Download Classification and Treatment of Vascular Malformations and tumours

Classification and Treatment of
Vascular Malformations and tumours
& Laser
Associate Clinical Prof Agneta Troilius Rubin, MD, PhD
Laser & Vascular Lesion Section
at the Dep of Dermatology
University Hospital
Malmö, Sweden
LASER
Apfelberg
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Light
Amplification by
Stimulated
Emission of
Radiation
Laser
• Man skapar ljus med särskild våglängd – kraftigt
förstärkt
• Effekt beroende på våglängd (nm), energi, färg
på objektet (chromofor i huden)
Våglängder, absorbtionskurva
Kromoforer i hud
• Melanin
• Hemoglobin
• Vatten
Mutidiciplinary Vascular Anomaly
Group in Malmö, Sweden
IRA
Prolifierande hemangiom
Segmental hemangioma
Oral steroids & Vacsular lasers
Efter steroidtabletter 6 injektioner&
laser
oral steroids & multiple pulsed dye
Ärr efter Cryo
behandling
Efter multipla PDL beh.
o steroider
I feel very privileged!
plastic surgery remains
Married!
Vascular Lasers and
Intense Pulsed Light Sources
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Alexandrite 755 nm, long puls
Nd:YAG- 532 nm, 1064 long pulse
Krypton - 568 nm – green
KTP 532 nm, 5-50 J, 1ms
Copper vapor - 578 nm - yellow
Pulsed dye – 585, 595 nm, longpulses – yellow
Diode - 800 nm
Intense pulsed light sources - 515- 690nm, 555-950
nm
Absorptions spektrum HbO2
1064
1064
IPL = Intense pulsed light
Good for many things…
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Hair removal
Vascular lesions
Photorejuvenation
PDT
Melasma – superficial
Superficial pigmented
lesions
• Acne
• Scars
Radiation
dermatitis
Before and after 3 PDL tx
with low fluence
3-4 J/cm2
Breast cancer
Radiation dermatitis
after PDL
Classification of Congenital Vascular
Anomalies
I Tumors
– arise by endothelial hyperplasia
II Malformations
- arise by dysmorphogenesis
- normal endothelial turnover
Mulliken and Glowacki`s Classification
of Congenital Vascular Anomalies
• I. Tumors
• II. Malformations
Hemangioma
capillary
lymphatic
venous
arteriovenous
Others
combined
Hemangiomas
• > 30 % are seen at birth
• 2 periods of rapid post-natal growth
(early infancy and 4-6 months of age)
• involution starts around 1 year of age and
takes around 5-12 years
The Life Cycle of a Hemangioma
(Schematic Representation)
Group A 60% complete involution
Group B 10% complete involution
Growth
A
1
B
6
AGE (yrs.)
12
Haemangioma
• Incidence 4-10% of infants
• Higher in females 4:1 and in white skin
• 80% single
• 20 % proliferate in skin and other organ
systems (liver,GE, brain)
• 15 % difficult, of these 1% mortality!
Diagnosis
• Medical history
• Physical examination
 accurate > 90 % of infants!
MR
Ultrasonography
Experienced radiologist!
After PDL
Hemangioma
after 6 PDL
Growth may
impair vision!
Treat early!
Ulcerating
hemangiomas
are painful!
After 1 I2PL tx
Excison also
posssible!
Ulcerating Hemangioma before & after
long pulsed GentleYAG with Cryo, topical
steroid gr IV & compression
Infection, painful, imobile!
Hemangiomas: Nomenclature
Excision!
Hemangiomas: Nomenclature
Excision!
Systemic Hemangiomatosis
> 5 Hemangiomas
Abdominal Ultrasound
– Flow through hepatic artery
and vein?
Abdominal MRI
• Thyroid function tests
incl.TSH
Kassabach Merritt phenomenon
Profound trombocytopenia with bleeding!
