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Persistent Vascular Lesion in a Young Boy

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 3-year-old boy presented with a vascular lesion involving the left orbit and face. He had a pink macule on his left cheek at birth, which became raised and discolored around age 3 to 4 weeks. He was diagnosed with a capillary hemangioma, and propranolol was started at age 1 month with progression despite dosage increases. Topical timolol was tried without improvement; oral prednisolone decreased the size of the lesion, but was poorly tolerated and discontinued. An ophthalmic evaluation at an outside hospital was concerning for amblyopia because of anisohypermetropia, greater on the left, and a left esotropia and hypertropia. A magnetic resonance image revealed an orbital mass surrounding the left lateral rectus muscle with mass effect on the globe and extension into the eyelid, pterygopalatine fossa, and cheek.

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Infantile hemangioma

D. Oral sirolimus

This is a complex hemangioma spanning multiple compartments of the left midface that has persisted despite propranolol, oral prednisolone, and multiple debulking surgeries. Sirolimus, an mTOR inhibitor that has antiangiogenic effects via regulation of cellular growth and proliferation pathways, is a viable treatment option for infantile hemangioma that has increasingly been used to treat refractory hemangiomas with success.16

Infantile hemangioma is a benign vascular tumor occurring in 5% of infants worldwide.7 These endothelial cells are characterized by rapid proliferation in the first 3 months of life followed by slow involution.7 Infantile hemangiomas are differentiated from other vascular tumors by their clinical course and glucose transporter 1 positivity.8 While many infantile hemangiomas require only observation, medical treatment is recommended for eyelid or orbit hemangiomas that cause visually significant ptosis, strabismus, astigmatism, and amblyopia.7

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Article Information

Corresponding Author: Catherine Y. Liu, MD, PhD, Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, University of California, San Diego, 9415 Campus Point Dr, La Jolla, CA 92093 (yul107@health.ucsd.edu).

Published Online: July 7, 2022. doi:10.1001/jamaophthalmol.2022.1541

Conflict of Interest Disclosures: Dr Liu reported a research grant from Horizon Therapeutics and royalties from Wolters Kluwer Health outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient’s family for granting permission to publish this information.

References
1.
Cho  YJ , Kwon  H , Kwon  YJ , Kim  SC , Kim  DY , Namgoong  JM .  Effects of sirolimus in the treatment of unresectable infantile hemangioma and vascular malformations in children: a single-center experience.   J Vasc Surg Venous Lymphat Disord. 2021;9(6):1488-1494. doi:10.1016/j.jvsv.2021.03.014 PubMedGoogle ScholarCrossref
2.
Hammill  AM , Wentzel  M , Gupta  A ,  et al.  Sirolimus for the treatment of complicated vascular anomalies in children.   Pediatr Blood Cancer. 2011;57(6):1018-1024. doi:10.1002/pbc.23124 PubMedGoogle ScholarCrossref
3.
Dávila-Osorio  VL , Iznardo  H , Roé  E , Puig  L , Baselga  E .  Propranolol-resistant infantile hemangioma successfully treated with sirolimus.   Pediatr Dermatol. 2020;37(4):684-686. doi:10.1111/pde.14163 PubMedGoogle ScholarCrossref
4.
Kaylani  S , Theos  AJ , Pressey  JG .  Treatment of infantile hemangiomas with sirolimus in a patient with PHACE syndrome.   Pediatr Dermatol. 2013;30(6):e194-e197. doi:10.1111/pde.12023 PubMedGoogle ScholarCrossref
5.
Hutchins  KK , Ross  RD , Kobayashi  D , Martin  A , Rajpurkar  M .  Treatment of refractory infantile hemangiomas and pulmonary hypertension with sirolimus in a pediatric patient.   J Pediatr Hematol Oncol. 2017;39(7):e391-e393. doi:10.1097/MPH.0000000000000961 PubMedGoogle ScholarCrossref
6.
Shoji  MK , Shishido  S , Freitag  SK .  The use of sirolimus for treatment of orbital lymphatic malformations: a systematic review.   Ophthalmic Plast Reconstr Surg. 2020;36(3):215-221. doi:10.1097/IOP.0000000000001518PubMedGoogle ScholarCrossref
7.
Krowchuk  DP , Frieden  IJ , Mancini  AJ ,  et al; Subcommittee on the Management of Infantile Hemangiomas.  Clinical practice guideline for the management of infantile hemangiomas.   Pediatrics. 2019;143(1):e20183475. doi:10.1542/peds.2018-3475 PubMedGoogle ScholarCrossref
8.
Polites  SF , Watanabe  M , Crafton  T ,  et al.  Surgical resection of infantile hemangiomas following medical treatment with propranolol versus corticosteroids.   J Pediatr Surg. 2019;54(4):740-743. doi:10.1016/j.jpedsurg.2018.08.001 PubMedGoogle ScholarCrossref
9.
Men  CJ , Ediriwickrema  LS , Paik  JS ,  et al.  Surgical intervention of periocular infantile hemangiomas in the era of β-blockers.   Ophthalmic Plast Reconstr Surg. 2020;36(1):70-73. doi:10.1097/IOP.0000000000001466PubMedGoogle ScholarCrossref
10.
Adams  DM , Trenor  CC  III , Hammill  AM ,  et al.  Efficacy and safety of sirolimus in the treatment of complicated vascular anomalies.   Pediatrics. 2016;137(2):e20153257. doi:10.1542/peds.2015-3257 PubMedGoogle ScholarCrossref
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