Bleomycin therapy for cystic hygroma

Role of Bleomycin Sclerotherapy as a Non-surgical Method for the Treatment of Cystic Hygroma of Head and Neck Region-an Institutional Study

Cystic hygroma is a benign congenital tumor of lymphatic origin. Most common location is head and neck region. Bleomycin is an antineoplastic glycopeptide antibiotic agent with sclerosing property. In our present study, we used bleomycin for intralesional sclerotherapy for cystic hygromas of head neck region, as an alternative to surgical excision. We also statistically analyzed the pattern of cystic hygroma in head and neck region. Our present study was a prospective observational study of 40 patients. The study period was 18 months. All patients were given intralesional bleomycin at the dose of 0.5 mg /kg body weight, not exceeding 10 units at a time. The injection was repeated if required, at an interval of 4 weeks up to 4-5 times. Each patient was followed up at regular interval up to 1 year. Most common age group was found to be between 0-7 years (55%). Mean age was 6.9 years. Posterior triangle of neck was the commonest site (35%). Excellent response was noted in 24 patients (60%) while good response was noticed in 11 patients (27.5%). Poor response in 5 patients (12.5%). No major side effects noted with bleomycin sclerotherapy. No recurrence was noticed in our study. Intralesional bleomycin is a safe, simple, relatively cheaper and effective nonsurgical treatment method for cystic hygroma of head and neck region. It can be used as a first line treatment modality. Still, a lot of research is needed to establish it as a gold standard treatment modality for cystic hygroma.

Sclerosing agents in the management of lymphatic malformations in children: A systematic review

PURPOSE

Sclerotherapy is frequently employed in treating lymphatic malformations (LMs), and multiple agents, practitioners and strategies exist. This review investigates the reported efficacy and safety of sclerosants in the pediatric population.

METHODS

Adhering to PRISMA guidelines, multiple databases were queried without linguistic or temporal restriction. Inclusion criteria were patients aged 0-18 exclusively receiving injection sclerotherapy for the treatment of LMs with follow-up data. Data abstracted included agent, dose, anatomic site and key outcome measures including complications (major/minor) and resolution rates (>95% reduction in volume). Critical appraisal was undertaken using the MINORS tool.

RESULTS

Forty-eight studies met the inclusion criteria with a mean MINORS score of 0.65 ± 0.08. Included studies yielded 886 patients, across nearly 30 years. The overall observed rate of success was 89%, with variable follow-up across publications (6 weeks - 10 years). Most reported LMs were macrocystic (82%) and had a higher resolution rate than mixed/microcytic variants (89%, 71%, 34%, p<0.01) For head/neck LMs, rates of complete regression for OK-432, bleomycin, and doxycycline were 67% ± 27% (n = 26), 91% ± 53% (n = 34) and 85% ± 16% (n = 52) respectively. Major complications were most commonly reported with OK-432, including airway compromise or subsequent operation.

CONCLUSIONS

In pediatric patients treated for LM by sclerotherapy, complication rates were low. Macrocystic lesions respond well but success rates were modest at best for microcystic disease. Differences in agent utilization were noted between high and low resourced contexts; despite its lack of federal approval, OK-432 was the most reported agent. Further prospective research is warranted. LOE: 3a.

Efficacy and safety of ultrasound-guided bleomycin combined with dexamethasone in the treatment of pediatric lymphangiomas

PURPOSE

This work aimed to report our experience with ultrasound-guided instillation for the treatment of lymphangiomas in children, so as to determine whether the combined use of bleomycin and dexamethasone achieved a higher response rate and a lower side effect rate.

METHODS

The medical records from patients with lymphangiomas between January 1st, 2013 and September 31st, 2020, were reviewed. Patients who received bleomycin combined with dexamethasone sclerotherapy were classified as the dexamethasone group, while those receiving bleomycin without dexamethasone were classified as the control group.

RESULTS

Altogether one hundred and twenty-seven patients were diagnosed with lymphangiomas. Among them, one hundred and five patients received bleomycin combined with dexamethasone injection, while the remaining twenty-two received bleomycin injection alone. The excellent rates were 89.52% [95% confidence interval (CI), 81.64-94.40%] in the dexamethasone group and 72.73% (95% CI, 52.51-92.94%) in the control group (p < 0.05). Additionally, the recurrence rates were 3.81% (95% CI, 1.22-10.03%) in the dexamethasone group and 13.64% (95% CI, 3.6-36.0%) in the control group (p > 0.05). After comparison between the two groups, the following risk factors were identified. These include >10 sacs at the initial stage of diagnosis, larger size after all injections, and response to the first injection.

CONCLUSIONS

Although there was no significant difference in the recurrence rate between the two groups, this retrospective study demonstrated that the excellent response rates were dramatically improved between the two groups, suggesting that bleomycin combined with DEX was an effective and highly safe treatment for all types of pediatric lymphangiomas. Moreover, this study also identified three novel features as the significant risk factors for recurrence.

Results of Injection Sclerotherapy with Bleomycin in Pediatric Lymphatic Malformations

Aim:

The aim of the study was to evaluate the results of injection sclerotherapy with bleomycin in pediatric patients with lymphatic malformations.

