Cutaneous haemangioma: prevalence and sonographic characteristics of associated hepatic haemangioma

Infantile hepatic hemangiomas: looking backwards and forwards

Infantile hepatic hemangiomas (IHHs) are common benign tumors seen in the liver of infants. IHHs are true infantile hemangiomas (IHs) and have phases of proliferation and involution parallel to those of cutaneous IHs. The definition and classification of IHH are still confusing in the literature. The mechanisms during the pathogenesis of IHH have yet to be discovered. The clinical manifestations of IHH are heterogeneous. Although most IHH lesions are asymptomatic, some lesions can lead to severe complications, such as hypothyroidism, consumptive coagulopathy, and high-output congestive cardiac failure. Consequently, some patients can possibly encounter a fatal clinical condition. The heterogeneity of the lesions and the occurrence of disease-related comorbidities can make the treatment of IHH challenging. Oral propranolol is emerging as an effective systemic approach to IHH with obvious responses in tumor remission and symptom regression. However, the precise clinical characteristics and treatment strategies for patients with severe IHH have not yet been well established. Here, we summarize the epidemiology, pathogenic mechanism, clinical manifestations, diagnosis, and treatment of IHH. Recent updates and future perspectives for IHH will also be elaborated.

Vascular anomalies: clinical perspectives

Vascular anomalies are classified as vascular tumors or vascular malformations according to their cellular features and biological behavior. Detailed history and clinical assessment allow for the proper clinical diagnosis of most vascular anomalies and guide the choice of imaging to evaluate them. This article discusses the general information needed from a clinical history and physical exam to formulate a diagnosis of vascular anomaly. Then, the authors review the clinical findings from the most common vascular tumors and vascular malformations.

Screening for infantile hepatic hemangioma in patients with cutaneous infantile hemangioma: A multicenter prospective study

BACKGROUND

Abdominal ultrasonography has been proposed to screen for infantile hepatic hemangioma (IHH) in patients with multiple cutaneous infantile hemangiomas (IHs).

OBJECTIVES

The aim of this study was to establish the optimal cutoff point for the number of cutaneous IHs needed to screen for IHH.

METHODS

We performed a prospective, multicenter study to screen for IHH in patients younger than 9 months who had multiple cutaneous IHs (n ≥ 3) on ultrasonography. For comparison, a group of patients with 1 or 2 focal cutaneous IHs was also recruited.

RESULTS

In total, 676 patients with at least 3 cutaneous IHs and 980 patients with 1 or 2 focal cutaneous IHs were enrolled. Thirty-one patients were found to have IHH. A higher number of cutaneous IHs was associated with an increased risk of IHH (R = 0.973; P < .001). Receiver operating characteristic curve analysis showed that 5 cutaneous IHs was the optimal cutoff point to screen for IHH, with an area under the curve of 0.872 (P < .001; 95% confidence interval, 0.789-0.955).

LIMITATIONS

This was an uncontrolled study.

CONCLUSIONS

Screening for IHH is recommended in patients younger than 9 months who present with 5 or more cutaneous IHs.

Pediatric hepatic vascular tumors

Vascular liver tumors in the pediatric population can present a diagnostic dilemma. The most common hepatic vascular tumors are hepatic hemangiomas; however the differential diagnosis can also include other benign lesions and malignant masses. Management is unique to the type and nature of the specific lesion. Thus, correct diagnosis and timely intervention is critical. The work up, diagnosis, and management of the different hepatic lesions are discussed in this paper.

