Vascular anomaly
Encyclopedia
A vascular anomaly is a kind of birthmark
caused by a disorder of the vascular development, although it is not always present at birth. A vascular anomaly is a localized defect in blood vessels that can affect each part of the vasculature (capillaries, arteries, veins, lymphatics or a combination of these). These defects are characterized by an increased number of vessels and vessels which are both enlarged and sinuous. Some vascular anomalies are congenital and therefore present at birth, others appear within weeks to years after birth and others are acquired by trauma or during pregnancy. Inherited vascular anomalies are also described and often present with a number of lesions that increase with patients’ age. Vascular anomalies can also be a part of a syndrome
and, occasionally, they can be acquired by trauma. The estimated prevalence of vascular anomalies is 4.5%. Vascular anomalies can occur throughout the whole body (skin, bone, liver, intestines, i.e.), but in 60% of patients vascular anomalies are localized in the head and neck region.
Vascular anomalies can present in various ways. Vascular anomalies that are situated deep below the skin, appear blue and are often called cavernous. Superfiscial vascular anomalies appear as red-coloured stains and are associated with vascular anomalies affecting the dermis.
Historically, vascular anomalies have been labeled with descriptive terms, according to the food they resembled (port wine, strawberry, cherry, salmon patch). This imprecise terminology has caused diagnostic confusion, blocked communication and even caused incorrect treatment, as it does not differentiate between various vascular anomalies. However, in 1982, Mulliken introduced a classifcation which replaced these descriptive terms and gave direction to the management of various vascular anomalies. This classification, based on clinical features, natural history and cellular characteristics, divides vascular anomalies into two groups: vascular tumors and vascular malformations.
Although the appearance of both vascular tumors and vascular malformations can resemble, there are important differences between both.
and pyogenic granuloma
.
infants, but rarely in dark skinned infants. It occurs in 20% of low weigth premature infants and 2.2 to 4.5 times more frequently in females. IH most commonly presents in the head and neck regio (60%), but also involves the trunk
and extremities
. One third of these lesions is present at birth as a telangiectatic stain or ecchymotic area. During the first four weeks of life, 70% to 90% appear. Lesions that are situated beneath the skin may not appear until 3 to 4 months of age, when the tumor is large enough. During the first 9 months, IH undergoes rapidly growth, which is faster than the growth of the child. This is called the proliferating phase. After 9 months, the growth of the tumor will decrease and equal the growth of the child for about 3 months. After 12 months, the tumor will start to involute and might even disappear. Involution stops in one-third of patient by the age of 3 years, in 50% by the age of 5 years and in 72% by the age of 7 years. Involution may result in residual telangiestasis, pallor, atrophy, textural changes and sometimes fibrofatty residuum.
Since 90% of IH is small, localized and asymptomatic
, treatment mainly consists of observation and awaiting until involution is complete. IH can be treated with corticosteroids, which accelerate involution: in 95% of patients, growth is stabilized and 75% of tumors decrease in size. Intralesional corticosteroids are most effective, but may require additional injections, as the effect is only temporarily. Systemic corticosteroids may cause lost of side-effects and are only used in problematic IH, which is too large to treat with intralesional injections.
During the proliferating phase, the tumor is highly vascular. Patients who undergo operative treatment during this period, are at risk for blood loss. Moreover, surgery during this phase, often leads to an inferior aesthetic outcome. However, patients may require intervention during childhood, because 50% of IH leave residual fibrofatty tissue, redundant skin, or damaged structures after involution. Waiting until involution is completed, ensures that the least amount of fibro fatty residuum and excess skin is resected, giving the smallest possible scar. Another option for treatment in the pulsed-dye laser. After involution residual telangiectasias can be treated with laser therapy.
Congenital hemangioma are divided into 2 subgroups: the rapidly involuting congenital hemangiomas (RICHs) and the non-involuting congenital hemangiomas(NICHs).