1.Kaposiform
hemangioendothelioma
2.Tufted angioma
Systemic steroids or Vincristin
PHACES syndrome
• Posterior fossa
malformation
• Hemangioma (facial)
• Arterial malformation
• Cardiac malformation
• Eye abnormalities
• Sternal raphe
Retrospective study
PDL laser tx
Results of treatment
70
Treated patients (109)
60
In 94 / 109 =
86 % clear
signs of
regression
58
50
multiple signs of involution
44
proliferation slowed down
40
minimal impact
30
still in treatment, yet no
results
20
10
3
0
4
Propranolol treatment have
revolutionized the treatment of
Hemangiom
Side effects of Propranolol
mainly the first weeks
50 % of our patients
• Sleeping disturbances- most common
(20 % of growns up)
• Cold hands and feet
• Diarrea
• Risk: Hypoglycemia
Astma
Ulcerating segmentell prolierative
hemangioma
at the age of 2 m
Before and 8 days/ 6 m after Laser
& Propranolol
antibiotic
Cleared at the age of 8 m
Segmentel Hemangioma after
Longpulsed YAG laser with good
result at the age of 4 yrs
Still high flow , warm and
sometimes painful.
Did not respond to Propranolol
during 1 ½ m
II Vascular
malformations
Capillary
Venous
Lymphatic
Arteriovenous
Mulliken and Glowacki`s Classification
of Congenital Vascular Anomalies
• I. Tumors
• II. Malformations
hemangioma
capillary
lymphatic
venous
arteriovenous
others
combined
Capillary malformations
Capillary malformation
= port wine stain
• congenital
• 0.3 – 2.1%
• equal between races and
sex
• grows with the child
• no involution
• ev. hypertrophic with age
Ytligare på bål &
extremiteter
(A Troilius et al. Acta Derm Venereol
2000;80:196-199)
Hals, bål, arm
lättare att beh. än ansikte
(Ackerman G et al. Lasers Med Sci. Jun;17(2):70-8)
Grade I - IV
Waner et al,1999
• Grade I
• youngest
• pale or light pink
macula
• smallest vessel 5080
m
• Grade II
• clearly marked macula
• makroscopic vessels
• 80-120 m
(Waner & Suen,1999)
• Grade III
• red macula
• more marked vessels where dead ends are
seen
• 120 - 150 m
(Waner & Suen, 1999)
Grade IV
thick, purple, palperble,
dilatated vessels >150 m
Recurrence ?
• 26 %
(32 / 122)
a few months –
2 (-4) years after PDL
(Troilius A, Thesis - Characterisation amd treatment of Port Wine Stains… 1999)
Histology before and 6 w after 532 nm
Sturge Weber syndrome
before and after make up
Konklusion
Behandla tidigt!
• Psychosociala reaktioner
förbättrades efter
behandling!
(Äldre mer negativa än yngre)
A Troilius et al. British J Dermatol 1998;139:59-65
and Dermatol Surg 2000;26:190-196)
”Nothing has so marked an in
fluence on the direction of man´s
mind as his appearance,
and not his appearance itself as
much as his conviction that it is
attractive or unattractive”
/Tolstoj/
II Vascular malformations
Capillary
Venous
Lymphatic
Arteriovenous
Venous malformations
• Present at birth (not always evident) as a
spongy blue mass or a faint bluish patch
• May flatten by pressure
• Enlarge and worsen until puberty or later
to a lesser degree
• Pain and stiffness
Venous
• Swell and enlarge in declive and proclive
positions and in efforts
• Thin-walled, dilated, sponge-like abnormal
channels
• Pheboliths are palpable
Venous
Solitary,
but mutiple cutaneous
or visceral can occur
No
involution
May
infiltrate the skin, the
muscles, bones and joints
(mainly limbs)
Treatment of Venous
Malformations
Laser
Photocoagulation
Laser
Photocoagulation
Sclerotherapy
Surgical excision
Venus malformation under sole
after Diode 810 nm, 80 W, 55 ms,
