Surgical resection of infantile

hemangiomas following medical

treatment with propranolol versus
corticosteroids
• Infantile Hemangioma (IH) is a benign vascular
tumor composed of endothelial cells and is one
of the most common pediatric tumors, occurring
in 4-10% of infants.
• Prior to 2008, systemic corticosteroids were the
first line of therapy for complicated IH. In 2008,
propranolol was discovered to be effective for the
treatment of cutaneous IH while being used to
treat cardiopulmonary conditions by Leaute-
Labreze et all
• Consensus was reached 2011 on the preferred
use of propranolol, it remains if propranolol is
associated with reduced need for surgical
resection of cutaneous IH compared to
corticosteroids.
• Surgical intervention for IH should be avoided
when possible given the increased anesthetic
morbidity among infants, thus it is important to
consider need for surgery as an outcome of
pharmacologic therapy.
• The purpose of this study --- determine the
need for of surgical resection, a measure of
medication efficacy, for IH with oral
propranolol vs corticosteroids.
• A single center, retrospective review was
performed of Hemangioma and Vascular
Malformation Center at Cincinnati Children’s
Hospital Medical Center (CCHMC) between
January 2005 and December 2014
• Data are presented as n (percentage) or
median (interquartile range; IQR). Univariate
and multivariable logistic regression analyses
were performed comparing the two groups
with the primary outcome of surgical
resection. Statistical significance was defined
as p≤.05.
• The practice transitioned from corticosteroids to
propranolol in 2010. Corticosteroid dosing was done
using oral prednisone starting at 2mg/kg for 4-8 weeks.
• Dose increase to 3 mg/kg/day was done selectively for
few patients. Medications were gradually tapered after
the lesions reached involution phase and stopped after
the lesions disappeared. Surgical resection was
performed for the following indications: local
complications, cosmetic impairment, or functional risk
that did not respond to medical therapy.
• Of all patients evaluated for IH during the study period,
247 were included; 52 patients were treated with oral
corticosteroids and 195 with oral propranolol.
• Median age at treatment was 3 months (IQR 2, 5) and
most patients were <1 year of age (94%). The majority
of patients had one lesion (73%); ≥5 lesions were
present in 15 patients (6%). The most frequent location
was head and neck (76%) followed by perineal and
extremity (both 9.2%). Surgical resection following
medical therapy was required in 32 patients (13%) with
median age at surgery 9 months
• Operative intervention was required in 14
patients treated with corticosteroids (27%) vs
18 patients treated with propranolol (9%;
p<.001; Table 2). There was no difference in
age at resection, race, sex, insurance type,
number of lesions or location of lesions
between those who required resection and
those who did not
• multivariable analysis treatment with
corticosteroids remained associated with
increased odds of surgical resection (OR=3.3,
p=.001; Figure 1)
• While retrospective and prospective studies have
demonstrated non-inferiority or superiority of
propranolol in terms of IH treatment, we report
decreased need for surgical resection of IH
associated with propranolol.
• In this study It is hypothesized that
propranolol results in vasoconstriction and
downregulation of angiogenic growth factors
during the growth phase, triggering an earlier
involution process through apoptosis
• One option for patients without adequate
response to medication is surgical resection.
Our retrospective data suggests propranolol
reduces the need for surgical resection among
those IH.
• Though the association between prematurity
and surgical resection requires further study
to identify its mechanism.
• In conclusion, treatment with propranolol was
associated with decreased odds of surgical
• resection of IH when compared to
corticosteroids. This study further supports
the efficacy of propranolol in treating IH