Contrast-Enhanced Ultrasound of Congenital and Infantile Hemangiomas: Preliminary Results From a Case Series

OBJECTIVE. The contrast-enhanced ultrasound (CEUS) imaging features of hepatic vascular tumors in infants, including infantile hemangioma (IH) and congenital hemangioma (CH), are not well reported. Frequent inaccurate use of lesion terminology in the literature has created diagnostic confusion. The purpose of this study is to describe the CEUS features of IH and CH. MATERIALS AND METHODS. Ten patients, ranging in age from 8 days to 16 months, with hepatic vascular tumors were included for retrospective analysis. Gray-scale ultrasound, color Doppler ultrasound, and CEUS features were reviewed, and interobserver kappa coefficients were calculated. Final diagnoses were clinically determined by a pediatrician with expertise in vascular anomalies except in one patient who underwent surgical excision. RESULTS. Of the 10 patients, five had CHs and five had IHs. All 10 lesions were hyperenhancing in the early arterial phase. In the portal venous phase, four of five (80%) CHs showed hyperenhancement relative to normal liver parenchyma, whereas four of five (80%) IHs showed isoenhancement. In the late phase, washout of contrast material was seen in three of five (60%) IHs, whereas one IH remained isoenhancing and one IH was hyperenhancing. None of the CHs showed late washout. Interobserver kappa coefficients for CEUS features ranged from 0.60 to 1.00. CONCLUSION. Except for the CEUS feature portal venous phase enhancement (κ = 0.60), good to excellent (κ = 0.74-1.00) agreement about CEUS features of IHs and CHs was observed. A significant proportion of IHs (60%) showed washout at delayed phase imaging, which has also been reported with malignancies. Recognition of the overlap in imaging appearance of these two entities is vital to preventing misdiagnosis of malignancy.

Efficacy of propranolol treatment in infantile hepatic haemangioma

AIM

The aim of this study was to assess the efficacy of propranolol treatment in multifocal and diffuse infantile hepatic haemangioma (IHH).

METHODS

A retrospective study of symptomatic or potentially symptomatic IHH was performed in our hospital between 2011 and 2016.

RESULTS

Thirteen patients were identified: 2 patients had diffuse lesions, and 11 patients had multifocal lesions, including 2 patients who had combined lesions that shared features of both multifocal and diffuse lesion patterns. Eleven (84.6%) patients had cutaneous infantile haemangioma. Hepatomegaly was the predominant clinical presentation. Hypothyroidism was identified in three patients, including one patient who had documented congestive heart failure (CHF). The median age at diagnosis and the median duration of treatment were 2.0 months (range 1.2-26.0) and 24.0 months (range 4.0-30.0). The median duration of follow-up was 30.0 months (range 3.0-48.0). For patients with hypothyroidism, the thyroid hormone level was normal after 4 weeks of propranolol and levothyroxine treatment. All but one patient responded well to propranolol treatment. The patient who failed to respond to treatment died of CHF and abdominal compartment syndrome induced by hepatomegaly. No significant side effects of propranolol were observed during follow-up.

CONCLUSIONS

Most multifocal and diffuse IHH respond well to propranolol. However, progressive cases may be fatal despite aggressive treatments. Our data suggest that propranolol may be considered the first-line treatment for multifocal and diffuse IHH due to its efficacy.

[Infantile haemangioma: an update]

Infantile haemangioma (IH) are the most frequent skin tumors in childhood. The diagnosis is usually established from the clinical picture and typical course of growth. Sectional imaging procedures are indicated in segmental, especially facial haemangiomas. The vast majority of IH are uncomplicated and do not require any treatment. In complicated IH, treatment should be initiated as soon as possible in order to avoid permanent damage. Propranolol is the treatment of choice for complicated IH.

