Hemangioma Treatment not One Size Fits All

Typically, surgery should be used to treat any disfiguring hemangioma or one that distorts or destroys a function, where no other modality can correct this, he stated.

In his experience, fewer than 50% of hemangiomas will involute (i.e., stop proliferating and shrink) to the point where laser plus or minus surgery will not be necessary. The vast majority of hemangiomas that do involute leave a residual fibrofatty area with loss of pigmentation and atrophic scarring, he noted. Further, it can take five, seven, or even 12 years for a hemangioma to involute completely.

Nowadays children attend preschool and are subjected to peer pressure very early in their lives. A disfiguring lesion that can be embarrassing and distressing for the child should be removed as early as possible, said Dr. Waner. The younger the patient, the less scarring and the easier it is for primary closure, he noted. However, if complete excision is not feasible, then surgery should be postponed at least nine months until the lesion has stopped growing.

Surgery should be considered as early in life as possible for lesions that cause functional problems, agreed Jonathan Perkins, DO, an otolaryngologist-head and neck surgeon at the University of Washington and Children’s Hospital in Seattle. In general, he said that in infants under the age of six months, hemangiomas of the eye and airway are the most common ones that require surgery.

When asked about success rates for surgery, Dr. Perkins said that there are no reports on large series of patients who have undergone surgery for hemangiomas. It depends on how you define success and the goals of surgery. For an airway hemangioma, success equals preventing tracheotomy, and surgery can accomplish this 90% of the time. For periocular hemangioma, success equals preventing amblyopia. We are able to do that with surgery or steroid injections up to 70% of the time.

For disfiguring hemangiomas of the face, the timing of surgery is controversial, according to Dr. Perkins. Dr. Waner is a proponent of very early surgery, while other experts believe that surgery should be delayed until after 10 months of age, or lower when the hemangioma has stopped proliferating.

We don’t know what the optimal timing is, Dr. Perkins stated.

He said that facial hemangiomas can be superficial (formerly called strawberry, red in color), deep (formerly called cavernous, often blue in color), or mixed. Superficial lesions can be treated with pulsed dye laser to reduce redness. Deeper lesions may require lifting the skin, excising the lesion, and replacing the skin over the area. Mixed lesions can be treated with laser to remove the redness and scarify the skin so that the superficial and deep portions of the lesions can be safely removed and the incision securely closed.

Other Vascular Lesions

It is important to recognize which vascular lesions are RICH (rapidly involuting tumors), because these do not require any treatment, Dr. Waner said. RICH tumors will involute completely by age two. By contrast, NICH (non-involuting tumors) may be persistent and continue to proliferate. The best treatment for these is not clear, Dr. Waner said, but systemic vincristine or interferon or embolization may be used. Kaposiform hemangioepithelioma are managed medically, usually with vincristine. Dr. Waner said that a high proportion of Kaposiform patients who are treated with interferon will develop spastic diplegia.