Successful management of an infant with a giant hemangioma of the retroperitoneum and Kasabach-Merritt syndrome with alpha-interferon

A Huge Subcutaneous Hematoma in an Adult with Kasabach-Merritt Syndrome

Patient: Male, 1

Final Diagnosis: Kasabach-Merritt syndrome with widespread hemangiomas and an infected huge hematoma in the right thigh

Symptoms: Gross hematuria

Medication: —

Clinical Procedure: CT-guided drainage • blood transfusion

Specialty: Hematology

Paravertebral and Retroperitoneal Vascular Tumour Presenting with Kasabach-Merritt Phenomenon in Childhood, Diagnosed with Magnetic Resonance Imaging

Kasabach-Merritt phenomenon (KMP) is characterized by vascular tumour and consumptive coagulopathy with life-threatening thrombocytopenia, prolonged prothrombin time and partial thromboplastin time, hypofibrinogenemia, and the presence of high fibrin split products. We report a case of 3-year-old boy with local aggressive vascular lesions associated with KMP. Magnetic resonance imaging revealed an extensive lesion at paravertebral and retroperitoneal regions that was infiltrating vertebrae. Although we did not get any response to steroid or propranolol treatment, partial response was observed radiologically with interferon-alpha treatment. Unfortunately, the patient died because of the uncontrolled consumptive coagulopathy that led to intracranial hemorrhage which was caused by huge knee hematoma after minor trauma.

Kasabach-Merritt phenomenon: a single centre experience

OBJECTIVE

Kasabach-Merritt phenomenon (KMP) can lead to life-threatening bleeding, and its optimum treatment has not been established. We review the experience of managing KMP in a single institution.

METHODS

A retrospective chart review on all children with KMP treated at the Hospital for Sick Children, Toronto, over an 18 yr period was carried out.

RESULTS

All 15 patients had profound thrombocytopenia and hypofibrinogenemia at presentation, half had bleeding symptoms, and three had cardiac failure. All patients received corticosteroids. Five responded to steroids alone, given for an average of 13 wk, increasing platelets to >20 x 10(9)/L at a mean of 6.2 d and fibrinogen >1 g/dL at 25.6 d. Ten patients received at least one other therapeutic modality in addition to steroids, including vincristine, interferon, anti-platelet agents and pentoxifylline. Five patients received vincristine, for a mean of 6 wk, with two patients responding. Eight patients received interferon, for a mean of 4 months, with two patients responding. Overall, the mean time to increasing platelets >20 x 10(9)/L was 56 d, to >150 x 10(9)/L was 88 d and fibrinogen >1 g/dL 49 d. Ten patients showed a partial response to embolisation, with a mean of 2.8 procedures performed. Thrombotic complications occurred in 7%. Twelve patients remain alive, with relapse in six patients, all treated successfully. One patient died, and two patients have been lost to follow-up.

CONCLUSION

KMP is a rare condition, with significant morbidity and mortality. The therapeutic approach should include a multidisciplinary team and consensus on guidelines.

Non-traumatic splenic rupture in a patient with Kasabach-Merritt syndrome

This report presents a case illustrating the complications of Kasabach-Merritt syndrome in a 22-year-old man. The patient presented with acute abdominal pain and profound anaemia; a CT scan revealed intraperitoneal bleeding from spontaneous splenic rupture. The patient underwent initial emergency laparotomy and splenectomy, with a subsequent further laparotomy to control haemorrhage. Blood products requirements were extensive: 28 units red blood cells, 14 units fresh frozen plasma, 10 units platelets, 10 units cryoprecipitate and 2× Novo VII. He was then transferred to a nearby tertiary care unit for further management to control his coagulaopathy and he made a full recovery after 4 weeks.

Adjuvant Antiangiogenic Therapy for Giant Cell Tumors of the Jaws

PURPOSE

To further evaluate a novel treatment protocol for the management of aggressive giant cell lesions (GCLs) consisting of enucleation followed by adjuvant subcutaneous interferon alpha therapy.

