Risk factors for infantile hemangioma: a meta-analysis

Hypoxia-driven angiogenesis and metabolic reprogramming in vascular tumors

Hypoxia is a hallmark of the tumor microenvironment (TME), and it plays a crucial role in the occurrence and progression in vascular tumors. Under hypoxic conditions, hypoxia-inducible factor 1-alpha (HIF-1α) is stabilized, inducing changes in the expression of various target genes involved in angiogenesis, metabolism, and cell survival. This includes the upregulation of pro-angiogenic factors like VEGF, which promotes the formation of dysfunctional blood vessels, contributing to the worsening of the hypoxic microenvironment. At the same time, hypoxia induces a metabolic shift toward glycolysis, even in the presence of oxygen, supporting tumor cell survival and proliferation by providing necessary energy and biosynthetic precursors. This review discusses the molecular mechanisms by which hypoxia regulates angiogenesis and metabolic reprogramming in vascular tumors, highlighting the intricate link between these processes, and explores potential therapeutic strategies to target these pathways in order to develop effective treatment strategies for patients.

Impact of congenital heart disease on clinical outcomes of oral propranolol therapy for Infantile hemangiomas: a propensity score-matched analysis

BACKGROUND

Oral propranolol is the first-line treatment for Infantile hemangioma (IH). However, there is a lack of studies indicating whether the congenital heart disease (CHD) makes a difference in oral propranolol therapy (OPT). Previous studies have only confirmed the safety and efficacy of OPT in asymptomatic CHD children.

OBJECTIVE

This study aimed to evaluate and compare the clinical outcomes in pediatric patients with CHD and those without CHD following OPT and to assess risk factors that may contribute to recurrence.

METHODS

A total of 310 children who received OPT for IH between January 2020 and January 2023 were included in a retrospective study. The study aimed to assess demographic data, clinical symptoms, auxiliary examinations, and treatment effects. To compare clinical outcomes between children with and without CHD, one-to-one propensity score matching (PSM) was applied.

RESULTS

Among the 310 patients, 192 (61.94%) had CHD. After propensity-matching analysis, in the presence of CHD, the age at treatment withdrawal was significantly higher (15.0 months vs. 12.0 months, P < 0.05), the treatment duration was longer (12.0 months vs. 10.0 months, P < 0.05), and the recurrence rate was greater (32.9% vs. 5.3%, P < 0.001). No significant difference in the degree of regression was observed between the CHD and non-CHD groups.

CONCLUSION

Pediatric patients with CHD exhibit a later age at treatment withdrawal, a longer duration of therapy, and a higher recurrence rate compared to those without CHD.

Cell Fate Regulation During the Development of Infantile Hemangioma

As the most common benign vascular tumor in infants, infantile hemangioma (IH) is characterized by rapid growth and vasculogenesis early in infancy, followed by spontaneous involution into fibrofatty tissues over time. Extensive evidence suggests that IH originates from hemangioma stem cells (HemSCs), a group of stem cells with clonal expansion and multi-directional differentiation capacity. However, the intricate mechanisms governing the cell fate transition of HemSCs during IH development remain elusive. Here we comprehensively examine the cellular composition of IH, emphasizing the nuanced properties of various IH cell types and their correlation with the clinical features of the tumor. We also summarize the current understanding of the regulatory pathways directing HemSC differentiation into endothelial cells (ECs), pericytes, and adipocytes throughout the stages of IH progression and involution. Furthermore, we discuss recent advances in unraveling the transcriptional and epigenetic regulation of EC and adipocyte development under physiological conditions, which offer crucial perspectives for understanding IH pathogenesis.

Efficacy and safety of atenolol vs. propranolol for treatment of infantile haemangioma: a narrative review

Infantile haemangioma (IH) remains the most common benign vascular tumour in childhood. Although most IH can be managed conservatively, a proportion of these lesions can cause disfigurement, ulceration or functional impairment, requiring prompt intervention. Propranolol, a lipophilic nonselective beta blocker, has been regarded as first-line therapy, following a serendipitous discovery of its use for IH in 2008. Although efficacious, it has been associated with adverse effects such as hypoglycaemia, bronchospasm, sleep disturbances and agitation in infant trials. Atenolol, a hydrophilic beta-1 selective blocker, has demonstrated similar efficacy and potentially greater tolerability, being less likely to cause sleep disturbances given its inability to cross the blood-brain barrier, and a decrease in bronchial reactivity. The purpose of this review is to explore and critique current knowledge about the efficacy and safety of propranolol vs. atenolol in children with an IH. In total, seven studies comparing the two beta blockers were identified in our search. Atenolol appeared to be as efficacious as propranolol and was associated with fewer central nervous system and bronchial-related adverse events. Further research exploring the optimal dosing for atenolol, particularly for ulcerated or syndromic IHs, as well as the incidence and management of rebound growth would be beneficial.

