Classification and ultrasound findings of vascular anomalies in pediatric age: the essential

Consensus statement for the diagnosis, treatment, and prognosis of kaposiform hemangioendothelioma

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor that typically presents in infancy or early childhood. As awareness of KHE increases, it is imperative that the management of KHE be updated to reflect the latest evidence-based guidelines. The aim of this study was to integrate the literature and Chinese expert opinions to provide updated recommendations that will guide the diagnosis, treatment, and prognosis of patients with KHE. According to this consensus statement, 28 nationally peer-recognized experts in vascular anomalies and an expert in evidence-based medicine were assembled and formed three consensus subgroups. A series of key themes and questions were developed for each group, including recommendations for diagnosis, treatment, and prognosis. A systematic search was conducted for English-language articles published in PubMed and other relevant studies identified by the expert panel. A diagnosis of KHE necessitates the integration of clinical, imaging, and histologic features. The treatment of KHE should be tailored to the specific characteristics of each patient, including the size of the lesion, the presence of symptoms, the location, and the overall condition of the patient. In addition to focusing on the disease itself, it is also important to consider the complications of KHE and their impact on prognosis. The recommendations presented herein are intended to assist in the guidance of clinical practice and decision-making in patients with KHE, with the objective of improving patient outcomes.

Application of color Doppler ultrasound in the treatment of infantile hemangioma by applying timolol combined with Cynergy dual-wavelength laser : Application of color Doppler ultrasound in the treatment of infantile hemangioma

To assess the utility of color Doppler ultrasound in guiding the treatment of infantile hemangiomas using a combination of topically applied timolol and Cynergy dual-wavelength laser. We selected 92 hemangioma patients from our outpatient clinic between March 2022 and September 2023. According to the Guidelines for Diagnosis and Treatment of Hemangiomas and Vascular Malformations (2019 edition), laser therapy is suitable for superficial localized or sporadic lesions, combined treatment or natural resolution of residual skin hemangioma lesions, remaining loose and uneven skin.All the patients in our group met the guidelines for Diagnosis and Treatment of hemangiomas and vascular malformations (2019 edition). The risk grade was medium risk and low risk, medium risk: hemangiomas on both sides of the face, scalp, hands and feet, with disfigurement risk and low risk of functional impairment; Hemangiomas in the body folds (neck, perineum, underarm), with a high risk of ulcer formation; Segmental hemangiomas > 5 cm- risk of ulcer formation on trunk, limbs, and skin, and permanent remains. Low risk: Trunk, limbs (not obvious), low risk of disfigurement and functional impairment. According to guidelines for moderate risk hemangiomas: Treat them early. Early and weak lesions can be given topical β-blockers, or pulsed dye laser; In the course of treatment, if the tumor growth cannot be controlled, the high-risk hemangioma treatment regimen should be followed. Low-risk hemangioma: If it is stable, follow up or try topical drugs; If the tumor is growing rapidly, the medium risk hemangioma treatment regimen is followed.These patients were divided into two groups, A and B. In group A, color Doppler ultrasonography was conducted, and patients were categorized into three groups based on their blood flow signals identified through color ultrasound. Among the 70 cases in group A with distinct blood flow signals, laser parameters were adjusted, and topical timolol was administered. In group B, the family members of the patients were reluctant to accept color ultrasound examination due to poor family conditions and the patient's uncooperation during color ultrasound examination,22 cases received direct treatment with topical timolol and Cynergy dual-wavelength laser upon hospital admission without undergoing ultrasound. The time gap between these treatments was one month. Both groups were followed up for one month to compare treatment effectiveness, adverse effects, and treatment durations. A total of 92 patients were included in this study, with 70 cases in group A (average age 4.05 ± 2.51 months) and 22 cases in group B (average age 4.00 ± 2.33 months). Hemangioma blood flow signals in group A were categorized as follows: no blood flow, sparse blood flow, and moderate blood flow in groups A1, A2, and A3, respectively. The effectiveness rate in group A was significantly higher than that in group B (90.0% vs. 72.7%, U = 637, P = 0.044). Group A exhibited lower adverse effect rates compared to group B (n = 14 [20.0%] vs. n = 9 [40.9%], U = 609, P = 0.049). Furthermore, the number of treatments showed a statistically significant difference (F = 26.830, P = 0.00) between the two groups. Doppler ultrasonography proves valuable in assessing the clinical effectiveness of hemangiomas. Future research may determine its ability to predict the number of laser treatments required.

