Classification and Treatment of Vascular Malformations and tumours & Laser

Associate Clinical Prof Agneta Troilius Rubin, MD, PhD Laser & Vascular Lesion Section at the Dep of Dermatology University Hospital Malmö, Sweden LASER

Apfelberg • Light • Amplification by • Stimulated • Emission of • Radiation Laser

• Man skapar ljus med särskild våglängd – kraftigt förstärkt • Effekt beroende på våglängd (nm), energi, färg på objektet (chromofor i huden) Våglängder, absorbtionskurva Kromoforer i hud

• Melanin • Hemoglobin • Vatten Mutidiciplinary Vascular Anomaly Group in Malmö, Sweden IRA

Prolifierande hemangiom Segmental hemangioma

Oral steroids & Vacsular lasers Efter steroidtabletter 6 injektioner& laser oral steroids & multiple pulsed dye Ärr efter Cryo Efter multipla PDL beh. behandling o steroider I feel very privileged!

plastic surgery remains Married! Vascular Lasers and Intense Pulsed Light Sources

• Alexandrite 755 nm, long puls • Nd:YAG- 532 nm, 1064 long pulse • Krypton - 568 nm – green • KTP 532 nm, 5-50 J, 1ms • Copper vapor - 578 nm - yellow • Pulsed dye – 585, 595 nm, longpulses – yellow • Diode - 800 nm • Intense pulsed light sources - 515- 690nm, 555-950 nm

• COOLING! Absorptions spektrum HbO2

10641064 IPL = Intense pulsed light Good for many things… • Hair removal • Vascular lesions • Photorejuvenation • PDT • Melasma – superficial • Superficial pigmented lesions • Acne • Scars Radiation dermatitis

Before and after 3 PDL tx with low fluence 3-4 J/cm2 Breast cancer Radiation dermatitis after PDL

Classification of Congenital Vascular Anomalies

I Tumors – arise by endothelial hyperplasia

II Malformations - arise by dysmorphogenesis - normal endothelial turnover Mulliken and Glowacki`s Classification of Congenital Vascular Anomalies

• I. Tumors • II. Malformations

Hemangioma capillary lymphatic Others venous arteriovenous

combined Hemangiomas

• > 30 % are seen at birth • 2 periods of rapid post-natal growth (early infancy and 4-6 months of age)

• involution starts around 1 year of age and takes around 5-12 years The Life Cycle of a Hemangioma (Schematic Representation)

Group A 60% complete involution

Group B 10% complete involution

Growth

A B

1 6 12

AGE (yrs.) Haemangioma

• Incidence 4-10% of infants

• Higher in females 4:1 and in white skin • 80% single • 20 % proliferate in skin and other organ systems (liver,GE, brain) • 15 % difficult, of these 1% mortality! Diagnosis

• Medical history • Physical examination  accurate > 90 % of infants!

MR Ultrasonography Experienced radiologist!

After PDL Hemangioma

after 6 PDL

Growth may impair vision!

Treat early! Ulcerating hemangiomas are painful!

After 1 I2PL tx

Excison also posssible! Ulcerating Hemangioma before & after long pulsed GentleYAG with Cryo, topical steroid gr IV & compression

Infection, painful, imobile! Hemangiomas: Nomenclature

Excision! Hemangiomas: Nomenclature

Excision! Systemic Hemangiomatosis

> 5 Hemangiomas

Abdominal Ultrasound – Flow through hepatic artery and vein?

Abdominal MRI

• Thyroid function tests incl.TSH Kassabach Merritt phenomenon Profound trombocytopenia with bleeding!

1.Kaposiform hemangioendothelioma 2.Tufted angioma

Systemic steroids or Vincristin PHACES syndrome

• Posterior fossa malformation • Hemangioma (facial) • Arterial malformation • Cardiac malformation • Eye abnormalities • Sternal raphe Retrospective study In 94 / 109 = PDL laser tx 86 % clear signs of Results of treatment

70 regression

60 58

50 multiple signs of involution 44

40 proliferation slowed down

minimal impact 30 still in treatment, yet no

Treated patients (109) results 20

10

3 4

0 Propranolol treatment have revolutionized the treatment of Hemangiom Side effects of Propranolol mainly the first weeks 50 % of our patients • Sleeping disturbances- most common (20 % of growns up) • Cold hands and feet • Diarrea

• Risk: Hypoglycemia Astma Ulcerating segmentell prolierative hemangioma at the age of 2 m Before and 8 days/ 6 m after Laser & Propranolol

antibiotic Cleared at the age of 8 m Segmentel Hemangioma after Longpulsed YAG laser with good result at the age of 4 yrs

Still high flow , warm and sometimes painful.

Did not respond to Propranolol during 1 ½ m II Vascular malformations

Capillary Venous Lymphatic Arteriovenous Mulliken and Glowacki`s Classification of Congenital Vascular Anomalies

• I. Tumors • II. Malformations hemangioma capillary lymphatic venous others arteriovenous

combined Capillary malformations Capillary malformation = port wine stain

• congenital • 0.3 – 2.1% • equal between races and sex • grows with the child • no involution • ev. hypertrophic with age Ytligare på bål & extremiteter (A Troilius et al. Acta Derm Venereol 2000;80:196-199)

Hals, bål, arm lättare att beh. än ansikte

(Ackerman G et al. Lasers Med Sci. Jun;17(2):70-8) Grade I - IV Waner et al,1999

• Grade I • youngest • pale or light pink macula • smallest vessel 50- 80 m • magnific x 6, transill. • Grade II • clearly marked macula • makroscopic vessels • 80-120 m

(Waner & Suen,1999) • Grade III • red macula • more marked vessels where dead ends are seen • 120 - 150 m

(Waner & Suen, 1999) Grade IV thick, purple, palperble, dilatated vessels >150 m

Recurrence ?