Characterization of the hepatosplenic and portal venous findings in patients with Proteus syndrome

Proteus syndrome (PS) is a rare disorder caused by a mosaic AKT1 variant that comprises patchy overgrowth of tissues derived from all three germinal layers affecting multiple viscera. We sought to delineate the extent of hepatoportal manifestations in patients with PS. We identified patients with PS who had abdominal imaging from 1989 to 2015 in a natural history study. Imaging was characterized for evidence of focal findings in the liver, spleen, and portal vasculature and for organomegaly. Relevant clinical and laboratory data were compared among those with or without organomegaly. Abdominal imaging was available on 38 patients including 20 who had serial studies. Nine patients had focal hepatic lesions including vascular malformations (VMs). Focal splenic abnormalities were noted in seven patients. Patients without cutaneous VMs did not have visceral VMs. Nine patients had splenomegaly, 12 had portal vein dilation, and 4 had hepatomegaly. There was a weak correlation of portal vein dilation to spleen height ratio (r² = 0.18, p < .05). On laboratory evaluation, hepatic function was normal but there was thrombocytopenia in those with splenomegaly; platelet counts were 179 ± 87K/μL compared to those with normal spleen size at 253 ± 57K/μL (p < .05). Overall, focal hepatosplenic abnormalities occurred in 11 of 38 (29%) patients with PS. Splenomegaly and portal venous dilation were both found in 8 of 38 (21%) patients; however, other than relative thrombocytopenia, there was no evidence of portal hypertension. Although the AKT1-E17K somatic variant is a suspected oncogene, there were no malignant lesions identified in this study.

Ultrasound with Doppler evaluation of congenital hepatic vascular shunts

Congenital aberrant hepatic vascular communications result from intrahepatic or extrahepatic errors in vascular development or involution during the transition from fetal to newborn hepatic circulation. These hepatic vascular shunts can be fortuitously discovered and asymptomatic, or can cause symptoms of varying severity, often presenting diagnostic dilemmas. Some hepatic vascular shunts resolve spontaneously while others require interventional radiologic or surgical closure. Affected patients are often first studied with real-time and Doppler ultrasound, so radiologists should familiarize themselves with the expected ultrasound findings of these vascular shunts for effective diagnosis, triage and management. In this review, the authors focus on ultrasound and Doppler findings of hepatic vascular shunts with underlying embryology, clinical features and management strategies. Broadly, these aberrant hepatic vascular communications include portosystemic venous shunts (which can be intra- or extrahepatic and include persistent patent ductus venosus), arterioportal, arteriovenous or mixed shunts.

Lesion Morphology in Multifocal Infantile Hemangiomas

BACKGROUND/OBJECTIVES

Multifocal infantile hemangiomas (MIHs; previously called neonatal hemangiomatosis) can be associated with extracutaneous hemangiomas. We observed different morphologic types of hemangiomas in children with MIHs and sought to find out whether they are related to the clinical course.

METHODS

This was a retrospective study of 103 infants with MIHs and a control group of 261 age-matched patients with solitary focal infantile hemangiomas (IHs) seen at an academic pediatric dermatology department between 2004 and 2014.

RESULTS

Two morphologic subtypes of hemangiomas were identified: miliary focal hemangiomas (MFHs; small, lens shaped) in 58 of 103 MIH patients (56.3%), and classical nonmiliary focal IHs (NMIHs; larger, irregularly shaped) in 17 of 103 patients (16.5%). MIHs featuring both types (mixed type) were observed in 28 of 103 patients (27.2%). MFH lesions were significantly smaller (mean 5.3 mm [range 1-20 mm] vs 22.0 mm [range 2-100 mm]), more numerous (23.4 ± 27.3 [range 5-175] vs 7.4 ± 2.8 [range 5-15] p < 0.001), and occurred up to an older age (6.0 ± 5.8 months [range 0-27 months] vs 3.8 ± 2.6 months [range 0-9 months]) than NMIHs. There was a weakly positive correlation between the number and presence of extracutaneous IHs in children with MFHs. Significantly more children with MIHs were delivered preterm than those with solitary IHs.

CONCLUSIONS

The number of IHs correlates inversely with their size. MFHs follow a clinical course different from that of classical IHs, are associated with prematurity, and may confer greater risk of extracutaneous hemangiomas. Miliary hemangiomas thus appear to present a separate IH subset requiring special attention.