Multimodal Ultrasound Diagnosis of Congenital Renal Arteriovenous Malformation: A Case Report

Traditionally, computed tomography angiography has been considered the gold standard for diagnosing renal arteriovenous malformation (AVM). Despite the sensitivity of ultrasound in detecting AVM through Doppler techniques, it often lacks the ability to provide detailed insights into the lesion. In this narrative, we present a case of unexplained hematuria accompanied by flank pain, which was conclusively diagnosed as congenital renal AVM via multimodal ultrasound. The pivotal contributions of color Doppler ultrasound and contrast-enhanced ultrasound are that they are instrumental in enabling an early and markedly precise diagnostic pathway.

Venous Malformations: Diagnosis, Management, and Future Directions

Venous malformations (VMs) represent the most common type of congenital vascular anomalies, characterized by slow-flow lesions arising from disorganized angiogenesis. These malformations can vary widely in size, location, and clinical impact, presenting significant challenges in diagnosis and management. A multidisciplinary approach is essential for optimizing care, with goals centered on symptom relief and functional preservation. Diagnostic evaluation typically involves clinical examination, imaging, and, in complex cases, genetic testing. Interventional radiology, particularly sclerotherapy and endovascular embolization, has become the first-line treatment, complemented by surgical and emerging molecular therapies, particularly targeting the mTOR/PI3K/AKT pathway. This review provides a comprehensive examination of the genetics, clinical presentation, and key diagnostic imaging aspects of VMs, along with a detailed discussion of current treatment modalities, emerging therapeutic techniques, and future directions for improving patient care.

Imaging of Vascular Anomalies

Vascular anomalies (VAs) are a heterogeneous group of vascular malformations and tumors that are frequently encountered in daily practice. While most are benign, malignant vascular tumors exist, as do other nonvascular soft-tissue malignancies that may masquerade as a benign VA. The subtleties of arriving at an accurate diagnosis can be intimidating, as new entities are described and names of conditions have been modified. Therefore, the goal of this article is to describe the classic imaging findings of VAs so that the interventional radiologist can confidently and competently contribute to management decisions, with special attention to ominous imaging features that should prompt biopsy or further imaging workup.

Soft Tissue Vascular Anomalies of the Extremities: A Proposed Diagnostic Approach

This narrative review aims to summarise the classification of vascular anomalies, their clinical presentation, and their radiological features to propose a diagnostic algorithm to approach patients with suspected soft tissue vascular anomalies of the extremities. The management of vascular anomalies necessitates a multidisciplinary approach. Clinical presentation and physical examination are sufficient in most cases to achieve a correct diagnosis. This is especially true for small congenital lesions of the skin and subcutaneous tissue. Imaging is used for accurate characterization of these lesions, especially in cases of atypical or vague clinical presentation, and to assess extension in cases of lesions that are larger and localized in deeper tissues.

Dermato-Radiological Evaluation of Congenital Limb Overgrowth Vascular Syndromes

International Society for the Study of Vascular Anomalies classification defines Congenital Limb Overgrowth Vascular Syndromes (CLOS) as a subset of vascular syndromes with other abnormalities that present with unilateral limb overgrowth. It includes Klippel-Trenaunay Syndrome, Parkes-Weber Syndrome, CLOVES (Congenital Lipomatous Overgrowth, Vascular Malformations, Epidermal Nevi, Spinal/Skeletal Anomalies/Scoliosis) Syndrome, Proteus Syndrome, PTEN Hamartomatous Syndrome, and Fibroadipose Vascular Anomaly. Due to their rare and complex nature, a multidisciplinary approach to diagnosis and treatment is required. A thorough clinical and radiological workup can go miles in reflecting on the patient's outcome. Here we report five cases of CLOS with their detailed dermato-radiological profiles.

Ultrasound Applications in Pediatric Orthopedics

Imaging techniques have significantly impacted physicians' capability for diagnosis and differential diagnosis for decades. The aim of this review is to update our knowledge regarding the use of US in orthopedic pediatric patients for diagnostic purposes or procedural/therapeutic purposes. This review demonstrates the application of US in trauma (long bone fractures, radial neck fractures, etc.), developmental anomalies such as developmental dysplasia of the hip and congenital dislocation of the patella, soft tissue pathologies (ganglion cyst, popliteal cyst, hemangioma, lipoma, etc.), tumors, apophysitis, joint effusion, and femoral acetabular impingement. US aid in musculoskeletal procedures has also been reported; US-guided procedures such as aspiration, injection, biopsy, foreign body removal, and peripheral nerve block reduce complications, thus making the procedures safer for the patient. Sonography is a fast, low-cost, mobile, non-invasive, and radiation-free diagnostic tool. Even though US requires a skilled operator and has a long learning curve, in experienced hands is the "orthopedic surgeon's stethoscope".