The rapidly involuting congenital hemangioma
, RICH, presents at birth as a solitary raised tumor with a central depression, scar, or ulceration
surrounded by a rim of pallor. It is noted for its involution which typically begins several weeks after birth and is completed no later than 14 months of age. After regression RICH may cause a residual deformity, such as atrophic skin and subcutaneous tissue. It mainly affects the limbs (52%), but also the head and neck region (42%) and the trunk (6%).
The non-involuting congenital hemangioma
, NICH, presents as a solitary
, well-circumscribed reddish-pink to purple plaque with central telangiectasia
and hypopigmented rim. In contrast to RICH, NICH does not involute and rarely ulcerates. It persists into late childhood and can even mimic a vascular malformation by growing commensurately with the child. Although NICH can resemble RICH in its external appearance, it can be differentiated from RICH by a greater elevation and coarse telangiectases. It mainly affects the head and neck region (43%), but also the limbs (38%) and the trunk (19%).
Surgical resection for congenital hemangiomas is rarely needed, because RICH undergoes postnatal regression and NICH is benign and often asymptomatic. Resection may be indicated to improve the appearance of the affected area, as long as the surgical scar is less noticeable than the lesion. Other indications are problematic ulcers with persistent bleeding or chronic infection.
Although most NICH lesions are non-problematic and do not cause significant deformity, the threshold
for resection of NICH is lower, because it neither involutes, nor responds to pharmacotherapy. RICH tumors are observed until involution is completed. Involuted RICH may leave behind atrophic tissue, which can be reconstructed with autologous grafts. It is often best to postpone excision until regression is complete.
There are effective pharmacologic treatments, which include intralesional corticosteroid injection, systemic corticosteroid injection, interferon α-2a or α-2b and angiogenic inhibitors. The use of corticosteroids leads to accelerated regression in 30%, stabilization of growth in 40%, lightening of color and softening of the tumor. However, 30% shows minimal or no response. Another drug treatment is interferon α-2a or α-2b. It is often used for patients who did not respond to corticosteroids. Although the response rate is much slower, it has been successful for 80% of children treated. The most serious side effect of interferon is a spastic diplegia
. Other therapeutic options are embolization and pulsed-dye laser, which improves residual telangiectasias in RICH and in NICH.
(KHE) is a rare vascular neoplasm that is locally aggressive but without metastatic potential. It occurs particularly in the skin
, deep soft tissue, retroperitoneum
, mediastinum
, and rarely in bone
. Although lesions occur solitary, they often involve large areas of the body, such as the head/neck region (40%), trunk (30%), or extremity (30%).
Usually, it is present at birth as a flat, reddish-purple, tense and edematous lesion.
Although half of lesions are congenital, 58% of KHE develop during infancy, 32% between age 1 and 10 years (32%) and 10% after 11 years of age. Moreover, adult onset has been described too with mainly males being affected. Both sexes are affected equally in children.
Lesions are often greater than 5 cm in diameter and can cause visible deformity and pain. During early childhood, KHE may enlarge and after 2 years of age, it may partially regress. Though, it usually persists longterm.
In addition, 50% of patients suffer from coagulopathy
due to thrombocytopenia
(<25,000/mm3), presenting with petechiae and bleeding. This is called the Kasabach-Meritt Phenomenon, which is caused by trapping of platelets and other clotting factors within the tumor. Kasabach-Meritt Phenomenon is less likely in patients with lesions less than 8 cm. As two-thirds of adult-onset KHE tumors are less than 2 cm, KHE in adults is rarely associated with Kasabach-Meritt Phenomenon.
Patients with KHE and Kasabach-Meritt Phenomenon present with petechiae and ecchymosis
.