The Evaluation, Diagnosis, and Management of Infantile Hemangiomas-A Comprehensive Review

Infantile hemangioma (IH) is the most common pediatric benign vascular tumor. Its pathogenesis is still poorly understood, and it usually appears during the first few weeks of life and follows a characteristic natural course of proliferation and involution. Most IHs are small, benign, resolve spontaneously, and do not require active treatment but only active observation. A minority of IHs are potentially problematic because they can cause life-threatening complications, permanent disfigurement, and functional impairment. Diagnosis is usually clinical, and propranolol is currently the mainstay of treatment. Other therapeutic modalities may be used alone or in combination, depending on the characteristics of the specific IH. New treatment options are being explored every day, and some are showing promising results. It is undeniable that therapeutic modalities for IHs must be selected based on the child's age, the size and location of the lesion, the presence of complications, the implementation conditions, and the possible outcomes of the treatment. The future of IH management will certainly be reflected in improved advanced imaging modalities, research into the genetic and molecular basis, the development of new pharmacological agents or techniques, and the development of standardized protocols, all to optimize outcomes with minimal side effects.

Malignant and Benign Head and Neck Tumors of the Pediatric Age: A Narrative Review

Malignant tumors of the head and neck are rare in children, but it is important to know these lesions and identify them early in order to have a good outcome for these patients. Benign lesions of the head and neck are much more frequent and have an excellent prognosis. For this reason, it is necessary to recognize the warning signs and symptoms and understand when to refer the patient to a reference center for the treatment of these pathologies. The clinical presentation of both benign and malignant lesions in children may be similar as usually, both categories have compressive effects. This confirms the fact that the clinical diagnosis is not sufficient and always requires instrumental investigations and biopsies. In this narrative review, we analyzed both malignant lesions such as lymphoma, rhabdomyosarcoma, thyroid tumors, salivary gland tumors, neuroblastoma, and nasopharyngeal carcinoma, and benign ones such as cystic dermoid teratoma, hemangioma, juvenile angiofibroma and fibrosis dysplasia. Indeed, we set out to discuss the most common lesions of this site by evaluating their characteristics to highlight the differentiation of malignant tumors from benign lesions and their correct clinical-therapeutic management. A literature search was carried out in the PubMed and Google Scholar databases to identify all narrative reviews addressing malignant and benign head and neck tumors of the pediatric age. In conclusion, the care of children affected by head and neck benign lesions and malignancy must be combined and multidisciplinary. It is essential to recognize the diseases early in order to differentiate and intervene as soon as possible for the correct clinical-therapeutic management.

Optimizing Propranolol Therapy for Infantile Hemangiomas: The Role of the Multidisciplinary Team

BACKGROUND

Oral propranolol therapy is currently the first choice for infants with infantile hemangiomas (IHs) requiring systemic treatment. This study aims to evaluate the safety and effectiveness of oral propranolol therapy for IHs and to assess the role of a multidisciplinary medical team in supporting optimal treatment.

MATERIALS AND METHODS

Clinical data were retrospectively reviewed from medical records in 150 Japanese infants with IH treated with propranolol orally at Toranomon Hospital. Patients with problematic IH, such as tumor-type IH or IH with ulceration, were eligible for inclusion. Treatment was managed by a medical team consisting of pediatricians, dermatologists, pediatric nurses, pharmacists, and nutritionists. Patients' general conditions and vital signs, such as blood pressure, pulse rate, respiratory rate, and blood sugar, were closely monitored before, one hour, and two hours after drug administration.