Clinical features and management of multifocal hepatic hemangiomas in children: a retrospective study

Multifocal hepatic hemangioma (MHH) is a benign hepatic tumor that is commonly diagnosed in children with multiple cutaneous infantile hemangiomas (IHs). We present a review of all children with MHH at our institutions. Of the 42 patients, the median age at presentation of MHH was 2.5 months. Thirty-six (85.7%) patients had cutaneous IHs. Twelve (28.6%) patients were symptomatic at presentation. There was no significant association between the number of hepatic hemangiomas and the number of cutaneous IHs. Fourteen (33.3%) patients received some form of treatment for hepatic hemangiomas. The most common type of treatment was oral prednisone in 8 patients, followed by oral propranolol in 6 patients. Two patients were totally resistant to prednisone treatment. They died from congestive heart failure or respiratory distress and coagulopathy. Two patients with problematic facial IH were treated with intralesional triamcinolone injection. The remaining 26 patients were managed with imaging surveillance. On follow-up, all of the survivors had a favorable outcome. Our study suggests that the clinical features of MHH are variable. Our data emphasize the treatment strategy that aggressive treatment is indicated in symptomatic or progressive MHHs, whereas observation management of asymptomatic patients with a few small lesions is safe and appropriate.

Impact of Screening for Hepatic Hemangiomas in Patients with Multiple Cutaneous Infantile Hemangiomas

OBJECTIVES

Hepatic hemangiomas are often found in association with multiple cutaneous infantile hemangiomas. Screening abdominal ultrasonography has been recommended for patients with five or more cutaneous lesions. We sought to determine whether hemangiomas found through screening had improved clinical outcomes.

METHODS

Patients entered into our hepatic hemangioma registry between 1995 and 2012 were reviewed.

RESULTS

Seventy-two patients with multiple cutaneous and hepatic hemangiomas were identified; 43 (60%) were detected through screening. The median age at diagnosis was 41 days for screened patients and 53 days for those not screened. Screening detected 40 (93%) multifocal and 3 (7%) diffuse hemangiomas, compared to 18 (62%) and 11 (38%), respectively, in the nonscreened group. Patients identified by screening had lower incidences of congestive heart failure and hypothyroidism and were less likely to receive treatment for their hemangiomas. The mortality rate in the children not screened was 28% (n = 8). None of the patients found by screening died (p < 0.001). Multivariate analysis of treated patients demonstrated that screening was a significant predictor of reduced mortality (p = 0.04).

CONCLUSION

Hepatic hemangiomas found through screening ultrasonography are less likely to develop serious clinical sequelae. Although the reasons for this may include detection of hemangiomas that are less likely to progress to symptomatic disease, it appears that it also allows for earlier intervention for more concerning (e.g. diffuse) subtypes. Screening may allow for closer surveillance and earlier treatment before life-threatening progression in a subset of infants with liver hemangiomas, preventing complications and reducing mortality.

Diagnosis and Management of Infantile Hemangioma

Infantile hemangiomas (IHs) are the most common tumors of childhood. Unlike other tumors, they have the unique ability to involute after proliferation, often leading primary care providers to assume they will resolve without intervention or consequence. Unfortunately, a subset of IHs rapidly develop complications, resulting in pain, functional impairment, or permanent disfigurement. As a result, the primary clinician has the task of determining which lesions require early consultation with a specialist. Although several recent reviews have been published, this clinical report is the first based on input from individuals representing the many specialties involved in the treatment of IH. Its purpose is to update the pediatric community regarding recent discoveries in IH pathogenesis, treatment, and clinical associations and to provide a basis for clinical decision-making in the management of IH.

Risk factors for mortality in patients with multifocal and diffuse hepatic hemangiomas

PURPOSE

Multifocal and diffuse hepatic hemangiomas are true infantile hemangiomas, which likely exist in a continuum. We reviewed our hepatic hemangioma registry to identify prognostic indicators for mortality.