Most KHE tumors are diffuse involving multiple tissue planes and important structures. Resection of KHE is thus often difficult. Treatment of kaposiform hemangioendothelioma is therefore medical. The primary drug is interferon alfa, which is successful in 50% of children. Another option is vincristine
, which has lots of side-effects, but has a respons rate of 90%. Drug therapy is often used in shrinking the tumor and treating the coagulopathy. However, many of these kaposiform hemangioendotheliomas do not completely regress and remain as a much smaller asymptomatic tumor. However, KHE stil has a high mortality rate of 30%.
Although complete surgical removal with a large margin has the best reported outcome, it is usually not done because of the risk of bleeding, extensiveness, and the anatomic site of the lesion.
Operative management may be possible for small or localized lesions. Removal of larger areas also may be indicated for symptomatic patients or for patients who have failed farmacotherapy. Resection is not required for lesions that are not causing functional problems, because KHE is benign and because resection could cause deformity.
, also known as lobular capillary hemangioma, is a small benign vascular tumor which primarily involves the skin (88.2%) and mucous membranes. Pyogenic granuloma appears as a red macule that grows rapidly, turns into a papule and eventually becomes pedunculated, being attached to a narrow stalk. The average diameter of these lesions is 6.5 mm. Although these lesions are small, they are often complicated by bleeding, crusting and ulceration. Microscopically, pyogenic granulomas are characterized by vascular proliferation
amidst granulation tissue
and chronic inflammatory infiltrate.
Pyogenic granulomas are rarely congenital. It commonly develops in infants: 42.1% develops within the first 5 years of life. This vascular tumor is twice as common in males as in females and 25% of lesions seem to be associated with trauma, an underlying cutaneous condition, pregnancy, hormonal alterations and medications. Pyogenic granulomas can also arise within a capillary malformation. Of all pyogenic granulomas, 62% is distributed on the head or neck, occurring mainly on the cheek and in the oral cavity. Lesions on the face may cause visible deformity.
Numerous treament methods have been described for pyogenic granuloma. Lesions which involve the reticular dermis
, may be out of the reach of pulsed-dye laser, cautery or shave excision and therefore have a recurrence rate of 43.5%. Definitive management requires full-thickness skin excision. Other options are currettage or laser therapy. Furthermore, thorough currettage and cauterization are often used for small lesions and full-thickness excision for larger lesion.
is a collective term for different disorders of the vasculature (errors in vascular development). It can be a disorder of the capillaries, arteries, venes
and lymphs or a disorder of a combination of these (lesions were named based on the primary vessel that was malformed). A vascular malformation consists of a clew of deformed vessels, due to an error in the vascular development (dysmorphogenesis). However, endothelial turnover is stable in these defects. Congenital vascular malformations are always present at birth, although they are not always visible. In contrast to vascular tumors, vascular malformations do not have a growth phase, nor an involution phase. Vascular malformations tend to grow proportionately with the child. Vascular malformations never regress, but persist throughout life.
Vacular malformations can be divided in slow-flow vascular malformations, fast-flow vascular malformations and complex-combined vascular malformations.
Birthmark
A birthmark is a benign irregularity on the skin which is present at birth or appears shortly after birth, usually in the first month. They can occur anywhere on the skin. Birthmarks are caused by overgrowth of blood vessels, melanocytes, smooth muscle, fat, fibroblasts, or...
caused by a disorder of the vascular development, although it is not always present at birth. A vascular anomaly is a localized defect in blood vessels that can affect each part of the vasculature (capillaries, arteries, veins, lymphatics or a combination of these). These defects are characterized by an increased number of vessels and vessels which are both enlarged and sinuous. Some vascular anomalies are congenital and therefore present at birth, others appear within weeks to years after birth and others are acquired by trauma or during pregnancy. Inherited vascular anomalies are also described and often present with a number of lesions that increase with patients’ age. Vascular anomalies can also be a part of a syndrome
Syndrome
In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms , phenomena or characteristics that often occur together, so that the presence of one or more features alerts the physician to the possible presence of the others...
and, occasionally, they can be acquired by trauma. The estimated prevalence of vascular anomalies is 4.5%. Vascular anomalies can occur throughout the whole body (skin, bone, liver, intestines, i.e.), but in 60% of patients vascular anomalies are localized in the head and neck region.
