HEMANGIOMA : QUESTION AND ANSWERS

Q. What is a hemangioma?
The word hemangioma comes from the Latin words hemangio meaning blood vessel and oma meaning tumor with active cell dividing activity. Hemangiomas differ from other vascular birthmarks in that they are biologically active, their growth is dependent from the growth of the child. They are the most common benign tumor of infants. Hemangioma growth is referred to as Hyperplasia, where as other vascular birthmarks growth is referred to as Hypertrophy.

Q. Who gets hemangiomas?
1 in 100 children each year in the U.S. will be born with a vascular birthmark that requires the opinion of a specialist (40,000). Most hemangiomas appear within a week or two after birth. Hemangiomas are up to 5 times more common in girls than boys. They are less likely to occur in African American babies then Caucasian babies. They occur more frequently in premature infants.

Q. Where do hemangiomas occur?
Hemangiomas are most often found on the head or neck (up to 80%), however, they may occur anywhere on the skin or internal organs. Children can develop a single lesion or they can have a dominant primary lesion with smaller associated hemangiomas. There can be an internal lesion with no associated lesions on the outside. Some children present with several small visible hemangiomas this may be indicative of a large hemangioma of the liver or GI tract. Any child with 3 or more cutaneous lesions should be evaluated by ultrasound to rule out internal lesions.

Q. How did my child get this Hemangioma?
The exact reason or more likely the combination of factors predisposing a child to the development of a hemangioma is still unknown. However thanks to diligent researchers across the country there are some factors currently being investigated.

1. Are Hemangiomas Genetic? Douglas Marchuk, Phd., associated with Duke University is collecting the names of families with 3 individuals who have a history of vascular birthmarks to dtermine if there is a genetic link.

2. Pathology work is being done by Martin Mihm, M.D., Director of Dermato- Pathology, Albany Medical Center, Albany, NY, has found estrogen receptors in hemangioma tissue samples. This finding may confirm that estrogen stimulated hemangiomas to grow. Dr. Mihm has been doing some other exciting research with Milton Waner, M.D., Arkansas Children's Hospital. Their research points to some new discoveries regarding the growth and involution of hemangiomas. Hopefully these findings will be reported in the next year.

3. We know hemangiomas occur frequently in lighter skinned than darker skinned infants. Melanocyte cells, which help prevent dark skinned people from developing skin cancer, may also play a role in hemangioma growth and may be the reason very few children with dark skin are diagnosed with a hemangioma.

Q. How are the doctors treating hemangiomas?
Up until recently uncomplicated hemangiomas were observed. This practice was based on research information from as far back as 1928, and was in large part due to the fact that there was no dictable treatment option available to physicians. It was hoped that most lesions would involute ( become smaller) on their own. About 50% will involute by age 5. However; those that do not involute by age 3-5 may take up to 10 years to resolve and will in general leave residual scaring requiring surgery. Most doctors are trained to have the patient wait, since in the past surgery most likely would leave scaring. Due to the advances in plastic surgery and the development of new laser technology many doctors are recognizing the benefit of early intervention even for uncomplicated hemangiomas. Many parents would rather deal with a small surgical scar then a large purple tumor. Today treatment options include surgical excision, laser treatments, steroid and or alpha interferon therapy and rarely embolization or scelerotherapy. Because data on this subject has been incomplete until now, parental pressure and the new treatment options are allowing knowledgeable physicians to abandon the benign neglect theory and selectively intervene as early as the neonatal period. Laser and steroid treatment have been successful in arresting the growth of hemangiomas in the first few weeks of life. Without intervention a hemangioma could continue to grow for one year.

Q. What are the complications of hemangiomas?
There are two general categories of complications arising from hemangiomas. Absolute indications for treatment due to complication include visual obstruction, airway obstruction or aural (ear) canal obstruction, significant visceral involvement or a large hemangioma causing high output heart failure. Relative indications for treatment include ulcerations, bleeding, pain and possibility of permanent facial disfigurement. Hemangiomas located in the perianal or genital areas may become infected or develop cellulitis. Lesions greater then 5 cm in diameter may be associated with platelet trapping (Kasabach-Merrit Syndrome). Infants presenting with 3 or more small hemangiomas should be evaluated for internal hemangioma of the liver or digestive tract. Visceral hemangiomas can lead to congestive heart failure or other organ dysfunction. All hemangiomas must be evaluated by a specialist to prevent complications from developing.

Q. What will happen if my child has a hemangioma?
Typically the hemangioma appears within 2 weeks after birth. Only 2% are actually visible at birth. It is usually noticed as a small red blemish or bump, most parents interpret it as a bruise or scratch but quickly become alarmed as it begins to rapidly grow. Current research indicates two growth cycles: 0-4 months for the first cycle, with a pause from 4-6 months and then a second growth, from 6 months - 1 year or sometimes longer. Between 12 months and 18 months of age, some areas may begin to show graying; indicating the Involution Phase. Many parents will notice a Rapid Regression of the lesion. Other parents note minor graying; indicating Slow Regression of the lesion. If the regression is rapid, the lesion will generally be gone by age 3-5 years of age, with none or only minor residual scaring. Otherwise; involution may take many years, following the 10% rule. 50% will involute by age 5, 70% by age 7, and 90% by the age 9. However, lesions which regress slowly generally leave scaring, atrophoderma (thinning of the skin), vascular stria, or contour irregularities of the skin. These children will need some type of corrective surgery.

Q. What do I do if my child has a hemangioma?
Unfortunately it is not possible to predict which hemangiomas will involute quickly or which will develop complications. Therefore, it is important to have each child evaluated by a physician specializing in hemangiomas. Many of the Children's Hospitals have Vascular Birthmark programs consisting of multispecialty clinics experienced in the management and treatment of hemangiomas. These programs may include the disciplines of plastic surgery, dermatology, hematology, radiology and otolaryngology. In addition there are many informational and support groups networking to assist families in making the best choice for their child. Hemangioma Newsline can assist you in finding the best care for your child.

References
1. Freeman, Sean., Hemangiomas: Treatment Protocol, Plastic and Laser Center, Charlotte, NC, April, 1997 (submitted for publication)
2. Interview with John Reinisch, Chief of Pediatric Plastic Surgery, Children's Hospital of LA, L.A., California, September 19995.
3. Interview with Linda Shannon, Hemangioma and Vascular Birthmark Foundation, Latham, NY, December 1995, April 1997.
4. Low, David W., Hemangiomas and Vascular Malformations. Seminars in Pediatric Surgery, Vol. 3 No. 2, 1994 pp 40-61.
5. Mulliken, J.B., Vascular Birthmarks, Hemangiomas and Malformations, Philadelphia, PA, Saunders 1988.
6. Silverman, Robert A., Hemangiomas and Vascular Malformations, Pediatric Clinics of North America, Vol38, No. 4, August 1991.
7. Video, Diagnosis and Classification of Vascular Lesions, Waner, Milton, MD, Hemangioma Hope Conference, August 1996.
8. Weber, T.R., Complex Hemangiomas of Infants and Children, Archives of Surgery, 125:1017, 1990

Hemangioma Newsline is a nonprofit organization established to provide families and physicians the most recent medical information in the management of patients with vascular birthmarks. Hemangioma Newsline is part of a network of organizations supporting, treating and educating patients of their options in the management of Hemangioma and other vascular lesions.

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