RESULTS

Close collaboration among multidisciplinary medical team members allowed for accurate patient evaluation, contributing to the early detection of side effects, even if asymptomatic. When side effects were suspected, pediatricians and dermatologists discussed the need to reduce or discontinue the medication. Of the 150 patients, no one experienced severe side effects. Although five cases (3.3%) were suspected of having mild side effects (i.e., hypotension, n = 3; hypotension and hypoglycemia, n = 1; inspiratory stridor, n = 1), treatment could be continued by adjusting the dosage. One hundred twenty patients have completed the oral propranolol therapy with successful outcomes.

CONCLUSIONS

This study provided additional evidence of the safety and effectiveness of oral propranolol therapy in 150 Japanese infants with IH. A well-functioning multidisciplinary medical team is essential for optimal patient treatment.

Analysis of infantile hemangioma without proliferation after birth

Infantile hemangiomas (IHs) are the most common benign tumors of infancy, occurring in approximately 5-10% of the population. Among what appear to be typical IHs with proliferative and involuting phases, we noticed that there are also IHs that are already present at birth and regress without proliferating. We therefore aimed to determine the frequency and clinical characteristics of this type of IH. A retrospective study was conducted on 176 lesions of 137 Japanese patients with IH. As a result, six lesions (3.4%) in three patients with IH (2.1%) were already present at birth and lacked subsequent proliferation. Analysis of the clinical characteristics of IHs without proliferation revealed that they are significantly less common in the head and neck region, which is the preferred site of the tumor, than typical IHs with proliferation (0% vs. 42.9%, p < 0.05 by Fisher's exact test). This suggests that when the clinical course of IH is uncommon, their distribution can also be atypical. Furthermore, all of the IHs without proliferation were superficial types, and there were no deep types in this cohort. This study demonstrates that the clinical course of IH can be diverse, and that very rarely there can be a type of IH that does not grow after birth. It may be necessary to consider conducting a detailed interview for the growth history at the first visit for the possibility of such a type of IH without proliferation, as it is likely that they can be followed up without the need for treatment.

A 6-Week-Old Boy With Irritability and Abdominal Distension

A 6-week-old boy is brought to the hospital for fussiness and abdominal distension. He was febrile on presentation and was admitted to the hospital for further evaluation. On subsequent examinations, he continued to demonstrate abdominal distension and tenderness to palpation. Ultrasonography of the abdomen was performed and revealed a heterogeneous liver mass. With further diagnostics, a diagnosis was made and treatment initiated, with the infant experiencing resolution of his symptoms. Our panel of experts first discuss the management of an infant with abdominal distension, then discuss the evaluation of a liver mass in an infant, including oncologic, vascular, and infectious etiologies.

Infantile hemangiomas: a dermatologist's perspective

Infantile hemangioma (IH), the most common vascular tumor in pediatrics, is thought to arise from aberrant stem cell responses to stimuli such as hypoxia. This review explores the diverse manifestations, complications, and management strategies for IH, emphasizing the importance of a multidisciplinary approach. The epidemiology and risk factors associated with IH, including connections to prematurity, low birth weight, and family background, are discussed. The intricate pathogenesis involving hemangioma stem cells, KIAA1429, hypoxia, and the renin-angiotensin system is examined. The natural history and clinical features, as well as extracutaneous involvements such as hepatic IH, PHACES syndrome, and LUMBAR syndrome, are detailed. Complications such as ulceration, functional impairment, hypothyroidism, and cosmetic concerns are highlighted. The differential diagnosis and diagnostic modalities, including colorimeters, high-frequency ultrasonography, and imaging techniques, are discussed. Management approaches, including the use of propranolol, atenolol, corticosteroids, alternative systemic treatments, topical therapy, laser therapy, and surgery, are comprehensively reviewed. The evolving landscape of IH management is underscored, with ongoing research exploring alternative treatments and individualized approaches based on IH characteristics.

The prevalence, complications, and risk factors for infantile hemangioma: a systematic review and meta-analysis

