Vivcharuk and Pashchenko: Therapeutic Strategy in Case of Hemangiomas in Children



Problem statement and analysis of the recent research

Most vascular anomalies involve the skin, namely the largest and most visible organ of the body requiring a very balanced approach to the treatment to achieve maximum cosmetic effect.

Hemangiomas are the most common tumors in infancy constituting 1 – 2.6 % of incidence. Their incidence in preterm newborns with low birth weight (less than 1000 g) can reach 30 %. Increase in the incidence is observed during the first year of life. A female to male ratio of 3: 1 to 5: 1 has been observed [1, 2, 3].

Hemangiomas are divided into infantile and congenital. Infantile hemangiomas appear after birth.

Congenital hemangiomas are defined as tumors present at birth. They occur in two forms:

  • rapidly involuting congenital hemangiomas (RICH) which begin to regress during early infancy and are fully involuted by the age of 12 – 14 months;

  • non-ivoluting congenital hemangiomas (NICH) which are characterized by proportional growth and never undergo regression. These tumors may be distinguished from the more common infantile hemangiomas by a variety of molecular and histopathologic markers (non-evoluting hemangiomas are not positive to the GLUT-1) [3, 4].

Hemangiomas exhibit unique biological cycle: they grow rapidly during 6 – 12 months of life (the proliferative phase). At the second stage, hemangiomas growth is proportional to the growth of the child, and finally enters a phase of slow regression (involuting phase) lasting 1-7 years, during which the endothelial matrix of hemangiomas is ​​replaced by loose fibrous or fibro-fatty tissue. Complete regression occurs by the age of 5 in half of the children, by the age of 7 in 70 %, and by the age of 10-12 in other children [3, 4].

During the involutive phase, almost normal skin remains in approximately 50% of children. In other cases the involved skin is damaged with telangiectasias, becomes thinned, loose, yellowish or scarred requiring cosmetic intervention. At the same time the child has psychosomatic disorders caused by the increased attention of others (especially children) to their outlook.

Regressing hemangiomas undergo careful observation. Hemangiomas with a high risk of complications (destructive growth, cosmetic defects, ulceration, amblyopia, compression of vital structures) require treatment. Pharmacological treatment includes angiogenesis inhibitors: corticosteroids, interferon, vincristine, propranolol. However, vincristine and interferon administration has significantly decreased from the beginning of propranolol introduction into clinical practice. Its advantages involve less significant side effects. In case of non-regressing hemangiomas, systemic treatment stabilizes the growth in the phase of proliferation without affecting the final regression of the neoplasm. The final cosmetic effect is usually achieved by surgical correction [1, 3].

Local treatment is carry out by compression, injection of corticosteroids and sclerosing agents in the tumor tissue, thermal degradation and surgical removal. The use of laser exposure is impractical because of low penetrating power of the rays and the appearance of scarring on the irradiated surface.

Excision is indicated in the following cases:

  • if there is a significant cosmetic defect after a complete hemangioma involution (scars, fibro-adipose tissue, excess skin), and it is evident that excision will be required in the nearest time or later;

  • if postoperative scar will be small or easily concealed.

Treatment of hemangioma located on the nose, eyelids, lips require special knowledge and high competence and individual approach [2, 3, 4].

Extensive excision of the maxillofacial area hemangiomas is not always possible due to the risk of bleeding, facial nerve injury, and cosmetic defects. This problem can be solved by the modern surgery methods using tissue-preserving electrosurgical technology. The variety of clinical and morphological features, localization and prevalence of vascular lesions require continual search for the effective methods of treatment to determine the optimal terms and methods of therapy.

The objective of the research was to improve cosmetic and functional results of treatment for extensive, non-regressing hemangiomas of cosmetically significant anatomical localization by removal with high-frequency electrocautery via EK-300M1 combined with systemic therapy or without it.

Materials and methods

During the last three years 146 children with voluminous, non-regressing hemangiomas and hemangiomas with the changes as a result of previously conducted, incorrect therapy (13 children after laser exposure and sclerosing therapy with poor results) were treated at the Regional Children’s Clinical Hospital # 1.

127 were hospitalized at the age under 1 year, 11 children – under 3 years and 8 children over 3 years.

