eMedicine Specialties > Pediatrics: Surgery > Vascular Surgery
Arterial Vascular Malformations Including Hemangiomas and Lymphangiomas
Updated: Aug 8, 2008
Introduction
Vascular malformations result from abnormal-sized vascular structures or an abnormal number of vascular structures. These malformations usually manifest as cutaneous birthmarks and have had a number of classifications, producing an array of confusing terms.
The evaluation and treatment of common vascular malformations, particularly hemangiomas and lymphangiomas, are discussed in this article. The widely accepted Mulliken and Glowacki classification system is used, and attempts are made to sort out the nomenclature that has been used over the years.1 The indications and value of the various interventions are also discussed.
When evaluating a patient with these types of malformations, one must also consider syndromes associated with vascular malformations, such as Klippel-Trenaunay-Weber syndrome and Sturge-Weber syndrome (see Klippel-Trenaunay-Weber Syndrome and Sturge-Weber Syndrome).2,3Other uncommon forms of vascular malformations have been reported. For example, PHACE syndrome (OMIM 606519) is a neurocutaneous syndrome that associates large, plaquelike, segmental hemangiomas of the face, with one or more of the following: posterior fossa brain malformations, arterial cerebrovascular anomalies, cardiovascular anomalies, eye anomalies, and ventral developmental defects, specifically sternal defects, and/or supraumbilical raphe. In a prospective, cohort study of 1,096 children with hemangiomas, 25 children met the criteria for PHACE, representing 20% of infants with segmental facial hemangiomas.4
History of the Procedure
Vascular tumors and malformations are rather unsightly lesions that often occur in children. Parents of these children often (understandably) pressure physicians to deliver definitive medical or surgical treatment. However, the acknowledgment of the natural involution of vascular tumors (hemangiomas) in the mid-twentieth century has changed the way these lesions are managed. In this article, the medical and surgical treatments of vascular tumors are discussed, and the way in which this involutional phase fits into the treatment plan is explained. However, less consensus surrounds the management of vascular malformations (lymphangiomas), especially in patients with diffuse disease.
In patients with vascular tumors, watchful waiting is now the accepted first step in the management of nonproblematic hemangiomas because 75% of these lesions involute, leaving a minimal residual scar. Medical treatment is the first-line approach to treating potentially destructive lesions and is discussed in detail below (see Treatment).
The technique and timing for surgical resection of hemangiomas has been a topic of contentious debate. Because, in most cases, these lesions involute without intervention, the surgeon must identify situations in which an excision procedure would produce a more cosmetically acceptable result than conservative treatment. In addition, the surgeon must choose a technique that leads to the best possible outcome. See Treatment for the recognized indications for surgery and a brief discussion on the various techniques. Note that, depending on the location of the lesion, surgical resection may be the initial treatment of choice.
In the past, capillary malformations were managed using various treatment modalities, including electrocautery and cryosurgery. However, these methods have fallen out of favor because of their poor efficacy and the degree of scarring that they cause. Today, most of these lesions are treated with an argon laser or a flashlamp-pumped pulsed dye laser (PDL).
Most surgeons agree that surgical excision of lymphangiomas is the treatment of choice in patients with localized disease. Studies have been performed to correlate the depth of the excision with the rate of recurrence (see Treatment). In addition, new medical treatments are being developed with encouraging results.
Management of diffuse lymphatic disease has historically been surgical, and, although techniques have improved over the years, treatment still involves multiple procedures with substantial morbidity.
Problem
Vascular tumors and malformations have often been described using a classification system based on morphologic characteristics. This practice has given rise to a countless number of names that are interchangeably used, often befuddling medical professionals. In 1982, Mulliken and Glowacki proposed a biologic classification of vascular tumors and malformations that has since gained wide acceptance.1 This system correlates histologic features with historical and physical findings to provide a simplified classification of vascular lesions. The system has been modified slightly over the years to incorporate new information.