The epidemiological landscape of infantile hemangioma (IH) has been extensively explored through diverse data sources; however, a scarcity of systematically pooled and quantified evidence from comprehensive global studies persists. In this meta-analysis, we systematically review available literature to elucidate the prevalence, distribution of lesions, complications, and risk factors associated with IH. A meticulous search encompassing the Cochrane Library, PubMed, Embase, and Web of Science identified 3206 records, of which 55 studies met the inclusion criteria. We found that the overall prevalence of IH is 2.8% [95% confidence interval (CI): 1.5-4.4%] (31,274,396 infants), and IH was located more frequently in the head and neck with a prevalence of 47.4% (95% CI: 39.5-55.4%). The overall prevalence of complications of IH is 24.3% (95% CI: 18.6-30.5%), ulceration is 16.0% (95% CI: 10.4-21.2%), bleeding is 5.6% (95% CI: 3.3-8.5%), visual impairment is 5.6% (95% CI: 3.0-8.9%), infection is 2.8% (95% CI: 1.5-4.8%), subglottic obstruction is 1.5% (95% CI: 0.5-3.0%), respectively. Through 27 studies, we have evaluated 35 factors encompassing perinatal factors, socioeconomic factors, maternal complications, drug factors, and antepartum procedures, and identified 18 risk factors that increase the prevalence of IH. These findings can greatly assist clinicians and family members in effectively evaluating the risk of IH, and determining whether pregnant women should undergo intensified monitoring or preventive measures.

Beyond Infantile Hemangiomas: A Glimpse into Overlapping Rare Syndromes Emphasizing the Vigilant Screening for PHACE and LUMBAR Syndromes

Infantile hemangiomas are the most common birthmark in newborns. They are clinically diagnosed and usually self-limited. However, there are several exceptions with aggressive types of hemangiomas that can be associated with extracutaneous anomalies, such as PHACE syndrome (posterior fossa anomalies, upper body hemangiomas, arterial anomalies, cardiac anomalies, and eye anomalies) and LUMBAR syndrome (lower body hemangiomas, ulcerations/urogenital anomalies, myelopathies, bony deformities, anorectal malformations/arterial anomalies, and renal anomalies). These two syndromes, described in the literature with distinct features, have rarely been reported in the same patient. We discuss one of the few cases reported with overlapping features of the PHACE and LUMBAR syndromes that initially presented with infantile hemangiomas, as well as other nonspecific skin and systemic findings. Minimal guidance has been described due to the need for more scientific literature. Our aim is to reinforce awareness of these two syndromes and the possibility of an overlap presentation between them. Furthermore, we emphasize the need for an interdisciplinary approach with screening for all known associations to avoid missing essential components of these syndromes that can lead to significant morbidity and lifetime complications.

Infantile hemangioma: the common and enigmatic vascular tumor

Infantile hemangioma (IH) is a benign vascular tumor that occurs in 5% of newborns. The tumor follows a life cycle of rapid proliferation in infancy, followed by slow involution in childhood. This unique life cycle has attracted the interest of basic and clinical scientists alike as a paradigm for vasculogenesis, angiogenesis, and vascular regression. Unanswered questions persist about the genetic and molecular drivers of the proliferating and involuting phases. The beta blocker propranolol usually accelerates regression of problematic IHs, yet its mechanism of action on vascular proliferation and differentiation is unclear. Some IHs fail to respond to beta blockers and regrow after discontinuation. Side effects occur and long-term sequelae of propranolol treatment are unknown. This poses clinical challenges and raises novel questions about the mechanisms of vascular overgrowth in IH.

Infantile Scalp Hemangiomas: Surgical Management and Lessons Learned

Infantile hemangiomas (IH) are common benign vascular tumors in pediatric patients, often found on the scalp. While most IH naturally regress without intervention, surgical excision becomes necessary when severe anatomic or physiological complications arise. This review examines previously published case studies on pediatric scalp IH excisions, focusing on surgical outcomes and complications. A comprehensive search of the US National Library of Medicine National Institutes of Health (PubMed) database identified 19 relevant case studies. Most patients were female, with a wide age range at the time of excision. Various anatomic locations and sizes of the hemangiomas were observed. The reviewed literature demonstrates that surgical excision of scalp IH can be performed with minimal complications, even for sizable tumors. Successful outcomes and low complication rates highlight the effectiveness of surgical intervention in cases of life-threatening IH sequelae. Further research is warranted to explore optimal timing, techniques, and adjunct therapies for surgical management of scalp IH.

Clinical characteristics of infantile haemangioma in twins: a retrospective study

BACKGROUND

Infantile hemangioma is one of the most common benign soft tissue tumors in infants. The pathogenesis of infantile hemangioma remains unclear and twin studies regarding its incidence may help clarify disease pathogenesis. Thus, this study aimed to analyze the clinical characteristics of infantile hemangioma in twin patients and discuss its clinical incidence.