3 Hz, 2mm spot, contact cooling
before
after
VM after diode
810 nm, 50 ms,
80W
Contact cooling
before & after
Absorption spectrum HbO2
1064
1064
Venous malformation
after alcohol inj. and long pulse Nd:YAG 532 cooling
Milton Waner, Little Rocks, Arkansas
II Vascular malformations
Capillary
Venous
Lymphatic
Arteriovenous
Lymfangiom
Lymphatic
• Congenital
• 65-75% diagnosed at birth
• 80-90 % diagnosed by the end of second
year
• Stress, hormonal surge, infection,
trauma
 increased volume of lymph
Lymphatic treatment
• I Microcystic infiltrating with clear
vesicles on the top  staged
excision
superficial  CO2
• II Macrocystic – puncture (only
temporary decompression),
sclerotherapy,
Glue OK-432 (a killed strain of group A
Streptocoocus)
• III Combined
Lymphatic - diagnosis
•Ultrasonography
•CT scans or MRI
•Direct puncture of lesion
Lymphatic Malformations:
Treatment
Macrocystic
Mucosal
OK 432
sclerotherapy
CO2
Laser ablation
Microcystic
Surgical excision
Lymphatic
after surgery
Prof Magnus Åberg, Plastic Surgery, Malmö, Sweden
II Vascular malformations
Capillary
Venous
Lymphatic
Arteriovenous
A-V
• Usually visible at birth or during childhood
• Mimic a PWS or Hemangioma
• Warm, throbbing
• High flow
• Multiple AV fistulas
AV
• Hormonal factors and traumas may induce
evolutivity
- thrill, increase in local heat and bruit
- draining veins tortuous and tense
Ärr
Erbium o CO2
Ärr för o efter laser
Tuberös skleros efter 1
Ultrapuls CO 2 behandling
After 1 CO2
Hidradenitis suppurativa
Hidradentitis suppurativa
• Inflammaion kring apokrina svettkörtlar
och hårsäckar – smärtsamma
akneliknande bölder, fistlar och ärrbildning
i axiller, ljumskar, genitalt
• Uttalad sjukdom, mycket lidande
• Rökstopp, viktnedgång, lokal
aknebehandling, tetracykliner, excision
med CO2-laser, Humira?
Before & after
4-8 tx I2PL
CO2 laser – our tx of choice!
• Excision - focused 3 mm collimated beam
0.2 mm spot, CW, 20 W
• Vaporisation ,
• Secondary healing ~ 4 w
Hair
Efter 6
behandlingar
med Ellipse
• Nu rakning
varannan
vecka
Medfödd
faun tail
(= focal lumbosacral
hypertrichosis)
Efter 3
behandlingar
Pigment
Q-switched frequency
doubled Nd:YAG
Biomechanics Incompletly understood
• Photoaccustic waves heat
tatto pigment causing
cavitation, rupture phagocystosis - removal by
macrophags
• Vacuolation with complete
clearance of tattoo particles in
most superficial dermis
(formation of atomic species
and gaseous products which
are rapidly dissolved in
Before and after 1 – 2 tx I2PL
Epidermalt
naevus
4 tx pulsed dye 510nm
Tatueringar
4 tx - QS Nd:Yag
4 tx QS Nd:Yag
Goitre
Ethiopian
Medicin tattoo
for 17 years ago
Skintype V
After several
QS Nd:YAG 1064 nm
Allergic reaction from red after 2
tx QS Nd;YAG
Epicutaneous test: 0
No history of mercury allergy
Histology – deep perivascular dermatitits
Erbium removal ?
A Troilius, 2000
Health risks!
• Both when applied and when
broken up via laser removal
• Heavy metals & azo dyes
– Medical Laser Report, April 2006
Traumatic tattoos
Traumatisk
tatuering
maskara
Efter 3 QS Nd:Yag
Traumatisk
tatuering billack
11 tx QS Nd:Yag
Militär explosion
3 tx QS Nd:Yag
Rocket explosion
After 6 QS Nd:YAG 1064 nm, 5-6 J/cm2
Warning!
• Laser ignition of traumatically embedded
gunpowder
• only if being shot at a short distance from
the skin
visible sparks and focal projectile ejection of
skin with pox-like scar formation
Fusade T et al.Dermatol Surg 2000 Nov;26
before
Future?
after