Vascular anomalies can present in various ways. Vascular anomalies that are situated deep below the skin, appear blue and are often called cavernous. Superfiscial vascular anomalies appear as red-coloured stains and are associated with vascular anomalies affecting the dermis.
Historically, vascular anomalies have been labeled with descriptive terms, according to the food they resembled (port wine, strawberry, cherry, salmon patch). This imprecise terminology has caused diagnostic confusion, blocked communication and even caused incorrect treatment, as it does not differentiate between various vascular anomalies. However, in 1982, Mulliken introduced a classifcation which replaced these descriptive terms and gave direction to the management of various vascular anomalies. This classification, based on clinical features, natural history and cellular characteristics, divides vascular anomalies into two groups: vascular tumors and vascular malformations.
Although the appearance of both vascular tumors and vascular malformations can resemble, there are important differences between both.
| Correct term | Incorrect terminology commoly used to describe vascular anomalies |
|---|---|
| Hemangioma | Strawberry Hemangioma Capillary Hemangioma Cavernous Hemangioma |
| Kaposiform hemangioendothelioma | (Capillary) Hemangioma |
| Pyogenic granuloma | Hemangioma |
| Capillary Malformation | Port-wine stain Capillary Hemangioma |
| Lymphatic Malformation | Lymphangioma Cystic hygroma |
| Venous Malformation | Cavernous Hemangioma |
| Arteriovenous malformation | Arteriovenous Hemangioma |
Vascular tumors
Vascular tumors, often referred to as hemangiomas, are the most common tumors in infants, occurring in 1-2%. Prevalence is even higher (10%) in premature infants of very low birth weight. Vascular tumors are characterized by overgrowth of normal vessels, which show increased endothelial proliferation. It can be present at birth, but often appears within a couple of weeks after birth or during infancy. There are different kinds of vascular tumors, but the 4 most common types are: infantile hemangioma, congenital hemangioma, kaposiform hemangioendotheliomaKaposiform hemangioendothelioma
Kaposiform hemangioendothelioma is an uncommon vascular tumor, first described by Zukerberg, Nickoloff, and Weiss in 1993, that affects infants and young children, with rare cases having also been reported in adults....
and pyogenic granuloma
Pyogenic granuloma
Pyogenic granuloma is a primarily oral disease which appears as an overgrowth of tissue due to irritation, physical trauma or hormonal factors...
.
Infantile Hemangioma
Infantile hemangioma is the most common vascular tumor. It is a benign tumor, which occurs in 4-5% of CaucasianCaucasian
Caucasian may refer to:*Anything from the Caucasus region**Peoples of the Caucasus or Caucasian peoples, humans from the Caucasus region**Languages of the Caucasus, languages spoken in the Caucasus region...
infants, but rarely in dark skinned infants. It occurs in 20% of low weigth premature infants and 2.2 to 4.5 times more frequently in females. IH most commonly presents in the head and neck regio (60%), but also involves the trunk
Trunk
Trunk may refer to:In biology:*Trunk, an elephant's proboscis or nose*Trunk, torso*Trunk , a tree's central superstructureIn containers:*Trunk , a large storage compartment*Trunk...
and extremities
Extremities
Extremities may refer to:* Extremities , a play by William Mastrosimone* Extremities , a film based on the play* limbs of the body, in medical terminology...
. One third of these lesions is present at birth as a telangiectatic stain or ecchymotic area. During the first four weeks of life, 70% to 90% appear. Lesions that are situated beneath the skin may not appear until 3 to 4 months of age, when the tumor is large enough. During the first 9 months, IH undergoes rapidly growth, which is faster than the growth of the child. This is called the proliferating phase. After 9 months, the growth of the tumor will decrease and equal the growth of the child for about 3 months. After 12 months, the tumor will start to involute and might even disappear. Involution stops in one-third of patient by the age of 3 years, in 50% by the age of 5 years and in 72% by the age of 7 years. Involution may result in residual telangiestasis, pallor, atrophy, textural changes and sometimes fibrofatty residuum.