Mulliken and Glowacki use the following criteria to separate vascular malformations into 2 broad categories:
- Vascular tumors are also known as hemangiomas. These tumors exhibit endothelial hyperplasia. Approximately 30% are visible at birth, and the remaining 70% appear in children aged 2-4 years. Postnatal growth is rapid, and involution is slow. In 1996, the International Society for the Study of Vascular Anomalies added the rapidly involuting congenital hemangioma, noninvoluting congenital hemangioma, Kaposiform hemangioendothelioma, tufted angioma, and pyogenic granuloma to the list of vascular tumors.
- Vascular malformations are subdivided into high-flow (arterial, arteriovenous) malformations and slow-flow (venous, capillary, lymphatic) malformations. They exhibit normal endothelial turnover. Approximately 90% are recognized at birth. They increase in size as the child grows.
Capillary and lymphatic malformations are the focus of this article and are used as models for vascular malformations.
The fading macular stain (ie, stork bite, salmon patch, nevus flammeus) is a common lesion that is often grouped with capillary malformations because of their similar appearance. The terms used to describe fading macular stains have often been used interchangeably with port-wine stain. This usage is incorrect because they are not permanent anomalies and, hence, not true vascular malformations. Fading macular stains are discussed only briefly because they should be included in the differential diagnosis of port-wine stains.
Frequency
Vascular tumors (ie, hemangiomas) are the most common tumors in infants. They are apparent in 1-2.6% of neonates at birth across all races, according to one series.5
Approximately 30% of hemangiomas are recognized in the newborn nursery. Prevalence is increased in preterm infants that weigh less than 1000 g and in white children younger than 1 year. The male-to-female ratio is 3:1.6
Vascular malformations include capillary and lymphatic malformations. Capillary malformations (ie, port-wine stains) occur in 3 per 1000 neonates.7 They are the most common type of vascular malformations. The lesions are present in neonates and darken during adolescence and middle age. The sex distribution is equal.
The incidence rate of lymphatic malformations is 1.2-2.8 per 1000 live births.8 Approximately 50% of lymphatic malformations are apparent at birth; 90% appear before age 2 years. Most reports indicate an equal male-to-female distribution.
Etiology
Vascular tumors (hemangiomas) are believed to result from developmental errors that occur at 4-10 weeks’ gestation. Most cases are sporadic; however, they are occasionally inherited in an autosomal dominant fashion with moderate-to-high rates of penetrance.9 See Pathophysiology for more details on the nature of these lesions.
Capillary malformations are generally considered to be sporadic lesions; however, pedigrees of autosomal dominant inheritance have been reported. Port-wine stains are also associated with Klippel-Trenaunay-Weber and Sturge-Weber syndromes. Mutations in the RASA1 gene may underlie the capillary malformation–arteriovenous malformation syndrome. A novel mutation in RASA1 has been reported to cause capillary malformation and limb enlargement.10 An extensive degree of phenotypic heterogeneity may be associated with deleterious mutations in RASA1.
The exact cause of lymphangioma formation is unknown, but most cases are believed to be sporadic. The formation of lymphangiomas possibly reflects a failure of lymph ducts to connect with the venous system during embryogenesis, abnormal sequestration of lymphatic structures, or both. Ongoing research has elucidated some of the vascular growth factors that may be involved in formation of lymphatic malformations such as VEGF-C and flt-4. Cases secondary to trauma and infection have also been reported.
Pathophysiology
Hemangiomas are the result of abnormal changes in angiogenesis that allow the overproliferation of vascular entities. Several authors have elucidated the complex interplay of angiogenic and angiostatic forces involved in normal and pathologic processes.11 However, fetal vascular development remains poorly understood. Many of the angiogenic markers (ie, FGF, VEGF, E-selectin, type IV collagenase) are increased during the proliferative phase.12 During the involutional phase of hemangiomas, a subsequent decrease in angiogenic factors occurs, with a 5-fold increase in endothelial cell apoptosis.13 These alterations in angiogenic factors may account for the increased vascular proliferation that occurs in hemangiomas.Microscopic hemangioma tissue reveals proliferating endothelial cells. During involution, endothelial cells flatten, the vessel lumens dilate, and fibrous tissue is deposited. Recent studies have also discovered hemangioma-specific antigens not found in normal skin. These include GLUT1, merosin, and Lewis Y antigen.
