Просмотр полной версии : крупная гемангиома около глаза

Ответьте, пожалуйста!

- скорее всего потребуется удаление, так как гемангиомы, если они мешают нормальной жизнедеятельности, в данном случае зрению, либо локализация в области важных органов-зрения, дыхания и т.д.-это показание к удалению
- можно проконсультироваться с несколькими специалистами-онкологи хорошо ориентируются в тактике по любым новообразованиям, также можно и у окулиста/офтальмолога проконсультироваться
- конечно возможно и наблюдение у специалистов центра, где Вы и наблюдаетесь, думаю, они также оценят скорее как показание к удалению

Спасибо большое, Мария Юрьевна! А удаление, Вы имеете ввиду, хирургическим путем? Наверное с кожной пластикой придется тогда?

Хотелось бы все же подготовиться к очной беседе со специалистом по лечению гемангиом. Хотите - верьте, хотите - нет, но на прием там отводится 5 минут!!! То есть предварительная запись на прием дает именно такой интервал! Поэтому там некогда будет долго раздумывать.
Если можно: основные варианты лечения в нашем случае и (буквально, в двух словах) их достоинства и недостатки.
Если я задала вопрос в непрофильном разделе - помогите перенести его, пожалуйста, или, может, можно "пригласить" онколога с форума посмотреть наш случай в этом разделе? Или офтальмолога...Я читала, что врачи иногда проводят здесь что-то вроде консилиума...
Большое спасибо!

вашу тему читает гораздо больше людей, чем вы думаете:)
согласна с предыдущими докторами. в вашем случае лучше провести удаление сейчас, т.к. за то время, которое обычно требуется, чтобы гемангиома прошла, можно навредить ребенку, т.к до года она будет расти, соответственно зрение у ребенка будет страдать, и т.п.
скорее всего удаление будет проводиться лазером, либо путем замораживания ангиомы. на лучевую терапию я бы не соглашалась

Спасибо за ответы!
Можно ли надеяться на немного более развернутый ответ по поводу возможных вариантов лечения такой крупной гемангиомы с учетом ее расположения? И какие недостатки у них есть?
Я читала, что лазер используется только на плоских образованиях. Что промораживание - наименее "управляемый" метод и чаще приводит к рубцам. Кроме того слышала об инъекциях гормонов или приеме их внутрь...Через неделю на пятиминутную консультацию, а информации пока почти нет.

Periorbital hemangiomas — Periorbital hemangiomas should be evaluated by an ophthalmologist experienced with hemangiomas and their treatment [10,11]. Therapy may be as simple as patching the unaffected eye to ensure that the partially obstructed eye is used. Medical therapy in concerning cases often includes corticosteroids (topical, intralesional, or systemic, on a case-by-case basis). Surgical excision can be a good option for small, localized lesions [10-12].

PHARMACOTHERAPY

Systemic steroids — Systemic corticosteroids (prednisone or prednisolone) remain the first-line therapy for the majority of complicated hemangiomas. The mechanism of action is still not well understood [6]. Vasoconstriction, inhibition of vasculogenesis, decrease in mast cells, and/or decrease in levels of estrogen are possible mechanisms that may be involved [19].

Dose and duration — The usual starting dose is 2 to 3 mg/kg per day, although some physicians advocate higher starting doses of up to 5 to 6 mg/kg per day. A single morning dose is preferred to minimize adrenal suppression. A response (stabilization ± regression) is usually seen within the first few weeks [19,20]. Treatment is generally continued for several months or more, depending upon the indications for treatment, the response, and the child's age at initiation [6]. Prednisone should be slowly discontinued since abrupt discontinuation or rapid tapering of corticosteroids while a hemangioma is still in its active growth phase may result in rebound proliferation [5].

Efficacy — When used during the proliferative phase, systemic corticosteroids often arrest hemangioma growth and may induce regression. In a meta-analysis that reviewed all case series of more than 5 patients in which hemangiomas were treated with systemic corticosteroids, 24 original case series were included [21]. Patients were given a mean prednisone equivalent daily dose of 2.9 mg/kg for a mean of 1.8 months. The response rate was 84 percent (95% CI 78-89 percent). A dose of prednisolone 3 mg/kg per day was found to be more effective than 2 mg/kg/day [21].