Since 90% of IH is small, localized and asymptomatic
Asymptomatic
In medicine, a disease is considered asymptomatic if a patient is a carrier for a disease or infection but experiences no symptoms. A condition might be asymptomatic if it fails to show the noticeable symptoms with which it is usually associated. Asymptomatic infections are also called subclinical...
, treatment mainly consists of observation and awaiting until involution is complete. IH can be treated with corticosteroids, which accelerate involution: in 95% of patients, growth is stabilized and 75% of tumors decrease in size. Intralesional corticosteroids are most effective, but may require additional injections, as the effect is only temporarily. Systemic corticosteroids may cause lost of side-effects and are only used in problematic IH, which is too large to treat with intralesional injections.
During the proliferating phase, the tumor is highly vascular. Patients who undergo operative treatment during this period, are at risk for blood loss. Moreover, surgery during this phase, often leads to an inferior aesthetic outcome. However, patients may require intervention during childhood, because 50% of IH leave residual fibrofatty tissue, redundant skin, or damaged structures after involution. Waiting until involution is completed, ensures that the least amount of fibro fatty residuum and excess skin is resected, giving the smallest possible scar. Another option for treatment in the pulsed-dye laser. After involution residual telangiectasias can be treated with laser therapy.
Congenital Hemangioma
Congenital hemangioma can be distinguished from infantile hemangioma because it is fully developed at birth. It forms during prenatal life and has reached its maximal size at birth. Congenital hemangioma can even be diagnosed in utero by prenatal ultrasound. Unlike IH, CH is more common in the extremities, has an equal sex distribution, and is solitary, with an average diameter of 5 cm. It commonly presents in the head and neck and in the lower extremities.Congenital hemangioma are divided into 2 subgroups: the rapidly involuting congenital hemangiomas (RICHs) and the non-involuting congenital hemangiomas(NICHs).
The rapidly involuting congenital hemangioma
Rapidly involuting congenital hemangioma
A Rapidly involuting congenital hemangioma is a cutaneous condition characterized by a fully developed congenital hemangioma at birth....
, RICH, presents at birth as a solitary raised tumor with a central depression, scar, or ulceration
Ulceration
Ulceration may refer to:-In medicine:*Ulcer , a discontinuity of the skin or a break in the skin that stops it from continuing its normal functions*Corneal ulcer, an inflammatory or infective condition of the cornea...
surrounded by a rim of pallor. It is noted for its involution which typically begins several weeks after birth and is completed no later than 14 months of age. After regression RICH may cause a residual deformity, such as atrophic skin and subcutaneous tissue. It mainly affects the limbs (52%), but also the head and neck region (42%) and the trunk (6%).
The non-involuting congenital hemangioma
Non-involuting congenital hemangioma
Non-involuting congenital hemangioma is a cutaneous condition, lesions occur slightly more often in male infants and are well developed at birth....
, NICH, presents as a solitary
Solitary
Solitary is the state of being alone. The term may refer to:* shortened form of solitary confinement in jail* Solitary but social, a type of social organization in biology where individuals forage alone but share sleeping space...
, well-circumscribed reddish-pink to purple plaque with central telangiectasia
Telangiectasia
Telangiectasias /tɛ.læn.dʒiː'ɛk.teɪ.ʃi:ə/ are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin...
and hypopigmented rim. In contrast to RICH, NICH does not involute and rarely ulcerates. It persists into late childhood and can even mimic a vascular malformation by growing commensurately with the child. Although NICH can resemble RICH in its external appearance, it can be differentiated from RICH by a greater elevation and coarse telangiectases. It mainly affects the head and neck region (43%), but also the limbs (38%) and the trunk (19%).
