods

Thirty-five patients with head and neck and extremities VM treated by sclerotherapy with bleomycin and sodium tetradecyl sulphate (STS) were retrospectively reviewed. A pre-treatment magnetic resonance imaging was done for all patients to diagnose the lesion. Each lesion received 1 to 11 sessions (average, 2.7; standard deviation [SD], 2.03). We evaluated percentage reduction in swelling size and a Likert scale review of subjective feelings of the patients.

Results

Sixteen had a complete obliteration; by sclerotherapy alone (n=13) and surgery after a 75% reduction (n=3). Ten patients had a significant reduction up to 75% and three patients by 50%. Four had a minimal decrease with reduction of 25% or less. Follow-up duration of the patients varied from a minimum of 6 months up to 3 years (average, 15.7 months; SD, 7.8 months). Of all patients, three refused further treatment and were lost to follow-up, while another two were referred to a dermatologist. Thirteen patients reported feeling excellent after the sessions. Eight patients claimed to feel slightly better compared to before the sessions started. Only three patients complained of feeling the same before and after the sessions. None of the patients still in follow-up have reported a recurrence of a lesion thus far.

Conclusion

Sclerotherapy using bleomycin and STS as sclerosants is a safe and effective primary treatment for VMs in the head and neck as well as in extremities.

Image-Guided Percutaneous Bleomycin and Bevacizumab Sclerotherapy of Orbital Lymphatic Malformations in Children

PURPOSE

To evaluate the effectiveness and safety of image-guided percutaneous sclerotherapy using bleomycin for macrocystic and bevacizumab (Avastin™) for microcystic orbital lymphatic malformations in children.

MATERIALS AND METHODS

Between October 2015 and July 2018, we prospectively evaluated 10 pediatric patients who presented clinically and radiologically with lymphatic malformations and were treated with percutaneous sclerotherapy. Patients with venous malformations were excluded. Eight females and two males with ages ranging from 3 to 17 years (mean: 8.8, SD: 4.9) were included. Guided with ultrasound and fluoroscopy, macrocysts were treated with bleomycin instillation. For microcystic components in three patients, bevacizumab was injected intralesional. All patients underwent ultrasound and non-contrast MRI to evaluate response to treatment after 6 weeks.

RESULTS

The malformations were macrocystic in seven patients and complex (macro/microcystic) in three. Twenty sclerotherapy sessions were performed, (range: 1-3 sessions, mean: 2, SD: 0.8). Clinically, there was a significant reduction in the proptosis after treatment (P = 0.007) and dystopia (P = 0.018). The local radiological response showed a reduction in the maximum lesions diameters and volumes after treatment (P = 0.005 and 0.005, respectively). Two of the three patients treated with bevacizumab showed a reduction in the lesions volumes by 90.4% and 63.4%, respectively, whereas one patient did not show volume reduction. Transient periorbital edema and ecchymosis occurred following the procedure with no major complications encountered. Follow-up ranged from 9-33 months, mean: 20.3, SD: 7.4.

CONCLUSION

Bleomycin sclerotherapy is a safe and effective treatment for orbital macrocystic lymphatic malformations. Further use of bevacizumab for microcystic lesions in a larger series is required to outline its efficacy and safety.

Percutaneous Sclerotherapy for Giant Symptomatic Liver Hemangiomas: A Pilot Study

This single-center prospective trial evaluated the safety and efficacy of percutaneous sclerotherapy for liver hemangiomas in 5 patients (1 man, 4 women; mean age 41.2 y) between 2016 and 2017. All patients were symptomatic (4 abdominal pain; 1 early satiety) and refused surgery. A single session of sclerotherapy with 20 cc mixture of 45 IU. Bleomycin in 10 cc distilled water and 10 cc Lipiodol (Ultra Fluide, Guerbet, France) was performed in all patients, achieving a 45.6%-71.1% lesion volume reduction and a 12.9%-41% reduction in the largest diameter of the lesion. Symptoms subsided in all patients during the 5-month follow-up period. Adverse events included a self-limited intraperitoneal hemorrhage in 1 patient.