METHODS

Registry records entered between 1995 and 2012 were reviewed. Clinical characteristics were evaluated for prognostic significance using the multivariable Cox proportional hazards model. Survival data were analyzed using the Kaplan-Meier product-limit method.

RESULTS

We identified 123 patients with multifocal (n=91) and diffuse (n=32) hepatic hemangiomas. Mortality was 16% (n=20); 40% (n=8) had multifocal and 60% (n=12) had diffuse lesions. A diagnosis of diffuse disease (hazard ratio: 9.9, 95% CI: 2.0-50.8, P=.002) and congestive heart failure (CHF) (hazard ratio: 3.9, 95% CI: 1.3-14.2, P=.031) were significant risk factors for mortality across the continuum; age at presentation, cardiomegaly, presence of shunts, and hypothyroidism were not statistically significant independent risk factors. Among patients with diffuse lesions, eight (67%) who died had abdominal compartment syndrome, which was also associated with mortality (P=.002).

CONCLUSIONS

Hepatic hemangioma patients with CHF or diffuse disease are at higher risk for mortality. Patients with multifocal lesions without CHF may go undetected until lesions become diffuse. Aggressive treatment of symptomatic patients and close follow-up of asymptomatic patients may improve mortality.

Differential diagnosis and management of liver tumors in infants

During the first year of life, most of the liver neoplasms are benign in origin, but some of these histologically benign lesions may be challenging in their management. Although most hepatic hemangiomas can be safely observed until involution is documented, some patients will need treatment due to progressive hepatomegaly, hypothyroidism and/or cardiac failure. Large mesenchymal hamartomas may require extensive hepatic resection and an appropriate surgical plan is critical to obtain good results. For malignant neoplasms such as hepatoblastoma, complete surgical resection is the mainstay of curative therapy. The decision about whether to perform an upfront or delayed resection of a primary liver malignant tumor is based on many considerations, including the ease of resection, surgical expertise, tumor histology and stage, and the likely chemosensitivity of the tumor. This article reviews the initial management of the more common hepatic tumors of infancy, focusing on the differential diagnosis and treatment options.

Rapidly involuting congenital haemangioma (RICH) of the liver

BACKGROUND

Rapidly involuting congenital haemangioma (RICH) is a benign neoplasm that may occur in many locations in the body. When RICH occurs in the liver, it may be confused with other lesions.

OBJECTIVE

To present a case series from a single institution.

MATERIALS AND METHODS

Retrospective review of pathological and imaging findings in infants with biopsy-proven hepatic RICH treated at a single hospital.

RESULTS

Four children (2 days to 6 weeks of age) presented between 2002 and 2007 with a solitary hepatic lesion. Needle biopsy excluded the alternative possibility of infantile haemangioma by showing negativity for GLUT1. Serial imaging confirmed rapid involution in each child.

CONCLUSION

RICH should be suspected in neonates who present with a solitary liver lesion and normal-for-age serum alpha-fetoprotein. Serial US scans should be used to confirm a progressive shrinkage of the lesion. Corticosteroids and β2-adrenergic antagonists have no proven effect in treating RICH. If the lesion grows, percutaneous needle biopsy is recommended to exclude a malignant tumour and to direct further management. Infants with cardiac failure should be treated medically. Embolization (with or without needle biopsy) should only be performed when this strategy fails.

Hepatic haemangioma-prenatal imaging findings, complications and perinatal outcome in a case series

BACKGROUND

The clinical presentation of foetal hepatic haemangioma (HH) is highly variable, from asymptomatic to life-threatening.

OBJECTIVE

The aim of this study was to describe foetal hepatic haemangioma and identify prognostic factors.

MATERIALS AND METHODS

Antenatal and postnatal imaging studies, clinical and biological records of infants with antenatally diagnosed HH (2001-2009) were reviewed.

