Is intralesional injection of OK-432 effective in the treatment of lymphangioma in children?

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee

BACKGROUND

Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment.

METHODS

Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question.

RESULTS

The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered.

CONCLUSION

Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

LEVEL OF EVIDENCE: 4

Intra-abdominal cystic lymphangioma in adults: A case series of 32 patients and literature review

Introduction

Cystic lymphangioma (CL) is a benign tumor originating from the lymph vessels. Lymphangiomas in the abdominal cavity are extremely rare, particularly in adults.

This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma (ACL) in adults.

Material and methods

We conducted a single-center, retrospective study of 32 adult patients with ACL admitted to surgical department “A” in “La Rabta Hospital” in Tunis, from January 1998 through December 2020. The demographic, clinical, biological, radiological characteristics, histopathologic, and therapeutic data were collected, as well as the surgical intervention used and the postoperative immediate and late complications.

Results

Thirty-two adult patients with ACL were recruited, including 20 females and 12 males. The median age at treatment was 47 (range 14–80) years. The most prevalent sites were the retroperitoneum (25%), the mesentery (21.9%), and the paracolic gutters (n = 18. 7%). Twenty patients underwent open surgery (62.5%), whereas 12 cases (37.5%) had laparoscopic surgery. Twenty-eight patients received total cystectomy (87%). Three recurrences were observed during follow-up (9.4%).

Conclusion

The clinical features of CL in adults remain unclear. The diagnosis is only confirmed by histopathological examination after complete surgical resection. The laparoscopic approach is considered safe and feasible.

•

Lymphangiomas in the abdominal cavity are extremely rare, particularly in adults.

•

Cystic lymphangioma is a benign tumor originating from the lymph vessels.

•

The clinical presentation is various.

•

Whenever possible, laparoscopic resection should be the treatment of choice.

•

To prevent a recurrence, complete excision is the best option.

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.

Giant cystic lymphangioma of right mesocolon: A case report

Introduction

Cystic lymphangiomas are rare benign tumors of the lymph vessels and are usually found in children. However, abdominal cystic lymphangioma in mesocolon is extremely rare in adult patients.

Presentation of case

We reported a 15-year-old female with giant cystic lymphangioma of the right mesocolon. On examination, only abdominal pain was confirmed. Abdominal computed tomography (CT) showed a large multiseptated cystic mass. The patient underwent a total right mesocolic excision with the lesion. The patient recovered well on postoperative follow-up and was discharged on the fifth day. No evidence of recurrence had also been found in three months follow-up period.

Discussion

The diagnosis of intra-abdominal cystic lymphoma is often dismissed because the clinical symptoms are nonspecific. It is easy confusion because the ultrasound and CT scan images are relatively similar to the mesenteric and omental cysts. Sclerosing therapies may cause long-term consequences such as local recurrences with a very high proportion. Complete resection, including resection of the involved organs, is necessary. With tumors surrounding the colon, surgeons should consider performing removal block colon-lesion.

Conclusion

Complete tumor removal is the optimal choice for the management of intra-abdominal cystic lymphangioma. However, incomplete resection may lead to local recurrence.

•

Intra-abdominal cystic lymphangiomas are rare benign tumors.

•

The most common location in mesenteric small bowel, in mesocolon is extremely rare.

•

Complete tumor removal is optimal choice for lymphangioma

Sclerotherapy for Benign Cystic Lesions of the Head and Neck: Systematic Review of 474 Cases

OBJECTIVE

The role of sclerotherapy for vascular lesions of the head and neck is well established. However, the efficacy of sclerotherapy for benign cystic lesions of the head and neck is less clear. The objective of this review is to determine the efficacy and safety of sclerotherapy for benign cystic lesions of the head and neck.

DATA SOURCES

PubMed/MEDLINE, Cochrane Library, and Embase.

REVIEW METHODS

The PRISMA guidelines (Preferred Reporting Systems for Systematic Reviews and Meta-analyses) were followed for this systematic review. Studies of patients with benign head and neck cystic masses treated primarily with sclerotherapy were included. Thirty-two studies met criteria for inclusion.

RESULTS

A total of 474 cases of sclerotherapy were reviewed. Agents comprised OK-432, ethanol, doxycycline, tetracycline, and bleomycin. Lesions in the analysis were ranula, thyroglossal duct cyst, branchial cleft cyst, benign lymphoepithelial cyst, parotid cyst, thoracic duct cyst, and unspecified lateral neck cyst. A total of 287 patients (60.5%) had a complete response; 132 (27.9%) had a partial response; and 55 (11.6%) had no response. OK-432 was the most widely utilized agent, with a higher rate of complete response than that of ethanol (62.0% vs 39.4%, P = .015). Fifty-three cases (11.2%) required further surgical management. One case of laryngeal edema was reported and managed nonoperatively.

CONCLUSION

Sclerotherapy appears to be a safe and efficacious option for benign cystic lesions if malignancy is reliably excluded. Efficacy rates are comparable to those of sclerotherapy for vascular malformations. The rate of serious complications is low, with 1 incident of airway edema reported in the literature.

