Haemangioma

Fifth stage

Surgery
Lec-4
د. بسام

9/3/2017

Haemangioma
Its benign endothelial tumor of blood vessels.
common skin lesion.
1% newborn,10% infant.
60% =head.
female/male=3/1.
Grow rapidly in first year then slowly involute.70% at 7 years.
80% solitary lesion &20%are multiple(viscera).

Classification:

Mullikan classify haemangioma into 2 groups:
1- vascular tumor:
rapid growth.
involutes ,leaving fibrosed skin +fat deposition.
increase endothelia cell activity.
increase number of mast cells.
capillary.
2-vascular malformation:
not regress with time.
not hyper cellular.
flat mature endothelium.
not proliferative.
cavernous


Clinical appearance:
depend on the depth &growth phase.
early lesion as strawberry ,elevated ,irregular.
size= small red elevated mark to huge tumor .
Deep lesion = blue or skin color.
on examination: comprisable but slowly refill .
Difficult to differentiate between cavernous and capillary haemangioma.
Microscopically: dilated vascular spaces within dermis and subcutaneous tissue.
Rapid growth result from:
- canalization.
- proliferation of angioblast.

Regression result from:

1- thrombosis.
2- sclerosis.
3-infarction.
- Most complications occur during proliferative phase.

Location:

In addition to size &complications it dictate the urgency of treatment?
1- periorbital lesion visual obstruction ambylopi a & sometimes visual impairment.
2- nasal opening obstruction apnea in neonates.
3- external auditory meatus conductive hearingloss.


History:
1- proliferating phase:
- a small sot appear several weeks after birth.
- grow rapidly for several months(8-12).
2- plateau phase :
- size not increase or decrease up to 2 years.
3- involution phase:
- started at 2-3 years .
- disappears by 5-7 years;
- leaving a patch of pale flaccid skin( fibro fatty tissue)

Complications:

1-superficial ulceration:
common.
my cause necrosis and bleeding.
Can be treated by dressing & systemic antibiotics.
Large ulcer need aggressive treatment.
2- bleeding :
can stop with compression or fibrin glue.
3- infection:
blood born.
May cause septicemia or local necrosis.
Treated by antibiotics.


4-Kassabach-meritt syndrome:
large size haemangiom secondary to trapedplatelets.
thrombocytopenia , coagulopatthy and hemolytic anemia.
growth phase

Its characterized by

Rapid increase in the swelling of haemangiom.
Tens and shining of overlying skin.
Surrounding area of ecchymosis and pitichia.
Bleeding tendency.

Laboratory finding:

Decrease platelet count (thrombocytopenia)
Dissimination intravascular coagulation
Decrease plasma fibrinogen
Prolong blooding time
Atteration in factor V,VIII,prothrombin time and thrombin time

5-Larg visceral lesion or multiple lesion can cause congestive heart failure secondary to shunting of blood.
6- functional impairment.


Treatment:
In general most lesions treated non surgically .
Factors affects the mode of intervention :
Site : eyelid or medial cantus treated by local injection of steroid
Size : big perineal haemangioma can be treated by diverting colostomy
Multiplicity : multiple lesion need systemic steroid
Presence of complications

Emergency treatment confind for life threatinig haemangioma

Example:
Massive liver enlargement
Conjestive heart failure high out put
Hearing or vision loss
Airway obstruction

Treatment options:

Active are intervention with close monitoring
Waiting involution of tumor
Laser therapy which may cause edema and later scaring
Intra lesion cortico steroid
Interferon
Excisional surgery
Systemic cortico steroid
Other drugs like bleomycin, cyclophosphamide.
Surgery
Indication in proliferative phase in infancy
Visual or subglottic obstruction
Compression of eye globe
Bleeding
Ulceration
Lesion with high risk of searing
Indication in involution phase
befer school age
Post ulcerative searing or residual skin
For cosmetic purposes