Comparison of wireless handheld ultrasound and high-end ultrasound in pediatric patients with venous malformations - First results

AIM

To evaluate the usefulness of handheld ultrasound in comparison with high-end ultrasound for lesion evaluation before and after sclerotherapy in pediatric patients with venous malformations (VMs).

MATERIAL AND METHODS

10 pediatric patients prior to and after sclerotherapy were scanned by an experienced examiner using handheld ultrasound (Vscan AirTM) and high-end ultrasound (LOGIQ E9/E10) as reference. Patients with associated venous thromboses and intralesional aneurysms had been excluded. Results were interpreted independently by two readers in consensus.

RESULTS

10 patients (4-17 years; 10.0±4.32 years; female n = 6, male n = 4) with 10 VMs (4 of the head and neck region, 4 of the upper and 2 of the lower extremities) were examined. 7 phleboliths were detected. The average rating score achieved by the high-end device never was less than 4, by Vscan AirTM never less than 3. An exception was the assessment of AV fistulas. In comparison with the evaluation of variables examined, we found a significant difference between the high-end scanner and the handheld device regarding the achieved image quality.

CONCLUSION

Vscan AirTM ultrasound device allows new possibilities for procedure planning and post-procedural control of pediatric patients with VMs.

Radiologic and Clinical Features of Infantile Hemangioma: Potential Pitfalls and Differential Diagnosis

Infantile hemangioma (IH) is the most common neoplasm in children, but it may mimic other types of vascular anomalies or nonvascular benign and malignant tumors. In most cases, the clinical appearance, time of onset, and pattern of involution facilitate its diagnosis. Imaging evaluation is not always needed since the IH features at clinical presentation are usually characteristic, but when needed, US and frequently MRI are the imaging modalities of choice. Clinical photography or photographic documentation plays a central role in monitoring these lesions over their clinical course. Photographic documentation can also add confidence and alert the radiologist when interpreting imaging studies. Some vascular anomalies, especially vascular malformations, are a frequent source of confusion, as these may resemble IHs clinically and at imaging. The lack of uniform terminology also hinders an accurate diagnosis. To unify the terminology and minimize confusion, the International Society for the Study of Vascular Anomalies created a helpful classification in 1994. In addition, radiologists need to be aware of and become familiar with other neoplasms in children that may resemble IH to avoid misdiagnosis and unnecessary procedures. Fibrous and lipomatous tumors are examples of benign tumors that can mimic IHs clinically and at imaging, whereas rhabdomyosarcoma, infantile fibrosarcoma, neuroblastoma, and lymphoproliferative disorders are examples of malignant neoplasms. The authors review the features of IH at clinical presentation and imaging evaluation, highlighting its different phases of evolution and stressing the importance of photographic documentation. The authors also review pitfalls of IH with helpful pearls for differentiation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material. See the invited commentary by Khanna and Briones in this issue.

Vascular Malformations and Tumors: A Review of Classification and Imaging Features for Cardiothoracic Radiologists

The International Society for the Study of Vascular Anomalies (ISSVA) classification is a comprehensive histology-based scheme that was updated in 2018. It is important for cardiothoracic imagers to understand this classification to ensure that accurate terminology is used and that archaic terms are avoided when vascular lesions are described. Knowledge of the various malformations (including common conditions, such as venous malformation, arteriovenous fistula, and arteriovenous malformation) and vascular tumors allows for timely diagnosis and appropriate management. This review describes various vascular anomalies, in accordance with ISSVA classification and terminology; highlights key imaging features associated with each; and discusses the role of different imaging modalities. Keywords: Pulmonary, Soft Tissues/Skin, Vascular, Arteriovenous Malformation © RSNA, 2023.