RESULTS

Sixteen foetuses had one focal lesion, with a mean volume of 75 ml (5-240 ml). One had multifocal HH. Most presented as a focal well-delimited heterogeneous vascular mass. Four had associated cardiomegaly, five had cardiac failure. Eight of the nine foetuses with cardiac disorders were symptomatic at birth: cardiac failure with pulmonary hypertension (9), consumptive coagulopathy (8), compartmental syndrome (2). All received supportive medical treatment, four embolisation. Five of these died. The remaining eight had a normal cardiac status. Two became symptomatic after birth: one with a large porto-hepatic shunt and one with significant mass effect. Prenatal cardiac abnormality (univariate, P = 0.031), enlargement of more than one hepatic vein (P = 0.0351) and large volume (P = 0.0372) were associated with symptomatic disease.

CONCLUSION

Hepatic haemangioma associated with prenatal cardiac disorders, large volume and more than one enlarged hepatic vein have poorer outcome and require specific perinatal multidisciplinary management.

Vascular anomalies in 5,621 patients: guidelines for referral

OBJECTIVE

To characterize referrals to a vascular anomalies center to determine which lesions should be treated by specialists.

STUDY DESIGN

Patients sent to our center between 1999 and 2010 were reviewed. Type of anomaly, anatomical location, sex, accuracy of referral diagnosis, and the geographic origin of the referred patient were analyzed.

RESULTS

Five thousand six hundred twenty-one patients had a confirmed diagnosis: 35.2% had a tumor and 64.8% had a malformation. Types of tumors included infantile hemangioma (85.9%), hemangioendothelioma (7.8%), congenital hemangioma (5.4%), and pyogenic granuloma (0.9%). Malformations consisted of venous (36.8%), lymphatic (28.3%), arteriovenous (14.3%), capillary (11.0%), and combined slow-flow (9.6%) lesions. Forty-three percent of the cohort resided outside of our region; these patients were most likely to have a malformation (51.9%) or rare vascular tumor (74.5%). Only 53.0% of patients had a correct referral diagnosis: 77.8% for infantile hemangioma and pyogenic granuloma, compared with 45.6% and 34.7% for malformations and rare tumors, respectively.

CONCLUSIONS

Two thirds of lesions sent to a vascular anomalies center are vascular malformations. Malformations and rare tumors are most likely to be misdiagnosed and referred from outside of the region. Vascular malformations (except for simple capillary lesions), rare tumors, and problematic infantile hemangiomas should be managed by specialists in this field.

Hemangiomas revisited: the useful, the unusual and the new. Part 1: overview and clinical and imaging characteristics

Hemangiomas are common vascular tumors occurring in children. Though most of the lesions present in infants and young children with a typical appearance, it is important to understand that they all do not behave in the same way. Rather, they are a group of vascular lesions with different clinico-pathological subtypes, with their clinical behavior varying with the stage of the tumor as well. As such, they can and do have a varied clinical, imaging and pathological appearance according to the location of the tumor and also the stage at which the patient is seen. In this pictorial essay, the classification, pathogenesis, clinical appearance, natural history and imaging characteristics of hemangiomas are reviewed and illustrated.

Prospective study of the frequency of hepatic hemangiomas in infants with multiple cutaneous infantile hemangiomas

