Scientific validation of clinical visual scales and Antera 3D™ consistency with derived measurements in the assessment of infantile haemangioma after laser therapy.

BACKGROUND: Laser therapy is a treatment for infantile haemangiomas. The efficacy of laser therapy for red lesions is determined by visual evaluation; however, this assessment is inaccurate and lacks objectivity. OBJECTIVE: To scientifically validate the consistency between pre- and post-treatment visual assessment grades for infantile haemangioma treated with pulsed dye laser (PDL) and the values calculated from images obtained with Antera 3D™. METHODS: This study involved 81 cases of infantile haemangiomas treated with PDL alone from 2012 to 2015 and with Antera 3D™ images of the lesions. Using images obtained before treatment and 4-6 weeks after the last treatment, the lesions were rated using a visual four-step scale. Ratings were categorised as Poor/Fair/Good/Excellent by the degree of improvement in the red colour tone. The red colour ratio was calculated using the haemoglobin distribution in the lesion and surrounding skin, and the improvement difference and improvement rate were then obtained. The correlation between the improvement difference and improvement rate, and visual evaluation was statistically analysed. RESULTS: No serious adverse effects were observed, with an average of 4.3 treatments per patient; 60.1% of the patients achieved Good/Excellent results. There were statistically significant differences in the post-treatment red colour ratio and improvement ratio in each category after visual evaluation classification. The improvement rate and the four visual grades were statistically correlated. CONCLUSION: This study confirmed the scientific validity of visual evaluation and the evaluation criteria calculated from Antera 3D™. This method could objectively determine treatment effectiveness.

Assessment of the efficacy of 595 nm pulsed dye laser in the management of facial flat angiomas. Results of a case series.

BACKGROUND: Studies on pulsed dye laser (PDL) have shown the best efficacy and safety data for treating vascular anomalies among the various lasers used and the 595-nm PDL has been used to treat cutaneous vascular anomalies for about 30 years. The purpose of this study was to assess the efficacy of 595 nm Pulsed Dye Laser in the management of facial flat angiomas present in the form of Port-Wine Stain. MATERIALS AND METHODS: Seven cases of PWS in Fitzpatrick skin type ranged from I to III and colour ranging from pink to purple, were treated with 595 nm pulse Dye Laser. Patients underwent to 6-8 laser sessions at 20-30 days intervals. Results obtained were judged by dermatologist, by comparing pre-treatment and post-treatment photographs, 6 months after the last session and a quartile scale of lesion clearance (4-point Investigator Global Assessment scale): 1 = no or low results (0%-25% of the lesion area improved), 2 = slight improvement (25%-50% of the lesion area cleared), 3 = moderate-good improvement (50%-75%), and 4 = excellent improvement (75%-100%) was used. Possible side effects such as blisters, hyper/hypopigmentation, and scarring were monitored. RESULTS: All patients observed global improvements. 71% of patients achieved excellent clearance and 29% patients achieved good-moderate clearance of their angioma. Patients were asked for a subjective evaluation of the results: 57% of patients were very satisfied, 29% were satisfied, and 14% patients were not very satisfied with the results. No patients were dissatisfied. No significant side effects were noted. CONCLUSION: This research confirms the efficacy of the 595 nm PDL for flat angioma management, without considerable side effects.

Early response assessment after CyberKnife stereotactic radiosurgery for symptomatic vertebral hemangioma by quantitative parameters from dynamic contrast-enhanced MRI.