Hepatic hemangiomas in childhood: the spectrum of radiologic findings. A pictorial essay

Hepatic hemangiomas (HHs) are the most common benign liver tumors in infancy, but despite their frequent occurrence, their radiologic appearance may be particularly challenging to assess, owing to unique anatomical and development features that distinguish their subtypes in the pediatric population. There are 3 main patterns of the lesions recognized in HHs: focal, multifocal and diffuse. Medical care strategies range from simple observation to surgery, and a timely diagnosis is crucial to establish the most appropriated clinical management and therapy. Ultrasound (US) is typically the first level examination of pediatric vascular anomalies, able to meet a satisfactory diagnosis and has proved very helpful to assess for involution through serial imaging. CT and MRI are second-level methods seldom performed, offering an anatomical panoramic view and clarification when US is non-conclusive. Histologic confirmation is rarely required. HHs show a variable sonographic appearance, with hypoechoic (mostly) or hyperechoic solitary\multifocal mass and wide features. Hepatic vessels assessment reveals an abnormal flow, enlarged vasa, decreased resistive index (RI) values, scarce blood supply distally to lesions and hyper vascular regions inside them. In this pictorial essay, we review HHs subtypes in further details, illustrate US, CT and MRI findings and clarify a recurrent dispute over the existing terminology.

Subcutaneous Granuloma Annulare vs. Subcutaneous Vascular Malformations in Children: A Diagnostic Challenge

OBJECTIVES

There are various subcutaneous lesions in children and often there is difficulty in obtaining an accurate diagnosis by non-invasive diagnostic procedures. Subcutaneous granuloma annulare (SGA) is a rare granulomatous disease that, even after imaging, is often mistaken for a low-flow subcutaneous vascular malformation (SVM). This study aimed to accurately identify clinical and imaging clues to distinguish SGA from low-flow SVM.

METHODS

We retrospectively analyzed complete hospital records of all children with a confirmed diagnosis of SGA and low-flow SVM who underwent MR imaging at our institution from January 2001 to December 2020. Their disease history, clinical and imaging findings, management, and outcome were evaluated.

RESULTS

Among 57 patients with granuloma annulare, we identified 12 patients (nine girls) with a confirmed SGA diagnosis who underwent a preoperative MRI. Their median age was 3.25 years (range 2-5 years). Of 455 patients diagnosed with vascular malformations, 90 had malformations limited to the subcutaneous area. Among them only 47 patients with low-flow SVM were included in the study and further analyzed. Our SGA cohort had a female predilection (75%) and a short history of lump appearance of 1.5 months. SGA lesions were immobile and firm. Before MRI, patients underwent initial evaluation by ultrasound (100%) and X-ray (50%). Surgical tissue sampling was performed in all SGA patients to establish a diagnosis. All 47 patients with low-flow SVM were diagnosed correctly by MRI. A total of 45 patients (96%) underwent surgical resection of the SVM. A careful retrospective review of imaging findings of patients with SGA and SVM showed that SGA present as homogenous lesions in the shape of an epifascial cap with a typical broad fascial base extending towards the subdermal tissue in the middle of the lesion. In contrast, SVMs always present with variable-sized multicystic or tubular areas.

CONCLUSIONS

Our study shows clear clinical and imaging differences between low-flow SVMs and SGA. SGA presents characteristically in the shape of a homogenous "epifascial cap," which distinguishes these lesions from multicystic heterogenous SVMs.

A Case Series of 18 Congenital Haemangiomas: Clinical, Histological and Ultrasound Features, and their Relationship with Complications and Atypical Behaviour

Recent studies have advanced our understanding of the clinical, histological and imaging characteristics of congenital haemangiomas (CHs), and have reported possible complications and atypical behaviour. The aim of this study is to describe the clinical, histological and ultrasound features of a series of CHs and to analyse their association with complications and atypical behaviour, with a view to providing diagnostic and management recommendations. The medical records, histology results and ultrasound images of all patients with CH diagnosed in the Dermatology Department of Alicante University General Hospital between 2006 and 2021 were retrospectively reviewed. A total of 18 patients were included, of whom 4 (22.2%) had complications. The most severe was 1 case with heart failure. There was a significant association between large CH size (> 5 cm) and the occurrence of complications (p = 0.019). The study identified 3 different lobule patterns, but found no relationship with CH subtype or other findings. The associations of venous ectasia, venous lakes and arteriovenous microshunts with occurrence of complications was borderline significant (p = 0.055). Study limitations were the small sample and the retrospective analysis. To conclude, haematological and cardiological assessment is indicated in large CHs and should be considered in CHs with ultrasound findings of venous ectasia, venous lakes or arteriovenous microshunts, as these cases present a greater risk of complications.