Hemangiomas were located on the head and neck in 56 % of cases, on the back, chest, abdomen, buttocks in 29 % of cases, on the limbs in12 % of cases, in the genital area in 3 % of cases. Multiple lesions were observed in 3 % of cases.

Prior to the treatment, each child underwent a comprehensive investigation, including clinical, laboratory, instrumental, functional examination, consultation of related specialists (ENT, ophthalmologist).

Ultrasonography of the internal organs, neurosonoscopy, electrocardiography, radiological methods of investigation (x-ray, computed tomography), morphological study of all removed tumors were performed.

Indications to different methods of treatment were based on the type, location, size and intensity of hemangioma growth.

Systemic therapy with propranolol was administered to 131 children, of which 67 children required additional surgical intervention. Hemangiomas excision and correction of residual changes (without systemic therapy) were performed in 19 children.

According to the histological study, 58% of excised hemangiomas were capillary, 42 % of them were capillary cavernous ones.

Results and Discussion

All children under the age of 12 months with an aggressive growth of large hemangiomas underwent primary systemic therapy with propranolol according to the scheme: 0.15 mg/kg/day with the dose increase up to 2 mg/kg/day. Positive result without side effects, typical for hormonal therapy, was observed. Complete therapeutic effect was achieved in 64 cases. Stabilization of growth was observed in 67 cases, but there was no hemangiomas regression requiring further application of surgical treatment methods. Response to therapy was not observed in 11 children. Therapy was stopped due to the manifestations of bronchospasm in 3 children. In the last case prednisolone therapy was administered.

Surgical treatment was performed in 86 children. Partial excision of hemangiomas was performed in 35 children.

The main criteria for excision were the possibility of full or partial removal of the tumor with good cosmetic effect. Interventions carried out using high-frequency electrocautery EK-300M1 in the “overlap” mode (AC voltage at the output frequency of 66 kHz, no modulation, the amplitude of the output voltage up to 100 V, the maximum output power 350 W). Working in this mode is the most effective in the conditions of high tissue moisture of occuring during bleeding typical for hemangiomas. It creates the conditions for bloodless removal of the tumor and allows it to differentiate the affected and healthy tissue, to remove the tumor in a single block, without the risk of implant growth.

Additional treatment, both systemic and local one, was not required in the majority of cases in the postoperative period. Hemangiomas regression was observed. The treatment was completed by sclerosing exposure in 4 cases and by continued propranolol in 10 cases.

No complications were observed.

The results of treatment were monitored for 6 months to 3 years. Complete recovery with a good esthetic effect was achieved in 96 % of children.

Conclusions

  • Treatment of voluminous and multiple hemangiomas in proliferative stage should be started with systemic therapy with β-adrenoblockers.

  • Systemic treatment with propranolol may be both as monotherapy and as a part of combined therapy for hemangiomas.

  • The presence of residual effects as well as secondary deformation after the physiological regression of hemangiomas or systemic therapy is an indication for surgical correction.

  • Application of tissue-preserving electrosurgical technology greatly enhances the capabilities of the treatment in children with voluminous hemangiomas in cosmetically important areas by improving the non-invasive effect, reducing blood loss and prevention of implantation growth.

  • Prospects for further research involve the development of clear criteria for conservative treatment effectiveness or the need to proceed to a surgical method for the treatment of hemangiomas in children.

References

1 

NA Dementieva. Improvement of the diagnosis and treatment of hemangiomas of the skin and mucous membranes in infants [thesis]. Kiev; 2014.

2 

GW, III Holcomb, JP Murphy, DJ Ostlie. Ashcraft’s Pedіatrіc Surgery. Philadelphia: ELSEVIER; 2014.

3 

P Puri, M Höllwarth, editors. Pediatric Surgery [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009. Vascular Anomalies; p. 659-673. doi:10.1007/978-3-540-69560-8

4 

M Wіllіam, M Schwartz, The 5-Mіnute Pedіatrіc Consult. 6th ed. Philadelphia:Lippincott Williams & Wilkins; 2012.



Copyright (c) 2017 V P Vivcharuk, Yu V Pashchenko

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