The safety and efficacy of high-dose intravenous corticosteroids and oral corticosteroids in the treatment of problematic infantile hemangioma were compared in a small randomized trial [22]. Infants treated orally had greater reduction in hemangioma size at 3 and 12 months than those who were treated with pulse corticosteroids, suggesting that oral corticosteroids should continue as the mainstay of treatment.

Adverse effects — Corticosteroid use for infantile hemangiomas often results in minor, transient side effects, but long-term complications are rare. Short-term effects are more likely to develop with higher doses and courses of six months or longer, and resolve with drug tapering.

The most common complication is the development of a cushingoid facies, which usually begins within the first one to two months of treatment [23].
Personality changes (eg, depressed mood, agitation, insomnia, restlessness) develop in about one-third of infants, usually during the first two weeks of therapy [23].
Delayed skeletal growth, which may be more readily apparent since a child grows most rapidly during the first year of life, results from a temporary inhibition of collagen synthesis. However, nearly all children catch up to the normal growth curve once therapy has been discontinued, usually by 2 years of age [23,24].
Gastric upset occurs in at least 20 percent of infants and can be relieved with histamine2 (H2) blockers, such as ranitidine hydrochloride, which many initiate routinely along with corticosteroids [23].
Serious corticosteroid complications, such as aseptic necrosis of the femoral head, hypertension, osteoporosis, and cataracts, are extremely rare in children [23].
Corticosteroids also depress the immune system by reducing neutrophil migration to sites of inflammation. (See "Secondary immune deficiency due to medications and infections (other than HIV)").

There is one case report of Pneumocystis carinii pneumonia (PCP, but officially renamed Pneumocystis jirovecii pneumonia) developing in an infant treated with corticosteroids for a life-threatening airway hemangioma [25]. While the true risk of PCP and the utility of antibiotic prophylaxis in this population is not known, many advocate that trimethoprim-sulfamethoxazole prophylaxis be given to at-risk infants, particularly those with airway involvement [25]. We do not routinely administer PCP prophylaxis to children being treated with systemic corticosteroids for infantile hemangiomas. However, PCP prophylaxis may be warranted in infants who have other risk factors for PCP (eg, premature infants with significant concomitant medical problems). (See "Epidemiology, clinical manifestations, and diagnosis of Pneumocystis carinii (P. jirovecii) pneumonia in non-HIV-infected patients").

Live virus vaccines (eg, measles, mumps, rubella [MMR], varicella, rotavirus), should not be administered while infants are taking supraphysiologic corticosteroid doses. In addition, because the varicella vaccine is not administered until children are at least one year of age, infants receiving corticosteroid therapy should avoid exposure to individuals with varicella infection. (See "Standard childhood immunizations" and see "Prevention of varicella-zoster virus infection: Chickenpox", section on Postexposure prophylaxis).

Supraphysiologic doses of corticosteroids may suppress the hypothalamic-pituitary-adrenal axis. "Stress doses" of corticosteroids may be necessary for infants who require medical or surgical hospitalization while undergoing corticosteroid therapy for infantile hemangiomas [26].

Intralesional steroids — Intralesional corticosteroid injections (eg, triamcinolone acetonide 10 to 40 mg/mL) may be beneficial for small (<3 cm in diameter), localized hemangiomas and for ulceration.

Dose and duration — Individual doses should not exceed 3 mg/kg. A response usually is noted within two weeks, with continued response over the ensuing six to eight weeks [11]. Serial injections are sometimes needed.

Efficacy — In one retrospective review, 155 hemangiomas of the head and neck were treated with intralesional corticosteroid therapy (three to six injections of triamcinolone acetonide (10 mg/mL at monthly intervals)) [27]. The overall response rate (with response defined as >50 percent reduction in volume) was 85 percent. Response varied according to the type of hemangioma, with 80 percent of superficial, 75 percent of deep, and 60 percent of combined hemangiomas demonstrating response.

Adverse effects — Intralesional therapy should be performed cautiously, particularly for periocular hemangiomas, which should be managed by a specialist, most often an ophthalmologist with knowledge and experience in this area. Rare but serious side effects, including eyelid necrosis, central retinal artery occlusion, and adrenal suppression, have been reported [28-32].

Topical steroids — The use of high-potency corticosteroids (eg, clobetasol propionate cream) for periocular hemangiomas has been mainly described in the ophthalmology literature [33,34], and is probably best for small superficial hemangiomas at risk for ulceration or small periocular lesions [35].

Adverse effects — Adverse effects most commonly include local skin atrophy if inadvertently applied to normal surrounding skin. Adrenal suppression is also a possibility, even with localized use [36-38].