Materials and Methods:

In this prospective cohort study, all consenting pediatric patients with macrocystic lymphatic malformations were managed with injection bleomycin sclerotherapy (0.5 mg/kg, not exceeding 5 mg at a time) under ultrasound (US) guidance. After aspirating the cyst fluid bleomycin was instilled intralesionally in a ratio of 5:1 (aspirated cyst fluid volume: diluted bleomycin solution volume). Patients were reassessed at three weekly intervals. The response to therapy was assessed clinically as well as by size and volume on ultrasound Doppler study. The response was classified as excellent response, i.e., complete regression, good response >50% regression, and poor response <50% regression.

Results:

Sixty patients with lymphatic malformations were enrolled in the study, the mean age was 3.22 years, and the male-to-female was 2.5:1. The most common site of lesion was in the neck (43.3%), followed by the axilla (15%) and flank (8.3%). The responses were excellent, good, and poor in 43 (71.6%), 12 (20%), and five (8.3%) patients, respectively. Two patients underwent surgical excision of the residual lesion. Complications noted were fever in six, local pain in five, and residual lesion in three patients.

Conclusion:

Sclerotherapy with bleomycin is simple, safe, and effective in the first line of management for macrocystic lymphatic malformations in children.

Management of cervicofacial lymphatic malformations requires a multidisciplinary approach

BACKGROUND/PURPOSE

Cervicofacial lymphatic malformations (CFLM) are rare, potentially life-threatening vascular anomalies, yet reports on multidisciplinary treatment strategies are lacking. We evaluated outcomes for CFLMs following sclerotherapy, surgical resection, and/or medical management.

METHODS

We identified children with a CFLM at a vascular anomalies center from 2004 to 2019.

EXCLUSION CRITERIA

retro-orbital malformations, untreated malformations, patients without follow-up. Primary clinical outcome was contour improvement, with significance defined as LM volume reduction of >50% by cross-sectional imaging.

RESULTS

Sixty-three children met inclusion criteria: 35 with macrocystic CFLMs, six with microcystic CFLMs, and 22 with mixed-type malformations. Mean post-intervention follow-up was 27.5 months. Fifty-eight patients underwent sclerotherapy (median: two treatments). Doxycycline and/or bleomycin were used in 95% of patients. After sclerotherapy, 97% of macrocystic CFLMs improved significantly compared to 82% of mixed and 67% of microcystic lesions. Sixteen children underwent surgical resection with 75% significantly improving; two additional patients were successfully treated with sclerotherapy after debulking surgery. Six children received sirolimus for microcystic disease, of which 33% significantly improved.

CONCLUSION

Sclerotherapy is very effective for macrocystic components of CFLMs, albeit less so for microcystic disease. Microcystic CFLMs frequently require surgical resection. Sirolimus is a helpful therapeutic adjunct, particularly for microcystic lesions, but more study is needed.

LEVEL OF EVIDENCE

Level II, prognosis study.

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

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

Efficacy and Clinical Outcomes of Bleomycin in the Treatment of Lymphangiomas: A Multicenter Experience

BACKGROUND

Bleomycin sclerotherapy became a popular nonsurgical option for the management of lymphangiomas. However, its efficacy has not been thoroughly evaluated. The purpose of this study was to assess the clinical outcomes and the effectiveness of bleomycin injection for the treatment of lymphangioma.

METHODS

This retrospective study was conducted in 4 centers and included 47 infants and children. All patients had bleomycin sclerotherapy between November 2005 and September 2020. Men presented 53.2% of the study sample (n = 25), and the most common site was the head and neck (n = 29, 61.7%).

RESULTS

Two injections were required in 11 patients (23.4%), and 7 patients (14.9%) required 3 or more injections. Excellent response was achieved in 63.8% (n = 30), 14 patients (29.8%) had a good response, and 4 had a poor response (8.5%). There was no difference in the response according to the site of the lesion (p = .75). The most frequent complication was recurrence (n = 11, 23.4%), and swelling occurred in 5 patients (10.6%). No patient had facial or phrenic nerve palsy or hoarseness. Two patients had persistent pain, and 2 had an infection (4.3%).

CONCLUSION

Intralesional bleomycin injection could be an effective therapy for lymphangiomas. The procedure has a low complication profile, and long-term study is recommended to evaluate the systemic and late bleomycin injection complications.

Education of pediatric surgery residents over time: Examining 15 years of case logs

BACKGROUND/PURPOSE

Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category.

RESULTS

In 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures.

CONCLUSION

Despite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases.

LEVEL OF EVIDENCE

Level II.

Bleomycin sclerotherapy in lymphangiomas of the head and neck region: a prospective study

Intralesional sclerotherapy for lymphatic malformations (LMs) has become a modality of choice because of the high morbidity and recurrence rates with surgical excision. Traditionally, the macrocystic variant has shown good results with sclerotherapy. This prospective study was performed to evaluate the role of bleomycin sclerotherapy in the management of different radiological variants of LM. A total of 142 patients were included in this study. The lesions were classified as macrocystic, microcystic, or mixed LMs on the basis of ultrasonography. All patients were managed by intralesional injection of bleomycin and were recalled after 4 weeks for evaluation. Colour photographs of the patients were taken before the onset of treatment and at each monthly visit, and were utilized to assess the response. Following the second, third, and fourth doses, the response was better in patients with the macrocystic variant than in those with the other two variants. However, after the completion of six doses, 80.3% of patients with the macrocystic variant, 67.4% with the microcystic variant, and 71.4% with the mixed type had a complete response. There was no difference in the overall response between the three types (P=0.28). Oedema, erythema, and local induration with fever were the most common adverse effects and were more common in younger children.

