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Vascular Malformations, Tumors, and Hemangiomas

  • Vascular malformations, tumors and hemangiomas all refer to a variety of non-cancerous birthmarks and lesions. Boston Children's Hospital is home to internationally renowned physicians for their expertise and innovative contributions to this highly specialized field.

    Hemangiomas

    • Infantile hemangiomas are the most common type of vascular anomaly
    • They are a benign (noncancerous) tumor
    • Occur in 4 to 10 percent of infants and more frequently in premature babies
    • Growths are typically noticed in the first two weeks of life
    • They enlarge rapidly, outpacing the rest of the body's growth for the first year
    • After infancy, they slowly regress
    • Usually fully involutes (shrink) by 5 to 7 years old
    • Some residual fatty tissue or thin skin may remain after involution

    Vascular malformations

    • Vascular malformations are benign (non-cancerous) lesions

    • They are present at birth, but may not become visible for weeks or months after birth

    • Unlike hemangiomas, vascular malformations do not have a growth cycle and then regress but instead continue to grow slowly throughout life.

    How Boston Children's Hospital approaches vascular anomalies

    The Vascular Anomalies Center at Boston Children's Hospital offers the latest diagnostic and treatment approaches, some of which were pioneered by our staff. Our team provides comprehensive consultation services to physicians and families worldwide, including referrals to local medical centers and physicians when appropriate.

    The Vascular Anomalies Center (VAC) at Children's is composed of a unique interdisciplinary team of 26 physicians, representing 18 departments, who have developed sub-sub specialization in the field of vascular anomalies. Many of these physicians are internationally renowned for their expertise and innovative contributions to this highly specialized field.

  • What causes a hemangioma or vascular malformation?

    A hemangioma is a benign (noncancerous) tumor formed by an abnormally dense group of endothelial cells (the cells that normally line the blood vessels).  The exact cause remains unknown.

    Most vascular malformations are sporadic (occurring by chance), though some are inherited in a family as an autosomal dominant trait. Autosomal dominant means that one gene is necessary to express the condition, and the gene is passed from parent to child with a 50/50 risk for each pregnancy. Males and females are equally affected and there is great variability in expression of the gene. In other words, a parent may unknowingly have had a hemangioma because it faded, but your child is more severely affected. The family may not come to the attention of a geneticist until the birth of the child with a more severe condition.

    What are some of the types of vascular malformation?

    There are several types of vascular malformations:

    • Capillary (port wine stains) always present at birth as pink or purple skin patches
    • Venous often confused with a hemangioma, these malformations are soft to the touch and the color disappears when compressed. They are most commonly found on the jaw, cheek, tongue and lips
    • Lymphatic formed when excess fluid accumulates within the lymphatic vessels
    • Arteriovenous abnormal connections between arteries and veins, resulting in a high flow, pulsating collections of blood vessels
    • Mixed - a combination of any of the other four types

    Symptoms

    What are the symptoms of a Vascular Malformations and Hemangiomas?

    Hemangiomas can be superficial or deep and most commonly have the following symptoms:

    • Superficial hemangiomas appear as bright red, flat or raised patches on the skin
    • Deep ones growing below the surface may not have an obvious outward appearance
    • Both types are usually compressible to the touch
    • They most often grow in the head or neck area, but they can involve any part of the body, including major organs
    • Their size is variable and while most patients only have one lesion, multiple hemangiomas can occur

    Vascular malformation symptoms are highly variable and depend on the type, size and location of the malformation.  Symptoms may be absent altogether or life threatening if it’s an arteriovenous malformation (AVM).

    Common arteriovenous vascular malformation symptoms include:

  • For all vascular anomalies, your child's physician will perform a careful medical history and physical examination. 

    Most hemangiomas are easily identified without any diagnostic testing. Deeper lesions may require the following diagnostic tests to evaluate the extent of the hemangioma:

    • Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

    • Ultrasound - an imaging technology that uses high frequency sound waves to view internal organs and structures and produce diagnostic pictures of the human body. Ultrasound is sometimes useful to detect soft tissue masses.

    Often times vascular anomalies are not found until they hemorrhage.  If your physician suspects a vascular anomaly, particularly an AVM, they may perform the following diagnostic tests:

    • Magnetic resonance imaging (MRI)

    • Computerized tomography scan (Also called a CT or CAT scan.) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

  • Most hemangiomas are small and non-problematic and won't require treatment.  However, the tumor should be monitored, especially if its obstructing vital structures such as eyes or throat, or if it ulcerates (bleeds). Also, if a child has multiple hemangiomas, they are at greater risk for internal lesions and patients should be referred to a specialist. 

    Your child's physician may decide to treat a problematic hemangioma with the following:

    • corticosteroid or other drugs
    • surgical removal
    • embolization of the blood vessels (injection of material into the blood vessels to block the blood inflow)

    In the case of large and/or life-threatening lesions, your child should be evaluated by an interdisciplinary team of specialists that includes plastic surgeons, dermatologists, ophthalmologists, radiologists, and other specialists, depending on what organs are involved.

    Because children may have a residual deformity following involution of the hemangioma, many are referred to a plastic surgeon to discuss reconstructive options.

    Treatment for vascular malformations at Boston Children's Hospital

    Treatment for vascular malformations depends upon the type, but may include the following:

    • For port wine stains, laser therapy is usually recommended

    • Arterial malformations are often treated by embolization (blood flow into malformation is blocked by injecting material near the lesion)

    • Venous malformations are usually treated by direct injection of a sclerosing (clotting) medication, which causes clotting of the channels

    Most often, a combination of these various treatments is used for effective management of the vascular anomaly.

  • Clinical research conducted by investigators in the Vascular Anomalies Center has resulted in new, more effective treatments. For example, the center's investigators were the first to use interferon alpha in the treatment of children with large life- or vision-threatening hemangiomas. Dr. Mulliken has described a simple technique for removal of hemangioma leaving a smaller scar than with conventional methods. In addition, Dr. Fishman has developed novel approaches to control intestinal bleeding caused by certain colorectal vascular malformations, such as blue rubber bleb nevus syndrome.

    Research Underway

    Some institutions have started treating hemangiomas with a beta blocker called propranolol; however, its effectiveness and risks compared to corticosteroid have not been studied. To find out more, Children's Vascular Anomalies Center is currently recruiting patients for a prospective, randomized trail to determine the safety and efficacy of propranolol versus corticosteroid.

    Research by Joyce Bischoff, PhD, Research Associate for Children's Vascular Biology Program, is revealing some causes of infantile hemangioma. Her research indicates that hemangioma growth may be due to an in utero mutation in a stem cell destined to become an endothelial cell. The mutation then causes the endothelial cells to multiply at an abnormal rate leading to the hemangioma. Dr. Bischoff and colleagues are currently working to identify potential medication to target this cell, thereby halting the growth or preventing its enlargement altogether.

    Vascular anomalies—birthmarks caused by abnormal development of lymph or blood vessels—are usually relatively stable. But sometimes they progress rapidly, requiring aggressive treatment to save the child's health or vision. Children's is investigating how urine testing can help predict when an anomaly is about to become a serious threat, and raises the possibility of new drug treatments.

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