PATIENTS AND METHODS

Using a retrospective case series study design, a sample of patients with aggressive GCLs was enrolled between April 1995 and June 2006. Lesions were enucleated with preservation of vital structures. Postoperatively, the patients received daily subcutaneous interferon alpha (3 million units/m2 of body surface area). Interferon treatment continued with regular clinical and radiographic follow-up until the surgical defects filled in with bone, as demonstrated by panoramic radiographs and confirmed by computed tomography. Side effects, such as fever, fatigue, weight loss, decreased white blood cell count, decreased platelet count and elevated liver enzymes, were monitored. After completion of interferon therapy, patients followed for 2 years without evidence of recurrence were considered cured of disease.

RESULTS

The study sample was comprised of 26 subjects (65% female) with a mean age of 18.5 years. At the time of this writing, 16 of the subjects have completed the protocol and are cured of disease, 6 are in remission, and 4 are in active treatment. Four subjects experienced significant side effects from the interferon, requiring modification of treatment.

CONCLUSIONS

Enucleation of aggressive GCLs with preservation of vital structures and adjuvant interferon is an excellent strategy for managing aggressive GCLs. Approximately 15% of subjects developed significant side effects limiting interferon administration and necessitating alternative therapies.

Sturge-Weber syndrome and associated congenital vascular disorders: a review

Sturge-Weber syndrome (SWS), Klippel-Trenaunay syndrome (KTS), and Parkes-Weber syndrome (PWS) represent a wide range of congenital vascular abnormality syndromes. Although many of the diagnostic criteria overlap for these syndromes, there are important differences among these diseases that carry important prognostic and therapeutic implications. This review attempts to clearly distinguish among SWS, KTS, and PWS, although loosely categorizing them as a family of congenital vascular disorders. A review of literature reveals that a variety of diagnostic tools exist that can help differentiate between the syndromes and assess risk for certain complications, which may help tailor various treatment modalities for a particular patient.

Effect of interferon-alpha-2b on porcine mesenchymal stem cells

PURPOSE

Patients undergoing enucleation and adjuvant interferon therapy for giant cell jaw tumors have been observed to exhibit exuberant bone formation in the resultant defects. We hypothesize that interferon promotes bone formation by enhancing mesenchymal stem cell (MSC) differentiation and by stimulating osteoblasts. This is a preliminary study to determine the effects of interferon on porcine mesenchymal stem cells (pMSCs) in culture.

MATERIALS AND METHODS

Isolated pMSCs were grown under the following conditions: 1) MSCs alone (negative control); 2) MSCs + osteogenic supplements (positive control); and 3) MSCs + interferon (experimental). Cell cultures were evaluated morphologically, by quantitative DNA analysis, and quantitative and qualitative alkaline phosphatase analysis.

RESULTS

Cells treated with interferon exhibited a slower but constant proliferation rate, did not clump, and produced more alkaline phosphatase as compared with the negative control.

CONCLUSION

The data indicate that interferon may act to differentiate MSCs into osteoblasts and to stimulate metabolic activity while not increasing the proliferation rate.

Retroperitoneal hemangioma of infancy

A premature infant presented with an incidental finding of a mass in the retroperitoneum adjacent to the adrenal gland seen on a renal ultrasound study. A clinical diagnosis of neuroblastoma was made based on imaging and laboratory studies; however, upon resection, histological examination revealed a cellular capillary hemangioma of infancy. Hemangioma should be considered in the differential diagnosis of asymptomatic retroperitoneal mass lesions in infants.

Endothelial lesions of soft tissues: a review of reactive and neoplastic entities with emphasis on low-grade malignant ("borderline") vascular tumors

Soft tissue proliferations composed of endothelial cells are a heterogeneous group of lesions that can cause diagnostic difficulty. Further complicating the issue is the constantly changing nomenclature of some entities, as well as reclassification of some vascular tumors from the high-grade malignant category to the low-grade malignant or borderline category. Modern ancillary techniques such as immunohistochemistry and cytogenetics have done little to advance our knowledge of these lesions. This review article outlines the most recent classification of endothelial lesions of the skin and soft tissues, with emphasis on the low-grade malignant (borderline) category. In addition, many tumor-like lesions containing an endothelial component are also discussed.

Antiangiogenic therapy with interferon alpha for giant cell lesions of the jaws

PURPOSE

Giant cell tumors are classified and treated based on their biologic behavior. We hypothesize that they are proliferative vascular lesions and would be expected to respond to antiangiogenic therapy. The purpose of this report is to present a treatment protocol consisting of enucleation, with preservation of vital structures, followed by subcutaneous interferon alpha.