Management of a case of orbital lymphangioma presenting in adulthood with negative-pressure aspiration and bleomycin injection

We hereby report a case of a 55-year-old woman, with complaints of sudden onset outward protrusion of left eye progressing over 2 months, along with pain and loss of vision. Visual acuity in the affected eye was light perception only. On imaging, a well-defined solitary cystic lesion was noted in the retrobulbar space, which showed no enhancement on contrast-enhanced MRI. We performed fluid aspiration from the cyst under negative pressure and injected bleomycin as a sclerosant, without attempting a surgical excision. The proptosis reduced visibly, and after a week, visual acuity improved to finger counting at 1 m. At the 6 months follow-up, the patient did not show any recurrence of proptosis. This report highlights the importance of sclerosant therapy without the need for surgical excision in managing macrocystic lymphangiomas in adult age group.

Expression of Embryonic Stem Cell Markers in Microcystic Lymphatic Malformation

Aim: To investigate the expression of embryonic stem cell (ESC) markers in microcystic lymphatic malformation (mLM). Methods and Results: Cervicofacial mLM tissue samples from nine patients underwent 3,3'-diaminobenzidine (DAB) immunohistochemical (IHC) staining for ESC markers octamer-binding protein 4 (OCT4), homeobox protein NANOG, sex determining region Y-box 2 (SOX2), Krupple-like factor (KLF4), and proto-oncogene c-MYC. Transcriptional activation of these ESC markers was investigated using real-time polymerase chain reaction (RT-qPCR) and colorimetric in situ hybridization (CISH) on four and five of these mLM tissue samples, respectively. Immunofluorescence (IF) IHC staining was performed on three of these mLM tissue samples to investigate localization of these ESC markers. DAB and IF IHC staining demonstrated the expression of OCT4, SOX2, NANOG, KLF4, and c-MYC on the endothelium of lesional vessels with abundant expression of c-MYC and SOX2, which was also present on the cells within the stroma, in all nine mLM tissue samples. RT-qPCR and CISH confirmed transcriptional activation of all these ESC markers investigated. Conclusions: These findings suggest the presence of a primitive population on the endothelium of lesional vessels and the surrounding stroma in mLM. The abundant expression of the progenitor-associated markers SOX2 and c-MYC suggests that the majority are of progenitor phenotype with a small number of ESC-like cells.

Use of percutaneous bleomycin sclerotherapy for orbital lymphatic malformations

PURPOSE

Bleomycin sclerotherapy has been shown to be a viable treatment for lymphatic malformations. However, its use for these lesions confined to the orbit is becoming increasingly documented in the literature. In this study, we summarize the clinical manifestations and outcomes observed following percutaneous bleomycin sclerotherapy for orbital lymphatic malformation.

METHODS

A 5-year retrospective chart review of patients with clinical, radiographic, and/or biopsy-confirmed diagnoses of orbital lymphatic malformation that received bleomycin sclerotherapy was conducted at the Emory Hospital and Clinics. Data examined included patient demographics, patient history and symptoms, clinical findings, radiographic findings, route of bleomycin delivery, and outcome.

RESULTS

Of the 10 patients who met inclusion criteria, the median age of treatment was 7 years. The most common presenting symptoms included vision change and proptosis. Nine of 10 patients demonstrated macrocysts (>1 cm) on imaging. Seven of 10 patients had histories of prior interventions including resections, cyst drainage, and debulking. Because 2 of these 10 patients were lost to follow-up, 8 patients remained for post-procedural evaluation. Four of these eight showed improvement of visual acuity after post-bleomycin sclerotherapy. In seven of eight patients, extraocular motility either improved or remained stable. Pretreatment and posttreatment exophthalmometer measurements obtained in four patients revealed an average improvement in proptosis of 65% from their average pretreatment measurements.

CONCLUSIONS

Our findings suggest that percutaneous bleomycin sclerotherapy is a viable option for treatment of orbital lymphatic malformations, with potentially greater benefit to those with macrocystic features.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous Drainage and Povidone-Iodine Sclerotherapy of Cervical Lymphatic Malformation

Lymphatic malformations in cases with macrocystic lesions can be treated with surgical excision or sclerotherapy using alcohol, bleomycin, doxycycline, or OK-432. We report a case of a 24-year-old woman who underwent percutaneous drainage and povidone-iodine sclerotherapy as primary treatment for cervical lymphatic malformation. The patient underwent povidone-iodine sclerotherapy for 3 consecutive days. After 8 months, ultrasonography of the lesion in the neck revealed complete resolution of the cervical lymphatic malformation without any complication. Povidone-iodine sclerotherapy can be a safe and cost-effective treatment option for cervical lymphatic malformation.

Aqueous intralesional bleomycin sclerotherapy in lymphatic malformation: Our experience with children and adult

Objectives:

Lymphatic malformations (LMs) are aberrant proliferation of sequestrated lymphatic vessels during early embryogenesis and do not communicate directly with the general lymphatic system. The absence of vascular flow is the hallmark of LMs and is usually symptomless apart from painless disfiguring mass with concerns regarding cosmesis.