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.

Operative Management of Neonatal Lymphatic Malformations: Lesson Learned From 57 Consecutive Cases

Aim of the study: Lymphatic malformations (LMs) are rare entities, sometimes difficult to treat, that may be life-threatening when intricately connected to airway structures. Invasive treatments are occasionally required, with sclerotherapy considered the treatment of choice and surgery as a second-line approach. The aim of the present study was to evaluate our multidisciplinary team experience in treating newborns affected by LMs requiring operative management, while defining early outcomes. Methods: Retrospective review of all consecutive patients admitted for LMs requiring operative management between January 2000 and January 2019. Patients were mainly characterized based on anatomical district of the LM (and further stratified based on the development of respiratory distress), need for tracheostomy, number of sclerotherapies, indication for surgery, and residual disease beyond the 1st year. Morbidity and mortality were also evaluated. Fisher exact test and Mann-Whitney test were used as appropriate. Statistical significance was set at p < 0.05. Results: Fifty-seven patients were included in the study, 36 with cervicofacial and/or mediastinal LMs and 21 with LMs of other anatomical districts. Due to the risk of developing respiratory distress at birth, patients with cervicofacial and/or mediastinal LMs were divided into two groups (8/36 group A vs. 28/36 group B). Group A patients are at higher risk for tracheostomy (7/8 group A vs. 1/28 group B, p = 0.0001) and more often require surgical reduction of the residual lymphatic abnormality (5/8 group A vs. 4/28 group B, p = 0.013). They also require sclerotherapies more often, but the difference is not statistically significant (8/8 group A vs. 19/28 group B, p = 0.15). Patients with cervicofacial/mediastinal LMs frequently suffer from persistent residual disease beyond the 1st year of life, significantly more often in group A (7/8 group A vs. 12/28 group B, p = 0.043). Conclusion: LMs are rare conditions with potential life-threatening behavior. Their intrinsic clinical complexity requires a multidisciplinary approach to the affected patients. Planning a long-term follow-up is essential because of the late-term problems those patients may experience.

An acute presentation of pediatric mesenteric lymphangioma: a case report and literature overview

INTRODUCTION

Lymphangioma accounts for 5% of benign pediatric tumors and less than 1% is located in the abdomen. While mesenteric lymphatic malformation or mesenteric lymphangioma (ML), mostly appears asymptomatic in adults, an acute clinical presentation is seen more often in children. Symptoms can mimic obstruction or peritonitis and diagnosis can therefore be challenging. Imaging studies are performed to exclude other causes of obstruction or peritonitis. Diagnosis of ML is always made by histology. Surgery is the treatment of choice and recurrence after complete resection is rare.

CASE REPORT

We describe an acute abdomen in a four-year-old boy caused by a mesenteric lymphatic malformation. Imaging studies at the emergency department were inconclusive and final diagnosis was made by histological examination. Surgical intervention with resection of an ischemic ileal segment was necessary. Complete resection of the ML was not possible without compromising the functional digestive outcome due to diffusely spread lesions in the mesentery of the small bowel. Follow-up with ultrasound was performed.

CONCLUSION

Mesenteric lymphangioma can cause an acute abdomen in children. Complete resection is recommended but might not be feasible without compromising the functional digestive outcome. Alternative treatments should be studied further to treat diffuse and complicated ML.

Airway obstruction caused by rapid enlargement of cervical lymphangioma in a five-month-old boy

Cervical lymphangioma can cause airway obstruction secondary to enlargement following infection. Physicians should be aware that the airway obstruction can progress rapidly when patients with cervical lymphangioma have respiratory symptoms. Sclerotherapy for lymphangioma can cause both transient swelling and airway obstruction; thus, prophylactic and elective tracheostomy should be considered.

OK-432 sclerotherapy of lymphatic malformation in the head and neck: factors related to outcome

BACKGROUND

No previous study to the best of our knowledge has examined the multiple factors related to the outcome of OK-432 sclerotherapy of lymphatic malformations.

OBJECTIVE

This study aimed to assess factors related to the successful outcome of OK-432 sclerotherapy for lymphatic malformations in the head and neck region.

MATERIALS AND METHODS

During a 6-year period, OK-432 sclerotherapy was performed in 26 patients with lymphatic malformations. Several factors related to the efficacy of OK-432 sclerotherapy were evaluated, including the type (macrocystic or microcystic), the maximum lesion diameter, amount and hemorrhagic cytology of the aspirate, degree of aspiration, injected dose of OK-432 and post-therapy inflammation-related symptom. In all cases, ultrasound (US) follow-up was performed.

RESULTS

Of the 26 cases, 13 (50%) showed successful elimination of the lymphatic malformations in the follow-up US after the initial session, and all successful cases were of the macrocystic type. The type of lymphatic malformation and the success of OK-432 sclerotherapy were significantly related (P = 0.0149). Of the 16 cases of complete aspiration, 11 (68.8%) showed a successful outcome. Further, of the 17 cases with inflammation-related symptom, 13 (76.5%) showed a successful outcome. While the degree of aspiration and presence of inflammation-related symptom showed a significant relationship with the success of OK-432 sclerotherapy (P < 0.05), no other factors showed a significant relationship.

