Volume 1, Issue 3 , Pages 213-216, September 2006
Successful laser-treatment of an endobronchial hemangioma in an infant
Article Outline
Summary
Capillary hemangioma situated within the left main bronchus was diagnosed in a 5-month-old male infant suffering from severe respiratory distress. Diagnosis was made by bronchoscopy, medium-enhanced computer tomography, endobronchial sonography, and histologic examination. We report the first successful resection of this kind of lesion using a Neodym-Yag laser. The infant was discharged free from clinical symptoms. No adverse effects could be detected in the follow-up examinations. In conclusion, even with endobronchial hemangiomas laser therapy offers a less invasive, safe, and fast alternative to surgical resection.
Keywords: Infant, Endobronchial, Hemangioma, Laser, Resection, Obstruction
1. Introduction
Hemangiomas, per se benign vascular proliferations, may be life threatening when situated in the airways. Given their potential for rapid proliferation during infancy subsequent obstruction may occur. The preferential location of most hemangiomas within the respiratory tract is the subglottic region. The biology of this lesion and its management has been reviewed extensively [1], [2], [3]. In contrast, endobronchial hemangiomas are extraordinary rare, even in childhood [4], [5], [6], [7], [8]. To our knowledge, all infants reported in the literature who presented with this kind of disease were treated by surgical resection [4], [5], [6], [7]. In this case report, we present an alternative approach, using laser therapy for the treatment of an endobronchial capillary hemangioma in a dyspnoeic male infant.
2. Case report
This 5-month-old dystrophic boy (body weight: 5
kg, <3th percentile) presented on admission with severe respiratory distress and clinical signs of airway obstruction. The infant has been treated as an outpatient for obstructive bronchiolitis during the last 3 months. There was no history of foreign body aspiration. Auscultation of the lungs gave an extreme prolonged expiratory stridor with an almost “silent chest” on the left side. Beside a small hemangioma placed on the right buttock, the rest of the clinical examination was inconspicuous. Hyperinflation of the left lung with displacement of the mediastinum to the right and beginning compression of the right lung was seen on the initial chest roentgenogramm. A subsequent rigid bronchoscopy performed under general sedation revealed a large, reddish colored tissue mass covered by mucosa that almost completely obstructed the left main bronchus (Fig. 1a). Visualization of the mass in a medium-enhanced computed tomography showed similar densities for the endobronchial mass and the neighboring vessels (Fig. 2). To exclude the presence of an aberrant intrapulmonary blood vessel an endobronchial sonography was performed, demonstrating a solid tumor (4.1mm×3.2mm) without major blood flow (Fig. 3). Following uncomplicated biopsy, an endobronchial capillary hemangioma was diagnosed by histologic examination (Fig. 4).
Fig. 1.
(a and b) Bronchoscopic view of the left main bronchus, before and after laser resection of the hemangioma.
Fig. 2.
Medium-enhanced computer tomography scan of the upper thorax. The lesion within the left main bronchus is indicated with an asterisk.
Fig. 3.
Enobronchial sonography of the hemangioma (4.1
mm×3.2mm).
Fig. 4.
Histologic preparation of the tissue (CD31(PECAM)-immunohistochemistry), showing a capillary hemangioma.
The child was initially treated symptomatically (including mechanical ventilation and systemic corticosteroids) until definite diagnosis. The complete removal of the endobronchial hemangioma could be achieved within two sessions using a Neodym-Yag laser (wavelength: 1046nm) via rigid bronchoscopy. The child was discharged free from clinical symptoms, but with residual hyperinflation of the left lung. Control bronchoscopy after 3 months showed no remaining airway obstruction or stricture of the left main bronchus (Fig. 1b). Hyperinflation of the left lung was beginning to recede and the infant improved to thrive (body weight: 7kg, 3th percentile).
3. Discussion
Noisy breathing in an infant with a cutaneous hemangioma warrants direct visualization of the airways. Approximately 50% of such infants have hemangiomas within the respiratory tract [3]. Infants with cutaneous hemangiomas involving the chin, lips, mandibular region, and neck are at greatest risk for airway involvement. Asymptomatic infants with extensive hemangiomas in this region of the face and neck (“beard” distribution) should be carefully monitored, since symptomatic hemangiomas of the airways will develop in 60% of these patients [3]. Most symptomatic hemangiomas are diagnosed by bronchoscopy. Dynamic contrast-enhanced CT has also been shown to be clinically useful [9]. In addition, endobronchial sonography may be used for primary diagnosis and to guide therapy [10]. However, the definite diagnosis can only be confirmed by histology.
Capillary hemangiomas, including those within the respiratory tract, are benign vascular tumors. They typically show a characteristic proliferation pattern [1]. Commonly appearing by the first months of life (nadir at the fifth month) they may regress spontaneously by the seventh year of life. However, lesions within the airways may rapidly progress to respiratory failure, which necessitates immediate relieve of symptomatic patients [2]. Many methods have been described for the treatment of subglottic hemangiomas, including corticosteroids, interferon, tracheostomy, carbon dioxide laser, cryotherapy, radiation, and surgical resection. All of the endobronchial hemangiomas described in the literature were treated by surgical resection [4], [5], [6], [7], [8]. Even though no complications are reported so far, it still remains a major intervention with large potential risks. Laser therapy, in contrast, offers a less invasive approach with possible preservation of the anatomic structures. Neodym-Yag, CO2, and KTP laser have been used for resection of subglottic hemangiomas. In a recent study CO2 laser led to a reduction in tracheostomy, morbidity, speech developmental delay compared to Neodym-Yag laser [11]. Since with Neodym-Yag laser there is energy dispation into deeper tissue, the incidence of scare formation may be increased. Therefore, the exact dimension of the lesion should be known for choosing the appropriate laser device. In this case, Neodym-Yag laser resection was performed very carefully, which made two sessions necessary for a complete removal of the airway obstruction. There were no detectable adverse effects in the follow-up examinations.
4. Conclusion
Respiratory distress due to hemangiomas within the airways warrants fast diagnosis. Endobronchial sonography, in particular, offers the advantage to stage the dimensions of the lesion “at the bed-side” and to guide laser therapy. As long as the lesion is accessible by rigid bronchoscopy, even endobronchial hemangiomas can be fast and reliably removed by laser resection, which may be less invasive compared to surgery. However, to reduce the risk of scare formation, an appropriate laser has to be chosen.
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PII: S1871-4048(06)00061-X
doi:10.1016/j.pedex.2006.05.006
© 2006 Elsevier Ireland Ltd. All rights reserved.
Volume 1, Issue 3 , Pages 213-216, September 2006
