Medical Management of Vascular Anomalies

Incidence and Factors Associated With Spontaneous Regression in Head and Neck Lymphatic Malformations

Importance

Head and neck lymphatic malformations (HNLMs) demonstrate considerable variability in their natural history. While some malformations cause chronic severe functional impairment, others are asymptomatic and spontaneously regress. Understanding the frequency and features associated with regression will aid clinicians and families in making informed treatment choices and avoid unnecessary risks of intervention for a subset of patients.

Objective

To assess the incidence, timing, and factors associated with spontaneous regression of HNLMs.

Design, Setting, and Participants

This retrospective cohort study across a single regional pediatric tertiary care academic center included patients aged 0 to 21 years with HNLM who were evaluated in the vascular anomalies clinic and prospectively enrolled in an institutional quality improvement database between 2003 and 2022. Observation was offered to patients without symptoms or functional compromise. Treatment decisions were made during routine clinical care.

Exposures

Age of HNLM onset and HNLM location, distribution, cystic structure, grade, and de Serres staging.

Main Outcome and Measures

The incidence of complete spontaneous regression was estimated. The strength of the association between exposures and regression was assessed using risk ratios, Cliff Δ, and Cramer V. A Kaplan-Meier curve was used to estimate the probability of spontaneous regression over time. The association of the exposures on the likelihood of spontaneous regression were assessed using 2-sided log-rank tests and Cox proportional hazards models.

Results

Of 298 patients with HNLMs, 173 (58.1%) were male, and most HNLMs were diagnosed prenatally or at birth (137 patients [46.0%]). Among HNLMs, 189 (63.4%) had a focal distribution, 228 (76.5%) were de Serres stage I or II, and 128 (43.0%) were macrocystic. Complete spontaneous regression occurred in 27 patients (9.1%) at a median (IQR) time of 12.0 (6.7-27.4) months from onset. Factors associated with a large difference in the rate of complete spontaneous regression included macrocystic structure, neck location, focal distribution, and grade 1 or de Serres I stage. HNLMs of the upper face or midface, with mixed or microcystic composition, or with extensive unilateral or bilateral involvement did not regress.

Conclusions and Relevance

In this cohort study, HNLMs that were macrocystic, of limited extent, and/or in the neck were more likely to completely spontaneously regress. A 1-year observation period for asymptomatic HNLM, particularly when favorable features are present, should be considered, as nonintervention may be curative. Future studies will examine interaction among these factors. This work contributes to a deeper understanding of HNLM natural history that can directly inform clinical decision-making, decrease treatment risk, and optimize patient outcomes.

Review of diagnosis, differential diagnosis, and management of retroperitoneal lymphangioma

Lymphatic malformation (LM) is the currently preferred term for what was previously known as lymphangioma. Retroperitoneal LMs are extremely rare, benign, cystic masses that arise from lymphatic vessels. They can be challenging to diagnose because they resemble other retroperitoneal cystic tumors. The development of treatment strategies for rare diseases, including retroperitoneal LM, requires the acquisition of new knowledge to enhance our understanding of the disease progression. Therefore, we present an update regarding fundamental and advanced issues associated with retroperitoneal LM. This review describes the epidemiology, histopathology, biomedicine, clinical manifestations, radiological features, differential diagnosis, and management of this lesion.

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.

Somatic activating BRAF variants cause isolated lymphatic malformations

Somatic activating variants in PIK3CA, the gene that encodes the p110α catalytic subunit of phosphatidylinositol 3-kinase (PI3K), have been previously detected in ∼80% of lymphatic malformations (LMs).1 , 2 We report the presence of somatic activating variants in BRAF in individuals with LMs that do not possess pathogenic PIK3CA variants. The BRAF substitution p.Val600Glu (c.1799T>A), one of the most common driver mutations in cancer, was detected in multiple individuals with LMs. Histology revealed abnormal lymphatic channels with immunopositivity for BRAFV600E in endothelial cells that was otherwise indistinguishable from PIK3CA-positive LM. The finding that BRAF variants contribute to low-flow LMs increases the complexity of prior models associating low-flow vascular malformations (LM and venous malformations) with mutations in the PI3K-AKT-MTOR and high-flow vascular malformations (arteriovenous malformations) with mutations in the RAS-mitogen-activated protein kinase (MAPK) pathway.3 In addition, this work highlights the importance of genetic diagnosis prior to initiating medical therapy as more studies examine therapeutics for individuals with vascular malformations.

Uterine Arteriovenous Malformation: A Pictorial Review of Diagnosis and Management

Uterine arteriovenous malformation (UAVM) is a rare condition and is classified as either congenital or acquired UAVM. Patients with UAVMs usually experience miscarriages or recurrent menorrhagia. Ultrasound is used for the initial estimation of UAVMs. Computed tomography and magnetic resonance imaging are noninvasive and valuable methods that provide good compatibility with digital subtraction angiography to support the diagnosis and treatment of UAVM. Timely diagnosis is crucial to provide appropriate treatment for alleviating complications. This article presents a pictorial and literature review of the current evidence of the diagnosis and management of UAVM.