CONCLUSION

The study results suggest that the macrocystic type and complete aspiration of cystic contents were important factors for the success of OK-432 sclerotherapy of lymphatic malformations, and that inflammation-related symptom was a predictor of a successful outcome.

Picibanil (OK-432) in the treatment of head and neck lymphangiomas in children

BACKGROUND

Picibanil (OK-432) is a lyophilized mixture of group A Streptococcus pyogenes with antineoplastic activity. Because of its capacity to produce a selective fibrosis of lymphangiomas (LMs), it has been approved by Japanese administration in 1995 for the treatment of LMs.

MATERIALS AND METHODS

We treated 15 children (age range: 6-60 months) affected by head and neck macrocystic LMs with intracystic injections (single dose of 0.2 mL) of Picibanil (1-3 injections).

RESULTS

Complete disappearance of the lesion was noticed in eight (53.33%) cases, a marked (>50%) reduction of LMs was found five (33.33%) cases, while a moderate (<50%) response was recorded in two (13.33%) cases. Picibanil side effects included fever, local inflammation, and transitory increase of blood platelets' concentration; a single case of anemia was resolved with concentrated red blood cells transfusion.

CONCLUSIONS

Intracystic injection of Picibanil is an effective and safe treatment for macrocystic LMs in pediatric patients and may represent the treatment of choice in such cases, especially where surgical excision is associated with the risk of functional/cosmetic side effects.

Surgical management of intra-abdominal cystic lymphangioma. Report of 20 cases

BACKGROUND

Cystic lymphangioma (CL) is a benign rare malformation of lymphatic vessels. Its discovery in adults is rare. Although it can affect any organ, the common forms found in adults are mesenteric and/or retroperitoneal CL. This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma in adults.

METHODS

We report a retrospective study from January 1998 to September 2010 concerning 20 patients who underwent surgical removal of a CL. We were interested in discovering the clinical, biological, and radiological characteristics of CL. The localization, size, and number of cysts have been reported, as well as the surgical intervention used and the postoperative immediate and late complications.

RESULTS

The median age was 46 years. Abdominal pain was the main symptom and was found in 15 patients (75%). Physical examination revealed an abdominal mass in 12 patients (60%). In four patients (20%), the cystic lymphangioma was incidental. Abdominal ultrasound and abdominal CT scan helped to highlight 22 cystic masses. CL diagnosis was established preoperatively in 13 patients (65%). Six patients (30%) were operated with a diagnosis other than CL. The diagnosis was made intraoperatively in one case (5%). Only two patients (10%) were operated on in emergency: one due to an infected CL and the other was CL complicated with intracystic hemorrhage. A laparotomy in 13 cases (65%) was the surgical approach used, whereas 7 cases (35%) benefited from a laparoscopy. No conversion was noted. The majority of the patients, 18 cases (90%), received a total cystectomy. Only two patients (10%) had recurrences of which only one was reoperated.

CONCLUSIONS

The diagnosis of CL often is facilitated by means of modern imaging; however, other diagnoses may be discussed, particularly hydatid disease endemic areas. If symptomatic lesions or complications arise, complete surgical excision, when possible without major sacrifice, seems to be the best therapeutic option to reduce the risk of recurrence.

[Lymphatic malformations in the head and neck: experiences with sclerotherapy]

BACKGROUND

Lymphatic malformations are rare tumors of the head and neck region. Complete resection is the mainstay of treatment in these cases. Surgery of lymphatic malformations is accompanied by various complications because of the adjacency to neurovascular structures and the infiltrative nature of these masses.

PATIENTS AND METHODS

Between March 2008 and April 2010 three patients with lymphatic malformations of the head and neck region were treated by sclerotherapy with OK-432 (Picibanil). Two young children and a male adult with a late relapse were enrolled. The children were treated under general anesthesia.

RESULTS

A complete remission of lymphangiomas of the external nose as well of the lateral neck could be observed after a single sclerotherapy with OK-432. No response was seen after multiple injections of OK-432 into the orbital lymphangioma and treatment was finally successful after resection.

CONCLUSIONS

Today sclerotherapy has to be considered in the planning of the treatment of lymphatic malformations. Intralesional treatment of lymphangiomas in the head and neck with OK-432 shows good clinical response. Sclerotherapy with OK-432 is safe, effective and associated with few side-effects. After sclerotherapy a surgical resection can be carried out without any problems.

[Severe iatrogenic airway obstruction due to lingual lymphangioma]

Lymphangioma of the tongue is a rare and benign tumour involving congenital and cystic abnormalities derived from lymphatic vessels. Treatment modalities include surgery and a large number of different intralesional injections of sclerosing agents. Presently, OK-432 (Picibanil(®)) is the preferred sclerosant and when administered intralesionally will result in inflammation, sclerosis, and cicatricial contraction of the lesion. We report a case of microcystic lymphangioma of the tongue in a 5-year-old boy treated with an intralesional injection of OK-432. In the immediate postoperative period, the patient suffered severe diffuse swelling, progressive upper airway obstruction with inspiratory stridor, and respiratory distress requiring emergency fiberoptic nasotracheal intubation. Although OK-432 injections are found to be safe and effective as a first line of treatment for lymphangiomas, local swelling with potentially life-threatening airway compromise should be anticipated, especially when treating lesions near the upper airway.