Role of ultrasound and colored Doppler examination in the diagnosis and the classification of the superficial soft tissue vascular anomalies

Background

Vascular anomalies are congenital lesions of abnormal vascular development, and a primary distinction have to be made between a vascular tumor and a vascular malformation, hemangiomas are considered the commonest vascular tumor, correct diagnosis is imperative for appropriate treatment. In this report, we tried to verify the role of ultrasonography and Doppler examination in the initial diagnosis, the classification of vascular anomalies and in the post-treatment follow-up.

Results (main findings)

This report included cases of vascular anomalies who attended the interventional radiology department as well as the vascular anomaly clinic in Abo El-Rish hospitals during the period 2019 through 2021. Data of all patients attending the clinic were prospectively examined. Files of 60 cases with vascular anomalies were available for review. The diagnosis of vascular anomalies was done according to their history and characteristic findings at clinical examination as well as U/S and color Doppler examinations, MRI and angiographic studies were done as needed. A significant female predominance was noticed. A significant predominance in the head and neck region was noticed (60%). Treatment was individualized according to each case; propranolol was chosen as the first line of treatment in IH. Intra-lesional steroids injections were done in hemangiomas, and intra-lesional bleomycin was done in venous and lymphatic malformations, endovascular embolization was done in high flow vascular malformations.

Conclusion

Ultrasound and color Doppler examination were effective and accurate methods in the diagnosis, the classification of superficial soft tissue vascular anomalies, the detection of early complications and in the follow-up after different treatment methods applied, it was also beneficial in the exclusion of non-vascular lesions.

Una tumefazione della parete addominale

A 12-year-old girl complained of a painless, slightly pulsatile abdominal lump for two months. Radiological imaging showed a fusiform lesion within the abdominal wall, between the external and internal oblique muscle, with nonhomogeneous echo-structure and high vascular density at the colour-power-Doppler analysis. The findings suggested an intramuscular arteriovenous malformation. The patient underwent a two-step treatment, namely a preoperative transarterial angioembolization of the nourishing vessels through the right femoral artery that was followed by a surgical resection of the lesion. Recovery was uneventful and during the follow-up no relapses were reported.

Palpable pediatric chest wall masses

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Atlas of Nervous System Vascular Malformations: A Systematic Review

Vascular malformations are frequent in the head and neck region, affecting the nervous system. The wide range of therapeutic approaches demand the correct anatomical, morphological, and functional characterization of these lesions supported by imaging. Using a systematic search protocol in PubMed, Google Scholar, Ebsco, Redalyc, and SciELO, the authors extracted clinical studies, review articles, book chapters, and case reports that provided information about vascular cerebral malformations, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 385,614 articles were grouped; using the inclusion and exclusion criteria, three of the authors independently selected 51 articles about five vascular cerebral malformations: venous malformation, brain capillary telangiectasia, brain cavernous angiomas, arteriovenous malformation, and leptomeningeal angiomatosis as part of Sturge–Weber syndrome. We described the next topics—“definition”, “etiology”, “pathophysiology”, and “treatment”—with a focus on the relationship with the imaging approach. We concluded that the correct anatomical, morphological, and functional characterization of cerebral vascular malformations by means of various imaging studies is highly relevant in determining the therapeutic approach, and that new lines of therapeutic approaches continue to depend on the imaging evaluation of these lesions.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Ultrasound patterns of localized cutaneous leishmaniasis and clinical correlations

A single-center retrospective study reviewed the following sonographic features of 18 confirmed cases of localized cutaneous leishmaniasis to identify shared presentation patterns: echotexture, lesion borders, hypodermal involvement, soft-tissue changes, and vascular pattern. A second objective was to correlate these patterns with clinical characteristics, including sex, age, anatomical location, nodule vs. plaque presentation, raised borders, granulation tissue, swelling, hyperkeratotic crusting, disease onset, and healing time. Two main patterns were identified with high-frequency ultrasonography. The first pattern was characterized by a high level of inflammation and deep hypodermal involvement, while the second variant showed involvement limited to the dermis, with minimal inflammation. The "inflammatory pattern" showed ill-defined borders, mixed echotexture, prominent vascularity with central distribution, and was correlated with clinical signs of ulceration, granulation tissue, raised borders, and longer healing time (p < 0.05). The "pauci-inflammatory pattern" presented a well-defined structure with decreased echogenicity, reduced or absent vascularity with minimal soft-tissue changes, and was associated with a shorter healing time (p < 0.05).

Autonomous diagnosis of pediatric cutaneous vascular anomalies using a convolutional neural network

OBJECTIVES

Design and validate a novel handheld device for the autonomous diagnosis of pediatric vascular anomalies using a convolutional neural network (CNN).

