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Infantile Hemangiomas and Malformations) Treat with confidence. Trusted answers from the American Academy of Pediatrics. Early Diagnosis and Intervention of Vascular Anomalies (Infantile Hemangiomas and Malformations) Bernard A. Cohen, MD, FAAP Professor of Dermatology and Pediatrics Johns Hopkins Center Linda Rozell-Shannon, PhD President and Founder Vascular Birthmarks Foundation Treat with confidence. Trusted answers from the American Academy of Pediatrics. Disclaimer . Presenter Bernard A. Cohen, MD, FAAP o I have no financial disclosures. o I am a member of the International Society for the Study of Vascular Anomalies (ISSVA). o There is finally a US Food and Drug Administration (FDA)-approved treatment for infantile hemangiomas. o I will discuss off-label use of medications for infantile hemangiomas. o Darrow DH, Greene AK, Mancini AJ, Nopper AJ, American Academy of Pediatrics Section on Dermatology, Section on Otolaryngology–Head and Neck Surgery, and Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015;136(4):e1060–e1104. Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenters have complete and independent control over the planning and content of the presentation, and are not receiving any compensation from Mead Johnson for this presentation. The presenters’ comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label. Treat with confidence. Trusted answers from the American Academy of Pediatrics. What’s new (and old but relevant) on Infantile Hemangiomas (and other assorted vascular lesions) Treat with confidence. Trusted answers from the American Academy of Pediatrics. Webinar Outline . Definitions…vascular tumors of infancy . Pathogenesis, morphology, course . Management of uncomplicated infantile hemangioma (IH) . High risk lesions…segmental, PHACES . New variants you should know . Rx options for complicated lesions Treat with confidence. Trusted answers from the American Academy of Pediatrics. First a little quiz… Hemangioma (A) or malformation (B)? Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D ArteriovenousA Capillary E CombinedB Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence.Hemangioma Trusted answers from the (A) American or Academy malformation of Pediatrics. (B)? HemangiomaTreat with confidence. Trusted answers(A) orfrom themalformation American Academy of Pediatrics. (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined HemangiomaTreat with confidence. Trusted answers(A) fromor the malformation American Academy of Pediatrics. (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma (A) or malformation (B)? A Capillary B Venous C Lymphatic D Arteriovenous E Combined Treat with confidence. Trusted answers from the American Academy of Pediatrics. Vascular Tumor vs Vascular Malformation Vascular anomalies Vascular Vascular tumor malformation Kaposiform Tufted Venous, arterial, Infantile hemangioendo- angioma and AVM, capillary, hemangioma thelioma other tumors lymphatic Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plast Reconstr Surg. 1982;69(3):412–422; Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol. 1997;13:375–423; and Workshops of the International Society for the Study of Vascular Anomalies (ISSVA): 1996 and April 2014 (www.issva.org/workshops). Treat with confidence. Trusted answers from the American Academy of Pediatrics. Definitions: Distinguish from Vascular Malformations Infantile Hemangioma Vascular Malformation . Usually not present . Present at birth at birth . Dynamic . Static . Regressing . Persistent . Proliferative . Non-proliferative Treat with confidence. Trusted answers from the American Academy of Pediatrics. Infantile Hemangiomas . Incidence 8–10% at 2 months (<1% of newborns) . Family history 8–10% . Location o Head, neck 50% o Trunk 30% o Extremities 20% (Data from multiple observational studies over last 5 decades.) Treat with confidence. Trusted answers from the American Academy of Pediatrics. Newer Epidemiologic Data . Female predominance: 2.4:1 o Previously published: 1.4–4:1 . White, non-Hispanic . Twins – usually only 1 affected . Mothers – increased age, placental abnormalities . Prematurity . Low birth weight o #1 risk factor for IH o For every 500-g decrease in birth weight, risk of IH increases 25% o Hemangiomas in 1 in 4 infants <1,000 g Chamlin SL, Haggstrom AN, Drolet BA, et al. Multicenter prospective study of ulcerated hemangiomas. J Pediatrics. 2007;151(6):684–689; Drolet BA, Swanson EA, Frieden IJ, Hemangioma Investigator Group. Infantile hemangiomas: an emerging health issue linked to an increased rate of low birth weight infants. J Pediatr. 2008;153(5):712–715; Darrow DH, Greene AK, Mancini AJ, Nopper AJ, American Academy of Pediatrics Section on Dermatology, Section on Otolaryngology–Head and Neck Surgery, and Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015;136(4):e1060–e1104. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Pathogenesis . Dysregulation of angiogenesis . Imbalance of pro- and anti-angiogenic factors . Dysregulation of endothelial cell proliferation Treat with confidence. Trusted answers from the American Academy of Pediatrics. VEGF & bFGF in serum during proliferative phase and in involuting phase Storch CH, Hoeger PH. Propranolol for infantile haemangiomas: insights into the molecular mechanisms of action. Br J Dermatol. 2010;163(2):269–274. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Infantile Hemangiomas: Morphology . Superficial . Deep (not to be confused with venous malformation) . Most both Superficial Treat with confidence. Trusted answers from the American Academy of Pediatrics. Subcutaneous Treat with confidence. Trusted answers from the American Academy of Pediatrics. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Combined superficial/deep Treat with confidence. Trusted answers from the American Academy of Pediatrics. Hemangioma Patterns . Focal (localized) . Multifocal (multiple localized) . Segmental Treat with confidence. Trusted answers from the American Academy of Pediatrics. Infantile Hemangioma . Size 1 mm–20 cm . Number 85% 1 lesion Rare >100 Treat with confidence. Trusted answers from the American Academy of Pediatrics. Infantile Hemangioma: Early Course . Early, pale macule, central telangiectasia . Growth phase (510 patients [Lampe, 1965]) 50% until 6 months 50% until 12 months 80–90% < X 2 5% X 3 2% X 4 . 85% peak by 3 months (most rapid growth 2–7 weeks) . Certain lesions with prolonged growth phase Brandling-Bennett HA, Metry DW, Baselga E, et al. Infantile hemangiomas with unusually prolonged growth phase: a case series. Arch Dermatol. 2008;144(12):1632–1637, and Darrow DH, Greene AK, Mancini AJ, Nopper AJ, American Academy of Pediatrics Section on Dermatology, Section on Otolaryngology–Head and Neck Surgery, and Section on Plastic Surgery. Diagnosis and management of infantile hemangioma. Pediatrics. 2015;136(4):e1060–e1104. 1 week 2 weeks 3 weeks Treat with confidence. Trusted answers from the American Academy of Pediatrics. Treat with confidence. Trusted answers from the American Academy of Pediatrics. Uncomplicated Infantile Hemangioma: Prognosis . (Generally) independent of o Size o Number o Sex o Location o Growth o Prematurity o Presence of deep component
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