Treatment of lymphatic malformations of head and neck with OK-432 sclerotherapy induce systemic inflammatory response

Systemic immune responses after OK-432 (Picibanil) sclerotherapy in patients with head and neck lymphatic malformations (LM) were examined to achieve a better understanding of the mechanism of OK-432 sclerotherapy and to evaluate the long-term treatment outcome. Serum samples from 17 consecutive patients with head and neck LMs were collected during a total of 26 OK-432 treatment episodes. Serum C-reactive protein (CRP), interleukins (IL) 1β, 6, 8, 10, tumor necrosis factor (TNF)-α, interferon (IFN)-γ, RANTES, immune protein (IP)-10 and macrophage chemoattractant protein (MCP)-1 as well as blood leukocyte counts were determined. Clinical outcome of the treatment was evaluated at the last visit and from patient files. Elevated serum levels of IP-10 (means at baseline 702 ng/L, after 1 day 1180 ng/L, after 4 weeks 691 ng/L) were seen on day one after OK-432 sclerotherapy (p < 0.05). C-reactive protein and leukocyte counts 1 day after treatment differed statistically significantly (p < 0.05) from the baseline. No significant differences with other cytokines investigated were observed. Patients with macrocystic LM responded better than patients with microcystic LM (p = 0.01). The elevated levels of IP-10, C-reactive protein and leukocyte levels indicate that OK-432 sclerotherapy induces systemic immune responses in patients with LM. The mechanisms of OK-432 sclerotherapy are still not precisely understood, but the IP-10 elevation may reflect local antiangiogenetic properties of immunoactivation induced by OK-432.

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.

Giant lymphangioma of the tongue

This report presents the treatment of an extensive lymphatic malformation of the tongue. Sclerosing agents are now widely used as the first-line treatment of lymphatic malformation. However, treatment of lymphatic malformation involving the face and the vital structures such as the airway remains to be challenging. A 4-year-old boy underwent a total of 15 OK-432 injection sclerotherapy treatments over a 2-year period, having slow progress until sudden enlargement of the tongue was noted shortly after the last injection. Partial excision of the lesion was performed. This case demonstrates the risk in treating large microcystic lymphatic malformation of the tongue with sclerotherapy and provides an insight in the management protocol.

OK-432 Therapy for Cervical Lymphangioma

OBJECTIVE

To describe our experience with sclerosing treatment of lymphangiomas in the head and neck region by intralesional injections of OK-432.

STUDY DESIGN

Case series.

METHODS

Patients with the diagnosis of a macrocystic-type cervical lymphangioma were treated by one to three intralesional injections of OK-432 (0.01 mg of OK-432/1 mL of lymphangioma fluid, up to a maximum of 0.2 mg in the first injection and 0.3 mg in the second or third injections). All injections were performed under ultrasound guidance. Children were injected under sedation.

RESULTS

Eleven patients were treated with injections of OK-432: 7 children and 4 adults. They were followed up for a period of 5 to 68 (mean 30) months. Eight (73%) patients had complete or subcomplete resolution of the lymphangioma after one or two injections. In three (27%) cases, no response was obtained (2 cases) or the lymphangioma recurred (1 case) after two to three injections. In two cases, surgical excision was performed. There was no evidence of fibrosis around the cysts. There were no complications to OK-432 injections.

CONCLUSION

Intralesional injection of OK-432 is an effective treatment modality for macrocystic-type lymphangiomas in the head and neck region. It has no complications, and surgical excision in case of failure is not compromised by fibrosis. Sclerosing of macrocystic-type lymphangiomas with OK-432 should therefore be considered before surgical excision.

Update on hemangiomas and vascular malformations of the head and neck

Although the current classification systems of vascular malformations and hemangiomas are increasingly accepted, there are nonetheless several aspects that show us how special and at the same time difficult it is to diagnose, evaluate, and treat some of those diseases. Close interdisciplinary cooperation of all involved disciplines is essential; the discussion of the adequate individual procedure must be performed in angioma boards, as it is already well established in the context of tumor boards. The interface of angioma therapy and tumor therapy seems to be very close, which is certainly true for the aspect of angiogenesis and of course for the inhibited proliferation as promising therapeutic approach of complex vascular malformations. This leads to another obvious necessity of intensifying experimental scientific research on vascular malformations and hemangiomas, which is a precondition for optimizing or elimination of different current problems and deficits in the mentioned field.

Intensive care experience with sclerotherapy for cervicofacial lymphatic malformations

OBJECTIVE

To describe a cohort of patients needing intensive care support after sclerotherapy for cervicofacial lymphatic malformations.

DESIGN

Retrospective review of case records of patients undergoing sclerotherapy between January 2004 and November 2006.