METHODS

We retrospectively analyzed the data of 83 pairs of twins with infantile hemangioma admitted to the Guangdong Provincial Women and Children Hospital and Henan Provincial People's Hospital between May 2016 and May 2022. Thirty-one pairs of twins among whom both developed infantile hemangioma and 52 pairs of twins among whom only one twin was affected were included. Analysis was performed using the Spearman correlation. Additionally, we analyzed the influence of factors such as sex, twin zygosity, preterm birth, birth weight, and assisted reproduction on the clinical characteristics of twins.

RESULTS

We observed that disease occurrence in both twins correlated with assisted reproduction (χ2 = 13. 102, P < 0.05) and preterm birth (χ2 = 36.523, P < 0.05). Twin zygosity (χ2 = 0.716, P > 0.05) and total birth weight of twins (t=-3.369, P > 0.05) were not correlated with infantile hemangioma. However, among twins, the ones with lesser birth weight were more likely to develop infantile hemangioma.

CONCLUSIONS

The clinical characteristics of infantile hemangioma in twins were consistent with their epidemiological characteristics. Female sex, preterm birth, less birth weight, and assisted reproduction increased the probability of morbidity in both twins. Analysis of the characteristics of infantile hemangioma in twins may assist further research and clinical treatment.

Global research trends of infantile hemangioma: A bibliometric and visualization analysis from 2000 to 2022

Background

Infantile hemangioma (IH) has received global attention, resulting in a significant volume of literature. However, there is a lack of bibliometric analyses specifically focusing on IH publications. This study aims to fill this gap by conducting a comprehensive analysis of IH publications, investigating their characteristics, contribution distribution, and developmental trends. By enhancing our understanding of IH and identifying potential research topics and collaborators, this study will contribute to the advancement of the field.

Methods

A total of 4333 articles and reviews on IH were collected from the Web of Science (WoS) database, spanning the years 2000-2022. The study encompassed a comprehensive analysis of IH publications, evaluating their quantity and quality. Additionally, we profiled publishing groups based on country, institution, author publication records, and collaboration networks. Lastly, we identified and summarized the prominent research topics.

Results

Annual publications on IH have increased over the past 20 years. The United States has the highest number of publications and the highest total number of citations. Pediatric Dermatology was the most influential journal in the IH field. The citation analysis indicated that the articles published by Léauté-Labrèze in 2008 had the highest number of citations. The articles published by North PE in 2000 and Boye E in 2001 laid a certain research foundation for this field. Concerning institutions, most of the cooperative relationships were established in the same country/region. The United States has the largest number of scientific research institutions and IH researchers, leading most of the cross-country collaboration. The University of California, San Francisco, Medical College of Wisconsin, Harvard University, and Shanghai Jiaotong University were the research centers that published the most IH-related research. Frieden IJ, Mulliken JB, and Drolet BA were the top three most influential authors. Frieden IJ, Garzon MC, and Mulliken JB were the top three authors with the most cited frequency. In addition, keywords and keyword co-occurrence networks prompted that the pathological mechanism of IH, clinical analysis, and other vascular anomalies are research hotspots. Analysis of trending topics suggests that research on IH has evolved from treatment-focused studies towards investigations of other vascular diseases and a series of clinical case studies. Currently, clinical case studies receive the most attention in the field.

Conclusions

This comprehensive bibliometric study provides a thorough analysis of post-2000 publications in the field of IH, offering insights into current research trends for the first time. The findings suggest that future investigations will continue to prioritize understanding IH mechanisms, treatment approaches, and treatment evaluation. Furthermore, the exploration of other vascular diseases and the inclusion of clinical case studies are expected to contribute to advancements in IH clinical practice. By identifying potential collaborators, partner institutions, and new research avenues, this study offers valuable guidance for future in-depth research on IH.