Design:

Sclerotherapy has gained prominence as a preferred treatment modality for macrocystic lesions. Here, we present our experience with use of aqueous bleomycin as intralesional sclerosing agent, an economical first-line treatment for macrocystic variant of LMs in children and adults. While bleomycin microsphere in oil has been commonly used in many previous studies, we have used aqueous bleomycin solution as the sclerosing modality which is easily available and economical.

Materials and Methods:

Twenty-seven patients of macrocystic LM including adults and children underwent bleomycin sclerotherapy under ultrasonography guidance. Number of sessions, dose administered, and the response to therapy along with all side effects were noted.

Results:

Sixteen patients received 3 or less sessions while rest needed 4–6 sessions of sclerotherapy for desired response. The response was excellent in 22 patients while 5 patients showed good response. Eleven patients developed minor side effects in form of fever, local infection, intracystic bleed, and local skin discoloration. Postsclerotherapy, surgery was performed in two patients.

Conclusion:

The better response in the present study can be attributed to targeting of individual cysts in multiloculated lesion, ultrasound-guided aspiration of the cysts content before drug delivery, and postprocedure compression which increases the contact time between cyst wall and bleomycin reducing the chances of postprocedure seroma formation. Since the drug acts on the endothelial lining of the cyst, volume of the cyst is the major determinant in response. Aqueous bleomycin had comparable results with oil-based microsphere establishing it as an economical alternative treatment modality.

Injection Snoreplasty: Investigation of Alternative Sclerotherapy Agents

OBJECTIVE: Palatal sclerotherapy with sodium tetradecyl sulfate (“injection snoreplasty”) was recently introduced as a safe and effective treatment for primary snoring. However, multiple other sclero-therapy agents also have excellent safety records and documented efficacy in the head and neck. Widely available and inexpensive agents were evaluated as potential palatal sclerosing agents for the treatment of snoring.

STUDY DESIGN AND SETTING: A described canine palatal flutter model was used to evaluate the palatal stiffening efficacy of ethanol, doxycycline, and hypertonic saline in comparison to 3% sodium tetradecyl sulfate (STS) and a negative control (normal saline). Based on the animal study results, a human pilot study with ethanol was performed with subjective and objective data.

RESULTS: Ethanol was found to be equally effective as 3% STS in the canine model. Doxycycline was effective but less so, and hypertonic saline was comparatively ineffective. Palatal injection in human patients with 50% ethanol was found to produce equivalent subjective and objective snoring efficacy and equivalent pain and recovery time compared with 3% STS. However, there was a higher rate of transient palatal fistula with ethanol. CONCLUSIONS AND SIGNIFICANCE: Injection snoreplasty with 50% ethanol is equally efficacious compared with 3% STS. There could be a higher fistula rate with the use of ethanol, although this complication has been self-limited and transient in every case.

Intralesional Bleomycin Injections for Vascular Malformations: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular malformations are congenital anomalies of the vascular system. Intralesional bleomycin injections are commonly used to treat vascular malformations. However, pulmonary fibrosis could potentially be a severe complication, known from systemic bleomycin therapy for malignancies. In this study, the authors investigate the effectiveness and safety of bleomycin (A2, B2, and A5) injections for vascular malformations, when possible relative to other sclerosants.

METHODS

The authors performed a PubMed, Embase, Cochrane Central Register of Controlled Trials, and gray literature search for studies (1995 to the present) reporting outcome of intralesional bleomycin injections in patients with vascular malformations (n ≥ 10). Predefined outcome measures of interest were size reduction, symptom relief, quality of life, adverse events (including pulmonary fibrosis), and patient satisfaction.

RESULTS

Twenty-seven studies enrolling 1325 patients were included. Quality of evidence was generally low. Good to excellent size reduction was reported in 84 percent of lymphatic and 87 percent of venous malformations. Pulmonary fibrosis was never encountered. Meta-analysis of four studies on venous malformations treated with bleomycin versus other sclerosants showed similar size reduction (OR, 0.67; 95 percent CI, 0.24 to 1.88) but a significantly lower adverse event rate (OR, 0.1; 95 percent CI, 0.03 to 0.39) and fewer severe complications after bleomycin. Symptom relief, quality of life, and patient satisfaction were reported inadequately.

CONCLUSIONS

The authors' data suggest that bleomycin is effective in reducing the size of lymphatic and venous malformations, and leads to a lower adverse event rate and fewer severe complications than other sclerosants. The included literature does not provide evidence that pulmonary fibrosis is a complication of intralesional bleomycin injections. This study represents the "best available" evidence; however, only low- to moderate-quality studies were available.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Pediatric lymphatic malformations: evolving understanding and therapeutic options

Multimodal treatment of lymphatic malformations continues to expand as new information about the biology and genetics of these lesions is discovered, along with knowledge gained from clinical practice. A patient-centered approach, ideally provided by a multidisciplinary medical and surgical team, should guide timing and modality of treatment. Current treatment options include observation, surgery, sclerotherapy, radiofrequency ablation, and laser therapy. New medical and surgical therapies are emerging, and include sildenafil, propranolol, sirolimus, and vascularized lymph node transfer. The primary focus of management is to support and optimize these patients' quality of life. Researchers continue to study lymphatic malformations with the goal of increasing therapeutic options and developing effective clinical pathways for these complicated lesions.