PURPOSE: The present study aimed to explore the value of DCE-MRI to evaluate the early efficacy of CyberKnife stereotactic radiosurgery in patients with symptomatic vertebral hemangioma (SVH). METHODS: A retrospective analysis of patients with spinal SVH who underwent CyberKnife stereotactic radiosurgery from January 2017 to August 2019 was performed. All patients underwent DCE-MRI before treatment and three months after treatment. The parameters included volume transfer constant (Ktrans), transfer rate constant (Kep), and extravascular extracellular space volume fraction (Ve). RESULTS: A total of 11 patients (11 lesions) were included. After treatment, six patients (54.5%) had a partial response, five patients (45.4%) had stable disease, and three patients (27.3%) presented with reossification. Ktrans and Kep decreased significantly in the third month after treatment (p = 0.003 and p = 0.026, respectively). ΔKtrans was -46.23% (range, -87.37 to -23.78%), and ΔKep was -36.18% (range, -85.62 to 94.40%). The change in Ve was not statistically significant (p = 0.213), and ΔVe was -28.01% (range, -58.24 to 54.76%). CONCLUSION: DCE-MRI parameters Ktrans and Kep change significantly after CyberKnife stereotactic radiosurgery for SVH. Thus, DCE-MRI may be of value in determining the early efficacy of CyberKnife stereotactic radiosurgery.

Clinical and economic impact of surgery for treating infantile hemangiomas in the era of propranolol: overview of single-center experience from La Paz Hospital, Madrid.

Propranolol has changed the management of infantile hemangiomas (IHs). We summarize the evolution of surgical treatment for IH at La Paz Children's Hospital (Madrid) in the era of propranolol, with a focus on hepatic IHs.Retrospectively, we compared surgical treatment of IHs in children referred during the periods 2004-2009 and 2009-2014. Hepatic IH mortality rates before and after the introduction of propranolol therapy were evaluated specifically.The majority of hemangiomas needing surgical excision were located on the head/face/scalp of female patients. Since the introduction of propranolol therapy, surgery for IH has decreased from about 60 to 6 procedures/year at our institution and no transplants for hepatic IH have been registered.Conclusions: Surgical procedures for IH have decreased by about 90% at our institution since the introduction of propranolol treatment and hepatic IH have not needed liver transplantation. Referrals for surgery for IH are generally the consequence of absent or delayed propranolol treatment. Given the significant reduction in the number of surgical procedures, propranolol can be considered as having a strong economic and social impact. What is Known: • The use of oral propranolol solution is currently considered as the treatment of choice in the management of infantile hemangiomas. • Propranolol treatment achieves better outcomes and less side effects than systemic corticosteroids. What is New: • Social and financial impact of the significant reduction in the number of reconstructive surgical procedures and liver transplants due to the use of propranolol in tertiary health institutions remains to be analyzed.

Management trends of infantile hemangioma: A national perspective.

INTRODUCTION: The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown. MATERIALS AND METHODS: The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4. RESULTS: The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001). CONCLUSIONS: Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

Less cost by using hanging maneuver and Pringle maneuver in left lateral hepatectomy through small laparotomy wound--experience of Southern Taiwan.

BACKGROUND: Laparoscopic segmentectomy for liver tumor located in the left lateral segment (LLS) is thought to be a standard protocol nowadays with several advantages, such as small wound, few blood loss, and short hospital stay. However, there are still many disadvantages during executing laparoscopic LLS segmentectomy. This manuscript aims to present the technique to execute LLS segmentectomy with small incision, hanging maneuver without Pringle maneuver in patients with tumor at LLS of the liver. MATERIAL AND METHODS: Between November 2010 and July 2011, hepatectomies through small incision for nine patients with benign and malignant tumors were performed at Kaohsiung Chang Gung Memorial Hospital, Taiwan. Perioperative and postoperative results, such as operation time, blood loss, incisional width, and postoperative stay were used to determine consequents for this technique. RESULT: Results demonstrated that modified LLS segmentectomy by the author's team was performed successfully in patient with liver tumor with fewer blood loss, smaller incisional width, and lower hospital cost than traditional open surgery. In addition, the instrument cost and blood loss in our series were less than that in laparoscopic LLS segmentectomy in published literature. CONCLUSION: Authors concluded that minimally incisional segmentectomy, with less cost and technical demanding, could be an alternative choice in patient with liver tumor at LLS.

