Original Article |
Corresponding author: Can Acipayam ( cacipayam@hotmail.com ) © 2022 Hüsnü Maraşli, Can Acipayam, Ufuk Utku Güllü, Serpil Dinçer, Emine Füheda Dalgiç, Seda Nida Karaküçük, Sadik Yurttutan.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Maraşli H, Acipayam C, Güllü UU, Dinçer S, Dalgiç EF, Karaküçük SN, Yurttutan S (2022) Evaluation of cases with infantile hemangioma requiring treatment. Folia Medica 64(1): 67-74. https://doi.org/10.3897/folmed.64.e58616
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Aim: Infantile hemangiomas are the most common benign vascular tumours in infants. In this study, we aimed to evaluate the effectiveness of propranolol therapy in patients with infantile hemangioma.
Materials and methods: This study included patients with infantile hemangiomas in the age range of 0 to 24 months who received propranolol therapy between September 2015 and 2019. Hemangioma activity score, ultrasonography imaging and photographic evaluations were performed before and at 6 months of treatment. Parental satisfaction with the results of treatment was recorded.
Results: Our study included 85 patients with infantile hemangioma requiring treatment. Twenty patients were boys and 65 were girls. The mean age at starting treatment was 7.2±5.9 months (median: 5.0). While the average lesion area measured by ultrasonography before treatment was 209.7±207.5 mm2, it reduced to 105.1±145.7 mm2 (p<0.001) after treatment. Similarly, while the mean hemangioma activity score was 3.8±0.9 before treatment, it decreased significantly to 1.3±0.8 after the treatment (p<0.001). A noticeable improvement in photographic evaluation with the treatment was observed in infantile hemangiomas of the patients and 82% of the families were satisfied with the results of the treatment.
Conclusions: The results of the study suggested that propranolol therapy used in the treatment of infantile hemangioma is an effective treatment option according to the photographic comparison, ultrasonography data, and hemangioma activity score evaluations.
hemangioma, infant, propranolol, treatment, ultrasonography
Infantile hemangiomas (IH) are the most common type of vascular tumours in infancy and childhood.[
Two scoring systems for infantile hemangiomas have been proposed to help clinicians assess the disease severity and treatment response: 1. The Hemangioma Severity Scale (HSS) was created in 2012 to divide patients into subgroups according to their complication risk profile and to help guide to their treatment needs.[
Our aim in this study was to evaluate objectively the efficiency of propranolol in treating patients with infantile hemangioma who received propranolol treatment by questioning HAS scores, USG data, photographic evaluations and satisfaction of their families.
We included in this study patients diagnosed with infantile hemangioma between September 2015 and September 2019 (aged 0-24 months), who started to take propranolol orally and were followed up afterwards. Ethics committee approval (2018/08) was obtained from the local Clinical Research Ethics Committee. The parents of the children included in the study were given detailed information about the study and a written informed consent was obtained from them.
A detailed medical history and demographic information of the patients included in the study were obtained. The hemangioma location, size, and hemangioma type were recorded from the files. USGs were performed to patients as radiological imaging. The patients were evaluated by a cardiologist with physical examination, echocardiography (ECHO) and electrocardiogram before treatment. While initiating propranolol therapy, the patients were hospitalized and monitored to ensure that they were not exposed to the side effects of the drug. Subsequent visits of the patients were done in the outpatient clinic. The drug was started with a low dose of 0.5 mg/kg/ per day for two days and reached up to 2 mg/kg/day. Blood pressure, pulse, respiration, and blood sugar were monitored during the hospital stay. The patients were invited to weekly controls within the first month after starting the propranolol treatment and monthly controls after the first month. Hemangioma dimensions of the patients were measured regularly every month with USG and photographic evaluation. Photographs of the patients before treatment and at 6 months of treatment were evaluated according to the scoring used in a study performed by Janmohamed et al.[
Criteria Title | Score |
Swelling score | |
Deep swelling: tense haemangioma | 6 point |
‘Neutral’ or <50% reduction at follow‐up | 4 point |
≥50% reduction at follow‐up | 2 point |
No more swelling at follow‐up | 0 point |
Colour | |
Bright/shining red all over [5] OR bright‐red edge [4] | 5 point/ 4 point |
Red or red‐purple OR matt red edge | 3 point |
Blue (or blue background in deep hemangiomas) | 2 point |
Grey | 1 point |
Skin‐coloured after activity | 0 point |
Total | |
Number of items scored | |
Preliminary HAS=total ÷ number of items scored | |
Ulceration | |
Ulcer ≤1 cm2 | 0.5 point |
Ulcer 1-25 cm2 | 1 point |
Ulcer ≥25 cm2 | 2 point |
HAS=preliminary HAS+ulcer score |
Statistical analysis was performed using SPSS 22.0 for Windows (SPSS, Inc.; Chicago, USA) package program. Descriptive values are stated as number (n), percentage (%), mean (avg.), and Standard deviation (SD), median (median). Pearson chi-square and Fisher tests were used to compare categorical variables. The conformity of the data to normal distribution was tested with the Kolmogorov-Smirnov and Shapiro-Wilk tests. Continuous variables were compared with parametric tests (paired sample t test and t test in independent groups) where it fits normally, and nonparametric tests (Wilcoxon, Mann-Whitney U, and Kruskal-Wallis test) where it does not comply with normal distribution. Significance level was taken as p<0.05.
