Vascular Anomalies & Hemangiomas

 

There are two main categories of growths in children involving the blood and lymph vessels. Often the diagnosis is straightforward and can be made on visual inspection, but occasionally requires special diagnostic studies such as an MRI scan to evaluate the extent of the growth or other growths not detectable on a routine exam.

 

Hemangioma

 

This group of lesions is usually not seen at birth or is present as a small red mole shortly after birth. The growth of these masses is variable. They may demonstrate slow progressive growth or may enlarge rapidly. They may develop anywhere on the skin including the mouth and anus. There may be other lesions in the airway lining or internal organs that may go undetected. The period of growth may last less than a month, but often occurs up to six to nine months of age. The treatment is dictated by the location and the rate of growth. For instance, if the mass is growing on the back, a wait-and-see approach is preferred. If the mass is growing in a cosmetically sensitive area such as the lip, nose or orbit with associated obstruction or ulceration, a more aggressive approach is appropriate. This approach includes the use of high dose steroids in conjunction with ulcer prophylaxis. This medication slows down or often halts the progression or growth until the growth phase of the lesion subsides. The medication is then tapered down.

The second modality of treatment is the pulse dye laser. The brand we use is the Candela Laser V-Beam. This laser emits laser energy that is adsorbed by the red in the lesion and is converted into heat energy which promotes collapse of the vessels. This treatment is used to promote involution at the skin level which may decrease the need for surgical excision or may prevent the need. The need for surgical excision is dependent on the degree of involution. About 50 percent of these lesions involute by age five. Roughly 70 percent involute by age seven. This involution may be partial or complete and may require some degree of removal or scar revision. Some of these lesions are complicated by ulceration and bleeding. Some parents elect to have the lesion removed early on to avoid complications and in some patients, early surgical excision is appropriate.

 

Vascular Malformations

 

The second category of vascular anomalies is the vascular malformation. These growths are detectable at birth and have reached most of their growth in relation to the size of the patient at birth. In other words, their growth is commensurate with the growth of the child. The subclassification of these lesions is dependent on the type of blood vessel involved and the amount of blood flow. For example, a venous malformation consists of veins, a venule malformation is called a portwine malformation and a growth with arteries and veins is an arterial-venous malformation or AVM.

 

Treatment for Venous Malformation: The management of these lesions often requires several modalities. The first modality often used is intralesional injection to promote collapse of the lesion. This method requires sedation of the child while a solution is injected into the vessels of the growth. If this is successful, subsequent surgical excision can be safely performed.

 

Treatment for Arterial-Venous Malformation: These lesions have a higher blood flow making surgical extirpation more difficult. This requires a procedure usually performed by an interventional radiologist to place a small tube through the larger blood vessel in the groin to the blood vessel feeding the mass. Small particles are then injected to promote collapse of the mass. Once this is done, surgical removal can be performed.

 

Treatment for Portwine Malformation: These lesions may be seen as a midline pink area of the skin at birth. They often regress, but occasionally require treatment. The lesion may also be seen in other areas of the body and is a result of a deficiency in the nerves that regulate blood flow to that area of the skin. Early treatment with lasers may prevent more difficult treatment in the future. Maintenance treatment is often required. If the malformation is located in a certain distribution of the face involving the fifth cranial nerve, an evaluation for Sturge-Weber syndrome should be done.

 

Lymphatic Malformation

 

The third category for vascular malformations involves the lymphatic system called a lymphatic malformation. This lesion is a sponge-like collection of abnormal channels and spaces that contain clear fluid. The incidence in babies is unknown, however, they are not uncommon. Other terms for LMs are cystic hygroma and lymphangioma.

 

Lymphatic channels sprout from veins in early embryonic life. Protein-rich fluid normally filters out of blood-filled capillaries into tissues throughout the body. The lymphatic system serves to transport this fluid back into the venous system. In the gastrointestinal tract, lymph is thicker, containing absorbed fat. This fluid is called chyle.

 

Although the precise cause is unknown, LMs are believed to be caused by an error in the formation of these tiny, thin-walled sacs and tubes in the embryonic period. No known food, medication, or activity during pregnancy can cause an LM.