1
Fifth stage
Surgery
Lec-4
.د
بسام
24/4/2016
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.
2
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 hearing loss.
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.
3
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 traped platelets.
thrombocytopenia , coagulopatthy and hemolytic anemia.
growth phase
Its characterized by
1- Rapid increase in the swelling of haemangiom.
2- Tens and shining of overlying skin.
3- Surrounding area of ecchymosis and pitichia.
4- Bleeding tendency.
Laboratory finding:
1. Decrease platelet count (thrombocytopenia)
2. Dissimination intravascular coagulation
3. Decrease plasma fibrinogen
4. Prolong blooding time
5. 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.
4
Treatment:
In general most lesions treated non surgically .
Factors affects the mode of intervention :
1- Site : eyelid or medial cantus treated by local injection of steroid
2- Size : big perineal haemangioma can be treated by diverting colostomy
3- Multiplicity : multiple lesion need systemic steroid
4- Presence of complications
Emergency treatment confind for life threatinig haemangioma
Example:
1- Massive liver enlargement
1- Conjestive heart failure high out put
2- Hearing or vision loss
3- Airway obstruction
Treatment options:
1- Active are intervention with close monitoring
2- Waiting involution of tumor
3- Laser therapy which may cause edema and later scaring
4- Intra lesion cortico steroid
5- Interferon
6- Excisional surgery
7- Systemic cortico steroid
8- Other drugs like bleomycin, cyclophosphamide.
Surgery
Indication in proliferative phase in infancy
1- Visual or subglottic obstruction
2- Compression of eye globe
3- Bleeding
4- Ulceration
5- Lesion with high risk of searing
Indication in involution phase
1- befer school age
2- Post ulcerative searing or residual skin
3- For cosmetic purposes