MATERIALS AND METHODS

Patients with a biopsy-confirmed giant cell lesion satisfying criteria for "aggressive giant cell tumor" were included. Instead of wide en bloc resection, lesions were enucleated and the patients started on interferon alpha-2 or beta (3,000,000 units/m(2)) 48 to 72 hours postoperatively. The subjects were followed by clinical examination and radiography, immediately after surgery and every 3 months until the bone cavity completely healed. Thereafter, follow-up was every 6 months.

RESULTS

Eight patients (7 females), with a mean age of 18.7 +/- 11.1 years, have been enrolled. Six tumors were in the posterior mandible, and 2 were in the anterior maxilla. The mean size was 29.0 mm (range, 15 to 70 mm). All patients underwent enucleation. There were no postoperative complications, and all patients tolerated interferon. There was no evidence of tumor growth during treatment. Seven of 8 patients have completed interferon therapy, and there have been no recurrences during 1 to 6 years of follow-up. The other patient continues on treatment with no evidence of disease.

CONCLUSION

Antiangiogenic therapy, in combination with curettage, is a promising strategy for treatment of aggressive giant cell tumors. Combined treatment results in a high rate of tumor control with decreased operative morbidity compared with conventional treatment.

Case report: Kasabach-Merritt syndrome: a review of the therapeutic options and a case report of successful treatment with radiotherapy and interferon alpha

We describe the successful treatment of a neonate with Kasabach-Merritt syndrome who received local irradiation and interferon alpha therapy after failure of corticosteroid treatment. A male neonate, born after an uneventful pregnancy, had a huge haemangioma involving the upper right cervical region as well as severe thrombocytopenia. He was treated with corticosteroids, interferon alpha and radiotherapy. Prednisolone therapy (5 mg kg(-1) day(-1)) was started at 41 days of age. No therapeutic effect was observed after 2 weeks. At this time the tumour size had increased dramatically, platelet counts had decreased progressively and coagulation abnormalities had developed. Because corticosteroid therapy had been ineffective and the child was in a life-threatening condition, irradiation was delivered up to a total dose of 9.5 Gy in five fractions. Simultaneously, prednisolone therapy was slowly decreased and interferon alpha therapy (3 million U m(-2) day(-1)) was started and continued for 6 weeks. After irradiation with 9.5 Gy and beginning interferon alpha therapy, the tumour decreased in size and coagulation parameters normalized within 4 weeks. 6 months later, platelet counts and coagulation parameters were still normal. The tumour had further decreased in size. No acute severe side effects were observed. Radiation therapy combined with interferon alpha treatment is an alternative treatment modality when high dose corticoid steroid therapy has been ineffective in patients with Kasabach-Merritt syndrome, despite the risks of growth delay and secondary malignancy. In children showing no response to corticosteroids, radiotherapy and/or interferon alpha should be considered in Kasabach-Merritt syndrome.

Pulsed 1064-nm Nd:YAG laser therapy for noninvasive treatment of a massive hemangioma: case report

OBJECTIVE

The author determined whether cutaneous Nd:YAG laser therapy is a viable treatment option for a massive hemangioma located in the musculus soleus muscle of a patient's left leg.

SUMMARY BACKGROUND DATA

Giant hemangiomas generally require aggressive medical or surgical therapy to address complications. Because of the size of the lesions, there are risks inherent with conventional treatment options. In selected patients, Nd:YAG laser therapy is a noninvasive approach to treating large, subcutaneous hemangiomas.

METHODS

A 59-year-old female patient, who was diagnosed with a large, venous-type hemangioma in the musculus soleus muscle of the left leg, was treated during two treatment sessions with Nd:YAG laser therapy. A Plexiglas ring was placed on the leg, over the hemangioma, to force the hemangioma closer to the surface and laser irradiation was applied to the skin.

RESULTS

At 6-month follow-up after the second treatment, magnetic resonance imaging (MRI) demonstrated 75%-80% reduction in lesion size. There were no permanent adverse effects encountered with the treatment method.

CONCLUSIONS

The author concludes that in carefully selected cases Nd:YAG laser therapy can be used to treat large hemangiomas whose size poses risks with surgical and other treatments.