Capillary malformations (port-wine stains) are groups of tortuous blood vessels located in the upper layers of the dermis. One study revealed that these lesions have decreased innervation in perivascular regions, which generates the hypothesis that the lesions are secondary to impaired vascular tone.14
Lymphangiomas are collections of lymph vessels filled with serous fluid. Their histology ranges from capillary-sized vessels to macroscopic fluid–filled vessels. Lymphatic malformations can be associated with gross anatomic deformities with severe involvement of the surrounding structures on the face or extremities. Research has begun to reveal some of the cell signals that may be involved in the formation of lymphangiomas. For example, VEGF-C has been found to be adequate in causing lymphatic hyperplasia.
Presentation
Hemangiomas are most commonly located on the head and neck (59%), followed by the trunk (24%), lower extremities (10%), and upper extremities (7%).15 Most are less than 2 cm in diameter but, in some instances, can cover large portions of the body. Typical presenting symptoms occur superficially, and the appearance can vary from a hypopigmented macule to a bruiselike macule.16 The course of these lesions includes a proliferative postnatal growth phase that lasts for 3-9 months, with a gradual involution that occurs over 2-6 years. Involution is usually complete by age 7-10 years. Only 50% of patients have completely normal-appearing skin at this time.
Recognizing atypical presentations and subclassifications of hemangiomas is critical for prognostic and treatment purposes. A congenital hemangioma is a lesion that is fully developed at birth. Deep hemangiomas have a blue discoloration because of their proliferation in the dermis and subcutaneous tissues. Multiple hemangiomas, often referred to as hemangiomatosis, appear as multiple smaller lesions. Pseudoclubbing may be the first sign of an underlying subungual hemangioma.17
When evaluating hemangiomas, a family history should be elicited. Although most are sporadic, infantile hemangiomas may be the result of an autosomal dominant trait. One study suggests that the formation of hemangiomas may be associated with mutational events that result in a loss of heterozygosity at a specific locus on chromosome 5.18 Mutations in genes responsible for regulation of vascular development, such as FGF-4, PDGF-b, and a tyrosine-kinase gene, have been linked to familial forms of hemangioma.19
Because hemangiomas may be a part of a syndromic complex, query about other symptoms that may be associated with Klippel-Trenaunay-Weber or Sturge-Weber syndromes. The triad of Klippel-Trenaunay-Weber syndrome symptoms includes vascular tumors of the limbs, trunk, or perineum; varicose veins; and bony and/or soft tissue hypertrophy of the extremities.2 The presenting symptom in patients with Sturge-Weber syndrome is often a facial lesion, most commonly a nevus flammeus located in the V1-V2 dermatomes. Other findings include a history of epileptic seizures, hemiplegia, visual field defects, and glaucoma.3
Most lymphangiomas are clinically apparent at birth, and almost all are apparent by age 2 years. Most appear as soft doughy masses that are located in the head and neck region, and most have no associated symptoms. Clinical manifestations are dependent on the flow of lymph within the channels of the lesion. Lymphangiomas may manifest as lymphedema, and larger lesions can involve the skeletal system and cause gross disfigurement. Large malformations in the neck or mediastinum can compromise the airway, leading to stridor, dysphonia, or dyspnea. Lymphangiomas have also been found in patients with Turner syndrome, Klinefelter syndrome, and Noonan syndrome.
Indications
Vascular tumors
Surgical excision of vascular tumors (hemangiomas) is controversial because most lesions involute with little intervention (75%).
Surgery is indicated if the procedure is anticipated to leave a scar that is more cosmetically acceptable than a scar due to medical therapy or following involution. Furthermore, in the following few specific situations, surgical intervention is considered inevitable: (1) if an abnormal scar or excess tissue is present after natural involution; (2) if lesions are ulcerated and bleed excessively or are associated with pain; and (3) if lesions interfere with the development or activities necessary for life, such as lesions of the eye, ear, or larynx.
