Margitta Poetke

Ten years of laser treatment of congenital vascular disorders: techniques and results

During the period of January 1984 - July 1993, we have treated 611 children with more than 2000 lesions of congenital vascular disorders (CVD) such as hemangiomas and vascular malformations. This number does not include the patients with port wine stains, which also have been treated by means of laser. Most of the CVD patients (n equals 467) presented hemangiomas of the face, the anogenital region, and the extremities, some were located in the trachea or mouth or in the urogenital tract. All of these hemangiomas were growing prior to intervention or showed complications such as bleeding, ulceration, superinfection, or obstruction. Nearly a quarter (n equals 144) of the patients presented vascular malformations, either of singular vessel type involvement or of mixed vascular genesis (venous, arterio- venous, veno-lymphatic or lymphatic) with various complications like tracheal obstruction or recurrent thrombophlebitis. According to our step program, which is based on a clinical classification, the hemangiomas were treated as early as possible, while the vascular malformations were only treated with laser when no other therapeutic technique (embolization, resection) was suitable. All patients were referred for laser treatment from other centers. The lasers used were Nd:YAG and Argon lasers with transcutaneous application with or without continuous ice-cube surface cooling or interstitial laser application. The treatments were performed either on in- or outpatient basis according to age, localization and with good to excellent results in most cases and a complication rate of less than 2%.

Laser Therapy of Haemangiomas and Vascular Malformations – Techniques and Strategies

Summary Lasers have been used in the treatment of haemangiomas since the early 1980s. Several study groups have reported good results, others have been less enthusiastic and emphasized other treatments like cryosurgery. We reviewed our experience with the use of laser therapy in treating complicated haemangiomas of infants. During a 15-year period, 1117 infants with haemangiomas were treated with the Nd:YAG laser. The lesions reported were particular troublesome because of significant cosmetic disfigurement, maceration or ulceration, bleeding, and of potential functional impairment. Superficial findings were treated using was a transcutaneous application with local ice cube cooling to protect the overlying skin. All deep-seated lesions were treated with interstitial laser irradiation. In trachaeal haemangiomas endoscopic laser destruction is an alternative to tracheostomy with good functional results and comparable or less morbidity. Overall, excellent results were achieved in 41% of infants and good results occured in 51%. On the basis of our results we conclude that laser therapy may successfully prevent enlargement and promote involution of haemangiomas with minimal adverse effects. Therapy should be initiated as early as possible, when lesions are relatively flat, for optimal results.

Interstitial Laser Treatment of Venous Malformations

Summary Objective: Venous malformations are aside from hemangiomas the most common vascular lesions observed in the pediatric age group. While interstitial Nd:YAG laser treatment was first used to treat hemangiomas in infancy, the mechanism of this treatment also can be used for venous malformations to reduce bulk and hypervascularisation, and improve contour and function. Study design: We reviewed our experience with the use of interstitial Nd:YAG laser therapy in treating complicated venous or mixed malformations. The lesions reported were particular troublesome because of significant cosmetic disfigurement, maceration or ulceration, bleeding, coagulopathy, painful swelling, and of potential functional impairment. During a 15-year period, 176 patients with predominantly venous malformations were treated by interstitial Nd:YAG laser treatment, and 157 of the 176 patients were treated additionally by transcutaneous Nd:YAG laser treatment with local ice cube cooling to protect the overlying skin. By using interstitial laser treatment, the laser beam was transmitted using a 0.6 mm bare fiber that was placed through an 16G abbocath into the lesion to be treated. The laser energy ranged from 5 W to 8 W in continuous mode. Color-coded duplex sonography was used for monitoring the procedure. Treatments were done under general anesthesia. Results: Overall, excellent results were achieved in 43% of patients and good results occured in 52%. In 5% treatment was deemed to have failed. Complications included paresthesia, dysesthesia, mild trismus, and local motoric plegia. All complications were transient and disappeared completely. Overall, satisfaction was high because of clear reduction of complaints, and all but 1 patient would have laser treatment again. Conclusions: On the base of our results we conclude that interstitial Nd:YAG laser treatment may successfully prevent enlargement and promote improvement with flattening of the lesion, less swelling, and improvement in the vascular red or bluish hue with minimal adverse effects.