A radiological classification system for intraneural vascular anomalies: assessment of potential for resection with high-resolution MRI.

BACKGROUND: Intraneural hemangiomas and vascular malformations are rare, with approximately 50 cases reported in the literature. They present a therapeutic challenge; surgical resection can result in damage to the nerve and lesion recurrence is common. We introduce a new framework to classify intraneural vascular anomalies in relation to the anatomic compartments of the nerve and assess amenability to surgical resection. METHODS: We retrospectively reviewed cases of intraneural hemangiomas and vascular malformations treated at our institution between 2003 and 2013 that had high-resolution 3-T magnetic resonance imaging (MRI). A review of the literature was also performed. Our cases and reports in the literature with available MRI data were sub-categorized according to their relationship to the paraneurium and epineurium of the nerve. RESULTS: Nine patients were identified with intraneural (subparaneurial or subepineurial) vascular lesions. Two patients had a predominantly subparaneurial involvement of the nerve, six patients had predominantly subepineurial involvement, and one patient exhibited extensive involvement in both compartments. Four patients were managed surgically and the rest conservatively. Targeted resection of two subparaneurial hemangiomas provided complete relief of symptoms and freedom from recurrence at 18 month and 24 months respectively. One patient with extensive subepineurial and extraneural vascular malformations did not appear to benefit from sub-total resection with interfascicular dissection. No surgical morbidity was noted in any of the cases. CONCLUSIONS: We believe that the subparaneurial compartment-a potential space between the epineurium and paraneurium-provides a tissue plane within which benign vascular lesions can occur. Hemangiomas and vascular malformations are complex and can occupy different intraneural and extraneural compartments. The anatomic framework aids surgical decision-making and ensures that all components of the lesion are considered. We advocate a multimodal approach in the treatment of these rare lesions.

Comparison of laparoscopic radiofrequency ablation versus open resection in the treatment of symptomatic-enlarging hepatic hemangiomas: a prospective study.

BACKGROUND: Radiofrequency ablation (RFA) has been demonstrated to be a promising therapy for symptomatic large hepatic hemangioma. However, there is a lack of studies to demonstrate the benefits and disadvantages of RFA as compared with surgical resection for managing hepatic hemangioma. The aim of this study was to evaluate the outcomes of RFA compared with conventional open resection (ORES) for the treatment of symptomatic-enlarging hepatic hemangiomas. METHODS: A total of 66 patients with symptomatic-enlarging hepatic hemangiomas (4 cm ≤ diameter < 10 cm) who required surgical treatment were divided into two groups: 32 patients underwent laparoscopic radiofrequency ablation (LRFA) and the other 34 patients underwent ORES. We compared the two groups in terms of radiologic response, clinical response, operative time, estimated blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications and hospital cost. RESULTS: The radiologic and clinical responses were comparable between groups. LRFA had significantly shorter operative time (138 vs. 201 min, P < 0.001) and less blood loss (P < 0.001) than ORES. Patients after LRFA experienced significantly less pain and required less analgesia use. Moreover, patients underwent LRFA had significantly shorter length of hospital stay (P < 0.001) and lower hospital cost (P = 0.017). No severe morbidities or mortality was observed, and the overall morbidity rate was similar between groups. CONCLUSIONS: As a new minimal invasive treatment option, laparoscopic radiofrequency ablation is as safe and effective a procedure as open resection for patients with symptomatic-enlarging hepatic hemangiomas smaller than 10 cm.

Assessment of pulsed-dye laser therapy for pediatric cutaneous vascular anomalies.