Capillary malformations
Surgical management of port-wine stains has largely fallen out of favor with the advent of the laser treatment. Surgical methods have included dermabrasion, electrocautery, and cryosurgery.
Lymphatic malformations
For the purposes of treatment, lymphangiomas are often divided into local and diffuse disease. In localized disease, a conservative period of watchful waiting is appropriate if the lesion causes no immediate compromise to life functions. However, fewer than 15% of lesions spontaneously regress. Some surgeons believe that if the lesion has not spontaneously regressed by age 5 years, surgical intervention is warranted. Other authors believe that excision should be performed sooner to avoid complications of lymphangioma, such as infection.20 Infection can be a severe sequela of lymphangiomas.
Most surgeons currently agree that complete excision is the preferred treatment for localized lymphangiomas, depending on the accessibility of the location. However, the close quarters of the head and neck provide for a tedious dissection that often results in sacrificing vital structures and significant impairment following surgery. In these cases, surgery may have to be avoided, and an alternate therapy should be pursued. Partial excision is frequently possible and is an acceptable alternative to complete excision, particularly if surgical resection would require removal of vital structures.
Management of diffuse lymphatic disease is a complex multistaged treatment associated with high complication rates. Patients and parents must be informed that management may be a lifelong endeavor and that significant morbidity may occur. Some studies report the use of nonsurgical therapy with special drugs that may promote regression of complex lymphangiomas. However, this treatment is not yet approved by the US Food and Drug Administration (FDA).
Relevant Anatomy
Vascular tumors
Hemangiomas located on the trunk or face may be psychologically damaging when children approach school age. This must be considered when discussing early intervention in these lesions. Lesions of the eye, ear, or larynx warrant early intervention because they may affect proper development of these organs or compromise the airway. Lesions involving the orbit should be properly evaluated by an ophthalmologist. In cases involving the larynx, the first priority is ensuring a secure airway.
Capillary malformations
Capillary malformations are frequently located on the face, where they often present a psychological problem.
Lymphatic malformations
In most series, the head and neck are the most common sites for lymphatic malformations, followed by the trunk, axilla, and extremities. In the head, the oral cavity and face area are the most common sites. In the neck, the posterior triangle is reportedly the most common site. However, many series have reported no difference between the anterior and posterior triangles. Right-sided lesions seem to predominate. Laryngeal involvement is not uncommon. Cases of diffuse disease may occur, encompassing large portions of the body.
Contraindications
Vascular tumors
No absolute contraindications to surgical resection of hemangiomas have been recognized. However, in cases of nontroubling vascular tumors, the surgeon should thoroughly discuss the alternatives before proceeding.
Capillary malformations
No absolute contraindications to laser surgery have been identified in patients with capillary malformations. The physician should assess the risk of complications. For example, the 585-nm PDL can damage choroidal and retinal vasculature if the patient is not wearing the appropriate protective eyewear. In addition, the possibility of damage to surrounding structures and tissues must be evaluated.
Lymphatic malformations
No absolute contraindications to surgery have been identified in the treatment of lymphangiomas. Surgical treatment of diffuse lymphatic disease is a complex multistaged treatment that has high complication rates. Patients and parents must be informed that management may be a lifelong endeavor and that significant morbidity may occur.
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References
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Further Reading
Keywords
vascular malformation, vascular tumor, lymphangioma, angioma lymphaticum, cystic hygroma, cystic hydroma, hemangioma, birthmark, birth mark, nevus, port-wine stain, port-wine mark, fading macular stain, salmon patch, nevus flammeus, flame nevus, stork bite, angel's kiss, Klippel-Trenaunay-Weber syndrome, Sturge-Weber syndrome, high-flow vascular malformation, arterial malformation, arteriovenous malformation, slow-flow vascular malformation, venous malformation, capillary malformation, lymphatic malformation, internal hemangioma, hemangiomatosis