Infantile Hemangioma: A Cross-Sectional Observational Study

(1) Background: With an incidence of 4-10%, infantile hemangiomas (IH) are the most encountered benign tumors in infancy. Low birth weight (LBW), prematurity, female sex, multiple gestations, and family history of IH are some of the statistically proven risk factors for developing IH. The aim of our study was to evaluate the prevalence of IH in our clinic and its connection to maternal and perinatal factors. (2) Methods: We conducted a cross-sectional study, over three years (2020-2022), at the Clinical Hospital of Obstetrics and Gynecology, "Prof. Dr. P. Sârbu", in Bucharest, Romania. (3) Results: During this period, 12,206 newborns were born and we identified 14 infants with infantile hemangioma. In our study, the prevalence of infantile hemangioma was 0.11%. The prevalence of IH in pregnancies obtained through in vitro fertilization was 1%, in twin pregnancies it was 2.27%, and in those with placenta previa, it was 4.16%. (4) Conclusions: Our findings provide a solid image of the prevalence of IH in our country and underline that the development of IH is strongly connected to maternal and perinatal variables, such as: preterm newborns, in vitro fertilization, high blood pressure, anemia, hypothyroidism, placenta previa, and twin pregnancy.

[Translated article] Congenital and Infantile Hemangiomas: Epidemiological, Clinical, and Treatment Characteristics Based on 3 Years' Experience at a Tertiary Care Hospital - A Retrospective Case Comparison and Review of the Literature

Distinguishing between congenital and infantile hemangiomas is challenging, but essential for appropriate treatment. The immunohistochemical marker glucose transporter type 1 is helpful, but biopsies are uncommon in this setting. The aim of this retrospective study was to describe and compare epidemiological, clinical, and treatment characteristics of congenital and infantile hemangiomas diagnosed at a tertiary care hospital over 3 years. We studied 107 hemangiomas: 34 congenital hemangiomas (rapidly involuting, partially involuting, and noninvoluting), 70 infantile hemangiomas, and 3 hemangiomas pending classification. Superficial infantile hemangiomas of the head and neck were the most prevalent tumors. Congenital hemangiomas were most often located on the trunk. Studied risk factors were more common in patients with infantile hemangiomas. In this group of patients, treatment response was independent of sex, in vitro fertilization, lesion depth and location, and type of treatment.

Long-term neurocognitive functioning of children treated with propranolol or atenolol for infantile hemangioma

The purpose of this study was to compare long-term neurocognitive functioning (working memory, processing speed, and attention) between children who had been treated with either propranolol or atenolol for infantile hemangioma during infancy. All eligible children (n = 158) aged 6 years or older and treated with propranolol or atenolol as infants were invited to participate in this two-center cross-sectional study. The primary outcome was the Wechsler Intelligence Scale for Children-V Cognitive Proficiency Index (CPI), a measure of working memory, processing speed, and attention. Secondary outcomes were general intelligence, auditory, visuospatial, and narrative memory, as well as executive functioning and sleep. A total of 105 children, of whom 36 had been treated with propranolol (age 6.0-11.8 years, follow-up time 1.6-9.7 years, 19% male) and 69 had been treated with atenolol (age 6.9-9.7 years, follow-up time 4.5-8.4 years, 19% male), were analyzed. The CPI and other neurocognitive outcomes did not differ between the propranolol and atenolol groups and were in line with general population test norms. Post hoc analyses revealed lower CPI scores for males, both compared to participating females (10.3 IQ points, medium effect size) and compared to matched test norms (12.4 IQ points, medium effect size).

CONCLUSIONS

 Long-term neurocognitive functioning did not differ between children treated with propranolol and those treated with atenolol for IH. Overall, propranolol and atenolol appear to be safe treatments for IH regarding long-term neurocognitive functioning. The substantially lower CPI scores in males warrant further investigation.

TRIAL REGISTRATION

 Netherlands Trial Register, NL7703 https://www.trialregister.nl/trial/7703 What is Known: • Infants with infantile hemangioma are effectively treated with propranolol or atenolol. • Parents and professionals are concerned about long-term neurocognitive effects.

WHAT IS NEW

• No long-term (≥ 6 years) differences in neurocognitive functioning were found between children treated with propranolol or atenolol. • Males treated with beta-blockers had substantially lower IQ scores than treated females and males from the general population, which is a matter of concern and should be considered when evaluating the risk/benefit ratio in less severe forms of infantile hemangioma.

Management of infantile hemangiomas: Recent advances

Infantile hemangiomas (IHs) are benign vascular tumors commonly observed in children. A small number of cases can manifest as organ or system dysfunction, permanent scarring, or even disfigurement. Currently, diagnosis is mainly based on clinical history, physical examination, and auxiliary inspection. In the treatment of a hemangioma, the functional damage caused by the lesion and complications that may endanger the patient’s life should be given priority. This suggests that identification, diagnosis, and referral to specialists during the early stages of IHs are important factors in preventing related complications and obtaining a better prognosis. During the past few decades, researchers have explored different treatments according to the condition, including oral or topical drugs, topical drug injections, laser surgery, and surgical treatment. However, oral propranolol remains a well-accepted first-line treatment. This article will primarily focus on the recent advances in the clinical diagnosis and treatment of hemangiomas, along with a literature review on the subject.