IMPORTANCE: Although facial vascular malformations are often treated by facial plastic surgeons, no reliable validated assessment tool exists for surgeons to assess results. OBJECTIVES: To use our assessment tool to analyze results from pulsed-dye laser therapy used for pediatric facial vascular malformations, and to determine interrater reliability of our assessment tool in a standard clinical environment without the use of professional photography. DESIGN: A blinded retrospective review of pediatric patients who underwent pulsed-dye laser therapy for treatment of hemangiomas of infancy (HOIs) and port-wine stains. Three pediatric otolaryngologists and facial plastic surgeons independently rated all of the pictures using our assessment tool. SETTING: Tertiary care pediatric hospital. RESULTS: Pulsed-dye laser therapy was performed in 22 patients, 17 with HOIs and 5 with port-wine stains. Patients with HOIs treated only by pulsed-dye laser showed, on average, a 50% to 75% improvement in color, 1% to 24%, improvement in thickness, and 1% to 24% improvement in size of the lesion. Eight patients with HOIs underwent surgery after laser therapy, and of these, 100% saw improvement in color, thickness, and size. Port-wine stains showed a 1% to 24% improvement in color and no improvement in thickness or size. Interrater reliability for questions 1 to 6 was 0.92, 0.92, 0.93, 0.91, 0.70, and 0.10, respectively. CONCLUSIONS AND RELEVANCE: Currently, no standardized or validated methods exist to evaluate results from intervention of pediatric facial HOIs and port-wine stains. Our assessment tool is reliable to assess patients with HOIs and port-wine stains who undergo pulsed-dye laser therapy and surgical reconstruction. LEVEL OF EVIDENCE: 3.

Infantile hemangioma: clinical assessment of the involuting phase and implications for management.

BACKGROUND: Infantile hemangioma involutes during childhood; the tumor decreases in size and its color fades. Reconstructive procedures are often withheld until the lesion stops improving. The purpose of this study was to determine the age at which involution of infantile hemangioma ends, and factors that influence its regression. METHODS: Consecutive patients with infantile hemangioma managed between 2007 and 2011 were studied retrospectively. The outcome variable was age at which the appearance of the infantile hemangioma ceased to improve. Predictive variables were sex, lesion size, location, tumor depth, ulceration, and history of treatment (local or systemic corticosteroid). RESULTS: The study comprised 81 patients. Infantile hemangioma was located on the head/neck (79.0 percent), trunk (13.6 percent), or extremity (7.4 percent). Average tumor area was 9.3 ± 9.7 cm. Twenty-six percent of the cohort was treated with a corticosteroid during the proliferative phase and 87.6 percent underwent reconstruction for a residual deformity. Kaplan-Meier analysis estimated that involution ceased at a median age of 36 months (interquartile range, 30 to 42 months), and 92 percent of tumors completed involution by 48 months. Multivariate Cox proportional hazards regression model showed that sex (p = 0.80), lesion size (p = 0.09), location (p = 0.77), tumor depth (p = 0.74), ulceration (p = 0.18), and previous local (p = 0.73) or systemic (p = 0.60) corticosteroid treatment did not influence regression. CONCLUSIONS: Most infantile hemangiomas do not improve significantly after 3.5 years of age. Reconstructive procedures should be considered at this age; the tumor has been allowed to regress and the deformity is improved before the development of long-term memory and psychosocial morbidity.

Intraoperative mapping and monitoring of the corticospinal tracts with neurophysiological assessment and 3-dimensional ultrasonography-based navigation. Clinical article.