Vincristine — Vincristine has been used in the treatment of the Kasabach-Merritt phenomenon associated with the nonhemangioma tumors kaposiform hemangioendothelioma and tufted angioma. In vitro, vincristine induces apoptosis of tumor and endothelial cells.

The use of vincristine has expanded to include more aggressive hemangiomas. It is now being used by many as second-line therapy for corticosteroid-unresponsive, life-threatening, or severely life-altering hemangiomas because of the recognition of the potential neurotoxicity of interferon. (See "Interferon alpha" below).

Vincristine is generally administered by a central venous catheter. Its administration is commonly overseen by a pediatric hematologist/oncologist [39-41]. Toxicities of vincristine include peripheral neuropathy, constipation, jaw pain, and rarely, leukopenia and anemia.

Interferon alpha — Interferon alpha, a potent inhibitor of angiogenesis, is used as a second-line agent therapy for aggressive hemangiomas not responsive to corticosteroids [2,42].

Dose — The initial dose of interferon alpha is 3 million units/m2 per day [1]. The interval between administration and response ranges from a few weeks to several months [6].

Efficacy — The efficacy of interferon alpha was illustrated in a report of 20 neonates and infants with life-threatening or vision-threatening hemangiomas that failed to respond to steroid therapy [42]. The hemangiomas regressed by 50 percent or more in 18 of the patients (90 percent) after an average of 7.8 months of treatment.

Adverse effects — Common side effects of interferon alpha that are usually transient include fever, irritability, neutropenia, and liver enzyme abnormalities [19]. The most concerning side effect of interferon is severe neurotoxicity, including spastic diplegia. In one meta-analysis, authors identified 441 patients with vascular lesions treated with interferon [43]. Eleven (2.5 percent) developed permanent spastic diplegia, and 16 developed (3.6 percent) motor developmental complications that reversed upon discontinuation of therapy. All of the patients were <1 year of age at initiation of therapy. The authors concluded that interferon should only be used in infants <1 year of age for life-threatening vascular tumors that have not responded to other forms of treatment.

Infants undergoing treatment with interferon should receive a baseline neurologic evaluation and close neurologic monitoring [43]. If at all possible, the drug should be stopped at first sign of neurologic abnormalities.

Propranolol — Propranolol, a nonselective beta-blocker, appears to inhibit the growth of infantile hemangiomas [44]. Potential mechanisms of action for propranolol include vasoconstriction, decreased expression of vascular endothelial growth factor and basic fibroblast growth factor, and/or triggering of apoptosis. (See "Epidemiology; pathogenesis; clinical features; and complications of infantile hemangiomas", section on Pathogenesis).

The use of propranolol to treat heart failure in two young children with infantile hemangiomas, was associated with a change in color, softening, and decrease in size of the hemangioma [44]. These effects were replicated in an open trial of propranolol in nine children with disfiguring hemangiomas. Although these findings are promising, additional study is needed before treatment with propranolol can be routinely recommended.

OTHER MODALITIES — When a hemangioma poses primarily cosmetic concerns, therapeutic intervention must be tailored on an individual basis. In addition to oral, topical, and intralesional corticosteroids, therapeutic options include laser therapy and surgery. Cautery, irradiation, and cryotherapy may produce more scarring than untreated lesions and are thus not generally recommended.

Pulsed dye laser — The pulsed dye laser cannot be expected to affect hemangiomas with deep involvement, since the depth of laser penetration is only 1.2 mm. Currently, the most accepted use of pulsed dye laser in the management of hemangiomas is the treatment of ulceration, postinvolution erythema, and/or telangiectasias [2]. Which hemangiomas benefit most from laser therapy and what the optimal settings are remain areas of controversy.

Efficacy — In a prospective trial, 121 infants (1 to 14 weeks of age) with early hemangiomas were randomly assigned to treatment with pulsed dye laser or observation and were followed until they were 12 months of age [45]. At one year of age, the proportion of lesions with complete clearance or minimal residual signs was similar in both groups (42 versus 44 percent for treatment and control groups, respectively). However, adverse effects were more common among the treatment group (28 versus 8 percent and 45 versus 15 percent for skin atrophy and hypopigmentation, respectively).

Adverse effects — The use of pulsed dye laser therapy for proliferating hemangiomas is controversial because of concerns regarding potential hypopigmentation, textural changes, and promotion of ulceration and/or scarring [13,45-48].

