Arterial Vascular Malformations Including Hemangiomas and Lymphangiomas Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Mar 20, 2012
 

Medical Therapy

Vascular tumors

Approximately 75% of hemangiomas involute without intervention and are in anatomically benign locations, making them a cosmetic issue. Therefore, parents must be educated about their child's condition, and the typical course of these lesions must be explained to them. In this manner, the physician can avoid hastily instituting medical therapy that may lead to a less desirable outcome. Regular follow-up visits should be scheduled to monitor the course of the lesion and to provide continuous reassurance to the parents.

The synthesis of informational advances in functional and phenotypic effects may enable the use of animal models to test less-invasive, targeted, perhaps locally administered, biological therapies.[29]

Medical intervention is indicated if hemangiomas are located in areas that hinder normal development, interfere with important life processes, or cause severe pain. Such locations include the eye, nose, and airways. Current practices include the following:

  • Systemic glucocorticoids are the first-line therapy for lesions that are life threatening or cause severe deformity.[30] Efficacy rates have been reported at 84% with prednisone equivalent doses of 2.9 mg/kg if administered during the proliferative phase.
  • Beta-adrenergic receptor blocker propranolol is a promising an oral agent for first-line systemic therapy of infantile hemangiomas.[31] It can produce a dramatic and rapid response, although serious consideration of the risks and benefits of its use must be considered.[32, 33] The topical beta-blocker timolol lotion may also be strikingly effective.[34]
  • Triamcinolone is indicated for smaller hemangiomas; intralesional injections administered every 4-6 weeks have been shown to result in faster rates of involution in 30% of patients.
  • Interferon alfa-2a is used for life-threatening or deforming lesions that do not respond to glucocorticoid therapy.[35] It is subcutaneously administered at a dose of 1-3 million U/m2 of body surface area.
  • Flashlamp-pumped PDL is indicated for superficial residual lesions that remain after involution; this is not effective on deep hemangiomas. Some studies have shown no advantage to early laser intervention versus conservative treatment, but a recent study suggests possible benefit.[36]
  • Local wound care is shown to alleviate pain and infection in ulcerated lesions.[37] Wet compresses can be used to debride the ulcer in conjunction with topical mupirocin, bacitracin, or metronidazole.

Capillary malformations

The first-line treatment of capillary malformations involves the flashlamp-pumped PDL or the argon laser.

The PDL is the treatment of choice in infants and children. Treatment involves a brief pulse that is relatively specific for the lesion, compared with that from the argon laser. This results in a lesser degree of damage to the surrounding tissues, minimizing the hypopigmentation often associated with treatment.

In one series, 15.3% of patients treated with the PDL experienced more than 90% lesional resolution, and 65.3% of patients had lightening from 50-90%. Poor or no response was observed in 17.8% and 1.2% of patients, respectively.[38] The 577-nm, 0.36-ms PDL has proven to be efficacious in light-colored stains and is more effective in younger compared with older children. The 585-nm PDL was developed and became popular in the mid 1990s because one study demonstrated an improved response in deeper lesions. With the use of the 585-nm, 0.45-ms PDL, some authors report the highest degree of blanching in pink lesions, while others find a lower degree of lightening in pink compared with red lesions.

Some authors report better results with fewer treatments in infants and young children, whereas others do not find significantly better results in the youngest age groups. Most studies report a more favorable response in lesions on the face or neck and on the torso, but one study did not find any significant difference in the required number of treatments for different body locations.

The argon laser is currently used in adults with darker or raised port-wine stains. This is because of the hypopigmentation and textural changes that are often the result of treatment.

Lymphatic malformations

For localized lymphatic malformations, various pharmacologic agents have been used around the world to treat lymphangioma. Some of the agents used in sclerotic therapy include boiling water, tetracycline, bleomycin, and cyclophosphamide. None of the treatments has been completely effective. Sclerotherapy may also be of value in venous malformations, acquired digital arteriovenous malformations, and hemangiomas.[39]

Special considerations should be taken with lymphatic malformations on the tongue or glottis. Malformations on the tongue (formerly known as lymphangioma circumscriptum) should be managed with laser resurfacing. If these lesions are large enough to interfere with respiration, tongue reduction surgery should be performed. Malformations on the glottis should be treated with carbon dioxide laser and debulking therapy with aggressive airway management.

Aspiration of lymphangiomas has been used in the past but has largely fallen out of favor because of the high rate of recurrence. However, it can still be useful to manage life-threatening lymphangiomas that are in need of immediate reduction.

Management of diffuse disease is usually surgical (see below), although cyclophosphamide may be a good choice for life-threatening diffuse neonatal hemangiomatosis that is unresponsive to corticosteroids.[40] However, an essential component of care in children with diffuse disease should involve a child psychiatrist because management of diffuse disease often entails lifelong morbidity.

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Surgical Therapy

Vascular tumors

When resecting hemangiomas, the surgeon must decide whether the result from surgical intervention would be more cosmetically acceptable than that from medical treatment or watchful waiting. In addition, the timing of resection should be considered because facial deformities can have a psychologic impact on children, especially when they enter the school years. Some surgeons, however, advocate postponing excision until after the involution phase of hemangiomas.

In April 2002, Mulliken et al studied the outcome of surgical resection of hemangiomas involving a circular excision with purse-string closure compared with that involving a standard lenticular incision.[41] A line of excision was drawn to include the area affected by hemangiomatous infiltration and any fibrofatty residuum. In involuted lesions, this included all areas that were atrophic, scarred, pigmented, or otherwise deemed irreversibly scarred. The marked area was then excised to the depths of the subcutaneous tissue, and the circular incision was drawn together using a single 4-0 or 5-0 purse-string suture. When the suture was tightened, ridges of skin were created at the newly formed wound margin.

If a small opening remained at the center of the purse-string, a gauze wick was placed inside, and the wound was dressed. The ridges leveled off over the course of several weeks, and after several months of scar remodeling, the physician and parents decided whether to accept the result or have the patient undergo a second procedure.

The study concluded that after a circular incision with purse-string closure, the mean scar area was 15% of the original area. The study also concluded that the mean scar length with circular excision would be 72% shorter than with lenticular excision. The results did not vary significantly among the phases in which the procedure was performed or between the techniques used in a second procedure (circular or lenticular). To date, no other excision and closure technique produces a smaller scar.

Lymphatic malformations

As stated above, surgical excision is the treatment of choice for localized lymphangioma if anatomically possible. Of the various surgical techniques that have been explored over the years, total removal of the tumor, leaving behind no cystic epithelium, has been the most reliable procedure. In one study, total resection led to no recurrences following the procedure. This is compared with recurrences in 6 of 7 patients if excision of only protruding cystic epithelium was performed.[42]

The surgical management of diffuse disease is often a complex and lifelong endeavor with substantial rates of morbidity. Patients and parents must be aware of this before surgery is undertaken so that the high likelihood of complications can be factored into the initial decisions in management.

The first step in managing diffuse cervicofacial disease is to allow for an adequate airway and adequate feeding. This often requires a tracheotomy and possibly a gastrostomy. The next task is to divide the patient into anatomic zones and then attempt to manage those zones as individual areas of localized disease until a given zone is completely free of disease. Failure to completely excise a diseased area predisposes the patient to a high rate of recurrence in that region. Approaching the divided components of the total malformation from the top down is also advisable, if possible, to avoid lymphatic swelling at more proximal locations. Children with diffuse cervicofacial disease also frequently require maxillomandibular reconstruction because of overgrowth of the facial bones. Depending on the severity of the disease and infiltration into local structures, these additional procedures can attenuate an already lengthy treatment process.

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Follow-up

Vascular tumors

As stated above, regular follow-up care is an integral part of the management of hemangiomas to monitor the natural history of the lesion and to provide ongoing comfort to the patient's parents. The physician should also monitor for potential adverse effects of treatment, including the following:

  • With local glucocorticoid treatment, a case of retrobulbar hematoma with subsequent blindness has been reported.
  • With systemic glucocorticoid treatment, adrenal suppression and other common adverse effects of systemic steroid therapy may occur.
  • With interferon alfa-2a administration, adverse effects include transient fever, neutropenia, and elevated liver function test results. Several cases of spastic diplegia, some of which were permanent, have also been reported in infants following treatment.
  • Laser therapy may produce hypopigmented lesions.

If the patient has undergone surgical excision, the physician and the parents should decide whether the results of the excision are acceptable or whether a second excision and closure should be performed.

Capillary malformations

Patients who received laser treatment for capillary malformations should be monitored for recurrence and for the adverse effects of laser therapy. The argon laser can result in hypopigmented lesions and textural changes in the skin. Although both of these outcomes are factored into the decision to use the argon laser, the physician and the patient should come to a consensus on an acceptable result after treatment. Recurrence can occur up to several years after treatment.

Lymphatic malformations

Patients who undergo excision of a localized lymphangioma should simply be monitored for recurrence. Individuals treated for diffuse disease are often lifelong patients and should receive regular follow-up. The support of a child therapist may be useful to help manage the psychosocial impact of the disease and treatment.

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Complications

Vascular tumors

In some cases, hemangiomas can be life threatening or severely problematic, interfering with eating, breathing, seeing, hearing, and speaking. These cases require immediate and aggressive intervention because delayed treatment can lead to improper development of these organ systems. The most common sequela of untreated problematic vascular tumors is amblyopia secondary to lesions of the upper eyelid. Such cases should be immediately evaluated by an ophthalmologist. Hemangiomas located on internal organs can be dangerous because they are difficult to detect. Furthermore, by the time they are detected, the infant often requires aggressive treatment. Despite intervention, internal hemangiomas are still associated with high mortality rates.

Infants who have hemangiomatosis (ie, multiple smaller hemangiomas) may also have internal lesions. Visceral hemangiomas occur in the liver, intestines, airway, and brain. If an infant has more than 3 clinically apparent hemangiomas, ultrasonography of the entire body should be performed to rule out internal lesions. Other suspicious findings include the following:

  • Jaundice, which may be a sign of liver hemangiomas
  • Bloody stools, which may be a sign of GI hemangiomas
  • Stridor or dyspnea, which may be a sign of airway hemangiomas

Capillary malformations

Patients with port-wine stains should be evaluated and monitored for a larger syndromic entity.

Hemangiomas that are part of the Klippel-Trenaunay-Weber syndrome can be located on the lungs, spleen, liver, bladder, or colon. Visceral involvement can often lead to substantial morbidity in the form of internal hemorrhage.

The recognized components of Sturge-Weber syndrome can appear at various points in the patient's life. Neurologic findings are evident within the first 2 years of life, often manifesting as seizures. In addition, patients can exhibit hemiparesis, visual field defects, or lower intelligence quotient (IQ) scores. Ocular defects, such as glaucoma or ocular hemangiomas, can lead to visual loss or retinal detachment that requires prompt evaluation and treatment.

Lymphatic malformations

Complications of lymphangiomas depend on the location and extent of disease.

Diffuse cervicofacial disease can result in mandibulomaxillary hypertrophy because of direct invasion of the bone and growth of the malformation within the bone. A secure airway is also essential in these patients; a tracheostomy may be required to avoid acute respiratory problems.

Lymphangiomas often swell with the onset of general viral infection or remote bacterial infection. This typically resolves with the resolution of the infection. Occasionally, lymphangiomas can become infected, and intravenous (IV) antibiotic treatment is required.

Collision of vascular and pigmentary anomalies

Occasionally, a vascular anomaly with be seen in association between congenital melanocytic nevi and infantile hemangiomas.[43] For example, a Spitz nevus may arise in direct contiguity to a glomuvenous malformation or phakomatosis pigmentovascularis may be seen in association with congenital melanocytic nevus.

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Outcome and Prognosis

Vascular tumors

As mentioned earlier, approximately 75% of hemangiomas of infancy involute without intervention. Involution is usually complete by age 7-10 years. Ulceration secondary to infection or trauma increases the risk of residual scarring. A large facial lesion is also more likely to leave an unacceptable scar. Patients with significant residual scarring may choose to undergo a surgical procedure. If systemic glucocorticoids are used in the manner stated above, efficacy rates of 84% have been reported. Side effects during and after treatment have also been previously mentioned. All treatments listed above are used primarily for troublesome situations or cases where scarring after involution is considered unacceptable. Studies to date have been unable to prove a significant change in outcome with earlier intervention versus watchful waiting.

Capillary malformations

The PDL has vastly enhanced the treatment efficacy of cutaneous capillary malformations. Laser wavelengths that are specific for the lesion result in a lesser degree of damage to the surrounding tissues, minimizing the risk of hypopigmentation. In one series, 15.3% of patients treated with the PDL experienced more than 90% lesional resolution, and 65.3% of patients had lightening from 50-90%.[38] Poor or no response was observed in 17.8% and 1.2% of patients, respectively.

Lymphatic malformations

Complete surgical resection of localized disease has proven to be extremely effective. Recurrence rates are low if complete removal of cystic epithelium is achieved.

Patients and parents undergoing surgical resection of diffuse disease should be aware that despite intervention, diffuse lymphatic disease entails lifelong morbidity. An essential component of care in these children should involve a child psychiatrist to cope with this stressful situation.

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Future and Controversies

Vascular tumors

To develop more effective medical treatments, studies are needed to clarify the pathogenic mechanism behind the formation of sporadic hemangiomas. Cases of autosomal dominant inheritance suggest a genetic predisposition to some hemangiomas. Identification of these genetic alterations may shed light on the pathogenesis behind sporadic cases.

Vascular malformations

Because some lesions spontaneously regress, evidence suggests that conservative treatment or a period of watchful waiting may be beneficial in cases in which disease is not life threatening. The efficacy of OK-432 (Picibanil) has been well documented for the treatment of localized lymphangioma in Japan; studies are underway in the United States.[44] A better understanding of the pathogenesis behind lymphangioma is needed to develop newer and more efficacious medical treatments.

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Richie L Lin, MD  Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Disclosure: Nothing to disclose.

Tzongjer J Wei, MD, MPH  Assistant Professor of Pediatrics, UMDNJ-New Jersey Medical School; Chief and Director, Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital

Tzongjer J Wei, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Herbert Dardik, MD, FACS  Clinical Professor of Surgery, Mount Sinai School of Medicine; Chief, Department of Surgery, Chief, Vascular Surgical Service, Englewood Hospital and Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeff L Myers, MD, PhD  Chief, Pediatric and Congenital Cardiac Surgery, Department of Surgery, Massachusetts General Hospital; Associate Professor of Surgery, Harvard Medical School

Jeff L Myers, MD, PhD is a member of the following medical societies: American College of Surgeons, American Heart Association, and International Society for Heart and Lung Transplantation

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Andre Hebra, MD  Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Neal Ammar, MD, to the development and writing of this article.

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Fully developed vascular tumor on the trunk of an infant.
Large vascular tumor that encompasses the upper extremity and portions of the trunk, clinically diagnosed.
A lower extremity port-wine stain in a patient with Klippel-Trenaunay-Weber syndrome.
 
 
 
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