Kasabach-Merritt syndrome: identification of platelet trapping in a tufted angioma by immunohistochemistry technique using monoclonal antibody to CD61

Kasabach-Merritt syndrome (KMS) consists of large and rapidly growing vascular tumors associated with thrombocytopenia, generalized petechiae, and bleeding. The cause of the thrombocytopenia is thought to be related to the trapping of platelets by the abnormal endothelium of the tumor. We report an infant with KMS that developed in association with a large tufted angioma. In this case we directly demonstrated platelet trapping in the vascular lumen of the tumor by an immunohistochemical technique using a monoclonal antibody against CD61, a marker of platelets and megakaryocytes.

The infant with a vascular tumor

Vascular birthmarks look alike in various tints of blue, pink, or red. These anomalies are either vascular tumors or vascular malformations. Hemangioma is the most common vascular tumor of infancy, typically appearing in the neonatal period. Hemangiomas grow rapidly during the first year of life and regress slowly during childhood. Treatment is indicated for problematic or endangering hemangiomas, usually the administration of corticosteroids or interferon-alfa, and in some instances, embolization or surgical resection. The more aggressive and rare vascular tumors, kaposiform hemangioendothelioma and tufted angioma, are often associated with thrombocytopenia and coagulopathy (Kasabach-Merritt phenomenon) and less responsive to pharmacological therapy. Vascular tumors, particularly hemangioma, are often confused with vascular malformations; although etiology, histology, and clinical behavior are quite different. Vascular lesions should be biopsied if there is any suspicion of malignancy.

Antiangiogenic therapy of a recurrent giant cell tumor of the mandible with interferon alfa-2a

We report a 5-year-old girl with a large rapidly growing giant cell tumor of the mandible that recurred 2 months after the first surgical excision and 3 months after a second resection. An angiogenic protein, (bFGF), was abnormally elevated in her urine. The patient was treated with interferon alfa-2a for 1 year because this agent inhibits angiogenesis by suppressing bFGF overexpression in infantile hemangiomas and in other human tumors. During this time the bone tumor regressed and disappeared, the urinary bFGF fell to normal levels, and the mandible regenerated. She has remained tumor-free and has been off therapy for 3 years at this writing. This first successful use of interferon alfa-2a to treat a mandibular tumor in a child demonstrates: 1) low grade tumors that overexpress bFGF may respond to interferon alfa-2a, in a manner similar to life-threatening infantile hemangiomas; 2) antiangiogenic therapy, given without interruption for 1 year, was safe and effective in this patient; and 3) treatment may be continued for 1 year without the development of drug resistance.

Diffuse splenic and visceral hemangiomas complicated by chronic consumption coagulopathy

The case of a 7-year-old girl with a 2 year history of easy bruising associated with thrombocytopenia is reported. On admission she presented with ecchymoses, abdominal distention and splenomegaly. Hemostasis investigation revealed a consumption coagulopathy. Several radiological studies failed to confirm the diagnosis of diffuse splenic and visceral hemangiomatosis, which was eventually established by an explorative laparotomy. Platelet count and the other coagulation abnormalities progressively returned to normal after splenectomy, although the remaining hemangiomas were extensive.

Successful multimodal therapy for kaposiform hemangioendothelioma complicated by Kasabach-Merritt phenomenon: case report and review of the literature

We present the management challenge provided by a patient with kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon. A female child presented at 14 months of age with an ecchymotic swelling of her right upper arm and axilla. Subsequently, she developed profound thrombocytopenia and hypofibrinogenemia (Kasabach-Merritt phenomenon). Biopsy of the lesion revealed kaposiform hemangioendothelioma, which has been reported as the predominant pathologic diagnosis associated with Kasabach-Merritt phenomenon. To achieve involution of the lesion and preserve function of the arm, the following interventions were involved: embolization, systemic interferon, cyclophosphamide, epsilon aminocaproic acid, and compression therapy. The clinical management of this patient was formidable until we arrived at the proper combination of therapies. Multimodal intervention may be required to manage fastidious hemangioendotheliomas of childhood, achieve clinical improvement, and prevent further morbidity.