Surgical resection for congenital hemangiomas is rarely needed, because RICH undergoes postnatal regression and NICH is benign and often asymptomatic. Resection may be indicated to improve the appearance of the affected area, as long as the surgical scar is less noticeable than the lesion. Other indications are problematic ulcers with persistent bleeding or chronic infection.
Although most NICH lesions are non-problematic and do not cause significant deformity, the threshold
Threshold
-Film and television:* Threshold * Threshold , an adaptation of the 1958 science fiction film It! The Terror from Beyond Space* Threshold , an American science fiction drama series...
for resection of NICH is lower, because it neither involutes, nor responds to pharmacotherapy. RICH tumors are observed until involution is completed. Involuted RICH may leave behind atrophic tissue, which can be reconstructed with autologous grafts. It is often best to postpone excision until regression is complete.
There are effective pharmacologic treatments, which include intralesional corticosteroid injection, systemic corticosteroid injection, interferon α-2a or α-2b and angiogenic inhibitors. The use of corticosteroids leads to accelerated regression in 30%, stabilization of growth in 40%, lightening of color and softening of the tumor. However, 30% shows minimal or no response. Another drug treatment is interferon α-2a or α-2b. It is often used for patients who did not respond to corticosteroids. Although the response rate is much slower, it has been successful for 80% of children treated. The most serious side effect of interferon is a spastic diplegia
Spastic diplegia
Spastic diplegia, historically known as Little's Disease, is a form of cerebral palsy that is a neuromuscular condition of hypertonia and spasticity in the muscles of the lower extremities of the human body, usually those of the legs, hips and pelvis...
. Other therapeutic options are embolization and pulsed-dye laser, which improves residual telangiectasias in RICH and in NICH.
Kaposiform Hemangioendothelioma
Kaposiform hemangioendotheliomaKaposiform hemangioendothelioma
Kaposiform hemangioendothelioma is an uncommon vascular tumor, first described by Zukerberg, Nickoloff, and Weiss in 1993, that affects infants and young children, with rare cases having also been reported in adults....
(KHE) is a rare vascular neoplasm that is locally aggressive but without metastatic potential. It occurs particularly in the skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
, deep soft tissue, retroperitoneum
Retroperitoneum
The retroperitoneal space is the anatomical space in the abdominal cavity behind the peritoneum. It has no specific delineating anatomical structures...
, mediastinum
Mediastinum
The mediastinum is a non-delineated group of structures in the thorax, surrounded by loose connective tissue. It is the central compartment of the thoracic cavity...
, and rarely in bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...
. Although lesions occur solitary, they often involve large areas of the body, such as the head/neck region (40%), trunk (30%), or extremity (30%).
Usually, it is present at birth as a flat, reddish-purple, tense and edematous lesion.
Although half of lesions are congenital, 58% of KHE develop during infancy, 32% between age 1 and 10 years (32%) and 10% after 11 years of age. Moreover, adult onset has been described too with mainly males being affected. Both sexes are affected equally in children.
Lesions are often greater than 5 cm in diameter and can cause visible deformity and pain. During early childhood, KHE may enlarge and after 2 years of age, it may partially regress. Though, it usually persists longterm.
In addition, 50% of patients suffer from coagulopathy
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
due to thrombocytopenia
Thrombocytopenia
Thrombocytopenia is a relative decrease of platelets in blood.A normal human platelet count ranges from 150,000 to 450,000 platelets per microliter of blood. These limits are determined by the 2.5th lower and upper percentile, so values outside this range do not necessarily indicate disease...
(<25,000/mm3), presenting with petechiae and bleeding. This is called the Kasabach-Meritt Phenomenon, which is caused by trapping of platelets and other clotting factors within the tumor. Kasabach-Meritt Phenomenon is less likely in patients with lesions less than 8 cm. As two-thirds of adult-onset KHE tumors are less than 2 cm, KHE in adults is rarely associated with Kasabach-Meritt Phenomenon.