Treatment of congential vascular disorders: classification, step program, and therapeutic procedures

Because of the different step programs concerning the preoperative diagnostic and the onset of therapy for the various types of congenital vascular disorders (CVD) a clear classification is important. One has to discern the vascular malformations, including the port wine stain, from the real hemangiomas which are vascular tumors. As former classification, mostly based on histological findings, showed little evidence to a clinical step program, we developed a descriptive classification which allows an early differentiation between the two groups of CVD. In most cases this can be done by a precise medical history of the onset and development of the disorder, a close look to the clinical signs and by Duplex-Ultrasound and MRI-diagnostic. With this protocol and the case adapted use of different lasers and laser techniques we have not seen any severe complications as skin necrosis or nerve lesions.

Pyogenic granuloma – Nd:YAG laser treatment in 450 patients

Abstract Background and objective: Pyogenic granuloma (PG) also known as “eruptive hemangioma”, “granulation tissue-type hemangioma”, “granuloma gravidarum”, or “lobular capillary hemangioma”, are well-demarcated, rapidly exophytic growing benign, usually pedunculated red (vascular) tumors on skin or mucosa. They belong to the group of capillary angiomas, but differ from infantile hemangioma. Occurrence is mostly posttraumatic, but also spontaneously, especially in children and pregnant women. A high risk of complication as bleeding or infection results from the vulnerable surface. Conventional surgical excision, cautery or cryotherapy may lead to relapse in addition to visible scar formation. Thus we remove PGs using laser, in most of cases with a continuous wave Nd:YAG laser. Methods: Before therapy, PGs of skin were initially rated in size and vascularization using color-coded duplex sonography. Usually the Nd:YAG laser (1064 nm) was employed. Laser settings and techniques were adjusted appropriately; i.e. pulsed, chopped or continuous wave for in-situ coagulation, in impression technique or by direct coagulation. Bigger and more pedunculated tumors have been coagulated at the base in a perpendicular fashion with bare fiber. The present paper is a retrospective cohort study of PGs which have been treated since the year 2000 in our clinic at the Ev. Elisabeth Klinik Berlin, Germany. In order to review our learning curve, the patients were divided into two groups according to the period of treatment: 1) patient group between the years 2000–2004; 2) patient group between the years 2005–2013. Results: In total, 450 patients with 454 PGs were treated between the years 2000–2013. The size of PGs at time of treatment was 2–15 mm. Forty percent of PGs showed former bleeding. Seventy-six percent (n=344) of PGs occurred during the first two decades of life; 60% of cases in this group (n=205) occurred during the first 5 years of age. Taken as a whole, no gender predominance (♂: 52%; ♀: 48%) was found. Interestingly in the first year of age there was a male predominance (♂: 61%); in contrary a female predominance (♀: 63%) in middle age was seen. Eighty percent of angiomas were located in the head-neck region, particularly on eyelids. In the years 2000–2004, 70% of cases were treated with the Nd:YAG laser; a single session was sufficient in 93% of this cases, and the recurrence rate was 7%. In contrast, in the years 2005–2013, Nd:YAG laser treatment was performed in 94% of cases with a recurrence rate of less than 4%. The most effective application mode was the use of the Nd:YAG bare fiber technique, for both coagulation in situ and radical removal with <1% recurrences. No complications such as postoperative bleeding or infection appeared. Clinical outcome was scored by two independent evaluators blinded to type and number of treatments by rating the postoperative control images and could be completed for 199 out of 450 patients. The cosmetic results, especially in the facial area (containing lips and eyelids), were good or excellent in 60% of the cases (n=120). Conclusions: Laser treatment proved to be a successful method with no relevant side effects or complications. Scarring was observed in 40% of the cases (n=79) and thus less compared with shave excision and cautery. Hence, it can be suggested to include the Nd:YAG laser into the options of first-line therapy for PGs.

Laser Treatment of Hemangiomas

The indication for any therapy in congenital vascular tumors are growing or other complications. Due to specific and calculable reactions, laser offers the best modality for localized therapy because only with laser it is possible to preserve the unaffected epithelial layer. Besides the different wavelengths with their specific absorption patterns, a great variety of tissue interactions can be achieved by varying the interaction time and surface protection by cooling and/or compression.

Infantile Hämangiome und andere kongenitale vaskuläre Tumoren

Kongenitale vaskulare Tumoren haben ein sehr breites Spektrum an Erscheinungsformen. Der haufigste und bekannteste ist das GLUT-1-positive infantile Hamangiom. Von den infantilen Hamangiomen mussen die kongenitalen Hamangioendotheliome, die in unterschiedlichen Verlaufsformen wie dem NICH, dem RICH und dem kaposiformen Hamangioendotheliom auftreten, unterschieden werden. Da die infantilen Hamangiome eine hohe Rate an Spontanregression zeigen, muss die Indikation zu einer Therapie streng gestellt werden. Andererseits kann exzessives Wachstum, abhangig von der Lokalisation, zu bleibenden Schaden fuhren, sodass eine fruhzeitige Diagnose und Indikationsstellung erforderlich ist.