SETTING

A tertiary, university-affiliated, pediatric teaching hospital.

PATIENTS

Five patients needing admission to a pediatric intensive care unit (PICU) following sclerotherapy with OK432.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Five patients needed a total of 13 PICU admissions. Ages ranged from 4 months to 19 months. All patients had extensive lesions that involved the airways, mediastinum, or floor of the mouth, documented by magnetic resonance imaging. Nine admissions involved elective intubation and ventilation following sclerotherapy due to the extent of lesions. There were four urgent admissions to the PICU with respiratory distress ranging from 3 to 18 days after sclerotherapy. The mean duration of admission was 7 days (total 93 days, range 2-22 days). Total ventilated hours were 1656 hrs with a range of 16.5-370 hrs per admission. Multiple procedures, such as drainage of cysts and further sclerotherapy procedures, were performed before extubation on the PICU.

CONCLUSIONS

Children with extensive disease and airway involvement need multiple PICU admissions. The potential for life-threatening respiratory embarrassment is unpredictable following sclerotherapy. Consideration should be given to performing further sclerotherapy while the patients are intubated in the PICU. The PICU provides a safe and secure environment for such procedures.

[Sclerotherapy for cystic lesions of the head and neck region]

Cystic lesions are frequently occurring diseases of the head and neck region. Complete surgical resection near to neurovascular structures can be accompanied by various complications. In selected cases intralesional injection of OK-432 could constitute an alternative. The average success rate of sclerotherapy of lymphatic malformations is 60%. Side effects are rare. Sclerotherapy is a minimally invasive, simple and cost-effective procedure performed without general anaesthesia at the outpatient clinic. Nerve lesions or troublesome scarring do not occur. In residual cases surgical excision is realisable without any difficulty. Repeated injections of sclerotherapy agents represent a disadvantage. Abscess formation has been observed as a rare complication. A malignant disease has to be excluded by cytological examination before commencing sclerotherapy. The intracystic injection of OK-432 is an effective treatment modality for cystic cervical lesions.

Unilateral lower limb swelling secondary to cavernous lymphangioma

INTRODUCTION

We report an unusual case of unilateral leg swelling secondary to cavernous lymphangioma (cystic hygroma), which normally affects the head and neck regions.

CASE REPORT

A 25 year gentleman presented to our department with a 13-year history of gradually increasing unilateral leg swelling and recurrent infections. Investigations showed appearances consistent with cavernous lymphangioma, and partial excision of the lesion led to resolution of symptoms.

DISCUSSION

The most common sites for cystic hygroma are the head and neck areas, but the extremities can be affected as demonstrated. Complete surgical excision is often difficult, and there is a tendency for recurrence. This case acts as an illustration of an uncommon yet important cause for unilateral leg swelling.

New Treatment of Early Fetal Chylothorax

OBJECTIVE

To evaluate OK-432, a preparation of Streptococcus pyogenes, in the treatment of early fetal chylothorax.

METHODS

A prospective study of all fetuses (n=7) with persistent early chylothorax (gestational ages 16-21 weeks) referred to the tertiary center of fetal medicine in Denmark in 2003-2005. Fetuses were injected with 0.2-1.0 mg of OK-432 into the pleural cavity. The treatment was repeated if there were persistent or increasing pleural effusions after 1-3 weeks. The main outcome measures included remission of pleural effusions and fetal and infant morbidity and mortality.

RESULTS

Total remission of pleural effusions was obtained in all fetuses after one or two intrapleural injections of OK-432. No adverse effects of the treatment were observed. No fetus developed hydrops, and all experienced an uncomplicated third trimester. All children were born healthy without pleural effusions, lung hypoplasia, or hydrops.

CONCLUSION

Persistent early chylothorax is a condition with a high mortality rate and no established treatment option. Use of OK-432 is a promising therapy for selected fetuses with persistent chylothorax early in the second trimester.

Intralesional injection of OK-432 for vision-threatening orbital lymphangioma

BACKGROUND

Surgical excision of orbital lymphangiomas is difficult, and almost always incomplete due to the diffusely infiltrative pattern of these tumors. The present report describes the successful use of intralesional OK-432 administration to treat two patients with intractable hemorrhagic proptosis due to orbital lymphangiomas.

METHODS

A 3-year-old girl (case 1) presented with aggressive proptosis and ptosis, and a 1-year-old boy (case 2) presented with massive proptosis and exposure keratopathy, associated with recurrent intracystic bleeding of an orbital lymphangioma. In case 1, 0.02 mg OK-432 was intracystically injected in a volume of 2 ml of physiologic saline. Due to a lack of therapeutic response, a second injection of 0.05 mg OK-432 in 1 ml was administered. In case 2, a single dose of 0.05 mg OK-432 in 1 ml was administered.

RESULTS

In both cases, intracystic administration of 0.05 mg of OK-432 in a 1-ml volume resulted in a successful outcome. The adverse effects were minor (mild transient fever and lid swelling), and rebleeding and intraocular pressure elevation did not occur. Proptosis and eyelid swelling gradually improved over 1 month, and completely resolved within 3 months of treatment.