STUDY DESIGN

Retrospective, cross-sectional study of medical images. Computer aided design and 3D printed manufacturing.

METHODS

We obtained a series of head and neck vascular anomaly images in pediatric patients from the database maintained in a large multidisciplinary vascular anomalies clinic. The database was supplemented with additional images from the internet. Four diagnostic classes were recognized in the dataset - infantile hemangioma, capillary malformation, venous malformation, and arterio-venous malformation. Our group designed and implemented a convolutional neural network to recognize the four classes of vascular anomalies as well as a fifth class consisting of none of the vascular anomalies. The system was based on the Inception-Resnet neural network using transfer learning. For deployment, we designed and built a compact, handheld device including a central processing unit, display subsystems, and control electronics. The device focuses upon and autonomously classifies pediatric vascular lesions.

RESULTS

The multiclass system distinguished the diagnostic categories with an overall accuracy of 84%. The inclusion of lesion metadata improved overall accuracy to 94%. Sensitivity ranged from 88% (venous malformation) to 100% (arterio-venous malformation and capillary malformation).

CONCLUSIONS

An easily deployed handheld device to autonomously diagnose pediatric skin lesions is feasible. Large training datasets and novel neural network architectures will be required for successful implementation.

Neonatal vascular anomalies manifesting as soft-tissue masses

The broad and heterogeneous spectrum of vascular anomalies ranges from an innocuous localized cutaneous discoloration to complex, extensive and life-threatening diagnoses. While many of these lesions are present at birth, smaller and deeper lesions might be clinically occult for months or years. Certain vascular anomalies commonly manifest in the prenatal or neonatal period and often have suggestive clinical and imaging features that can aid the radiologist in making a correct diagnosis. The characteristics of such lesions presenting very early in life, particularly those manifesting as soft-tissue masses, are the focus of this review.

Vascular lesions of the pediatric orbit: A radiological walkthrough

Vascular anomalies of the pediatric orbit represent a heterogeneous group that include both vascular tumors and vascular malformations. The disorder may initially be silent and then associated with symptoms and/or function damage, depending on the type of vascular anomaly and its extension. Vascular tumors include benign, locally aggressive (or borderline) and malignant forms while vascular malformations are divided into "simple", "combined" and syndromic, or "low flow" or "high flow". Both entities can arise in isolation or as part of syndromes. In this review, we describe the imaging findings of the vascular lesions of the orbit in the pediatric population, which are key to obtain a correct diagnosis and to guide the appropriate treatment in the light of the new genetic and molecular discoveries, and the role of the radiologist in their multidisciplinary management. We will also touch upon the main syndromes associated with orbital vascular abnormalities.

Imaging of peripheral vascular malformations - current concepts and future perspectives

Vascular Malformations belong to the spectrum of orphan diseases and can involve all segments of the vascular tree: arteries, capillaries, and veins, and similarly the lymphatic vasculature. The classification according to the International Society for the Study of Vascular Anomalies (ISSVA) is of major importance to guide proper treatment. Imaging plays a crucial role to classify vascular malformations according to their dominant vessel type, anatomical extension, and flow pattern. Several imaging concepts including color-coded Duplex ultrasound/contrast-enhanced ultrasound (CDUS/CEUS), 4D computed tomography angiography (CTA), magnetic resonance imaging (MRI) including dynamic contrast-enhanced MR-angiography (DCE-MRA), and conventional arterial and venous angiography are established in the current clinical routine. Besides the very heterogenous phenotypes of vascular malformations, molecular and genetic profiling has recently offered an advanced understanding of the pathogenesis and progression of these lesions. As distinct molecular subtypes may be suitable for targeted therapies, capturing certain patterns by means of molecular imaging could enhance non-invasive diagnostics of vascular malformations. This review provides an overview of subtype-specific imaging and established imaging modalities, as well as future perspectives of novel functional and molecular imaging approaches. We highlight recent pioneering imaging studies including thermography, positron emission tomography (PET), and multispectral optoacoustic tomography (MSOT), which have successfully targeted specific biomarkers of vascular malformations.

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.

Granuloma annulare subtypes: sonographic features and clinicopathological correlation

PURPOSE

Diagnosis of granuloma annulare (GA) is based on the clinical and histopathological findings. However, only sporadic case reports of subcutaneous GA sonography have been published to date. The objective of this study was to evaluate the ultrasonographic patterns of the different clinical variants of GA: localized, generalized, subcutaneous, and perforating.