Arteriovenous Malformations: Syndrome Identification and Vascular Management

PURPOSE OF REVIEW

Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. More recently, the treatment paradigm has shifted to endovascular therapy such that embolization and sclerotherapy are now considered the first line of treatment. Although there is still a role for traditional surgical techniques, it is now most commonly integrated with endovascular therapies in a hybrid fashion. The goal of this review is to provide a greater understanding of the diagnosis and treatment of vascular malformations.

RECENT FINDINGS

Vascular malformations can be high-flow (arteriovenous shunting) or low-flow (venous or lymphatic). Clinical presentation and treatment is different for each. Treatment of high-flow lesions must be directed at reducing or eliminating the nidus, usually via super-selective catheterization and embolization. Low-flow lesions are usually treated by direct injection of sclerosing agents under fluoroscopic or ultrasound guidance. The cornerstone of managing patients with vascular malformations is making the proper diagnosis, which is often challenging. Even after a diagnosis is made, therapy itself may be challenging and generate frustration among patients and providers. Frequently, the treatment of vascular malformations is characterized by only slow and incremental improvements without complete lesion eradication. By combining a thorough understanding of the vascular malformation disease process with an array of endovascular techniques, vascular interventionalists may contribute greatly to the care of these patients.

Target-initiated synthesis of fluorescent copper nanoparticles for the sensitive and label-free detection of bleomycin

Fluorescent copper nanoparticles (CuNPs) have received great attention due to their distinct characteristics of facile synthesis, tunable fluorescence emission, high photostability, and biological compatibility, and they have been widely used for chemical and biological analyses. Bleomycins (BLMs) are widely used antitumor agents for the clinical treatment of various cancers. Here, we develop a sensitive and label-free fluorescence method for the quantitative detection of BLM on the basis of BLM-initiated enzymatic polymerization-mediated synthesis of fluorescent CuNPs. We design two hairpin DNAs: one (Hp1) for the recognition of BLM and the other (Hp2) for signal amplification. In the presence of BLM, it may recognize and cleave the 5'-GC-3' site of the Hp1 stem, releasing the 8-17 DNAzyme fragment. The resultant 8-17 DNAzyme fragments may bind with the loop of Hp2 to form a partial double-stranded DNA (dsDNA) duplex, initiating the cyclic cleavage of Hp2 in the presence of Zn2+-dependent DNAzymes and generating numerous new DNA fragments with the free 3'-OH terminal, which can induce the formation of a poly(thymine) (poly-T) sequence with the assistance of terminal deoxynucleotidyl transferase (TdTase). Subsequently, the ploy-T sequence may function as the template for the synthesis of CuNPs with strong fluorescence emission. This method shows good selectivity and high sensitivity with a detection limit as low as 8.1 × 10-16 M, and it exhibits good performance in serum samples. Moreover, this method has distinct advantages of simplicity and low cost, holding great potential in clinical diagnosis and biomedical research.

Patient-Reported Outcomes of Bleomycin Sclerotherapy for Low-Flow Vascular Malformations and Predictors of Improvement

Purpose

There is paucity of data on patient-perceived outcomes of bleomycin sclerotherapy for low-flow vascular malformations. In this study, the long-term outcomes of bleomycin sclerotherapy were investigated in terms of quality of life (QoL) and patient-perceived changes in health.

Materials and Methods

A cohort of Dutch patients with vascular malformations treated with bleomycin sclerotherapy (June 2010-November 2015) completed a questionnaire evaluating disease symptoms, QoL (Short Form 36), patient-perceived change in health status (Global Rating of Change scales) and treatment satisfaction. QoL was assessed for the patient’s status before and after treatment and was analyzed relative to an age and sex-matched Dutch reference population. Predictive factors associated with QoL and patient-perceived improvement in overall health status were assessed using multivariable linear and logistic regression analyses, respectively.