CONCLUSIONS

Intralesional administration of 0.05 mg/ml OK-432 (delivered in 1 ml) resulted in the successful treatment of two cases of orbital lymphangioma. Although this drug concentration is higher than in previous reports, there were no major adverse effects.

Treatment of lymphangioma in children: our experience of 128 cases

PURPOSE

The aim of this study is to investigate the optimal treatment for lymphangioma in children by analyzing the effectiveness and complications of treatment modalities.

METHODS

We reviewed 128 patients with lymphangioma treated at our institution between 1979 and 2005. Periods of treatment were divided arbitrarily into 2 groups: period I, from 1979 to 1988 (n = 53); and period II, from 1989 to 2005 (n = 75). According to radiological appearance, patients were grouped into 4 types: single cystic (SI; n = 23), macrocystic (MA; n = 11), microcystic (MI; n = 69), and cavernous (CA; n = 25).

RESULTS

Sclerotherapy as primary treatment was performed in only 2 patients (3.8%) in period I using bleomycin but increased significantly in period II to 48 patients (64.0%) using OK-432 (P < .01). Nevertheless, primary surgical excision (69/78 patients, 88.5%) was significantly more successful than sclerotherapy (32/50, 64.0%) (P < .01). The following are the locations and types of lesions: head/neck (n = 69; SI, 11; MA, 5; MI, 42; CA, 11), trunk (n = 34; SI, 6; MA, 6; MI, 15; CA, 7), and extremities/other (n = 25; SI, 6; MI, 12; CA, 7). The effectiveness of sclerotherapy in SI, MA, MI, and CA types was 90.9%, 100%, 68.0%, and 10.0%, respectively. Seventeen patients (SI, 1; MI, 8; CA, 8) who received primary sclerotherapy required surgical excision with good outcome. Complications after primary surgical excision were more serious compared with sclerotherapy.

CONCLUSION

Sclerotherapy with OK-432 was not as effective as reported in the literature. We recommend OK-432 injection therapy alone for SI and MA types and surgical excision after pretreatment with OK-432 for MI and CA types.

Sclerotherapy of cervical cysts with Picibanil (OK-432)

The effectiveness of intralesional sclerotherapy of lymphangiomas and ranulas with OK-432 (Picibanil) has been proved in several clinical studies. The aim of our study was to review the effectiveness of sclerotherapy of benign cervical cysts with Picibanil as an alternative method to surgical excision. Between March 2002 and March 2006, a prospective observational study was carried out to assess the effects of Picibanil on cervical cysts. Between 2002 and 2006 we treated 14 patients having cervical cysts through intralesional application of Picibanil with a dose of 0.01 mg/ml. So far we used Picibanil with 13 patients achieving a high success rate. In eight cases we observed, both clinically and ultrasonographically, a nearly complete regression, and a complete regression of the cysts in three cases. In two cases the cysts atrophied. In these cases only residual findings could be observed. In one case we extirpated the remaining cyst. If there is no clear reaction of the cyst to the treatment, an excision is indicated 6 weeks after the injections to gain meaningful histological examination. No significant complication after sclerotherapy with Picibanil was observed. According to our results the application of OK-432 (Picibanil) is a safe and effective primary method for sclerotherapy of benign cervical cysts which can replace surgical extirpation in special cases. However, the risk of malign diseases has to be excluded before the commencement of the Picibanil treatment.

Treatment of Cystic Lymphatic Vascular Malformations with OK-432 Sclerotherapy

BACKGROUND

Cystic lymphatic vascular malformations are benign lesions that can cause disfigurement and functional impairment. Complete surgical resection is often difficult, and clinical recurrence is common. Sclerotherapy has been used as an alternative to excision. OK-432 is a lyophilized mixture of Streptococcus pyogenes and benzylpenicillin which, when injected into a lesion, has shown significant ability to reduce its size or obliterate it completely.

METHODS

The authors report a series of 12 patients treated in this fashion at the Vascular Anomalies Clinic, British Columbia Children's Hospital, between 1999 and 2004. All patients underwent imaging of the lesion: 10 had magnetic resonance imaging, one had a computed tomographic scan, and one had ultrasound examination. Six patients had macrocystic malformations (cysts > or = 2 cm) and six had microcystic or combined lymphaticovenous malformations. Patients were treated with intralesional injection of OK-432. The position of the injection was confirmed by angiography and/or ultrasound in 10 cases. Response to treatment was assessed clinically.

RESULTS

All patients with macrocystic malformations had complete resolution or good response to treatment. None required any additional treatment. In contrast, those with microcystic or combined malformations responded poorly. All of these patients underwent subsequent excision without adverse consequences. The size and location of the lesion did not correlate with response to treatment. Seventy-five percent of patients experienced pyrexia. Local swelling is an expected phenomenon and must be anticipated, particularly for lesions near the airway.

CONCLUSIONS

OK-432 is an excellent treatment for patients with macrocystic lymphatic malformations. However, it is ineffective for microcystic lesions.