Excisional surgery — Surgical excision is often reserved for involuted lesions with residual scars or loose skin; pedunculated cutaneous hemangiomas (because of the risk of scarring); small, localized periorbital hemangiomas; and for slowly involuting lesions in cosmetically concerning locations [19,49]. Excisional surgery may also be considered for large periocular hemangiomas, refractory ulcerated hemangiomas, and nasal-tip hemangiomas, but only if medical therapy is thought to pose a greater risk and the resultant scar is likely to be acceptable. In cases without complication, but for which there is uncertainty about the outcome, the benefits and risks of surgical intervention must be carefully considered, since the surgical scar may be worse than the results of spontaneous involution [20,50].

если не поймете ссылки, данные выше, напишите, вкратце переведу.
в каком городе вы живете? на самом деле, это не вы должны идти "подготовленной " к доктору, а он должен рассказать вам о возможных вариантах лечения со всеми плюсами и минусами, поэтому, странно, что консультация занимает 5 минут

Здравствуйте!
Большое спасибо за развернутый ответ. Я в Петербурге (о чем писала в первом сообщении). 5 минут на консультацию - это не преувеличение - именно на такой интервал выдаются номерки в нашем Городском центре по лечению гемангиом.
В целом текст понятен, но, если позволите, я задам несколько уточняющих вопросов?

В тексте:
Cautery, irradiation, and cryotherapy may produce more scarring than untreated lesions and are thus not generally recommended.
Вы писали немного ранее:
скорее всего удаление будет проводиться лазером, либо путем замораживания ангиомы. на лучевую терапию я бы не соглашалась
Вы имели ввиду сложившуюся практику? То есть лучше к любым хирургическим методам отнестись крайне настороженно - скептически?
По прочтении я стала склоняться к местным иньекциям гормонов, тем более что припоминаю, что о них заходила речь на консультации. Вопрос в следующем (этот момент я не совсем поняла): инъекции с меньшей вероятностью дают системные реакции, чем прием преднизолона внутрь? Или это во мне стереотип страха перед "приемом гормонов", а на самом деле прием внутрь не менее эффективен и более безопасен, чем инъекции?
Еще раз спасибо, с нетерпением жду пояснений.

По прочтении я стала склоняться к местным иньекциям гормонов
- все-таки лучше посоветоваться со специалистами очно и выслушать их аргументы, т.е. не торопитесь до приема, а вопросы все напишите на бумажки
- инъекции особого смысла не имеют, в данном случае скорее обосновано как раз хирургическое удаление, но этот вопрос нужно конечно обсуждать, можно с несколькими врачами, главное- очно

Здравствуйте!
Вы писали немного ранее:

Вы имели ввиду сложившуюся практику? То есть лучше к любым хирургическим методам следует отнестись крайне настороженно - скептически?
По прочтении я стала склоняться к местным иньекциям гормонов, тем более что припоминаю, что о них заходила речь на консультации. Вопрос в следующем (этот момент я не совсем поняла): инъекции с меньшей вероятностью дают системные реакции, чем прием преднизолона внутрь? Или это во мне стереотип страха перед "приемом гормонов", а на самом деле прием внутрь не менее эффективен и более безопасен, чем инъекции?
Еще раз спасибо, с нетерпением жду пояснений.

на самом деле очень многое зависит от врача, который вас будет консультировать, от его опыта. не знаю как в питере, а в москве, когда вопрос стоит об удалении, в первую очередь рекомендуют криодеструкцию.
лазер более эффективен, чем крио, но стоит он дороже.
мое мнение, вы правы, начать лучше с инъекций стероидов. побочные эффекты могут быть даже при наружном применении гормональных кремов. но, в вашем случае, должны приниматься во внимание все плюсы и минусы лечения и нелечения
паралельно с офтальмологом желательно обсудить вопрос попеременного закрытия глаз повязкой (чтобы не развивалось косоглазие, и оба глазика работали одинаково).

Спасибо, пожалуй, пока вопросов больше нет. Ждем повторного очного осмотра. К офтальмологу в ближайшее время.

- у кортикостероидов еще есть при применении в области глаз(наружные даже стероиды) такой побочный как глаукома, поэтому на счет стероидов нужно проконсультироваться со специалистами
- в данном случае от локализации много зависит-в том числе и выбор метода, ждем, что Вам скажут коллеги на консультации:bo: