Multimodal management of diffuse neonatal hemangiomatosis

Visceral and mucosal involvement in neonatal haemangiomatosis

BACKGROUND

Two types of neonatal haemangiomatosis (NH) are distinguished: diffuse which is associated with a high rate of mortality linked to mucosal/visceral involvement, and benign.

OBJECTIVES

First, this study aimed to examine the frequency of mucosal and visceral (especially hepatic) involvement in NH, according to skin extension, and second, it aimed to examine clinical, pathological (with glucose transporter 1 (GLUT-1) immunostaining), and imaging features of NH, including follow-up data.

METHODS

This was a descriptive retrospective study carried out in the University Hospital Center of Tours, France.

RESULTS

The study included 19 patients with cutaneous NH (number of skin haemangiomas ranging from 5 to >100). Mucosal involvement was observed in 32% of all cases (100% and 19% in diffuse and other cutaneous cases respectively) and hepatic involvement in 42% (67% and 38% respectively). The number of hepatic haemangiomas ranged from 1 to >10. Half of the hepatic haemangiomas cases exhibited increased hepatic arterial blood flow.

CONCLUSIONS

Mucosal and hepatic involvement was frequent in cases with a high number of cutaneous haemangiomas (>100), but only frequency of mucosal involvement was statistically significant (P = 0.021).

Hepatic infantile hemangiomas treated with oral propranolol--a case series

Hepatic infantile hemangiomas may be associated with morbidity and mortality, and traditional therapies may be associated with significant side effects. Since propranolol has been recently used successfully to treat cutaneous infantile hemangiomas, we decided to use it in three patients who presented with hepatic and skin hemangiomatosis. Three patients with skin and hepatic infantile hemangiomas, two of whom had evidence of cardiovascular compromise and one of whom had extensive liver involvement and hypothyroidism, were treated with oral propranolol. Regression of both skin and hepatic hemangiomas was noted in all patients, as was resolution of the cardiac symptoms and decreased thyroid requirement in two patients each. Propranolol was well tolerated without any adverse effects. Propranolol should be considered as a potential first-line therapy in patients with symptomatic hepatic hemangiomatosis.

Diffuse neonatal hemangiomatosis presenting as bilateral iris hemangiomas in an infant

PURPOSE

To describe a case of diffuse neonatal hemangiomatosis presenting as bilateral iris hemangiomas.

METHOD

Case report.

PATIENT

A 2-month-old girl presented with bilateral enlarging red masses of her irises, congestive heart failure, and abdominal distension. The iris masses were diagnosed as hemangiomas, and she was found to have diffuse neonatal hemangiomatosis also involving her skin, liver, heart, and cerebellum.

RESULTS

The patient's systemic hemangiomas were successfully treated with four cycles of weekly intravenous vincristine (0.05 mg/kg/dose) with concurrent resolution of her right iris hemangioma within 6 weeks. The left iris lesion then regressed within 1 month following 1 subTenon injection of 20 mg of triamcinolone acetonide with residual iridocorneal adhesions at the site.

CONCLUSION

Diffuse neonatal hemangiomatosis should be considered in the setting of bilateral iris hemangiomas. Also, this case demonstrates that iris hemangiomas associated with diffuse neonatal hemangiomatosis may respond to systemic vincristine, and that periocular steroids may be useful for treating iris hemangiomas that are unresponsive to systemic vincristine alone.

Enhanced growth of hepatic hemangiomatosis in two adults after postmenopausal estrogen replacement therapy

