Surgucation ep 2. Hemangioma

In this episode Drs. Mikael Petrosyan and Phil Guzzetta discuss what a parent needs to know if their child has Hemangioma.  Current recommendations and treatments. 
for more information visit childrensnational.org vascular anomalies clinic. 
email: info@surgucation.com
twitter: @surgucation

Transcript

Speaker 1 0:09

This is certification surgical education for parents. We are here to inform inspire connect India certification episode to infantile hemangiomas. Hi, welcome

Welcome Surgucation

Speaker 2 0:43

Certification . Our surgical education for parents today. I want to welcome Dr. Phil Gazeta. He is professor of surgery at children's national hospital. He is a mentor to everyone here at children's. He's a wealth of knowledge. He's also runs a vascular anomalous clinic. I thought that it would be very interesting for parents to learn about the various vascular anomalies that children presents with. And , uh , what's interesting is even for me, who's been in surgery for awhile . Uh , some of the lesions that we encounter in clinics consult them to give me help with that. And I'm sure parents are out there wondering if their kids have those lesions and what to do with them. Welcome Dr. Gazeta . Thanks for joining us. Thank you, Michael. Um, what, what is the difference between hemangioma

What is Hemangioma

Speaker 2 1:26

and vascular anomalies? I know they're interchangeably used, but there's definitely a difference. And what do the parents need to know about those two entities?

Speaker 3 1:33

Okay, well , uh, vascular anomalies encompass a great number of different diagnoses, but far and away. The

How Common Are They

Speaker 3 1:40

most common one we do see is an infantile hemangiomas. So , um, infantile hemangiomas are , um , very common. There are more common in girls than they are in boys. They're most common in the head and neck area, but they can occur anywhere. And , uh , we know that they're more common in Caucasians and other races. What about premature babies? And in babies who are born premature, which we define as less than 36 weeks, the more premature you are, the more likely you are to have a He-Man Joma and

Why Do They Occur?

Speaker 3 2:14

why do they occur? So we're not exactly certain why these occur, but there's also a family predilection for these. If you have a first order order, relative like a mother or father, who's had a human genome , you're more likely to have a human genome as well. So are there three phases just

Three Phases of Hemangioma

Speaker 3 2:32

to be clear, there are three phases, correct. So the first phase is what we call the proliferative phase and that's a period of rapid growth. And that's usually pretty much over by the time the child is three or four months of age. And the second phase is what we call the plateau phase in which they don't tend to get much bigger, but they don't tend to get much smaller either. Um, usually towards the end of this period, which usually lasts between six and nine months or roughly between the age of nine months, 12 months of age , um, towards the end of that period, we start to see the color of the human genome, a change. So most team man Gemma's are present on the skin and you can see reddish to purplish discoloration as they get towards the end of the plateau phase frequently, it gets to be less red or even get gray in the center. And that's a sign that it's starting to go into the third phase, which is the Involution phase in which the human genome is gets smaller over a period of time. The period of time that the human Joma is in this envelope phase varies. Um , but it can be as long as several years. So depending on the size and the depth of the human genome, it gives us a pretty good idea what it's going to look like. Long-term

Speaker 2 3:46

About the congenital hemangiomas.

Congenital Hemangiomas

Speaker 3 3:50

Um, these are fully formed at birth and they have a variable pattern. Some of them , um, rapidly involute without any treatment. And we call those rapidly involuting congenital hematomas, or R I C H then some do not involute and we call those non involuting congenital human genome is N I C H and seven partially involuted that's called a P I C H partially involuting congenital hemangioma. But again, this is a very small percentage of the human genome is C uh , that we see,

Speaker 2 4:23

We treat him on Dumas depending

Speaker 3 4:26

And upon the location and the size of the He-Man Jomon . We may elect to treat some of these children medically. So do all the hemangiomas require

Speaker 2 4:36

Surgical resection. I know this is a surgical podcast, but I know we don't really do any operations on that .

Speaker 3 4:42

Almost never if the, depending upon the size and the location of the hematoma , if they're in , uh , infantile

What is the Treatment?

Speaker 3 4:49

hemangiomas, if they're in an area we consider critical, like in the upper eyebrow , um , that could obstruct the visual field if they're , um, on the lips , um, in which the baby couldn't feed because of , uh , irritation , um, if they're very large and distorting something , uh , area that we see them sometimes is on the tip of the nose, which can , um, give them quite a bulbous shape to their nose and damage the cartilage or behind the ear, if they're quite large and pushing down on the ear, those are areas that we consider of critical location, and we treat those patients with a medication.

Speaker 2 5:26

What is the current medication?