Between September 2015 and September 2019, a total of 236 patients applied to our clinic with the diagnosis of hemangioma. Eighty-five of these patients were included in the study. Similar to the relevant literature, the following points were taken into consideration when the patients were included in the treatment: cases with infantile hemangioma posing cosmetic problems, ulcerated, bleeding, large size, respiratory distress and intention to require surgery if left untreated were treated.[
n | % | |
Gender | ||
Male | 20 | 23.5 |
Female | 65 | 76.5 |
Kinship | ||
Yes | 12 | 14.1 |
No | 73 | 85.9 |
Descriptive ınformation regarding age, birth week, body weight, height, and head circumference of the cases
Unit | n | Mean ± SS | Median | Minimum-Maximum | |
Age | month | 85 | 7.2±5.9 | 5.0 | 0-24 |
Birth week | week | 85 | 37.5±2.2 | 38.0 | 29-41 |
Birth weight | g | 85 | 3039.2±749.0 | 3100.0 | 745-4700 |
Body weight | g | 85 | 7469.2±2195.9 | 7000.0 | 955-14000 |
Height | cm | 85 | 66.7±9.6 | 66.0 | 33-95 |
Head circumference | cm | 85 | 42.2±4.0 | 42.0 | 23.5-49.0 |
n | % | |
A single hemangioma | 65 | 76.5 |
Multiple hemangioma | 20 | 23.5 |
Head-neck | 36 | 42.4 |
Extremity-body | 29 | 34.1 |
Periocular | 8 | 9.4 |
Anogenital | 8 | 9.4 |
Internal organ | 2 | 2.4 |
Inside mouth | 2 | 2.4 |
Total | 85 | 100.0 |
n | % | |
There are no complications | 42 | 49.4 |
Cosmetic problem | 28 | 32.9 |
Ulceration | 5 | 5.9 |
Bleeding | 5 | 5.9 |
Ulceration + bleeding + cosmetic problems | 2 | 2.4 |
Airway obstruction | 1 | 1.2 |
Bleeding + cosmetic problems | 1 | 1.2 |
Mortality secondary to Kasabach Merritt syndrome | 1 | 1.2 |
Total | 85 | 100.0 |
Comparison of patients with USG and HAS score before and after propranolol treatment
n | Mean ± SD | Median | Minimum-Maximum | p * | |
Receiving USG before treatment | 75 | 209.7±207.5 | 126.0 | 3.0-1250.0 | <0.001 |
Receiving USG after treatment | 75 | 105.1±145.7 | 41.0 | 0.0-640.0 | |
HAS score before treatment | 70 | 3.8±0.9 | 4.0 | 2.0-6.0 | <0.001 |
HAS score after treatment | 70 | 1.3±0.8 | 1.3 | 0.0-4.0 |
Example of infantile hemangioma before and after treatment. (a) a hemangioma on the left leg before treatment; (b) a hemangioma on the left leg after treatment.
Example of infantile hemangioma before and after treatment. (a) a large hemangioma in the right post auricular area before treatment; (b) a hemangioma in the right post auricular area after treatment.
Although infantile hemangiomas usually enter the process of involution spontaneously, it is necessary to closely monitor the natural course of these benign lesions. It should be taken into consideration that infantile hemangiomas can progress and, accordingly, have undesirable results and the necessity of early treatment should be evaluated very well.[
In this study, 85 patients were evaluated over a 4-year period. Similar to the study conducted by Ding et al.[
The HAS that we used in our study and the HSS reported by Moyakine et al.[
In our study, while evaluating the response to the propranolol treatment, the HAS scoring, USG data, and photographic evaluation were taken as criteria. Familial’ satisfaction was questioned at every check. Considering other studies in the literature, we believe that our study is more objective, since the HAS score, the USG data, and photographic evaluation were used together to evaluate the response to the treatment.
To our knowledge this is the first study in which the HAS score, the USG data, and photographic evaluation parameters were used together. As a result of all these evaluations, the propranolol treatment in our study was found to be an effective and reliable treatment modality in infantile hemangiomas.
We would like to thank all our patients with infantile hemangioma, their families, and our clinic staffs for supporting the study.
Author contributions
H.M. and C.A. designed the study; U.U.G., S.N.K., and E.F.D. collected and analyzed data; S.D. and S.Y. wrote the manuscript. All authors read and approved the final manuscript.
Disclosure
The authors declare no conflict of interest.