Thrombocytopenic coagulopathy (Kasabach-Merritt phenomenon) is associated with Kaposiform hemangioendothelioma and not with common infantile hemangioma

Children with a large vascular tumor and associated Kasabach-Merritt coagulopathy respond inconsistently to therapy and have a high mortality rate. For this reason, we undertook a retrospective study of 21 such patients, and focused on clinical, radiographic, and histopathologic features. The male to female ratio was 1:1.6. Tumor was noted at birth in 50 percent of patients; the remainder appeared throughout infancy. The location was cervicofacial (n = 2), shoulder/upper limb (n = 4), trunk including retroperitoneum (n = 11), and lower limb (n = 4). These tumors grew rapidly to large size and were characterized by cutaneous purpura, edema, and an advancing ecchymotic margin. In contrast to common hemangioma, magnetic resonance imaging showed diffuse enhancement with ill-defined margins, cutaneous thickening, stranding of subcutaneous fat, hemosiderin deposits, and small feeding and draining vessels. All tumors were Kaposiform hemangioendothelioma (KHE); none were infantile hemangioma. Light microscopy showed irregular lobules or sheets of poorly formed, small vascular channels infiltrating and entrapping normal tissues. Characteristic features included spindle-shaped endothelial cells, diminished pericytes and mast cells, microthrombi, and hemosiderin deposits. Wide endothelial intercellular gaps and incomplete basement membranes were seen by electron microscopy. Dilated, hyperplastic, lymphaticoid channels were prominent in one tumor. KHE in 14 infants was treated with interferon alpha-2a: 6 had accelerated regression; 2 had stabilization of growth; and 6 evidenced no response. The mortality rate was 24 percent (5 of 21); this included three infants with retroperitoneal KHE. Kasabach-Merritt phenomenon does not occur with common hemangioma. Rather it is associated with the more aggressive KHE and rarely with other vascular neoplasms. Variable response to current pharmacologic therapy underscores our inadequate knowledge of the pathogenesis of thrombocytopenia in KHE.

Efficacy of bleomycin treatment for symptomatic hemangiomas in children

Five children aged 5-19 years had pain in massive, inoperable hemangiomas. They were treated with intralesional injections of 2 mg bleomycin as a 0.4 mg/ml solution in the painful area. The injections were repeated after 4 -6 weeks for a total of 6 -10 times. All children were relieved of pain, and the swelling was reduced in all cases. There were no complications or side effects. Bleomycin therapy of painful, massive hemangiomas can be recommended in older children.

Outcome of radiation therapy for patients with Kasabach-Merritt syndrome

PURPOSE

The efficacy of radiation therapy for Kasabach-Merritt syndrome, which is characterized by a huge hemangioma with consumption coagulopathy, remains controversial. In this study, we retrospectively investigated the treatment outcome of radiation therapy for seven neonates with Kasabach-Merritt syndrome.

METHODS AND MATERIALS

During the past 25 years we have seen seven children with Kasabach-Merritt syndrome who were treated with radiation therapy. Their ages ranged from 1 day to 5 months, with a median age of 1 month. The hemangioma was located in the extremities in four of seven children. Tumor sizes ranged from 70 cm to more than 150 cm in greatest diameter. Initial platelet counts were all less than 40,000/mm3 except for one patient. In principle, the total dose applied to the hemangioma was 8-10 Gy, with a daily dose of 1 Gy five times a week.

RESULTS

Four of seven hemangiomas responded dramatically, with a concomitant rise of the platelet count to radiation therapy. Although the remaining three hemangiomas, all of which were ill circumscribed by widespread overlying shiny, dusky purple skin, became less tense during radiation therapy. Disseminated intravascular coagulopathy was not improved, but they have responded favorably to two or three courses of radiation therapy with an extended radiation field by 1.5 years of age. As a result, all seven patients are now surviving with no evidence of hemangioma or hematological abnormalities. Shortening of the extremity was observed in three patients who received multiple courses of radiation therapy.

CONCLUSIONS

Radiation therapy appears to be one of the effective treatment options for Kasabach-Merritt syndrome despite the risk of growth delay and malignancy.

Successful treatment of infantile hemangiomas with interferon-alpha-2b

PURPOSE

Hemangiomas are benign tumors occurring in 10% of infants. A small percentage are complicated by blockage of vital structures, consumptive coagulopathy, or heart failure, resulting in a mortality of -20% of patients with complications. Here, we describe four infants with complicated hemangiomas responding to interferon-alpha-2b therapy.

