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Hemangioma |
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The most common benign (non-cancerous) tumor in infants are hemangiomas.
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Hemangiomas is a benign tumor of endothelial cells that normally line the blood vessels. These cells multiply at an abnormally rapid rate and form tightly packed vascular channels (extra blood vessels).
Hemangioma usually appear shortly after birth and grow quickly during the first year, called the proliferative phase. This is followed by a much slower process of shrinking, or regressing called the involuting phase, which may take from one to about seven years. Thereafter, the tumor enters its final, shrunken state called the involuted phase, after which it will never regrow.
Regression of the hemangioma is complete in 50 percent of children by age 5 and in 70 percent of children by age 7. By the time a child reaches 10 to 12 years of age, involution of the tumor is complete. Some residual fatty tissue or thin skin may remain after involution.
Hemangiomas that begin in the womb and are fully grown at birth are extremely rare; they are called congenital hemangiomas. They do not grow after birth and they behave differently:
- some shirk by 17-14 months and are called "rapidly involuting congenital hemangiomas" (RICH)
- and others persist called "non-involuting congenital hemangiomas" (NICH).
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- Hemangiomas are the most common tumors in infancy and childhood.
- Hemangiomas are three to five times more common in females (especially fair-skinned) than in males.
- They occur more frequently in Caucasian infants than in Asian infants.
- Between 4 and 10 percent of Caucasian infants have at least one hemangioma by one year.
- They are rare in African-American infants.
- The incidence of hemangiomas can be as high as 25 percent in premature infants of a low birth weight (fewer than 1,000 grams).
- Hemangiomas also occur more frequently in twins.
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Hemangiomas are not usually hereditary, although 10 percent of infants have a family history of these vascular birthmarks. Although the exact cause is not yet known, researchers at Children's Hospital Boston are close an answer. Studies have shown that the abnormal hemangioma endothelial cells carry a mutation and derive from an early stem cell.
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About one-third of the time, hemangioma's first signs are noticed while the child is in the hospital nursery. The average age when hemangioma appears is two weeks. Hemangiomas never develop in an adult.
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- Approximately 60 percent of hemangiomas occur in the head and neck area.
- About 25 percent occur in the trunk.
- 15 percent occur in the arms or legs.
- Most (about 80 percent) hemangiomas grow as a single tumor.
- About 20 percent occur in multiple areas.
In addition to the skin, multiple hemangiomas can develop in virtually any internal organ, especially the liver, and also the brain and gastrointestinal tract.
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Hemangiomas appear in many forms- from well-localized lumps to flat extensive (sheet like) lesions.
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The appearance of a hemangioma depends on many factors, including whether it is:
- superficial or deep
- in the growing (proliferation), shrinking (involution) or shrunken (involuted) phase
- congenital (fully grown at birth) or appears shortly after birth.
If the tumor is near the skin surface is called a "superficial" hemangioma. It often looks like a raised bright red patch, sometimes with a textured surface (hence the once-commonly used term "strawberry hemangioma"). Veins radiating from the tumor may also be visible beneath the skin. As the hemangioma begins to involute, or shrink, the red color fades. Usually, the last traces of color are gone by the time the child reaches 7 years.
A tumor that grows in the lower layers of the skin or in the muscle, called "deep" hemangioma, appears bruise-like or bluish or may not be visible at all. These deep forms are often not found until two to four months of age.
Congenital hemangiomas look different than the more common type that grows after birth. They are enlarged at birth and have a grayish cast with prominent veins and may be encircled by a pale halo.
Many parents find it reassuring to see before and after photographs of children who have had a hemangioma similar to their child's tumor. This gives them an idea of what to expect at each stage of the tumor's development or after treatment.
Parents who view these images need to keep in mind that every child's tumor is unique, therefore their child's outcome may be different. The child's primary care physician or vascular anomalies specialist is the best source of information about what a particular child's outcome will most likely be.
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There are no ways to prevent hemangiomas. Nothing the mother does or does not do prior to or during pregnancy plays any role in whether her child develops a hemangioma.
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Since the majority of hemangiomas are small and disappear on their own without any treatment, it is usually not necessary for a child to be seen by a specialist in vascular anomalies. The child should be followed by a primary care physician, who can monitor the lesion, provide support and reassurance, and contact a vascular anomalies specialist if the situation warrants.