Appraisal of efficacy and safety of intralesional injection of high concentration of bleomycin A5 for treatment of huge macrocystic lymphatic malformations in cervical region

The objective of this study was to investigate the therapeutic effects and safety of intralesional injection of high concentration of bleomycin A5 for huge (more than 5 cm in diameter) macrocystic lymphatic malformations (LMs) in the cervical region. Thirty-two patients with huge macrocystic LMs were treated with percutaneous injection of bleomycin A5 in our department between 2006 and 2011. Among them, 13 patients had unilateral submandibular lesions, and 19 patients had lesions in anterior cervical regions. The age of patients ranged from 10 months to 29 years (mean age, 11.4 y). The concentration of the drug was as high as 2.7 mg/mL (8 mg/3 mL) with an addition of dexamethasone. The mean sessions of injection were 1.6 (1-3 sessions). Repeated injection interval was 4 to 6 weeks. The follow-up period was 6 months to 4 years after the last treatment, and the mean follow-up time was 18 months. The results were evaluated based on clinical examination and Doppler ultrasonography scan. The clinical follow-up showed excellent response in 28 of the 32 patients, whereas 4 of the 32 patients also had a satisfactory response. No serious complications were encountered. Intralesional injection of high concentration of bleomycin A5 was an effective and safe treatment of huge macrocystic LMs in the cervical region and can obtain satisfactory results esthetically and functionally without surgery.

Management of lymphatic malformations in children

PURPOSE OF REVIEW

To review the literature on lymphatic malformations and to provide current opinion about the management of these lesions.

RECENT FINDINGS

Current treatment options include nonoperative management, surgery, sclerotherapy, radiofrequency ablation, and laser therapy. New therapies are emerging, including sildenafil, propranolol, sirolimus, and vascularized lymph node transfer. The primary focus of management centers on the patient's quality of life.

SUMMARY

Multimodal treatment of lymphatic malformations continues to expand as new information about the biology and genetics of these lesions is discovered, in addition to knowledge gained from clinical practice. A patient-centered approach should guide timing and modality of treatment. Continued study of lymphatic malformations will increase and solidify a treatment algorithm for these complicated lesions.

Cross-sectional study comparing different therapeutic modalities for cystic lymphangiomas in children

OBJECTIVE

Here, we describe our experience with different therapeutic modalities used to treat cystic lymphangiomas in children in our hospital, including single therapy with OK-432, bleomycin and surgery, and a combination of the three modalities.

METHODS

We performed a retrospective, cross-sectional study including patients treated from 1998 to 2011. The effects on macrocystic lymphangiomas and adverse reactions were evaluated. Twenty-nine children with cystic lymphangiomas without any previous treatment were included. Under general anesthesia, patients given sclerosing agents underwent puncture of the lesion (guided by ultrasound when necessary) and complete aspiration of the intralesional liquid. The patients were evaluated with ultrasound and clinical examinations for a maximum follow-up time of 4 years.

RESULTS

The proportions of patients considered cured after the first therapeutic approach were 44% in the surgery group, 29% in the bleomycin group and 31% in the OK-432 group. These proportions were not significantly different. Sequential treatment increased the rates of curative results to 71%, 74% and 44%, respectively, after the final treatment, which in our case was approximately 1.5 applications per patient.

CONCLUSION

The results of this study indicate that most patients with cystic lymphangiomas do not show complete resolution after the initial therapy, regardless of whether the therapy is surgical or involves the use of sclerosing agents. To achieve complete resolution of the lesions, either multiple operations or a combination of surgery and sclerotherapy must be used and should be tailored to the characteristics of each patient.

Vascular anomalies: classification, imaging characteristics and implications for interventional radiology treatment approaches

The term vascular anomaly represents a broad spectrum of vascular pathology, including proliferating vascular tumours and vascular malformations. While the treatment of most vascular anomalies is multifactorial, interventional radiology procedures, including embolic therapy, sclerotherapy and laser coagulation among others, are playing an increasingly important role in vascular anomaly management. This review discusses the diagnosis and treatment of common vascular malformations, with emphasis on the technique, efficacy and complications of different interventional radiology procedures.

Intralesional injection of pingyangmycin is a safe and effective treatment for microcystic lymphatic malformations in the tongue

Objective

To evaluate the efficacy and safety of intralesional injection of pingyangmycin for the treatment of microcystic lymphatic malformations (LMs) in the tongue.

Methods

Eighteen patients with tongue microcystic LMs were treated with intralesional injection of pingyangmycin. The concentration of the drug was 1 mg/mL with an addition of dexamethasone. Repeated injections were performed at an interval of 3–4 weeks. The results were evaluated by clinical examinations and Doppler ultrasonography scan. The follow-up period was 12 months to eight years after the last treatment and the mean follow-up time was three years. All patients received 1–8 injections (mean, 3.0 injections) for the whole course of treatment. The total dose of pingyangmycin administered was 8–64 mg (mean, 24 mg).