PATIENTS AND METHODS

Four children with hemangiomas were treated with interferon-alpha-2b for complicating heart failure (1), visual impairment (2), or coagulopathy (1). Patients received interferon-alpha-2b alone or in conjunction with corticosteroid therapy over 2 to 9 months. Imaging studies and urinary basic fibroblast growth factor (bFGF) levels were used to monitor treatment response.

RESULTS

Three of four patients demonstrated involution of the hemangiomas with improvement in their coagulopathy or visual impairment. The fourth patient expired due to cardiac complications despite radiologic evidence of hemangioma involution. Side effects associated with interferon-alpha-2b treatment included elevated transaminases (2) and leukocytosis (2), which resolved upon completion of therapy. One patient developed mild gross motor delay (1), which improved after cessation of therapy. Decreased urinary bFGF levels correlated with hemangioma involution.

CONCLUSION

Interferon-alpha-2b therapy is an effective, well-tolerated treatment for complicated hemangiomas. Measurement of urinary bFGF levels may provide an objective method for monitoring treatment response.

Infants with Kasabach-Merritt syndrome do not have "true" hemangiomas

OBJECTIVE

In 1940 Kasabach and Merritt described an infant with a vascular anomaly, extensive purpura, and thrombocytopenia; they called his lesion "capillary hemangioma." Hemangioma is a benign tumor that grows in infancy and is characterized by proliferation of endothelial cells and regression during childhood. Although Kasabach-Merritt syndrome (KMS) is frequently mentioned as a possible complication of hemangioma, our experience suggests that the anatomic vascular lesion underlying the thrombocytopenia is not a "true," classic, involuting type of hemangioma of infancy and childhood.

STUDY DESIGN

We reviewed the clinical and hemostasis data and the response to treatment in 22 cases of KMS, and we analyzed the biopsy specimens of 15 of them.

RESULTS

Clinically none of the 22 patients had classic hemangioma. There was no female preponderance. All patients had severe thrombocytopenia (lowest platelet count = 3000/mm3) and consumption of fibrinogen. Histologically, none had the typical "capillary," involuting type of hemangioma of infancy: they exhibited either a tufted angioma or a kaposiform hemangioendothelioma pattern; all specimens also contained numerous abnormal lymphatic-like vessels; lymphatic malformation was the major component in two patients. The infants exhibited a heterogeneous response to a number of therapeutic regimens, as noted in other reports. Severe morbidity was present; three of our patients died, and one had leg amputation. "Residua" were, in fact, residual vascular neoplasia, variable in duration, and not a stable fibrofatty residuum, as in classic involuted hemangioma; only the hematologic phenomenon was "cured" after a period of years.

CONCLUSIONS

KMS is a distinctive disease of infancy, but the underlying vascular lesion is not a "true," classic, involuting type of hemangioma of infancy. This is a different vascular tumor with a resemblance pathologically to either tufted angioma or kaposiform hemangioendothelioma in association with lymphatic-like vessels. Whether the underlying lesion in KMS is a single anatomic entity or heterogeneous cannot be definitely concluded from this study. We need a better understanding of the pathogenesis of KMS to improve our therapeutic management.

Successful management with interferon alpha-2a after prednisone therapy failure in an infant with a giant cavernous hemangioma

A giant cavernous hemangioma of the left arm with severe thrombocytopenia and consumptive coagulopathy was observed in a neonate. Initial treatment with prednisone, platelet transfusions, and clotting replacement failed to control the bleedings. The child was then treated with daily subcutaneous infusions of interferon alpha-2a. Coagulopathy rapidly improved and transfusions were drastically reduced. The hemangioma regressed progressively and disappeared after 4 months of treatment.

