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Hemangiomas and vascular malformations of the head andneck

2000; Elsevier BV; Volume: 43; Issue: 3 Linguagem: Inglês

10.1016/s0190-9622(00)70274-x

1097-6787

María C. Garzon,

Vascular Tumors and Angiosarcomas

Hemangiomas and vascular malformations of the head and neck Milton Waner, MD, and James Y. Suen, MD, editors, New York, 1999, Wiley-Liss. Hemangiomas and Vascular Malformations of the Head and Neck, coedited and predominantly coauthored by Milton Waner, MD, and James Suen, MD, provides the dermatologist with a surgeon's perspective on the often challenging and controversial management of vascular birthmarks. In so doing, the coauthors and coeditors call upon their experiences at a subspecialty vascular anomalies referral center. The book fittingly begins with a review of classification of vascular birthmarks. Readers will appreciate the authors' use of the biologic classification that was first proposed by Mulliken and Glowacki in 1982. The biologic classification categorizes vascular birthmarks as hemangiomas and malformations based on their clinical manifestations and biologic behavior. Before the introduction of this classification, lesions such as venous malformations were often referred to as “hemangiomas.” During the past almost 20 years, the classification has provided a framework for discussion of these heterogeneous vascular lesions. The classification was recently altered slightly to reflect developments in the field so that the current classification refers to vascular tumors and vascular malformations. Suen and Waner use the original classification in their text with minor modifications. The natural history of hemangiomas and the various types of vascular malformations are reviewed within the book. One of the most controversial statements in the text is that the majority (60%) of hemangiomas located on the head and neck will ultimately require surgical correction. The authors base their conclusion on their experience and on a calculation derived from two earlier published articles that reviewed the natural history of hemangiomas. Unfortunately, the use of these earlier articles likely leads to an overestimate of the percentage that will require surgical correction. The article by Finn and colleagues published in 1983 used data collected from patients who were referred to a specialized vascular anomalies clinic, thereby selecting for lesions that were likely larger or more significant. She and her coauthors concluded that 80% of hemangiomas that involuted after 6 years of age did so “imperfectly,” leaving residual lesions (Finn MC, Glowacki J, Mulliken JB. J Pediatr Surg 1983;18:894–900). The second portion of the calculation relies on a natural history study by Bowers published in 1960, which noted that 50% of hemangiomas involuted spontaneously by 5 years of age (Bowers RE, Graham EA, Tomlinson KM. Arch Dermatol 1960;82:59, 667–72, 680). However, the study was published before the recognition that vascular malformations and hemangiomas were distinct lesions that might mimic each other and therefore might underestimate the percentage of lesions that regress. The latter raises the problematic issues associated with many natural history studies that exist regarding hemangiomas. Readers should carefully place all natural history studies into historical perspective and closely review the diagnostic criteria employed in the study when drawing conclusions from the presented data. The book is well illustrated with good photographs that enhance the text. The chapter on the surgical pathology of vascular lesions provides an excellent review of this very challenging subject. The authors pay careful attention to the natural history of hemangiomas as they progress through their cycle of proliferation to involution. They provide a thoughtful and careful review of the current literature with particular attention to newer developments in pathogenesis of hemangiomas. Moreover, they provide a thorough review of other vascular tumors that may mimic hemangiomas and attempt to place these lesions in a context for pathologists and clinicians. Particularly impressive is their effort to define commonly used and potentially problematic terminology such as hemangioendothelioma and Masson's pseudoangiosarcoma into the framework of the current biologic classification of vascular birthmarks. The treatment sections for hemangiomas and vascular malformations contain numerous “pearls” that will be of particular interest to the surgeon and those who perform laser surgery. Management of hemangiomas is examined in greater depth. As part of the discussion, Drs Waner and Suen appropriately raise the issue of predicting cosmetic acceptability at ultimate outcome. In addition, they remind readers that spontaneous regression or involution should not be equated with disappearance of the hemangioma. They discuss that the concept of “benign neglect” is outdated when it comes to the management of facial hemangiomas. However, they fail to address more current strategies that are employed by many physicians who follow up patients with hemangiomas. Many in the field agree that “benign neglect” does not address the needs of patients and families with facial hemangiomas and prefer to employ a strategy for which the term “active nonintervention” has been coined (Tanner JL, Dechert MP, Frieden IJ, et al. Pediatrics 1998;101:446–52). Active nonintervention may be employed for lesions that do not appear to require aggressive therapy at initial evaluation. It includes vigilant reassessment of all lesions with recognition that more aggressive intervention may be required in the future. The conclusion that the majority of head and neck hemangiomas will require surgical correction is reiterated throughout the text and appears to guide the authors' philosophy of management. In the text they propose treatment algorithms for problematic lesions based on their clinical experience. They discuss the utility of pharmacological intervention in the first year of life followed by surgical correction of residual lesions at 3 to 4 years of age. However, in other sections they discuss early and late surgery without clearly defining their parameters, which is somewhat confusing to the reader. Perhaps the authors' location at a specialized referral center where they may often encounter patients who have not responded to or been dissatisfied with less aggressive management has helped formulate their opinions with regard to early aggressive pharmacological and surgical management. The message that all physicians managing hemangiomas, particularly those located on the head and neck, should recognize that it is difficult to predict the growth pattern and ultimate outcome is an important one. Moreover, they should be aware that surgical correction of residual defects might be required at some point in the management of these lesions. The timing of surgical correction should include a thorough review of functional impairment, possible adverse surgical outcomes, expertise of the surgeon performing the surgery, and psychosocial considerations. Hemangiomas and Vascular Malformations of the Head and Neck is a personal book that contributes the experience of these well-known surgeons to this challenging and often controversial area of medicine. Physicians who participate in the daily management of these patients will find it particularly readable.