OBJECT: Preserving motor function is a major challenge in surgery for intraaxial brain tumors. Navigation systems are unreliable in predicting the location of the corticospinal tracts (CSTs) because of brain shift and the inability of current intraoperative systems to produce reliable diffusion tensor imaging data. The authors describe their experience with elaborate neurophysiological assessment and tractography-based navigation, corrected in real time by 3D intraoperative ultrasonography (IOUS) to identify motor pathways during subcortical tumor resection. METHODS: A retrospective analysis was conducted in 55 patients undergoing resection of tumors located within or in proximity to the CSTs at the authors' institution between November 2007 and June 2009. Corticospinal tract tractography was coregistered to surgical navigation-derived images in 42 patients. Direct cortical-stimulated motor evoked potentials (dcMEPs) and subcortical-stimulated MEPs (scrtMEPs) were recorded intraoperatively to assess function and estimate the distance from the CSTs. Intraoperative ultrasonography updated the navigation imaging and estimated resection proximity to the CSTs. Preoperative clinical motor function was compared with postoperative outcome at several time points and correlated with incidences of intraoperative dcMEP alarm and low scrtMEP values. RESULTS: The threshold level needed to elicit scrtMEPs was plotted against the distance to the CSTs based on diffusion tensor imaging tractography after brain shift compensation with 3D IOUS, generating a trend line that demonstrated a linear order between these variables, and a relationship of 0.97 mA for every 1 mm of brain tissue distance from the CSTs. Clinically, 39 (71%) of 55 patients had no postoperative deficits, and 9 of the remaining 16 improved to baseline function within 1 month. Seven patients had varying degrees of permanent motor deficits. Subcortical stimulation was applied in 45 of the procedures. The status of 32 patients did not deteriorate postoperatively (stable or improved motor status): 27 of them (84%) displayed minimum scrtMEP thresholds > 7 mA. Six patients who experienced postoperative deterioration quickly recovered (within 5 days) and displayed minimum scrtMEP thresholds > 6.8 mA. Five of the 7 patients who had late (> 5 days postoperatively) or no recovery had minimal scrtMEP thresholds < 3 mA. An scrtMEP threshold of 3 mA was found to be the cutoff point below which irreversible disruption of CST integrity may be anticipated (sensitivity 83%, specificity 95%). CONCLUSIONS: Combining elaborate neurophysiological assessment, tractography-based neuronavigation, and updated IOUS images provided accurate localization of the CSTs and enabled the safe resection of tumors approximating these tracts. This is the first attempt to evaluate the distance from the CSTs using the threshold of subcortical monopolar stimulation with real-time IOUS for the correction of brain shift. The linear correlation between the distance to the CSTs and the threshold of subcortical stimulation producing a motor response provides an intraoperative technique to better preserve motor function.

Emerging concepts in airway infantile hemangioma assessment and management.

OBJECTIVE: The purpose of this study was to evaluate changes in airway infantile hemangioma treatment. STUDY DESIGN: Retrospective. SUBJECTS: Airway hemangioma patients, tertiary pediatric hospital. METHODS: Data collected included age at diagnosis, evaluation methods, hospitalizations, airway size, and interventions. Patients were divided into group A (1981-1993) and group B (1994-2005) and were analyzed using descriptive statistics, the Fisher exact test, and the Student t test. RESULTS: Thirty-two subjects were identified. Nasopharyngoscopy was used more in group B (11/16 [69%]) than group A (4/16 [25%], P=0.032). CT angiography (3/16 [19%]) and laryngeal distractors (11/16 [69%]) were only used in group B; these techniques showed airway hemangiomas to be "transglottic," not just "subglottic." Intralesional steroids alone (3/16 [19%]) and primary hemangioma excision (2/16 [13%]) were new treatments used in group B. Frequent direct laryngoscopies (>six) correlated with tracheotomy (5/32 [16%], P=0.015). Presenting age (<2 months) impacted treatment more than airway hemangioma size. CONCLUSIONS: New methods of airway infantile hemangioma assessment changed our concept of airway hemangiomas and their primary treatment.

Cardiac hemangioma.

Cardiac hemangiomas are benign vascular tumors that can affect patients of any age.

[Medical dermatologic laser therapy. A review]. / Medizinische dermatologische Lasertherapie. Eine Ubersicht.

The medical indications for laser therapy have been somewhat overlooked, perhaps because of the success of cosmetic laser therapy. As a result, many effective medical treatments are not covered by insurance companies. Lasers are helpful in many aspects of dermatologic treatment. Examples include pigmented lesions (Becker nevus), benign tumors (organoid nevi, adenoma sebaceum), dyschromias (traumatic tattoos), inflammatory diseases of the skin and subcutaneous tissue (lupus erythematosus, scars), hypertrichosis, premalignant lesions, and vascular lesions (hemangiomas and malformations). The various disorders which can effectively be treated with lasers are reviewed.