Results

Fifteen patients had complete response with no cosmetic or functional problems. Three patients with macroglossia had a reduction of 50–90% in the lesion size and needed secondary surgery. No serious complications were encountered.

Conclusion

The results suggested that intralesional injection of pingyangmycin is an effective and safe treatment for microcystic LMs in the tongue, and can be used as the first-line treatment protocol.

Non surgical management of cystic lymphangioma

Aim/Purpuse: To evaluate our experience of 19 patients of lymphangioma who were treated by intralesional Bleomycin.

MATERIALS AND METHODS

Nineteen patients of lymphangioma aged between 16 days to 11 years were managed in the department. The male-female ratio was of 2:1. Commonest sites were in the neck (58%) followed by axilla (21%). The patients were treated by intralesional bleomycin injection. Bleomycin was given at a dose not exceeding 0.5 unit/kg/dose at interval of 2 weeks. Reduction in size of the mass was noted in between 2 weeks to 16 weeks and number of injections required for each patient varied from 1 to 6. Follow up ranged from 1- 7 Year.

RESULT

In injection group, significant reduction of mass was noted in 84% (n=l6) and 57% (n=11) of them showed complete disappearance. No serious complications were noted in any patient.

CONCLUSION

Our experience showed that Bleomycin in aqueous solution is a good sclcrosing agent in the management of lymphangioma.

Intralesional bleomycin in lymphangioma: an effective and safe non-operative modality of treatment

Introduction:

Lymphangiomas are benign hamartomatous lymphatic tumors. The mainstay of the therapy is surgical excision, but due to its infiltration along the nerves and muscles, total excision is not always possible. In the present study, we have evaluated the clinical profile of all the cases of lymphagiomas coming to our department and evaluated the efficacy of intralesional Bleomycin as a sclerosing agent in its management.

Materials and Methods:

In this prospective study, all patients were evaluated clinically and color Doppler ultrasonography (USG). The required dose was calculated as 0.5 mg/kg body weight, not exceeding 10 units at a time. The response was assessed clinically and on the basis of color Doppler USG.

Results:

Thirty-five patients of lymphangioma were included in the study. The neck region was the most common site of involvement. The response was excellent in 7 (20%), good in 26 (74.29%), and poor in 2 (5.71%) patients. The complications included fever, transient increase in size of swelling, local infection, intraluminal bleed, and skin discoloration in 10 patients.

Conclusion:

This therapy may be used as primary modality instead of surgery in selected group of patients.

Cystic hygroma

Surgical management of cystic hygroma is very challenging since it has a thin wall consisting of endothelium which can easily be torn during its enucleation leading to recurrence. The other treatment options are intralesional injection of OK-432, triamcinolone followed by surgical excision, if necessary, injection of sclerosing agents, repeated aspiration, radiotherapy and finally spontaneous regression without any form of treatment. This is a case report of cystic hygroma of parotid region where regression occurred without any form of treatment.

A Step-by-Step Practical Approach to Imaging Diagnosis and Interventional Radiologic Therapy in Vascular Malformations

Within vascular anomalies, vascular malformations are those present at birth that grow with the patient and exhibit abnormal dilated vascular channels lined by mature endothelium. Vascular tumors, the other group of vascular anomalies, demonstrate endothelial hypercellularity. Vascular malformations are further divided into low-flow varieties (capillary, venous, and lymphatic malformations) and high-flow varieties (arteriovenous malformation and fistula). All malformations exhibit a predictable group of clinical patterns that vary in severity and rate of progression. The interventional radiologist must incorporate this clinical data with characteristic ultrasound and magnetic resonance findings to arrive at a diagnosis. One must then decide in a multidisciplinary fashion, based on objective clinical criteria and image-based morphology, if the patent is a candidate for intervention. Sclerotherapy is a technique used to treat vascular malformations whereby an endothelial-cidal agent is introduced into the endoluminal compartment to initiate vascular closure. The high flow rate of an arteriovenous malformation requires the incorporation of superselective transarterial, direct, and transvenous access with flow reduction techniques to deliver adequate dose of sclerosant and embolic to the nidus. Satisfactory outcomes are seen in over half of all malformations patients. Similar treatment-related complications are seen between malformations but are lowest in lymphatic and highest in arteriovenous malformations.

Cystic hygroma: an overview

Cystic hygromas are the cystic variety of lymphangioma, common locations being cervico-facial regions and axilla. Respiratory distress, recurrent infections or cosmetic reasons are the main indications of the treatment. The ideal treatment is complete surgical excision; however, there is a gradual conversion towards sclerosant therapy. This article reviews the current literature and discusses the various problems encountered during the management of these lesions.

Bleomycin: A worthy alternative

CONTEXT

Lymphangiomas are developmental anomalies presenting mainly in the first two years of life. Surgical excision has been the mainstay of treatment; however a potentially disfiguring surgery along with presence of important structures in the vicinity and infiltration into surrounding structures makes the dissection difficult.

AIMS

To study the safety and efficacy of Bleomycin as a sclerosing agent for lymphatic malformations in children.

SETTINGS AND DESIGN

Prospective non comparative nonrandomized trial.