Infantile/Capillary Hemangioma of the Uterine Corpus: A Rare Cause of Abnormal Genital Bleeding

BACKGROUND

Infantile hemangiomas are vascular anomalies. However, they rarely cause genital bleeding. Here, we present the case of a young female with an endocavitary hemangioma who presented with abnormal uterine bleeding (AUB).

CASE

The patient was an 8-year-old female with genital bleeding. Transabdominal pelvic ultrasound showed a 20-mm highly vascularized focal intrauterine endocavitary lesion. Vascular computerized tomography excluded vascular anomalies. Magnetic resonance imaging suggested a hemangioma. Minimally invasive open surgery was performed to remove the lesion. Subsequent pathology analyses confirmed an infantile/capillary hemangioma.

CONCLUSIONS

Infantile hemangiomas are vascular anomalies that should be considered potential causes of AUB in early puberty. The study of these cases should include pelvic ultrasound and vascular magnetic resonance imaging. Experienced surgeons can successfully accomplish fertility-sparing surgical procedures.

SUMMARY

We describe an unusual case of peripubertal AUB caused by an endocavitary capillary hemangioma. Management included fertility-sparing surgery and the complete resolution of symptoms.

Machine Learning Approaches in Traditional Chinese Medicine: A Systematic Review

Machine learning (ML), as a branch of artificial intelligence, acquires the potential and meaningful rules from the mass of data via diverse algorithms. Owing to all research of traditional Chinese medicine (TCM) belonging to the digitalization of clinical records or experimental works, a massive and complex amount of data has become an inextricable part of the related studies. It is thus not surprising that ML approaches, as novel and efficient tools to mine the useful knowledge from data, have created inroads in a diversity of scopes of TCM over the past decade of years. However, by browsing lots of literature, we find that not all of the ML approaches perform well in the same field. Upon further consideration, we infer that the specificity may inhere between the ML approaches and their applied fields. This systematic review focuses its attention on the four categories of ML approaches and their eight application scopes in TCM. According to the function, ML approaches are classified into four categories, including classification, regression, clustering, and dimensionality reduction, and into 14 models as follows in more detail: support vector machine, least square-support vector machine, logistic regression, partial least squares regression, k-means clustering, hierarchical cluster analysis, artificial neural network, back propagation neural network, convolutional neural network, decision tree, random forest, principal component analysis, partial least squares-discriminant analysis, and orthogonal partial least squares-discriminant analysis. The eight common applied fields are divided into two parts: one for TCM, such as the diagnosis of diseases, the determination of syndromes, and the analysis of prescription, and the other for the related researches of Chinese herbal medicine, such as the quality control, the identification of geographic origins, the pharmacodynamic material basis, the medicinal properties, and the pharmacokinetics and pharmacodynamics. Additionally, this paper discusses the function and feature difference among ML approaches when they are applied to the corresponding fields via comparing their principles. The specificity of each approach to its applied fields has also been affirmed, whereby laying a foundation for subsequent studies applying ML approaches to TCM.

Good Clinical Responders to Topical Timolol in Patients with Infantile Hemangiomas: A 7-Year Retrospective Study of 328 Korean Patients

Background

Topical timolol is widely used for treatment of superficial infantile hemangioma (IH). However, little is known about factors that affect the response to topical timolol treatment.

Objective

This study aimed to investigate the efficacy, safety, and predictive value for good response to topical timolol for IH.

Methods

A retrospective review of medical records and clinical photos of 328 patients with IH treated with topical timolol 0.5% solution was conducted. Serial clinical photographs were compared with those at the initial visit using a 100-mm visual analogue scale (VAS). Treatment response was defined as an improvement of at least 75% from baseline in IH lesions within 12 months of treatment.

Results

Overall, IH patients treated with topical timolol showed significant improvement from baseline, showing that the final VAS score within 12 months of treatment was 69.7±20.4. The multivariable logistic regression analysis showed age at initiation of treatment (p=0.007), length of gestation and fetal growth (p=0.03), depth (p=0.01), and flexural area (p=0.007) were significantly associated with treatment response. Only four patients (1.1%) reported local irritation.