Alcoholic solution of zein (Ethibloc) sclerotherapy for treatment of lymphangiomas in children

PURPOSE

The aim of this study was to report the experience and efficacy of Ethibloc sclerotherapy as treatment of lymphangiomas.

METHODS

Between 1992 and 2004, 63 patients had Ethibloc sclerotherapy for lymphangiomas at our institution. Computed tomographic scan or magnetic resonance imaging and clinical evaluation determined efficacy of the treatment. Results were classified as excellent (> or =95% decrease in lesion volume), satisfactory (> or =50% decrease and asymptomatic), or poor (<50% decrease or symptomatic).

RESULTS

Sixty-three patients with 67 lesions underwent sclerotherapy with a median of 2 treatments per patient. Thirty-five involved the neck; 10, the head and face; and 22, the thorax or limb. Thirteen were predominantly microcystic; 28, macrocystic; and 26, mixed. Of the 63 patients, 6 underwent sclerotherapy for postsurgical residual lesions. Results were classified by type: of the 54 macrocystic/mixed cases, 26 (49%) had excellent, 19 (35%) had good, and 9 (16%) had poor results; in the 13 predominantly microcystic lesions, 3 (23%) had excellent, 7 (54%) had good, and 3 (23%) poor results. Five patients (7.7%) required surgery for complications; 2, for scar revision; 2, for persistent drainage; and 1, for a salivary fistula. Infection occurred in 4 patients (6.2%) after sclerotherapy. Follow-up averaged 3.5 years (range, 12 months to 12 years).

CONCLUSION

Ethibloc sclerotherapy is a safe and effective alternative to surgical excision of macrocystic lymphangiomas and can be used for postsurgical recurrences.

Further experience with OK-432 for lymphangiomas

This study includes all the children treated with OK-432 for lymphangioma at our institute. Twenty-nine children treated between 1999 and 2003 are reported for the first time: twelve cases regressed completely, eight cases regressed more than 50% and seven remained unchanged; two cases were lost at follow-up. The outcome was related to the size of the cysts, the larger ones having a better prognosis. The adverse reactions are discussed and the methods of treatment are described in detail. Fifteen children, treated before 1999 and already reported, are reviewed after a long-term follow-up. Four had a recurrence: one regressed spontaneously and three needed further treatment. The other 11 had no complaints. Even considering the risk of recurrence, OK-432 therapy remains our first line therapy for lymphangiomas, avoiding surgery in most cases.

Cutaneous Vascular Lesions

Vascular anomalies are lesions seen in all surgical disciplines, particularly in pediatric patients. Specialization in vascular anomalies involves a team effort, with the team consisting of plastic surgeons, general surgeons, neurosurgeons, pediatricians, interventional radiologists, dermatologists, ophthalmologists, otolaryngologists, hematologists, and pathologists. Inconsistent nomenclature in the literature has historically resulted in confusion about classification, diagnosis, and treatment. A biologic classification system has emerged, based on clinical observations, natural history, and cellular features, which separates vascular anomalies into two broad categories: vascular tumors and vascular malformations. For many vascular anomalies, photodocumentation, psychosocial support, and communication are important throughout the treatment course.

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.

OK-432 and lymphatic malformations in children: the Starship Children's Hospital experience

BACKGROUND

Surgery has previously been the mainstay of treatment for lymphatic malformations but has attendant problems of marked scarring, high chance of recurrence and potential nerve damage. Alternative management for these lesions involves the intralesional injection of OK-432. The present paper reviews OK-432 use in lymphatic malformations in children.

METHODS

A retrospective chart review was carried out of children undergoing intralesional OK-432 therapy from the Departments of Paediatric Surgery, Paediatric Otolaryngology and Plastic Surgery at Starship Children's Hospital, Auckland.

RESULTS

Over the past 4 years, seven children under the age of 5 years underwent OK-432 therapy as day-case procedures requiring between one and seven procedures each. Four children had lesions involving the axilla/chest wall, two involved extra-mylohyoid tissues in the neck and one child had lymphatic malformation involving tongue, floor of mouth and an extra-mylohyoid component. Spontaneous haemorrhage into a cystic space may be the cause of the observed partial resolution of the lymphangiomas in two. A predictor of a successful outcome was the ability to aspirate fluid prior to injection. Ultrasound guidance was useful to localize the lesions for aspiration and injection. Macrocystic lesions respond well to OK-432 therapy but the response of microcystic or cavernous lesions to OK-432 is disappointing and surgery remains the definitive treatment for these microcystic lesions.

CONCLUSION

OK-432 appears to be a safe and effective treatment for the macrocystic component of lymphatic malformations.

Management of lymphatic malformations

PURPOSE OF REVIEW

Innovative otolaryngologists, plastic surgeons, craniofacial surgeons, pediatric surgeons, radiologists, anesthesiologists, neonatologists, obstetricians, and scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of lymphatic malformations. This article reviews the publications over the past 2 years with respect to these advances.