METHODS

In this retrospective observational study, we analyzed and correlated the clinical, histopathological, and sonographic features of 15 patients diagnosed with GA.

RESULTS

We included 8 women and 7 men with a mean age of 48.4 years (8-77 years). We found three different sonographic patterns depending on the clinical variant of GA: poorly defined hypoechoic band including the dermis (dermal pattern), irregularly shaped hypoechoic hypodermal lumps (hypodermal pattern), and ill-defined hypoechoic dermal and subcutaneous lesions (mixed pattern). Five cases showed increased blood flow signal on Doppler interrogation.

CONCLUSION

Although our findings are broadly consistent with the previous reports of subcutaneous GA, the sonographic features in localized, generalized, and perforating GA have not been previously reported.

A review of paediatric soft tissues masses referred to a tertiary musculoskeletal sarcoma centre

OBJECTIVES

To determine the differential diagnosis of musculoskeletal soft tissue masses in children referred to a specialist musculoskeletal oncology unit.

METHODS

All children (0-18 y) referred to a specialist musculoskeletal oncology unit over a 20-month period (September 2018-May 2020) were retrospectively reviewed. Demographic data and referral diagnoses were obtained from the electronic patient notes. MRI findings and histopathological results were recorded. The comparison of non-neoplastic, benign neoplastic and malignant diagnoses at the point of referral and final diagnosis was determined.

RESULTS

116 patients were included, 60 (51.7%) males and 56 (48.3%) females with mean age of 10.6 years (3 months-18 years). 69 (59.5%) patients were referred with a suspected sarcoma, 29 (25.0%) with a suspected benign tumour and 18 (15.5%) with a non-neoplastic lesion. A diagnosis was achieved by histological assessment in 61 (52.6%) cases, microbiological assessment in 3 (2.6%) or clinical and imaging assessment in 52 (44.8%). 67 (57.8%) cases had non-neoplastic pathology, 39 (33.6%) a benign tumour, 4 (3.4%) an intermediate-grade tumour, 6 (5.2%) a malignant tumour.

CONCLUSIONS

Although over half of children referred to a specialist musculoskeletal oncology unit were suspected of having a soft tissue sarcoma at referral, only 5.2% were diagnosed with a malignant tumour.

ADVANCES IN KNOWLEDGE

Approximately, 6 of 69 (8.7%) children referred to a specialist musculoskeletal oncology unit with a suspected soft tissue sarcoma will have a malignant lesion. Most paediatric soft tissue masses are non-neoplastic, the commonest diagnosis being a vascular malformation.

Ultrasonography of Pediatric Superficial Soft Tissue Tumors and Tumor-Like Lesions

Ultrasonography (US) is usually the first imaging examination performed to evaluate palpable or visible superficial soft tissue lesions that are common in children. Although clinical assessments, such as age at presentation, clinical course, and overlying skin discoloration, are important for the differentiation of pediatric soft tissue lesions, US allows a specific diagnosis of some typical benign lesions and helps in guiding further investigation since it provides detailed information about the lesion location, characterization including solid versus cystic, vascularity, and compressibility. Therefore, sufficient knowledge of the normal anatomy, proper ultrasonographic techniques, and the imaging findings of common and uncommon soft tissue lesions in children are crucial for accurate assessment and management of patients. In this article, we review the techniques and imaging findings focusing on the ultrasonographic features of a variety of superficial soft tissue lesions detected in children.

Venous malformations

Venous malformations include a spectrum of slow-flow malformations that together are the most common forms of vascular anomalies. Care of these patients requires a multi-disciplinary approach. Goals of care are to ameliorate symptoms and to preserve function. Use of therapeutic compression garments remains the mainstay of therapy. There are new and promising therapies over the last few years that will be invaluable tools for optimal care of this complex patient population. Advances in medical therapy through inhibition of the mTOR/PI3K/AKT pathway with Sirolimus and more proximal targeted drugs along with advances in sclerotherapy techniques are promising for the long-term improvement and amelioration of symptoms in patients with venous malformations.