Current Medication for Treatment of Hemangiomas

Speaker 3 5:29

Our current medication that we prefer is a medication called propranolol. It's a beta blocker agent. That's been used for many decades for patients with congenital heart disease, but it's only been used relatively recently in the last 10 to 12 years for patients with He-Man [inaudible] . So , um, again, I would say probably two thirds of the patients, either the human genomes are small and not in critical areas, and we do not treat them at all, or if they are in critical areas, one additional area I would like to mention is sometimes , um, if they're in the diaper area , um, they can become very irritated and actually develop a little sores on them because of the constant presence of stool and urine. And , um, if the patients have irritation of that area, we treat them with , um , propranolol as well. There are alternate medicines. Um, primary one is a steroid, but , um, unfortunately at the age at which these children are treated, which again is less than a year of age and most of them less than six months of age , um, the steroids , um, prevent the child from growing linearly. So the propranolol has a good track record. It has low , um, complication rate, although there are some complications, which is why we don't treat everybody with it. Um, but overall, yes, it's rare that we need to do an operation. What about the , um , I know laser treatment has been part of the overall treatment.

What About Laser Treatment?

Speaker 3 6:56

Do you see success with laser treatment ? Yes . So a laser is like beauty. It's only skin deep. So if you have a , um , residual purple area that's , uh , disfiguring, then , um , that can be treated with the laser, but it really doesn't do anything to the deep component. So this is a typical infantile hemangiomas of the extremity. And you can see that , um, uh, reddened area. This

Discussion of Cases

Speaker 3 7:22

is a child , um, about two months of age. So , um, this was not present at all at birth, and then grew , um, started growing at about a month of age frequently. What the parents will say is , um, Oh, I thought it was a little scratch on the cheek and then over the course of a month or so it will become quite large. You can also see in this picture , uh , sometimes there's a little whitish area around the human Joma what we call a halo. Um, and it just means that the blood vessels are being recruited to make this human Joma . So the He-Man Joma is a group of small blood vessels capillaries. And the reason that they go away when they do is because over time they get little bitty clots in them, and that's what causes them to shift from a bright red to a gray, and then gradually to return to the normal skin color. So on a lesion like this in this location, we would not treat , um, it doesn't, it does not need any medication , um, depending upon the location, sometimes if they're relatively small , um, like on a cheek , um, then we will treat them with a topical agent of form of the beta blocker called Timolol. Um, but that's really dependent upon the location and the size of the lesion. So , um , I was mentioning previously that , um, sometimes when these go away, they do leave some , um, some residual , uh , deformity. You see, this is a , this is a child. This child is about , uh , eight months of age. And , uh , you can see the human Joma beneath the ear. Um, this is one that we would treat with a propranolol because of its size and because of its location and the fact that it's distorting the ear. And then , uh , this is a picture taken at six years of age. So about five years later. And fortunately for this child , uh , you see, this is very minimal , um, cosmetic abnormality, the redness that you see , um , beneath that's something that could be treated with laser. Uh , but fortunately this child did not require any surgical intervention.

When is Surgery an Option?

Speaker 3 9:25

When do you actually offer surgical treatment? Sometimes when they go through this progression of these three stages, proliferation, plateau, and Involution at the end of this period. And we generally consider that to be at four or five years of age, if they have a large deep component, they may be left with some residual fibrofatty tissue. That tissue tends to look like cellulite. And so if it's, if it's unsightly, depending upon where it is, and it's kind of lumpy and bumpy, then that's a patient that we would consider doing an operation for. This is another child who

Discussion of Cases with Fibro-fatty changes

Speaker 3 9:59

is , um , would be appropriately treated with , um, with propranolol. Um, I think you can see that , uh , there's some ulceration, a sore in the middle of it. This can be very painful and , um, because of its size and its location, this is a child we would treat with a propranolol. Um, this child was treated and , um, over the course of a couple of years, you can see that even though the human genome has largely gone away, it's left a pretty unsightly , uh , lesion. Um, this is that fibro fatty tissue that can be left when there's quite a deep component. And this is a child who would be , um, considered a candidate for treatment with a surgical procedure to , um, to improve the appearance. So it's, it's unusual for us to have to operate on these patients , um, in the immediate period, but longterm , some of them do require a surgical procedure. Now, what do you

Speaker 2 10:52

Say to parents when they have multiple

What if you have multiple Hemangiomas

Speaker 2 10:54

hemangiomas? Do you have to worry about something or do you tell them otherwise?

Speaker 3 11:00

Yes, that's a small percentage of our patients, but if the patients have four or more human dramas, we know that those patients are at risk for also having a human genome of the liver. So we routinely do an abdominal ultrasound, fortunately , um, although that sounds like a serious problem. Most of our patients with human genomes of the liver are not ill and do not require treatment. Some can become very ill, but that usually happens in the first months or so of life. So if they have a liver He-Man Joma and it's identified at three or four months of age, usually that's just something we watch and does not need treatment. Wonderful. And so

Speaker 2 11:38

Those are the hemangiomas, which is the good thing about it is you don't need an operation. You just need to come and see vascular someone in vascular anomalies who is well known in the field. And most of them get treated with medications and it goes on ,

Speaker 3 11:50

Yes, that's , that's good . If you had to pick something

Speaker 2 11:54

Wrong with your child, this is a good thing to pick up those parents who have kids with him angiomas or other vascular anomalies. Uh, this information will be helpful. And if there's any questions or concerns or any further evaluation that needs to be done for your child, please visit us veterans

Outro

Speaker 2 12:10

national.org, or you can also direct email us for@certification.com . Thank you again. You're welcome, Michael ,

Speaker 1 12:18

Have a great day.