MATERIALS AND METHODS

The study was carried out in 15 children between Day 5 of life to 12 years of age who presented between May2008 to May 2009. Bleomycin aqueous solution was injected intralesionally at a dose not exceeding 0.6 to 0.8 mg. /kg Body wt. The response to therapy was monitored clinically by measuring the length, breadth and area as well as by measuring the two largest perpendicular dimensions. The response was graded as excellent [total disappearance], good [>50% reduction] and poor [<50% decrease]. Those patients with diffuse lymphangiomas associated predominantly with hemangiomatous malformations, mediastinal, spinal or retroperitoneal extensions, visceral lymphangiomas, those with infections were excluded from the study.

STATISTICAL ANALYSIS USED

None applicable.

RESULTS

The reduction in the size of the mass usually took between two weeks to ten months. The average duration of follow up has been ten months. A significant response was seen in 8 out of the fifteen [53.33%] patients. 5 patients [33.33%] patients showed a good response to therapy and achieved >50% reduction in the size of their swellings. 2 patients [13.33%] showed a poor response to therapy and achieved less than 50% reduction in the size of the swelling. Complications of the therapy were few and far between. 2 patients developed fever after injection, one patients reported a transient increase in size of swelling, 2 patients have developed discoloration of the overlying skin and are currently being followed up for final outcome. None of the patients developed leucopenia or leukocytosis. All of the complications were managed with conservatively. Patients are on long term follow up to evaluate long term effects, if any.

Complications of embolization

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Intralesional bleomycin injection treatment for vascular birthmarks: a 5-year experience at a single United Kingdom unit

BACKGROUND

The authors present their experience using an established chemotherapeutic agent as a scarless treatment for vascular birthmarks. One hundred sixty-four of more than 600 patients seen in the authors' center received intralesional bleomycin injection over 5 years.

METHODS

Patient demographics, clinical response, treatment, and complication details were recorded prospectively. Respiratory surveillance was provided by adult and pediatric pulmonologists. Eighty-one venous malformations, 39 hemangiomas, 26 lymphatic malformations, 10 mixed malformations, two arteriovenous malformations, two cystic hygromas, two capillary malformations, and two angiokeratomas underwent intralesional bleomycin injection.

RESULTS

The authors observed that 45.7 percent of patients completed treatment in a mean of 3.8 sessions and mean duration of 107 days. Complete resolution occurred in 56.0 percent, with a 93.3 percent overall response rate, and 82.7 percent of lesions demonstrated complete response or significant improvement. Three patients developed transient skin hyperpigmentation. One patient each developed skin ulceration, blistering, infection, swelling, headache, bruising, and rash. One patient required intubation following treatment of a panfacial and thoracic lymphatic malformation. A full recovery ensued. No patients developed pulmonary fibrosis. One venous malformation recurred.

CONCLUSIONS

The authors' single-site multidisciplinary team has successfully treated complex and recurrent vascular anomalies with acceptable complication and recurrence profiles. These findings represent the authors' experience and provide a reference for the management of these challenging lesions.

Lymphangioma: Is intralesional bleomycin sclerotherapy effective?

PURPOSE

This study aims to evaluate the effectiveness of intralesional bleomycin sclerotherapy in the treatment of lymphangioma in children and to determine the incidence of complications in the treatment.

METHODS

This is a retrospective study of 24 children diagnosed with lymphangioma and treated with intralesional injection of bleomycin aqueous solution from January 1999 to December 2004.

RESULTS

Complete resolution was seen in 63% (15/24) of lesions, 21% (5/24) had good response and 16% (4/24) had poor response. The tumour recurred in 2 patients. Two other patients had abscess formation at the site of injection. No other serious complications or side effects were observed.

CONCLUSION

Intralesional bleomycin therapy was very effective in the treatment of lymphangioma. Our results were comparable to other published studies. Bleomycin administered as intralesional injection was found to be safe as there was no serious complication or side effect observed in this study.

Sclerotherapy for lymphatic malformations in children: a scoping review

PURPOSE

This scoping review assesses the literature and summarizes the current evidence on sclerotherapy for the treatment of lymphatic malformations in pediatric patients.

METHODS

A comprehensive search of published and unpublished literature was conducted using multiple databases. Title, abstract, and full-text screening was conducted by 2 independent clinicians. All discrepancies were resolved during consensus meetings.

RESULTS

A total of 182 articles were retrieved. Forty-four articles were removed as duplicates, and 11 articles were added after reviewing prominent studies. After full-text abstraction, 44 articles and 2 conference proceedings (N = 882 patients) were included in the final results. Twelve articles were classified as level II and 34 articles as level IV evidence. Picibanil (OK-432) was the primary agent used in most included studies. Postinjection symptoms with OK-432 were primarily fever, swelling, and erythema at the site. Life-threatening complications were uncommon and involved postinjection swelling of cervical lesions causing airway compromise.

CONCLUSIONS

The literature regarding sclerotherapy for lymphatic malformations is of a low level of evidence and suffers from a lack of standardization. Randomized clinical trials focused on OK-432, bleomycin, or alcoholic solution of zein; standardized dosing protocols; and consistent and reliable outcome reporting will be necessary for further development of treatment guidelines.