Conclusion

This study demonstrated that topical timolol treatment was an effective and well-tolerated treatment for IHs. Physicians are encouraged to consider several patient- or lesional factors that might affect treatment response to achieve better clinical outcomes.

Infantile Hemangiomas: An Update on Pathogenesis and Treatment

Infantile hemangiomas are the most common benign vascular tumors in infancy. This review includes an update on the current knowledge on pathogenesis, a discussion on indications for treatment, and a review of the mechanisms underlying the different treatment methods. Although most infantile hemangiomas require only active observation because of their natural course, which results in involution, about 10% present with complications that require immediate treatment. The basic treatment includes systemic and topical options. In cases of insufficient response or rebound growth, other forms of treatment should be considered. In some cases, combined therapy might be initiated.

Analysis of onset and clinical characteristics in Japanese patients with infantile hemangioma

Infantile hemangioma (IH) is a common benign tumor during infancy, although the detailed mechanism behind it has not been fully elucidated. Based on previous studies, we hypothesized that formation of hemangioma might be triggered by secondary physiological events (perinatal hypoxia or mechanical stress during delivery) in patients carrying germline risk mutations. We aimed to clarify the mechanism by evaluating whether head and neck lesions were more frequent in patients in who IH appeared after birth compared with those in who it was present at birth. Clinical data of 62 lesions in 51 patients with IH were collected. All patients were analyzed for correlation of onset with gender, localization, family histories, gestational age, birth weight, and clinical subtypes. Distribution of lesions on the head and neck was slightly more frequent in the after-birth IH group, compared with those with IH present at birth, but without significant difference (47.6% vs. 40.0%, p = 0.32). On the other hand, the ratio of superficial and deep type IH at birth was significantly altered compared with that in IH after birth (19:0 vs. 26:7, p = 0.039). In addition, IHs appearing after birth tended to more commonly have multiple lesions than those with IH present at birth, with statistically significant difference (25.8% vs. 0%, p = 0.0164). There may therefore be different triggers for IHs at birth and IH after birth. Further studies with greater number of patients are necessary to validate these findings.

Infantile hemangioma. Part 1: Epidemiology, pathogenesis, clinical presentation and assessment

Infantile hemangioma (IH) is the most common pediatric vascular tumor. Its pathogenesis is poorly understood but thought to represent an aberrant response of pluripotent stem cells to stimuli such as hypoxia and the renin-angiotensin-system. IH usually appears during the first few weeks of life and follows a characteristic natural trajectory of proliferation and involution. Their clinical appearance depends on their depth and distribution. Classification comprises superficial, mixed and deep IH as well as IH with minimal or arrested growth. Multifocal IHs are more likely to be associated with infantile hepatic hemangioma, and although the need for screening based on a specific number of IH has been recently debated, 5 remains the most widely acceptable cut off point. Large facial or lumbar IH warrants investigation for PHACE and LUMBAR syndrome, respectively. Complications of IH include ulceration, obstruction or functional impairment, hypothyroidism, and cosmetic sequelae. Differential diagnoses mostly consist of other vascular tumors and vascular malformations, though IH may sometimes mimic non-vascular tumors or developmental anomalies. Diagnosis is usually clinical and biopsy rarely indicated. High-frequency ultrasonography may help with the differential diagnosis, particularly with subcutaneous lesions. Referral to other specialists may be required in specific cases.

News on infantile haemangioma. Part 1: clinical course and pathomechanism

Currently, there is no doubt that the first choice of treatment for alarming infantile haemangiomas (IHs) is oral beta-blockers. However, research in this field remains active, as the pathogenesis of IH is still not completely elucidated. Furthermore, there are different approaches to the management of IHs with beta-blockers. In Part 1 of this review we will discuss the state-of-the-art evidence for IH with regard to (i) the definition, epidemiology, course, risk factors and sequelae, and (ii) the pathogenesis, focusing on genetic studies. This review will update the reader on the latest developments in the pathogenesis of IH. Furthermore, we hope this review will give more insight into risk factors and sequelae of IH, thereby contributing to better decisions in the clinical management of patients with IH. The therapy and evaluation of IHs will be discussed in Part 2 of this review.