Prospective assessment of the safety and benefit of laparoscopic liver resections.

BACKGROUND/PURPOSE: Laparoscopy represents an alternative to open surgery for virtually all digestive surgery procedures, with the anticipated short-term advantage of reduced esthetic prejudice, postoperative pain, and duration of in-hospital stay. In this study, we investigated the safety and benefits of laparoscopic liver resections in patients with benign solid liver tumors. METHODS: Laparoscopic liver resection of up to two segments for benign liver tumor was performed under continuous carbon dioxide (CO(2)) pneumoperitoneum in 21 patients with no underlying chronic liver disease. The risk of gas embolism was assessed by end-tidal CO(2) and O(2) saturation, and the hemodynamic variations were monitored by a Swan-Ganz catheter. The postoperative course was compared with that following open surgery by matched-pair analysis. RESULTS: No patient experienced gas embolism or was converted, and clamping of the hepatic pedicle resulted in hemodynamic variations comparable to those observed during open surgery. Duration of surgery (177 vs 156 min.), intraoperative blood loss (218 vs 285 ml), modifications of postoperative liver function tests, and incidence of postoperative complications (10% vs 10%) were comparable to those after open surgery. Laparoscopic resection was associated with a 50% reduction (15.5 vs 31.6 mg) in morphine consumption during the first postoperative days, a reduction of the delay to oral intake of 0.8 days, and a reduction of in-hospital stay of 1.4 days. CONCLUSIONS: Liver resections of up to two segments can be performed by laparoscopy using the same technique as that used during open surgery. However, the benefits observed compared with open surgery appear to be limited.

[Retrorectal tumors: an assessment of the abdominal approach]. / Tumeurs rétrorectales: intérêt de la voie abdominale isolée.

UNLABELLED: Retrorectal tumors are frequently resected by a posterior trans- or parasacral approach, while the anterior abdominal approach is generally reserved for small tumors situated above the sacral promontory. STUDY AIM: The aim of this retrospective study was to assess the use of the abdominal approach for the treatment of large tumor masses situated in the presacral space, and to evaluate the results in terms of resectability, morbidity, and risk of recurrence. PATIENTS AND METHODS: Between 1986 and 1998, six female patients (age range: 25 to 79 years) with a retrorectal tumor (mean diameter: 7.5 cm) were operated on by abdominal approach. Clinical findings, morphological and histological data, the surgical resection procedure, and post-operative morbidity were studied. RESULTS: Pathological findings showed that all the tumors were benign: neurofibroma (n = 2), dermoid cyst (n = 1), rectal duplication (n = 1), myelolipoma (n = 1), and epithelioid hemangioma (n = 1). Complete tumor resection was obtained macroscopically and microscopically in all cases. The postoperative course was uneventful, with no tumor recurrence detected at a mean follow-up of 31 months. CONCLUSION: The anterior abdominal approach allows the complete resection of a retrorectal large tumor mass, and provides an interesting alternative to the posterior approach, with low morbidity and an absence of functional impairment.

Efficacy of flashlamp-pumped pulsed dye laser therapy for port wine stains: clinical assessment and histopathological characteristics.

Clinicopathological evaluation of flashlamp-pumped dye laser therapy for port wine stains was conducted on 474 subjects (135 male and 339 female) ranging in age from less than a year to 85 years (median = 17; lower quartile = 7 and upper quartile = 28). There was a significant variation in the rate of favourable response among lesion sites but the variation in relation to sex, age and radiation dose was not significant. Histological investigations of skin biopsy specimens from 23 subjects indicated that the mean depth of vessels is the main prognostic factor. The critical value (standard error) of the mean depth for a favourable response was estimated as 930(50) microns. Applications of this estimate to clinical prognosis are discussed.