Update on extracranial arteriovenous malformations: A staged multidisciplinary approach

Arteriovenous malformations (AVMs) are vascular lesions that are thought to arise from congenital errors during development of vessels resulting in abnormal connections between arteries and veins. Though most AVMs develop in the brain or spinal cord, they can occur anywhere in the body. These extracranial or peripheral AVMs have a predilection for the head, neck, and limbs. Since these malformations infiltrate normal soft tissue, management requires selective treatment with preservation of normal surrounding architecture. Therefore, they are best addressed through a staged multimodal and multidisciplinary approach, using a combination of different laser, interstitial, intravascular and surgical techniques to specifically target anomalous vessels. The goal of treatment is overall disease improvement and symptom control with interventions that do not result in outcomes worse than the disease itself. Recently, the discovery of somatic and germline mutations in peripheral AVMs have contributed to a better understanding of the pathophysiology, resulting in promising new pharmacologic treatments. Recent evidence suggests that adjuvant medical therapy can enhance and sustain interventional and/or surgical outcomes. Herein we describe how a new understanding of the etiology and physiology of extracranial AVM provides guidance to current treatment approaches.

A bump: what to do next? Ultrasound imaging of superficial soft-tissue palpable lesions

Soft-tissue palpable lesions are common in clinical practice, and ultrasound (US) represents the first imaging option in the evaluation of a patient with a soft-tissue swelling. A full and systematic US assessment is necessary, however. This includes grayscale, color- and power-Doppler, spectral-Doppler, and possibly elastography facilities, as well as a trained operator. Several lesions showing characteristic US features can be diagnosed confidently, without any further work-up, and the high spatial resolution of ultrasound in the superficial layers can be a powerful tool to discriminate their etiologies. Second-level options, to be reserved for indeterminate cases or those suspected malignant at initial ultrasound, include magnetic resonance imaging, percutaneous fine-needle aspiration or biopsy, and surgical-excision biopsy. In this article, we discuss the proper US approach for addressing superficial soft-tissue lesions.

Evaluation of sclerotherapy of benign oral vascular lesions with monoethanolamine oleate

OBJECTIVE

To investigate the efficacy of sclerotherapy with monoethanolamine oleate (MEO) in a series of cases of benign oral vascular lesions (BOVL).

MATERIAL AND METHODS

Clinical records and images were retrieved (2015-2019), and data regarding age, gender, location, size, symptomatology, treatment and outcomes of patients were collected. All patients were diagnosed according to the classification of International Society for the Study of Vascular Anomalies and received the same treatment protocol (MEO 0.05 g/mL). The collected data were submitted to descriptive analysis and Pearson's chi-square test (p ≤ 0.05).

RESULTS

Thirty-seven patients were treated. Most were female (70.3%) aged 9 to 88 years (median, 57.5 ± 17.4 years). Lower lip (54.1%) was the most affected site followed by buccal mucosa (16.2%). Thirty-two lesions were asymptomatic and 35.1% showed ≤ 0.5 cm in size. In 48.6% of the patients, only one application of MEO was performed. Complete regression occurred in 62.2% of cases, whereas 27% showed partial regression. One patient showed hypersensitivity during treatment. There was no significant difference between clinical outcome and age, anatomic site, size, and number of applications of MEO.

CONCLUSIONS

Sclerotherapy with MEO is an acceptable and affordable treatment and can provide satisfactory results in BOVL, especially where other treatment options could compromise the esthetic aspects.

CLINICAL RELEVANCE

As it is a non-invasive therapy leading, in most cases, to adequate clinical results, safety, and tolerability, sclerotherapy with MEO can be considered an effective treatment for BOVL.

Thyroglossal duct cysts and site-specific differential diagnoses: imaging findings with emphasis on ultrasound assessment

Thyroglossal duct cysts (TGDCs) are the most common congenital abnormality of the neck, accounting for approximately 70% of congenital neck lesions. Two-thirds of thyroglossal duct anomalies are diagnosed within the first three decades of life, with more than half being identified before 10 years of age. The age of presentation, clinical examination and imaging are essential for an accurate diagnosis. This review aims to summarize the imaging findings of TGDCs and their main differential diagnoses with emphasis on ultrasound assessment. A focus on site-specific key differentiating between them is also addressed.

Skin cancer: findings and role of high-resolution ultrasound

Currently available high-resolution transducers allow a detailed ultrasound (US) assessment of skin tumors. US complements clinical examination, dermoscopy, and biopsy in the initial differential diagnosis, surgical planning, locoregional staging, and follow-up of patients with skin malignancies. It is important for dermatologists, skin surgeons, and US operators to be aware of the US imaging findings and to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. The purpose of this review article is to address the most common indications for US in skin oncology and to provide a comprehensive guide to the gray-scale and color-Doppler findings in cutaneous malignant tumors.