Liver hemangiomatosis is defined as extensive hemangioma in the liver. Although hemangioma is the most common hepatic tumor, diffuse hepatic hemangiomatosis is very rare. Most cases of hepatic hemangiomatosis are seen in infancy, but it is extremely rare in adults. This is the first report, showing the enhanced growth of diffuse hepatic hemangiomatosis after hormone replacement therapy. We report herein two unrelated women, 47 and 42 year-old, from different regions of Turkey, who admitted to hospital because of right abdominal pain with diffuse hepatic hemangiomatosis, developed after hormone replacement therapy for menopause. The patients were healthy, except for hemangiomatosis, and their physical examination, routine laboratory tests, and tumor marker levels were within normal limits. It should be noted that their abdominal ultrasonography was normal before hormone therapy, but ultrasonography on admission revealed numerous, ill defined, diffusely located liver nodules in both patients. Dynamic magnetic resonance imaging and scintigraphy have revealed that these lesions are compatible with hemangiomatosis. These results suggest that hepatic hemangiomatosis was induced by estrogen therapy. Consequently, hormone replacement therapy was discontinued, and the patients were followed up for 3 years. Their physical examination and blood chemistry, including liver enzymes, remained within normal range, and the follow-up examination with ultrasonography showed no changes in size of lesions. Because of the possible association of hemangioma with estrogen administration, decisions should be made carefully about estrogen therapy for patients who already have hemangioma, and the periodic ultrasonograpy examination should be planned to detect possible new growth of liver hemangiomatosis.

Two infants with life-threatening diffuse neonatal hemangiomatosis treated with cyclophosphamide

Diffuse neonatal hemangiomatosis (DNH) is a rare, frequently fatal disorder characterized by multiple cutaneous and visceral hemangiomas. Complications include high-output cardiac failure, hemorrhage, hepatic failure, and consumption coagulopathy. We present two cases of neonates with DNH. We prescribed cyclophosphamide after failure of corticosteroids. Cyclophosphamide induced a fast regression of the lesions with no side effects in both infants. We were able to stop treatment after 3-4 courses of cyclophosphamide in both infants because of the excellent response. Cyclophosphamide seems to be a safe and effective treatment in patients suffering from life-threatening DNH unresponsive to corticosteroids.

Hemangiomas of infancy: clinical and biological characteristics

Hemangiomas of infancy are common in the general pediatric population, are usually easily diagnosed, and generally do not require treatment. However, a small but significant percentage of hemangiomas of infancy may develop complications, including infection or ulceration. In addition, hemangiomas located in some anatomic regions may be associated with other anomalies and therefore require more careful monitoring and earlier intervention to prevent permanent sequelae. This review focuses on distinguishing hemangiomas from vascular malformations and delineates the natural history of hemangiomas of infancy, with an emphasis on identifying those hemangiomas that require additional evaluation and closer follow-up. Current treatment modalities, including the use of systemic steroids and the pulsed-dye laser, are discussed. In addition, several conditions that often present with cutaneous hemangiomas are described, including PHACES syndrome and neonatal hemangiomatosis. Finally, an assessment is made of the current understanding of the biology of hemangioma proliferation and involution, including the role of endothelial growth factors and GLUT1, a new marker for hemangiomas of infancy.

Life-threatening cutaneous conditions in neonates

One of the major medical concerns in neonates is their vulnerability to life-threatening complications. Early diagnosis of potentially serious medical conditions is essential in prevention of such complication by prompt administration of appropriate treatments. Recognition of cutaneous manifestations of potentially fatal diseases may assist a clinician in management of newborns. To overview the full spectrum of this category of conditions, Medline search was performed for cases of cutaneous manifestations associated with mortality during the first month of live that were published in the English language literature since 1977. This is a concise review of the clinical aspects of most of the potentially life-threatening disorders in neonates divided by basic morphology of their cutaneous manifestations.

Anterior segment tumors: current concepts and innovations

The most common anterior segment tumors are primary neuroepithelial cysts, uveal melanomas, metastatic tumors, and benign tumors. In the majority of cases, the diagnosis can be made utilizing a careful clinical history and ocular examination. Ultrasound examination (low and high frequency) has become an indispensable tool used to determine tumor extension and involvement of the surrounding structures. In particular, high-frequency ultrasound has been used to uncover iris pigment epithelial cysts, to allow for the diagnosis of small ciliary body melanomas, and to measure tumors for plaque radiation planning. Whereas fluorescein angiography and computerized tomography have come to play a limited role, fine-needle aspiration biopsy has been found to be quite helpful in selected cases. Once the diagnosis is established, treatment decisions depend on the tumors' location, size, local extension, patterns of growth, and secondary complications. Most anterior segment tumors can be observed for growth prior to treatment. Other options include local resection (iridectomy, lamellar sclerouvectomy, or eye-wall resection) and radiation (ophthalmic plaque or external beam). Enucleation is typically employed if these eye- and vision-sparing treatments are not possible and for uncontrollable secondary glaucoma. This review examines the unique role of high-frequency ultrasonography for the diagnosis and treatment of anterior segment tumors as well as an overview of clinical practice.