Patients with KHE and Kasabach-Meritt Phenomenon present with petechiae and ecchymosis
Ecchymosis
An ecchymosis is the medical term for a subcutaneous purpura larger than 1 centimeter or a hematoma, commonly called a bruise. It can be located in the skin or in a mucous membrane.-Presentation:...
.
Most KHE tumors are diffuse involving multiple tissue planes and important structures. Resection of KHE is thus often difficult. Treatment of kaposiform hemangioendothelioma is therefore medical. The primary drug is interferon alfa, which is successful in 50% of children. Another option is vincristine
Vincristine
Vincristine , formally known as leurocristine, sometimes abbreviated "VCR", is a vinca alkaloid from the Catharanthus roseus , formerly Vinca rosea and hence its name. It is a mitotic inhibitor, and is used in cancer chemotherapy.-Mechanism:Tubulin is a structural protein that polymerizes to...
, which has lots of side-effects, but has a respons rate of 90%. Drug therapy is often used in shrinking the tumor and treating the coagulopathy. However, many of these kaposiform hemangioendotheliomas do not completely regress and remain as a much smaller asymptomatic tumor. However, KHE stil has a high mortality rate of 30%.
Although complete surgical removal with a large margin has the best reported outcome, it is usually not done because of the risk of bleeding, extensiveness, and the anatomic site of the lesion.
Operative management may be possible for small or localized lesions. Removal of larger areas also may be indicated for symptomatic patients or for patients who have failed farmacotherapy. Resection is not required for lesions that are not causing functional problems, because KHE is benign and because resection could cause deformity.
Pyogenic granuloma
Pyogenic granulomaPyogenic granuloma
Pyogenic granuloma is a primarily oral disease which appears as an overgrowth of tissue due to irritation, physical trauma or hormonal factors...
, also known as lobular capillary hemangioma, is a small benign vascular tumor which primarily involves the skin (88.2%) and mucous membranes. Pyogenic granuloma appears as a red macule that grows rapidly, turns into a papule and eventually becomes pedunculated, being attached to a narrow stalk. The average diameter of these lesions is 6.5 mm. Although these lesions are small, they are often complicated by bleeding, crusting and ulceration. Microscopically, pyogenic granulomas are characterized by vascular proliferation
Proliferation
Proliferation may refer to:*Nuclear proliferation*Chemical weapon proliferation*Cell proliferation* The proliferative phase of wound healing...
amidst granulation tissue
Granulation tissue
Granulation tissue is the perfused, fibrous connective tissue that replaces a fibrin clot in healing wounds. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size it heals...
and chronic inflammatory infiltrate.
Pyogenic granulomas are rarely congenital. It commonly develops in infants: 42.1% develops within the first 5 years of life. This vascular tumor is twice as common in males as in females and 25% of lesions seem to be associated with trauma, an underlying cutaneous condition, pregnancy, hormonal alterations and medications. Pyogenic granulomas can also arise within a capillary malformation. Of all pyogenic granulomas, 62% is distributed on the head or neck, occurring mainly on the cheek and in the oral cavity. Lesions on the face may cause visible deformity.
Numerous treament methods have been described for pyogenic granuloma. Lesions which involve the reticular dermis
Reticular dermis
The reticular dermis is the lower layer of the dermis, found under the papillary dermis, composed of dense irregular connective tissue featuring densely packed collagen fibers. It is the primary location of dermal elastic fibers....
, may be out of the reach of pulsed-dye laser, cautery or shave excision and therefore have a recurrence rate of 43.5%. Definitive management requires full-thickness skin excision. Other options are currettage or laser therapy. Furthermore, thorough currettage and cauterization are often used for small lesions and full-thickness excision for larger lesion.