Multiple cutaneous infantile hemangiomas have been associated with hepatic hemangiomas. Screening of infants with five or more cutaneous infantile hemangiomas with abdominal ultrasound is often recommended. The aim of this study was to determine the frequency with which hepatic hemangiomas occur in infants with five or more cutaneous infantile hemangiomas compared to those with one to four cutaneous infantile hemangiomas and to characterize the clinical features of these hepatic hemangiomas. A multicenter prospective study of children with cutaneous infantile hemangiomas was conducted at pediatric dermatology clinics at Hemangioma Investigator Groups sites in the United States, Canada, and Spain between October 2005 and December 2008. Data were collected, and abdominal ultrasonography was performed on infants younger than 6 months old with five or more cutaneous infantile hemangiomas and those with one to four cutaneous infantile hemangiomas. Twenty-four (16%) of the 151 infants with five or more cutaneous infantile hemangiomas had hepatic hemangiomas identified on abdominal ultrasound, versus none of the infants with fewer than five (p = 0.003). Two of the 24 infants with hepatic hemangiomas received treatment specifically for their hepatic hemangiomas. Infants with five or more cutaneous infantile hemangiomas have a statistically significantly greater frequency of hepatic hemangiomas than those with fewer than 5. These findings support the recommendation of five or more cutaneous infantile hemangiomas as a threshold for screening infants younger than 6 months old for hepatic hemangiomas but also demonstrate that the large majority of these infants with hepatic hemangiomas do not require treatment.

Update on vascular tumors of infancy

PURPOSE OF REVIEW

Advances have been made in the pathogenesis, diagnosis and management of vascular tumors of infancy in the past year. Propranolol therapy for infantile hemangiomas (IH) is now being used widely, and case reports, series, and adverse effects are reviewed. Kaposiform hemangioendothelioma and tufted angioma are less common than IH but more often associated with coagulopathy (Kasabach-Merritt phenomenon).

RECENT FINDINGS

Recent work suggests that stem cells, mediated by the Notch signaling pathway, may become proliferating endothelial cells that comprise IH. Large, segmental IH are more likely to develop complications that can include life-threatening bleeds; however, solitary large IH do not appear to increase the risk of hepatic IH. Segmental IH may herald underlying structural anomalies of the brain, cerebral, and cardiac vessels (PHACE syndrome--Posterior fossa defects, Hemangiomas, Arterial anomalies, Cardiac defects and Coarctation of the aorta, Eye anomalies), and new criteria aid in diagnosis. Propranolol therapy is effective in life-threatening IH and appears to stop growth and hasten involution in proliferative and plateau phase IH. Adverse effects include bradycardia, hypotension, hypoglycemia, and bronchospasm. A recent review of kaposiform hemangioendothelioma finds that an associated coagulopathy (Kasabach-Merritt phenomenon) occurs in 72%.

SUMMARY

Propranolol appears to be tremendously efficacious with fewer side effects than systemic corticosteroids, but its proper place in the therapeutic algorithm for IH and other vascular tumors awaits controlled study.

Dynamic MR angiography of upper extremity vascular disease: pictorial review

Unlike peripheral lower extremity vascular disease, upper extremity vascular disease is relatively uncommon. While atherosclerosis and embolic disease are the most common causes of upper extremity ischemia, a wide variety of systemic diseases and anatomic abnormalities can affect the upper extremity. Upper extremity ischemia poses a significant diagnostic and therapeutic challenge for both clinicians and radiologists. Although history and physical examination remain the mainstays of diagnosis, imaging can be vital in confirming suspected disease and guiding treatment planning. Digital subtraction angiography is often the preferred method for detection of upper extremity vascular disease, particularly for characterization of complex arteriovenous anatomy such as in vascular malformations and for evaluation of dialysis fistulas and grafts. However, this modality is invasive, requires iodinated contrast agents and radiation, and may fail to demonstrate significant extraluminal disease. More recently, magnetic resonance (MR) angiography techniques have made important advances, permitting higher temporal and spatial resolution that is preferable for diagnosing upper extremity vascular disorders. In this review, the authors present an overview of upper extremity MR angiography techniques and protocols, revisit the often variable vascular anatomy of the arm and hand, and offer examples of various pathologic entities diagnosed with MR angiography. Finally, several imaging pitfalls that one must be aware of for accurate diagnosis are illustrated and reviewed.