Pulmonary capillary hemangiomatosis associated with primary pulmonary hypertension: report of 2 new cases and review of 35 cases from the literature

Pulmonary capillary hemangiomatosis (PCH) is a rare cause of primary pulmonary hypertension characterized by thin-walled microvessels infiltrating the peribronchial and perivascular interstitium, the lung parenchyma, and the pleura. These proliferating microvessels are prone to bleeding, resulting in accumulation of hemosiderin-laden macrophages in alveolar spaces. Here we report 2 cases of PCH with pulmonary hypertension, 1 of them associated with mechanical intravascular hemolysis, a feature previously reported in other hemangiomatous diseases, but not in PCH. Case 2 was diagnosed by pulmonary biopsy; to our knowledge the patient is the second adult to be treated with interferon alpha-2a. Review of the literature identified 35 patients with PCH and pulmonary hypertension. The prognosis is poor and median survival was 3 years from the first clinical manifestation. Dyspnea and right heart failure are the most common findings of the disease. Hemoptysis, pleural effusion, acropachy, and signs of pulmonary capillary hypertension are less common. Chest X-ray or computed tomography scan usually shows evidence of interstitial infiltrates, pulmonary nodules, or pleural effusion. Hemodynamic features include normal wedge pressures. Radiologic and hemodynamic findings are undifferentiated from those of pulmonary veno-occlusive disease but differ from other causes of primary pulmonary hypertension. Epoprostenol therapy, considered the treatment of choice in patients with primary pulmonary hypertension, may produce pulmonary edema and is contraindicated in patients with PCH. Regression of lesions was reported in 1 patient treated with interferon therapy and 2 other patients stabilized, including our second patient. PCH was treated successfully by lung transplantation in 5 cases. Early recognition of PCH in patients with suspected primary pulmonary hypertension is possible based on clinical and radiologic characteristics. Diagnosis by pulmonary biopsy is essential for allowing appropriate treatment.

Bilateral multifocal hemangiomas of the orbit in the blue rubber bleb nevus syndrome

PURPOSE

To report the clinical findings and surgical treatment of multifocal, bilateral orbital hemangiomas in a patient with the blue rubber bleb nevus syndrome, a rare vascular disorder characterized by distinctive cutaneous and visceral hemangiomas.

DESIGN

Interventional case report.

METHODS

Review of clinical findings, radiologic studies, and treatment of the patient.

RESULTS

A 36-year-old female with multifocal, bilateral orbital lesions was seen with severe proptosis and decreased visual acuity of the left eye. Surgical debulking of multiple cavernous hemangiomas of the orbit resulted in decreased proptosis and an improvement in visual acuity. Subsequent histopathologic analysis and the results of a systemic workup revealing multiple, distinctive, cutaneous and visceral lesions were found to be consistent with the blue rubber bleb nevus syndrome.

CONCLUSIONS

Although hemangiomas of the orbit are relatively common occurrences, multifocal, bilateral lesions may exist in the setting of underlying systemic hemangiomatosis. Bilateral or multifocal hemangiomas associated with cutaneous or visceral lesions should alert the clinician to the possibility of a number of syndromes that may have life-threatening consequences.

Diffuse neonatal hemangiomatosis without cutaneous lesions in an adult--a case report

Diffuse neonatal hemangiomatosis (DNH) is a rare disorder that first presents with multiple cutaneous and visceral hemangiomas during the neonatal period and has a high mortality rate. The authors report a long-term survivor of DNH who presented with multiple visceral hemangiomas without cutaneous lesions. Vascular endothelial growth factor (VEGF) may play an important role in tumor progression.