There are exceptions. A child should be referred to a vascular anomalies specialist if the diagnosis is unclear or if the hemangioma is large, growing rapidly, or at risk of causing endangering or disfiguring complications.
A child who has multiple hemangiomas in the skin should also be evaluated by a vascular anomalies specialist, as this sometimes signifies that there is a hemangioma in an internal organ, such as the liver or gastrointestinal tract. These can be life-threatening and require treatment.
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While complications are uncommon, they can occur in some children. Complications include ulceration (skin breakdown), which can bleed or become infected; obstruction of vital functions such as vision, or breathing; distortion of facial features; and, very rarely, internal bleeding or high output cardiac (heart) failure resulting from a large hemangioma in an internal organ. Only about 1 percent of hemangiomas cause life-threatening complications.
About 5 percent to 10 percent of children with a hemangioma develop an ulcer, typically on the lip or the peri anal region. An ulcer is usually effectively treated with topical antibiotics and frequent cleansing and dressings. Sometimes oral medications or surgical or resection may be necessary. Bleeding, which is rare, can usually be controlled by applying pressure to the area. An ulcer usually heals within a few weeks and does not recur. Nevertheless, ulceration results in scarring that may require surgical treatment.
Hemangiomas that obstruct an airway or interfere with vision, or eating require prompt treatment. An infant with a hemangioma in the upper eyelid, even a small one, should be immediately evaluated by a pediatric ophthalmologist (eye doctor), as these can permanently affect the child's vision. Usually drug therapy is needed; some well-localized eyelid hemangiomas can be surgically removed
Because of their size or location, some hemangiomas can cause distortion of facial features. To prevent permanent tissue damage and/or subsequent emotional trauma, these may require drug treatment to slow their growth and shrink the tumor.
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Most hemangiomas are diagnosed by examining the child and correlating the physical findings with the medical history. An accurate diagnosis can be made in more than 90 percent of infants. It is essential that an accurate diagnosis be made because some vascular birthmarks look like an infantile hemangioma but may, in fact, be a vascular malformation. A vascular malformation is different than a hemangioma and requires an entirely different treatment approach.
If there is any uncertainty about whether a vascular birthmark is a hemangioma or a vascular malformation, ultrasonography, a non-invasive diagnostic tool, usually provides a definitive answer. In some instances, magnetic resonance imaging (MRI), which is also non-invasive radiological test, may be necessary to make the diagnosis and determine the extent of the tumor.
If there is any suspicion of a malignancy (cancer), a biopsy should be performed. A biopsy involves removing a small section of tumor tissue for microscopic examination by a pathologist.
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Most hemangiomas do not require any treatment (other than observation) because they slowly go away on their own. In most children, they disappear completely, leaving normal or slightly blemished skin. In some children, loose skin, discoloration, or tiny, dilated blood vessels called telangiectasias may remain after the hemangioma has fully involuted. Surgical removal or laser therapy to improve the child's appearance may be advised, usually before the child starts school.
Some hemangiomas require early medical attention, either because they are disfiguring or might endanger the child's normal functions or life. These include hemangiomas that obstruct essential functions such as breathing, vision, or hearing; ulcerate or frequently bleed or become infected; or distort facial features.
The usual treatment options for hemangioma include medications and/or an operation. The most common drug therapy is corticosteroid (given by injection directly into the tumor or taken orally). Vincristine (an anti cancer drug given intravenously) and rarely interferon (given by daily injection) may be needed to treat a life-threatening vascular tumor.
For some hemangiomas, such as eyelid tumors that do not respond to medication or tumors that obstruct the airway, removal may be advised. An operation to remove a disfiguring hemangioma that is not fully involuted may sometimes be recommended to spare a child emotional distress. The benefits of an early operation must be carefully weighed against the appearance of scarring, which occurs in every operation.
Laser therapy is not recommended for growing hemangiomas and may, in fact, cause scarring. Pulsed-dye laser only lightens the surface color. CO2 laser may be used for removing hemangioma inside the child's airway.Laser therapy is effective for removing telangiectasias that may remain after the hemangioma has involuted.
Rarely, embolization a procedure in which particles are injected into the blood vessels to stop the blood flow, is used to treat children with complications from a liver hemangioma or to stop bleeding that does not respond to medication.
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