RECENT FINDINGS

Fast-sequence MRI limits motion artifacts and allows prenatal MR to be used as a complementary study to ultrasound in the evaluation of large congenital neck masses. Three-dimensional ultrasonography may also be helpful in evaluating prenatal lymphatic malformations. Fluorescence in situ hybridization techniques can be used to evaluate lymphatic malformations for prenatal chromosomal analysis with emphasis on chromosomes 13, 18, 21, X, and Y. The sclerosing agent OK-432 is effective for macrocystic lymphatic malformations but showed less promise for microcystic lesions, mixed lesions, and lesions outside the head and neck region. Somnoplasty shows promise for reduction of tongue lymphatic malformations. Surgical excision, staged when necessary, continues to be integral to management in many cases.

SUMMARY

Basic science research has furthered understanding of lymphatic malformations. Clinical research has expanded and refined our diagnostic and therapeutic options for patients with these lesions. Further identification of genes selectively expressed by lymphatic endothelium should facilitate identification of usable vascular markers that can enable analysis of the underlying biology, physiology, pathology, and treatment of the lymphatic system and its malformations.

[Increasing abdominal pain caused by abdominal tumor in a 21-year-old female]

Lymphangiomas are congenital malformations which occur mostly in the neck and head region of children. They are rarely located in the mesenterium or retroperitoneum in adults. We present a case of mesenteric cystic lymphangioma in a young woman who was admitted to hospital with a history of increasing abdominal pain. We discuss diagnostic means, differential diagnosis, and therapeutic management of the disease.

Use of the deep inferior epigastric perforator flap in a 15-month-old boy after resection of lymphatic malformation

Lymphatic malformations are benign tumors that arise from congenital defects of the lymphatic system. Despite the fact that all lymphatic malformations develop embryologically, their presence may not be detected until the tumor enlarges from hemorrhage or infection. Typical of these tumors is a slow-growing, asymptomatic phase with the potential for rapid and massive expansion and a tendency to infiltrate into surrounding tissues. These tumors are associated with a high rate of recurrence, especially with incomplete excisions. To minimize the chance of recurrence, a complete resection of a groin microcystic lymphatic malformation was performed on this 15-month-old boy, creating a significant defect in the upper thigh. Immediate coverage was felt to be the best option for reducing any associated morbidity. We used a skin-soft tissue flap supplied by perforators of the deep inferior epigastric artery to repair the wound. Using this technique, the musculofascial structures in the abdominal wall were completely spared, and the skin and fat were transferred on a vascular leash to the desired location. The donor site was closed by approximating the fascial edges without tension. The defect on the thigh was filled with tissue of similar thickness and characteristics, avoiding potential contour irregularities and color mismatch. The deep inferior epigastric perforator (DIEP) flap is a useful option for groin defects and can be applied safely in the pediatric population.

[Sclerotherapy with OK-432 for cystic tumors in the neck region]

BACKGROUND

The intralesional injection of OK-432 has been proposed as an effective treatment of lymphangiomas and ranulas. The aim of this study was to review our experience with sclerotherapy of benign cervical cysts as an alternative method to surgical extirpation.

PATIENTS AND METHODS

We performed a case note review of six patients who received OK-432 injections in a concentration of 0.01 mg/ml between March 2002 and December 2003.

RESULTS

Disappearance of the lesions was achieved after one to three injections in all patients. We found a complete remission in two of six patients and a marked reduction in four of six patients. There were no significant complications observed.

CONCLUSION

OK-432 is an effective alternative in the treatment of benign cervical cysts, but it is very important to exclude malignancy-associated diseases before instillation of OK-432. Long-term results will be awaited.

Percutaneous Sclerotherapy of Lymphangiomas with Acetic Acid

PURPOSE

To evaluate the efficacy of percutaneous image-guided sclerotherapy of lymphangiomas with use of acetic acid.

MATERIALS AND METHODS

Twelve patients with lymphangiomas were treated with acetic acid as the sclerosant. There were eight male patients and four female patients, ranging in age from 1 to 29 years (mean, 11 years). The lymphangiomas were located at the neck (n = 5), upper extremity (n = 3), axilla (n = 1), cervicomediastinum (n = 1), anterior chest wall (n = 1), and retroperitoneum (n = 1). Two patients had recurrent lymphangiomas after surgery and two patients had undergone failed sclerotherapy with another sclerosant. The acetic acid used as the sclerosant was 40%-50% in concentration, and the amounts used ranged from 2 mL to 70 mL (mean, 11.3 mL), which was equivalent to 4.6%-50% (mean, 30.6%) of the aspirated lymphatics. All procedures were performed under ultrasonographic and fluoroscopic guidance. The sclerosant was removed after sclerotherapy. All patients except one underwent one treatment session.

RESULTS

Complete resolution of the lymphangioma was achieved in eight patients (66.7%), good resolution (>50% reduction) was achieved in three (25.0%), and poor resolution (<50% reduction) was seen in one (8.3%). Complications encountered included pneumonitis adjacent to the lymphangioma (n = 1), pain (n = 2), hematuria (n = 1), and tingling sensation in the forearm (n = 1).

CONCLUSION

Percutaneous sclerotherapy of the lymphangiomas with use of acetic acid is an effective method without serious complications.