Results

Seventy-seven patients, with a median follow-up of 22 months, were enrolled. About half of the respondents (49.3%) indicated that they perceived (any form of) improvement in their overall health status. Most often improved were the specific health aspects ‘pain’ (54.5%) and ‘overall severity of symptoms’ (57.1%). No factors were significantly predictive for patient-perceived improvement in health with respect to the vascular malformation. Impairment in work- or study-related activities prior to sclerotherapy was found to negatively impact physical QoL at follow-up (p = 0.03).

Conclusion

Approximately half of patients with low-flow vascular malformations indicate an improvement in overall health status following bleomycin sclerotherapy, particularly concerning pain and severity of symptoms. However, most patients only perceived little to moderate improvement to their health and desire further treatment.

Bleomycin sclerotherapy for eyelid venous malformations as an alternative to surgery or laser therapy

PURPOSE

To evaluate the clinical outcome of patients with venous malformation (VM) involving the eyelid treated with bleomycin sclerotherapy.

METHODS

A retrospective review was performed of 18 consecutive patients with VM involving the eyelid who underwent bleomycin sclerotherapy. Patients' clinical presentation, details of sclerotherapy, and post-sclerotherapy resolution of the lesion as well as any procedure-related complications were evaluated.

RESULTS

Twelve women and six men of mean age 34.3±20.4 years underwent sclerotherapy with bleomycin. Chief complaints were cosmetic disfigurations with or without hemifacial deformity (n=2), pain in engorgement area (n=2), pain and swelling from venous thrombosis (n=2), swelling or engorgement obstructing their eyesight (n=2), or eyelid dysfunction (n=1). The lesions were only in the eyelid in three patients; otherwise they were extended out of the eyelid either superiorly (n=3), laterally (n=8), inferiorly (n=8), and/or posteriorly to the orbit (n=8) to various extents. Conjunctival involvement was present in 13 patients. 14 patients had received prior treatments including surgery, laser therapy, or non-bleomycin sclerotherapy. With an average three sessions of bleomycin sclerotherapy (average total dose 34.5 mg), more than 80% shrinkage was observed in seven patients (38.9%), 50-80% shrinkage in eight patients (44.4%), and 30-50% shrinkage in two patients (11.1%). One patient had recurrence, which was successfully treated again with bleomycin. No procedure-related complications were noted.

CONCLUSIONS

The use of bleomycin appears to be a simple, safe, and effective treatment for venous malformations involving the eyelid, avoiding more elaborate and challenging surgical or laser interventions, and is even effective in full thickness lesions.

Role of intralesional bleomycin and intralesional triamcinolone therapy in residual haemangioma following propranolol

With the emergence of propranolol as the first choice of treatment for problematic infantile haemangioma at many centres, the number of patients with a partial or non-response to propranolol has also been growing. This study investigated the role of intralesional bleomycin and triamcinolone in patients with residual disease following propranolol therapy for infantile haemangioma. Sixty-seven patients with residual haemangioma were assigned randomly to receive either intralesional bleomycin (group A, n=36) or intralesional triamcinolone (group B, n=31). The response to treatment and adverse effects were assessed in both groups. All patients received at least four doses and a maximum of six doses of the assigned drug. In group A (mean follow-up 9.38months), 47.2% had an excellent response and 44.4% a good response. In group B (mean follow-up 7.42months), 25.8% had an excellent response and 48.4% a good response. There was no difference in overall response between the groups (P=0.074). Among patients who were initially non-responders to propranolol, bleomycin showed a better response than triamcinolone (P=0.037). This may be due to an overlap in the mechanism of action of propranolol and triamcinolone. Thus, intralesional bleomycin should be preferred in patients with no initial response to propranolol therapy, while bleomycin or triamcinolone can be used in patients with a partial response to propranolol therapy, as they have equal efficacy.