Interferon alpha-2a therapy for disseminated intravascular coagulation in a patient with blue rubber bleb nevus syndrome. A case report

The authors present a sixteen-year-old girl with blue rubber bleb nevus syndrome (BRBNS) associated with disseminated hemangiomas involving the skin, oral cavity, skeletal muscle, and cerebrum. Although she denied neurologic symptoms, magnetic resonance imaging of the brain demonstrated dilatated cerebral veins and the Chiari I malformation. Examination of hemostasis revealed disseminated intravascular coagulation (DIC) manifesting as Kasabach-Merritt syndrome, with the potential for life-threatening bleeding or thrombosis in the central nervous system. Since successful management of life-threatening hemangiomas with interferon alpha-2a (IFN alpha-2a) has been reported, the authors administered IFN alpha-2a with an improvement in hemostasis. These findings suggest that IFN alpha-2a therapy is beneficial for relieving the life-threatening consumptive coagulopathy associated with BRBNS.

Hematuria in a newborn infant caused by bladder hemangioma

A newborn boy had gross hematuria caused by hemangiomas of the bladder. The sonographic examination and the voiding cystourethrogram showed an irregular and thick bladder wall with a lesion extending into the vesical lumen. Cystoscopic examination and biopsy of the lesions were diagnostic of hemangioma. Immediately after lesion fulguration, the hematuria disappeared, and 3 weeks later the follow-up ultrasound examination showed resolution of the lesion. At 1 year, the patient's urinalysis and ultrasound scan were normal. To our knowledge, this is the first reported case of hematuria in a newborn caused by a bleeding hemangioma of the bladder.

Multimodal management of diffuse neonatal hemangiomatosis

Diffuse neonatal hemangiomatosis is a rare, frequently fatal disorder. We describe the case of a neonate with numerous cutaneous and ocular hemangiomas. Hepatic hemangiomas were noted at 4 weeks of age, associated with congestive heart failure resulting from hepatic arteriovenous shunting. This condition was controlled by treatment with prednisone, interferon alfa-2b and hepatic embolization. Treatment of cutaneous hemangiomas with the tunable dye laser prevented hemorrhage, facilitated routine skin care, and allowed uninhibited intravenous access during hospitalization.

Chronic consumption coagulopathy due to an occult splenic haemangioma: Kasabach-Merritt syndrome

We report an 11-year-old girl with a 2-year history of bruising associated with thrombocytopenia and dysfibrinogenaemia. On admission she presented with a large subcutaneous haematoma and splenomegaly and was severely anaemic. Laboratory investigations revealed signs of consumption coagulopathy. Radiological examination showed splenic, retroperitoneal and intra-ossal haemangiomas. After splenectomy, platelet count and coagulation parameters returned to normal.

CONCLUSION

Contrary to widely held views, occult visceral haemangioma can lead to Kasabach-Merritt syndrome beyond infancy and is not necessarily associated with visible cutaneous haemangioma. It should be included in the differential diagnosis of chronic thrombocytopenia at any age. Early determination of fibrinogen degradation product levels is advised in order to detect an underlying chronic consumption coagulopathy prompted by an extensive search for multifocal haemangioma.

Interferon-alpha-2a for the treatment of complex hemangiomas of infancy and childhood

OBJECTIVE

The authors describe the use of interferon-alpha-2a (IFN-alpha-2a) in the treatment of complex hemangiomas and review the role of interferon (IFN) in this example of an angiogenic disease.

SUMMARY BACKGROUND DATA

Hemangiomas are the most frequent tumors of infants and children. They grow rapidly for 6 to 8 months and then resolve over a period of years. Approximately 5% produce life-, sight-, or limb-threatening complications, with mortality rates between 20% and 50%. Aggressive therapy with steroids, arterial ligation or embolization, or surgery has been used in these situations with variable results and high morbidity. Recently, IFN-alpha was found to be effective treatment in these complex hemangiomas.

METHODS

Four infants and one child were treated with IFN-alpha-2a at an initial subcutaneous dose of 1 million units/m2/day and a sustained dose of 3 million units/m2/day for 5 to 11 months. Appropriate laboratory values were monitored and adverse reactions and ultimate response to therapy were recorded.

RESULTS

Two patients experienced minor complications that were managed easily. Three patients had total or near-total regression of the hemangioma, one had partial (50%) regression, and one had stabilization but no regression after an average of 7.1 months of IFN therapy.

CONCLUSION

Interferon-alpha inhibits angiogenesis and endothelial cell migration and proliferation in vitro. The patients in this study add to the growing number who have benefited from IFN therapy. As such, IFN-alpha should be considered as a first-line agent in treating complex hemangiomas of infants and children.