Treatment of lymphangioma of the face with intralesional bleomycin: case discussion and literature review

Surgical treatment of lymphangioma of the face is a difficult task to achieve due to close vicinity of the lesion to the facial nerve and possibility of scar tissue formation. Inefficient surgical removals generally will give rise to high recurrence rates because of infiltrative and diffuse extension of the lesion. However, complete cure has been described by non-surgical methods. A 5-year-old girl with extensive lymphangioma of the left cervicofacial area was treated with intralesional bleomycin injection under ultrasonographic guidance. Case discussion and related literature review was presented.

Percutaneous sclerotherapy of massive macrocystic lymphatic malformations of the face and neck using fibrin glue with OK-432 and bleomycin

Picibanil (OK-432) and bleomycin have been used as alternative sclerosing agents for lymphatic malformations. This study evaluated the clinical curative effect of sclerotherapy using fibrin glue combined with OK-432 and bleomycin for the treatment of macrocystic lymphatic malformations of the face and neck. Fifteen paediatric patients (6 males; 9 females, aged 13 months to 14 years) who had received percutaneous sclerotherapy for massive macrocystic lymphatic malformations of the face and neck were retrospectively reviewed. Affected regions included the neck, parotid region and parapharynx, mouth floor, face and cheek, and orbital regions. All patients showed preoperative symptoms of space-occupying lesions between 4 cm × 5 cm and 12 cm × 16 cm in size. Fibrin glue with OK-432 and bleomycin was injected under general anaesthesia. All patients received preoperative and follow-up CT scans. Outcomes were assessed by three surgeons. All patients exhibited mid-facial swelling for 3-4 weeks after surgery, but no major complications. Follow-up periods ranged from 8 to 16 months. Eight lesions were completely involuted, five were mostly involuted, and two were partially involuted. Percutaneous sclerotherapy using fibrin glue with OK-432 and bleomycin provided a simple, safe, and reliable alternative treatment for massive macrocystic lymphatic malformations of the face and neck.

Sclerotherapy for cervical cystic lymphatic malformations in children. Our experience with computed tomography-guided 98% sterile ethanol insertion and a review of the literature

PURPOSE

The treatment of cystic lymphatic malformations of the neck and mediastinum is controversial. Surgical management may be limited by the invasiveness of the procedure, the complex anatomy of this region, and the high recurrence rate. An alternative therapeutic method is sclerotherapy. We report our experience in the treatment of cystic lymphatic malformations of the neck by computed tomography (CT)-guided instillation of 98% sterile ethanol in children.

METHODS

Eight children with clinical suspicion of cervical cystic lymphatic malformation were assessed by ultrasonography (US) and magnetic resonance imaging (MRI) to define the location, size, and number of cystic cavities. The CT-guided instillation of 98% sterile ethanol was performed. Cystic fluid was analyzed by fine-needle aspiration cytology. Clinical and US or MRI follow-up was performed after 1 and 3 months and at 1 and 2 years.

RESULTS

The results were excellent with complete disappearance of the lesion in 7 (87.5%) of 8 patients. One patient (12.5%) with satisfactory results required a second alcohol injection with an excellent outcome. No allergic reactions or complications were observed.

CONCLUSIONS

The CT-guided 98% sterile ethanol sclerotherapy is a good alternative to surgical therapy. This procedure seems accurate, minimally invasive, safe, low cost, and reliable without untoward complications. Moreover, it does not exclude later surgical treatment.

Ethanol sclerotherapy with 'injection and aspiration technique' for giant lymphatic malformation in adult cases

Ethanol is a commonly used sclerosant for lymphatic malformation (LM), and recent evidence has shown that macrocystic LMs respond very well to percutaneous sclerotherapy. However, the volume of absolute ethanol that can be injected safely is small (0.5-1 ml/kg), and that is the reason it is often ineffective in extensive LM. We report two cases of giant LM with occasional high fever and pain or abnormal gait. To overcome dose limitation and to prevent systematic toxicities, we performed both injection of absolute ethanol and aspiration of it after 5 min exposure to LM. The injected maximum ethanol dose per one session is 70-260 ml and no systemic complication occurred. The 1-3 sessions of those procedures reduced the frequency of high fever and improved the swelling of those lesions. The injection and aspiration technique maximises the efficacy of sclerotherapy for extensive macrocystic LM in adults.

Lymphatic malformations: review of current treatment

OBJECTIVE

Summarize current knowledge of lymphatic malformation medical, sclerotherapy, and surgical treatment; and highlight areas of treatment controversy and treatment difficulty that need improvement.

METHODS

Panel presentation of various aspects of lymphatic malformation treatment.

RESULTS

The mainstay of lymphatic malformation treatment has been surgical resection, which has been refined through lesion staging and radiographic characterization. Intralesional sclerotherapy in macrocystic lymphatic malformations is effective. Suprahyoid microcystic lymphatic malformations are more difficult to treat than macrocystic lymphatic malformations in the infrahyoid and posterior cervical regions. Bilateral suprahyoid lymphatic malformations require staged treatment to prevent complications. Lymphatic malformation treatment planning is primarily determined by the presence or possibility of functional compromise. Problematic areas include chronic lymphatic malformation inflammation, dental health maintenance, macroglossia, airway obstruction, and dental malocclusion.

CONCLUSIONS

Lymphatic malformation treatment improvements have been made through radiographic characterization and staging of lymphatic malformations. Direct malformation involvement of the upper aerodigestive tract can cause significant functional compromise that is difficult to treat.