The successful treatment of diffuse neonatal hemangiomatosis with flashlamp pulsed dye laser

Diffuse neonatal hemangiomatosis is a rare disease with the distinctive features of multiple hemangiomas of the skin and visceral organs. These lesions have been treated with systemic corticosteroids, interferon-alpha, and their combination. We report a patient with diffuse neonatal hemangiomatosis who had multiple cutaneous and hepatic hemangiomas. Single therapy with the flashlamp pulsed dye laser was effective for cutaneous hemangiomas, whereas the hemangiomas of the liver remained stable and no liver dysfunction or hemorrhage has occurred so far, even with no treatment.

[Use of interferon in a case of hepatic hemangioma]

Hepatic hemangioendothelioma can have a fatal outcome. After failure of classic therapies, and when surgery or arterial embolization are not possible, those benign tumours may benefit from interferon alpha treatment.

CASE REPORT

We report a case of a 14-month-old infant who presented with hepatic hemangiomatosis and cardiac failure. The disease can neither be controlled by steroids nor by radiotherapy associated with digitalo-diuretic treatment. Due to the important vascular volume of the tumour, neither surgical care nor arterial embolization were possible. Thus this infant was treated for ten months by interferon alpha. The evolution was favourable: cardiac failure, calcifications and volume of the angiomatosis were regressive.

CONCLUSION

Interferon alpha treatment helps to control cardiac failure and the course of hepatic hemangioma in childhood.

New clinical observations in hemangiomas

Much research in endothelial biology is aimed at developing methods to stimulate productive angiogenesis or inhibit unwanted angiogeneseis. Hemangiomas provide a model for endothelial proliferation and involution. This article is intended to update the reader with new information regarding hemangiomas of infancy, the most common tumor of childhood. Topics such as possible origin, management issues, and psychosocial stresses are addressed. This field is constantly changing, but an effort has been made to include most of the recently reported articles. Our hope is that this information will enable physicians caring for patients with hemangiomas to better address the concerns of their patients and families.

The antiangiogenic agents TNP-470 and 2-methoxyestradiol inhibit the growth of angiosarcoma in mice

BACKGROUND

Endothelial malignancies, such as angiosarcoma and hemangioendothelioma, are often resistant to chemotherapy and surgery, and may result in death. Improved means of therapy are needed for these disorders.

OBJECTIVE

We wanted to determine whether angiosarcoma can be treated with angiogenesis inhibitors in mice.

METHODS

Mice were inoculated with a cell line that gives rise to angiosarcoma and were treated with the angiogenesis inhibitors 2-methoxyestradiol and TNP-470. Response to therapy was monitored by measurement of tumors.

RESULTS

TNP-470 caused an 84% reduction in tumor size, and 2-methoxyestradiol caused a 68% reduction in tumor size.

CONCLUSION

Angiogenesis inhibitors are highly effective in treatment of angiosarcoma in mice. Clinical trials of these agents in humans with angiosarcoma and hemangioendothelioma are warranted.

Histopathology of the eye in diffuse neonatal hemangiomatosis

PURPOSE

To report the ocular presentation and histopathology of a patient with diffuse neonatal hemangiomatosis.

METHODS

Case report. A 3.7-kg female was born at term. Multiple hemangiomas were present, and the patient died 39 days after birth.

RESULTS

Widespread cutaneous and visceral hemangiomas were present. Ophthalmic examination disclosed bilateral eyelid and conjunctival hemangiomas. The right eye had multiple iris hemangiomas, hyphema, vitreous hemorrhage, and discrete subretinal lesions. Histopathology of the right eye demonstrated hemangiomas involving the iris, ciliary body, and ciliary processes.

CONCLUSION

Diffuse neonatal hemangiomatosis was associated with ophthalmic findings of multiple hemangiomas involving eyelid, conjunctiva, iris, ciliary body, and ciliary processes.