Hemangioma

Overview

By Tina Shahian, PhD

A hemangioma, also known as a vascular tumor, is an abnormal accumulation of blood vessels in the skin. They are one of the most common birthmarks associated with childhood and affect 10% of all children. About a third of diagnosed hemangiomas are present at birth (congenital hemangioma), while the remaining cases appear during the first three months of life (infantile hemangioma).

Hemangiomas close to the skin’s surface are called capillary hemangiomas, while those deeper beneath the skin’s surface are called cavernous hemangiomas.

Most hemangioma tumors are benign and not expected to spread beyond their original boundaries. The majority of hemangiomas are barely visible by age ten, without any medical intervention. Surgery or drug therapy is needed when complications such as bleeding or ulceration occur, or if the lesion interferes with vision or other vital functions. Larger and/or disfiguring hemangioma lesions on the face can be emotionally distressful for the child and his/her caregivers. Large hemangiomas may cause scarring or permanent change to the affected skin.

Causes and Risk Factors

A hemangioma is an abnormal bundling and growth of blood vessels. Although the exact cause is not known, there is some evidence that the tumor initiates from a multi-potent stem cell. This evidence is being used to develop treatments that prevent the excessive growth of the tumor.

Hemangiomas are not linked to hereditary or dietary factors. However, they are more common in Caucasian female infants and premature babies.

Symptoms

An infant's capillary hemangiomaSuperficial (or capillary) hemangiomas develop close to the skin’s surface and often begin as a pink, flat area that becomes raised, with a bright red color. They mostly occur on the face and neck, and less frequently on the trunk and extremities. Deeper (or cavernous) hemangiomas form beneath the skin and appear skin-colored or bluish; these lesions can affect vision, breathing, or other bodily functions, depending on their location. Both superficial and deep hemangiomas may be present together. While most hemangioma lesions occur as a single growth, multiple lesions may be present in some cases.

Hemangiomas develop over three stages:

  1. Proliferation
  2. Quiescence
  3. Involution.

The proliferation, or fast-growing, stage occurs during the first three months of life in the majority of cases. A typical lesion grows to 0.5–5 cm in diameter, with some reaching up to 20 cm in diameter. Superficial hemangiomas grow to their signature bright red (or strawberry) color, while deep hemangiomas appear bluish and may protrude from beneath the skin. The lesion is the most prone to ulceration and bleeding during this period of rapid growth.

Most hemangiomas complete their growth over the course of 4-6 months and enter a quiescent (slow growing) stage, which lasts from 9 to 12 months of age. Then, the lesion begins to spontaneously lighten and shrink (involution).

Diagnosis

Hemangioma tumors are generally diagnosed visually. Additional tests may be performed to assess size and morphology.

  • Ultrasound. This test uses sound waves to construct an image of the tumor, allowing clinicians to inspect the degree of vascularization.
  • Imaging tests. Magnetic resonance imaging (MRI) and computed tomography (CT) are used to determine tumor size and proximity to other tissues.
  • Biopsy. A tissue biopsy is performed if cancer or a legion other than a hemangioma is suspected.

Treatment and Prevention

The majority of hemangiomas, especially superficial subtypes, shrink without intervention over the course of 5-10 years. In these cases, watchful monitoring is the routine course of action. However, an estimated 40% of hemangiomas require treatment because of complications that include visual obstruction, difficulty breathing and cardiac failure. The most common complication associated with hemangiomas is ulceration and bleeding, which is caused by drying, cracking or other physical injury to the lesion. Hemangiomas are most susceptible to injury during the proliferation stage. Ulcerated/bleeding lesions can be painful and require immediate medical attention in order to prevent excessive bleeding and infection.

The choice of treatment depends on the type, size and location of the hemangioma.

  • Medication. Steroid (direct injections, oral or topical) and beta-blocker drugs (propranolol) may be used early on to shrink large tumors, especially cavernous hemangiomas. Due to the risk of side effects associated with using steroids and beta-blockers in infants, their use is reserved for problematic lesions.
  • Laser surgery. Laser light is used for shrinking hemangioma tumors or for cosmetic improvements to the affected area. For example, the appearance of discolored skin and minor scars can be minimized using laser therapy.
  • Surgery. In some cases, surgery is used to excise the lesion in order to prevent irreversible damage to vision or permanent disfiguration of the affected area.

Currently there is no way to prevent hemangiomas. Bleeding and ulceration of hemangioma lesions can be avoided by keeping the area clean, moisturized and protected from rough or sharp objects.

Sources

  • “Hemangioma". MedlinePlus. Retrieved Oct 23, 2014. http://www.nlm.nih.gov/medlineplus/ency/article/001459.htm.
  • "Hemangioma". Mayo Clinic Foundation. Retrieved Oct 23, 2014. http://www.mayoclinic.org/diseases-conditions/hemangioma/basics/definition/con-20028587.
  • “Hemangioma". Boston Children’s Hospital. Retrieved Oct 23, 2014. http://www.childrenshospital.org/health-topics/conditions/hemangioma.
  • Richter, G.T. and Friedman, A.B., “Hemangiomas and Vascular Malformations: Current Theory and Management”. Int J Pediatr. 2012. Review.
  • “Infantile Hemangioma”. Medscape. Retrieved Nov 12, 2014.  http://emedicine.medscape.com/article/1083849-overview#a0156.
  • “Hemangiomas”. Children’s Hospital, Los Angeles. Retrieved Nov 12, 2014. http://www.chla.org/site/c.ipINKTOAJsG/b.5302707/#.VGYz3cnYoeo.