• 26 % (32 / 122) a few months – 2 (-4) years after PDL

(Troilius A, Thesis - Characterisation amd treatment of Port Wine Stains… 1999)

Histology before and 6 w after 532 nm Sturge Weber syndrome before and after make up Konklusion

Behandla tidigt!

• Psychosociala reaktioner förbättrades efter behandling!

(Äldre mer negativa än yngre)

A Troilius et al. British J Dermatol 1998;139:59-65 and Dermatol Surg 2000;26:190-196) ”Nothing has so marked an in fluence on the direction of man´s mind as his appearance, and not his appearance itself as much as his conviction that it is attractive or unattractive”

/Tolstoj/ II Vascular malformations

Capillary

Venous

Lymphatic

Arteriovenous Venous malformations

• Present at birth (not always evident) as a spongy blue mass or a faint bluish patch • May flatten by pressure • Enlarge and worsen until puberty or later to a lesser degree • Pain and stiffness Venous

• Swell and enlarge in declive and proclive positions and in efforts • Thin-walled, dilated, sponge-like abnormal channels • Pheboliths are palpable Venous

Solitary, but mutiple cutaneous or visceral can occur

No involution

May infiltrate the skin, the muscles, bones and joints (mainly limbs) Treatment of Venous Malformations

Laser Laser Sclerotherapy Photocoagulation Photocoagulation

Surgical excision Venus malformation under sole after Diode 810 nm, 80 W, 55 ms, 3 Hz, 2mm spot, contact cooling

before

after VM after diode 810 nm, 50 ms, 80W

Contact cooling before & after Absorption spectrum HbO2

10641064 Venous malformation

after alcohol inj. and long pulse Nd:YAG 532 cooling Milton Waner, Little Rocks, Arkansas II Vascular malformations

Capillary

Venous

Lymphatic

Arteriovenous Lymfangiom Lymphatic

• Congenital • 65-75% diagnosed at birth • 80-90 % diagnosed by the end of second year • Stress, hormonal surge, infection, trauma  increased volume of lymph Lymphatic treatment • I Microcystic infiltrating with clear vesicles on the top  staged excision

superficial  CO2

• II Macrocystic – puncture (only temporary decompression), sclerotherapy, Glue OK-432 (a killed strain of group A Streptocoocus)

• III Combined Lymphatic - diagnosis

•Ultrasonography •CT scans or MRI •Direct puncture of lesion Lymphatic Malformations: Treatment Macrocystic Mucosal Microcystic

OK 432 CO 2 Surgical excision sclerotherapy Laser ablation Lymphatic

after surgery

Prof Magnus Åberg, Plastic Surgery, Malmö, Sweden II Vascular malformations

Capillary

Venous

Lymphatic

Arteriovenous A-V

• Usually visible at birth or during childhood • Mimic a PWS or Hemangioma

• Warm, throbbing

• High flow • Multiple AV fistulas AV

• Hormonal factors and traumas may induce evolutivity - thrill, increase in local heat and bruit - draining veins tortuous and tense Ärr Erbium o CO2 Ärr för o efter laser Tuberös skleros efter 1

Ultrapuls CO 2 behandling

After 1 CO2 Hidradenitis suppurativa Hidradentitis suppurativa

• Inflammaion kring apokrina svettkörtlar och hårsäckar – smärtsamma akneliknande bölder, fistlar och ärrbildning i axiller, ljumskar, genitalt • Uttalad sjukdom, mycket lidande • Rökstopp, viktnedgång, lokal aknebehandling, tetracykliner, excision med CO2-laser, Humira? Before & after 4-8 tx I2PL CO2 laser – our tx of choice!

• Excision - focused 3 mm collimated beam 0.2 mm spot, CW, 20 W • Vaporisation , • Secondary healing ~ 4 w Hair Efter 6 behandlingar med Ellipse

• Nu rakning varannan vecka

Medfödd faun tail (= focal lumbo- sacral hypertrichosis)

Efter 3 behandlingar Pigment Q-switched frequency doubled Nd:YAG Biomechanics - Incompletly understood

• Photoaccustic waves heat tatto pigment causing cavitation, rupture - phagocystosis - removal by macrophags

• Vacuolation with complete clearance of tattoo particles in most superficial dermis (formation of atomic species and gaseous products which are rapidly dissolved in extracellular fluid) Before and after 1 – 2 tx I2PL Epidermalt naevus

4 tx pulsed dye 510nm Tatueringar 4 tx - QS Nd:Yag 4 tx QS Nd:Yag Goitre Ethiopian Medicin tattoo for 17 years ago

Skintype V

After several QS Nd:YAG 1064 nm Allergic reaction from red after 2 tx QS Nd;YAG

Epicutaneous test: 0

No history of mercury allergy

Histology – deep perivascular dermatitits

Erbium removal ? A Troilius, 2000 Health risks!

• Both when applied and when broken up via laser removal • Heavy metals & azo dyes

– Medical Laser Report, April 2006 Traumatic tattoos Traumatisk tatuering maskara

Efter 3 QS Nd:Yag Traumatisk tatuering billack 11 tx QS Nd:Yag Militär explosion 3 tx QS Nd:Yag Rocket explosion

After 6 QS Nd:YAG 1064 nm, 5-6 J/cm2 Warning! • Laser ignition of traumatically embedded gunpowder

• only if being shot at a short distance from the skin

visible sparks and focal projectile ejection of skin with pox-like scar formation

Fusade T et al.Dermatol Surg 2000 Nov;26 before after

Future?