Vascular Lesions: Hemangiomas

Congenital vascular tumors have a wide variety of origins. The most common congenital vascular tumor is the GLUT-1 positive infantile hemangioma (IH). This has to be differentiated from the congenital hemangioendothelioma. While the majority of IH have a high rate of spontaneous regression, severe complications are possible and it is important to identify the dangerous forms as early as possible and start early treatment to prevent secondary complications.

[4.04] CO2-laser treatment of patients with anogenital lichen sclerosus

Objective The lichen sclerosus is a non-inflammatory, chronic disease most probably with auto-immunological genesis. Different conservative therapies exist: the local or systemic treatment with estrogens, corticosteroids and immunomodulators. The clinical presentation and the subjective complaints are not persistently improved by these conservative methods. For several years we have used laser skin ectomy as an alternative to the vulvectomy that has now become obsolete. In this presentation we will demonstrate the surgical technique and show the results achieved with our technology. Material and methods During the last 8 years we treated 184 patients aged between 17 and 84 years, who were suffering from an anogenital lichen sclerosus. After histological confirmation of the diagnosis, we performed the laser skin ectomy with a CO 2 laser. The postoperative healing, the clinical course of the subjective complaints and the recurrence rate were evaluated. We investigated the spectrum of age, the duration of conservative therapy as well as the findings of genital synechiae and atrophies at the initial stage of our therapy. We furthermore investigated the occurrence of squamous cell carcinomas amongst our patients. Results The number of treatments per patient was between zero (recommendation of conservative treatment prior to laser surgery was successful) and ten treatments. The average number of treatments was 1.7. Fifteen percent of incoming patients showed synechiae; genital atrophies were seen on 20% of our new patients. Using laser skin ectomy a precise separation of pre-existing synechiae was possible. The ablation of the affected layers maintaining the papillary region can also be achieved with high precision. With the laser ablation a large wound area results and is subject to intensive wound treatment. The average healing time was 3 weeks. Two patients suffered retarded healing with subsequent super infection due to adiposity-related difficulties in wound treatment. The super infection was successfully treated with a five-day medication with oral cephalosporin. Success of the treatment was seen in all of our patients. A clear improvement of objective and subjective symptoms such as itching, erosions, rhagades and hemorrhage was achieved. The recurrence period was 6 months to 4 years. Not all patients returned for follow-up check-up. Four patients suffered vulvar and perianal squamous cell carcinomas after a long-term persisting recurrent lichen sclerosus. Conclusion Laser therapy is an effective option with good results showing clear improvement of objective and subjective symptoms, in particular for those patients where a conservative treatment had not been successful. The main advantage of our treatment is the precise ablation of only the directly affected zones. The patients did not have to undergo additional mutilating treatments. With beginning recurrence, single affected zones could be ablated in outpatient treatment. Our treatment method is relatively simple and helps our patients have long periods of time without recurrence of symptoms.

Zehn Jahre Laserbehandlung von Hämangiomen and Vaskulären Malformationen (CVD)

Durch die Weiterentwicklung der Behandlungsmoglichkeiten angeborener Gefaserkrankungen (Congenital Vascular Disorders, CVD), besonders der Lasertechnologien, besteht heute die Moglichkeit einer fruhzeitigen und schonenden Therapie. Daher sollten Hamangiome zur Verhinderung einer Ausbreitung schon im Prodromalstadium behandelt werden. Auch vaskulare Malformationen sollten fruhzeitig behandelt werden, um die durch die pathologische Zirkulation hervorgerufenen Sekundarerscheinungen moglichst gering zu halten. Fur eine exakte Therapieplanung and Erfolgskontrolle ist eine eindeutige Zuordnung der verschiedenen Formen der angeborenen Gefaserkrankungen notwendig. Es mussen die Vaskularen Malformationen, zu denen auch der Naevus flammeus gehort, von den eigentlichen Hamangiomen differenziert werden. Beide Formen unterscheiden sich hinsichtlich ihrer Genese and ihres Spontanverlaufs, konnen jedoch beide zu erheblichen Komplikationen fuhren. Aufbauend auf die derzeitige therapeutische Einstellung fur eine Friuherkennung empfiehlt sich fur die tagliche Routine die Durchfuhrung eines einfach handzuhabendes Stufenprogramms, anhand dessen die einzelnen Schritte der Behandlung von Hamangiomen (Abb.1) bzw. Vaskularen Malformationen (Abb.2) geplant werden konnen.