Vascular malformations
Vascular malformationVascular malformation
Vascular malformation is a term used to refer to blood vessel abnormalities. Vascular malformations and vascular tumors both belong to vascular anomaliesThere are many types, but the most common is arteriovenous malformation....
is a collective term for different disorders of the vasculature (errors in vascular development). It can be a disorder of the capillaries, arteries, venes
Vénès
Vénès is a commune in the Tarn department in southern France.-References:*...
and lymphs or a disorder of a combination of these (lesions were named based on the primary vessel that was malformed). A vascular malformation consists of a clew of deformed vessels, due to an error in the vascular development (dysmorphogenesis). However, endothelial turnover is stable in these defects. Congenital vascular malformations are always present at birth, although they are not always visible. In contrast to vascular tumors, vascular malformations do not have a growth phase, nor an involution phase. Vascular malformations tend to grow proportionately with the child. Vascular malformations never regress, but persist throughout life.
Vacular malformations can be divided in slow-flow vascular malformations, fast-flow vascular malformations and complex-combined vascular malformations.
Slow-flow vascular malformations
- Capillary malformation (also known as port-wine stain): Capillary malformations are flat, reddish lesions that typically affect the skin, mostly around the head and the neck, who darken with age, contrary to birthmarks such as salmon patch, Nevus simplex or vascular stain, who lighten or disappear within the first few years of life. Capillary malformations are 11% of the vascular malformations. Syndromes associated with capillary malformations are: Sturge-Weber syndromeSturge-Weber syndromeSturge–Weber syndrome, sometimes referred to as encephalotrigeminal angiomatosis, is a rare congenital neurological and skin disorder. It is one of the phakomatoses and is often associated with port-wine stains of the face, glaucoma, seizures, mental retardation, and ipsilateral leptomeningeal...
and Klippel-Trenaunay syndrome. Capillary malformations can be treated with IPLIPL-Sports:* Indian Premier League, a cricket league* Indonesian Premier League, a football league* Iran Pro League, a football league* Irish Premier League, a former football league* Israeli Premier League, a football league-Computing :* IBM Public License...
-(Intensed-pulsed-light)-therapy or surgical reduction.
- Venous malformation is a bluish lesion compressible on palpation, the masses enlarge with physical activity or a dependent position. The bluish lesion is caused by dilated venous channels. Venous malformations can be painful in the morning due to stasis and microthrombi within the veins. Venous malformations’ localization is usually in the head and neck. Venous malformations are the most common vascular anomaly, they are 40% of all vascular malformations. Venous malformation can be treated with sclerotherapySclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
and surgical reduction
- Lymphatic malformation is a benign growth of the lymphatic system. They result from a blockage or defect of the lymphatic vessels as they are forming. 28% of all vascular malformations consists of lymphatic malformations. Lymphatic malformations can be treated with sclerotherapySclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
and surgical reduction
Fast flow vascular malformtations
All fast flow malformations are malformations with an arterial type in it. Contain bout 14% of the vascular malformations.- Arterial malformation
- Arteriovenous fistulaArteriovenous fistulaAn arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm....
(AVF) : a lesion with a direct transition in fistulas between an artery and a vein.
- Arteriovenous malformationArteriovenous malformationArteriovenous malformation or AVM is an abnormal connection between veins and arteries, usually congenital. This pathology is widely known because of its occurrence in the central nervous system, but can appear in any location. An arteriovenous malformation is a vascular anomaly. It is a...
: a lesion with a direct connection between an artery and a vein, without an intervening cappillary bed, but with an interposed nidus of dysplastic vascular channels in between.
Combined-complex vascular malformations
a combination of various vascular malformations. They are complex because they’re a combination of two different types of vessels.- CVM: capillary venous malformation
- CLM: capillary lymphatic malformation
- LVM: lymphatic venous malformation
- CLVM: capillary lymphatic venous malformation. CLVM is associated with Klippel-Trenaunay syndrome
- AVM-LM: Arteriovenous malformation- lymphatic malformation
- CM-AVM: capillary malformation- arteriovenous malformation