Hepatic hemangiomas: subtype classification and development of a clinical practice algorithm and registry

PURPOSE

Hepatic hemangiomas, though histologically benign, may be associated with significant morbidity and mortality in afflicted infants. The literature presents much confusion regarding the natural history and treatment options for hepatic hemangiomas. Clinical manifestations range from asymptomatic self-limiting lesions to congestive heart failure associated with high-volume vascular shunting to fulminant hepatic failure with hypothyroidism, abdominal compartment syndrome, and death. There has been little rationale to choose among observation, corticosteroid, other pharmacologic agents, arterial embolization, hepatic artery ligation, resection, or liver transplantation for any given patient.

METHODS

We analyzed several recent retrospective radiologic analyses and pathologic studies to determine whether hepatic hemangiomas could be categorized, allowing prediction of their natural history and rational choice of therapies based upon their clinical presentation and radiographic appearance.

RESULTS

We propose that hepatic hemangiomas do not represent a single entity but, rather, 3 principle categories of lesions: focal, multifocal, and diffuse. Because these 2 categories represent different anatomical and physiologic variants, so, too, may they respond differently to previously anecdotally applied treatment regimens. With input from international multidisciplinary authorities on hemangiomas, we developed and proposed a clinical practice algorithm for the evaluation and management of hepatic hemangiomas. Toward that end, we propose a plan to institute a web-based international hepatic hemangioma registry. Participants in the registry could obtain no-cost centralized review of imaging studies (and histology if available) and guidance regarding the management algorithm from an established multidisciplinary team. In exchange, the registry will facilitate the acquisition of systematic clinical and imaging information.

CONCLUSION

Longitudinal observation of response to more directed treatment protocols may contribute greatly to the understanding of these potentially fatal tumors.

Hemangiomas: new insights and classification

Infantile hemangiomas are the most common tumors of infancy, but less common vascular tumors also can affect young infants and children. In most cases, the diagnosis of IH can be made clinically, but imaging studies and even biopsy may be required in less-than-typical cases. With a careful history and physical examination focusing on the timing, location, and type of hemangioma, as well as extracutaneous signs and symptoms, the general pediatrician will know when to be concerned about a high risk vascular tumor and proceed with referral or further evaluations.

Update on hemangiomas and vascular malformations

PURPOSE OF REVIEW

Our knowledge base in the area of vascular anomalies is growing rapidly. With greater understanding of classification and diagnosis, as well as with the numerous areas of research bringing further awareness on the complexity of these lesions, we are improving our ability to treat them. We will attempt in this article to summarize the developments in the field of vascular anomalies over the last year.

RECENT FINDINGS

Emphasis on correct classification is still a high priority in the literature and yet there remains a great deal of misinformation. Many new developments in the basic science of these lesions are allowing better understanding of why these lesions occur while improving our management in these patients. Advances in laser surgery as well as sclerotherapy techniques have improved our ability to treat extensive lesions and also improve patients' quality of life.

SUMMARY

Many new and exciting areas of discovery occur almost daily in the field of vascular anomalies. Due to the breadth of this topic, it is certain that not all articles can be reviewed however the author has tried to present the most recent and clinically relevant breakthroughs in the field.

Lumps and bumps in children-when to worry: recent trends in recognition and pathology of hemangiomas of infancy and Spitz nevi

PURPOSE OF REVIEW

Hemangiomas are common, and most lesions are benign. Careful attention needs to be paid to these lesions; however, because their growth can be unpredictable, they can have important complications and can serve as markers of underlying malformations. The consequences of hemangiomas are extensive and can be challenging to recognize.

RECENT FINDINGS

Recent knowledge of the pathogenesis and diagnosis of these lesions has helped raise awareness of their classification and clinical significance. Spitz nevi can also be a challenging lesion to diagnose and treat, although for different reasons. These are lesions composed of melanocytes with clinical and histopathological findings that we easily misdiagnosed and can have significant implications for patient care.

SUMMARY

Both of these important lesions in infants and children are reviewed in further detail with particular attention to recent trends.