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The most common differential in adolescence is a Diagnosis primary malignant tumor of bone (osteosarcoma vs Ewing sarcoma) or infection buy discount minocin antibiotics for uti pain. Occasionally generic minocin 50 mg with amex antibiotic synonym, the 288 Case 64 chemotherapy regimen is modified postoperatively Axillary Angiography Report (tailoring) buy generic minocin from india necro hack infection, depending on the response of the tumor Angiogram (midarterial phase) is performed with to the induction chemotherapy. The pathological the arm placed in the abduction position following response is determined by evaluating the amount of induction chemotherapy. Note there is no uptake of tumor necrosis by careful examination and study of contrast within the proximal humerus or the ex- the resected tumor mass by a standard pathological traosseous component. Approximately 90% to 95% of all osteosarcomas can today be removed via limb- sparing surgery instead of an amputation. The indi- Discussion cations for amputation include massive tumors with Angiography following induction chemotherapy is neurovascular involvement, pathological fracture, one of the most reliable imaging techniques to de- infection, or the occurrence of a tumor in an ex- termine the impact (i. The absence of any The specific recommendation for this patient uptake correlates with a good tumor response (i. In addition, preoperative an- sparing surgical resection of the right proximal giography is helpful to the surgeon in planning the shoulder girdle. The most common drugs used include doxorubicin (Adriamycin), cis- platin, ifosfamide, and high-dose methotrexate. The major nerves and vessels to humerus, the lateral portion of the scapula includ- the arm can be preserved, and the bony resection ing the glenoid, and the lateral one third of the site can be reconstructed with a metallic endopros- clavicle. A modular segmental prosthesis is presently cemented in place, and the head is placed anterior being used for most patients with osteosarcomas. It is suspended from the Following surgery and wound healing, patients scapula and remaining clavicle by Dacron tape. The with osteosarcomas are treated with postoperative reconstruction also consists of multiple muscle chemotherapy for 6 to 12 months, depending transfers, especially the pectoralis major and the upon various protocols. The deltoid muscle is the main muscle that is resected at the time of surgery because it typ- ically provides an adjacent covering for the tumor mass. There is no need for arte- ■ Axillary Angiogram rial grafts or nerve reconstruction. Discussion Approximately 90% to 95% of all osteosarcomas of the proximal humerus can be treated by a limb- sparing resection instead of an amputation. The tu- mor is resected and the defect is reconstructed with a segmental modular prosthesis. The resection can either be intra-articular (through the joint) or extra- articular (en bloc removal of the proximal humerus including the glenoid). All muscles attaching to or arising from the proximal humerus are considered at risk for tumor spread. In general, tumors of the prox- imal humerus are best treated by extra-articular re- sections when undertaking a limb-sparing proce- dure, because there is a high incidence of local Figure 64. Following complete wound healing, the patient Case Continued begins a postoperative chemotherapy regimen that The wound heals well except for a small area of flap includes doxorubicin (Adriamycin), cisplatin, and necrosis, which requires debridement and secondary ifosfamide. Note the absence of the gle- the proximal humerus along with the glenohumeral noid. The area of semicircular ossification around joint, deltoid, and other attaching muscles. Local recurrence several years; it represents metaplastic new bone following this type of resection for high-grade bone and is an attempt to create a “new” glenoid. Plain radiograph of the specimen shows the proximal humerus, which is sclerotic (area of osteosarcoma), and the attached ■ Specimen Photograph and X-Ray glenoid and acromion, demonstrating a complete extra-articular resection. The pink material represents malignant osteoid made by the malignant stroma cells. The remaining tumor osteoid (pink) re- ally, osteosarcomas occur at the ends of long bones, mains with no viable cells seen between them. Tu- whereas Ewing sarcomas occur in the axial skeleton, mor osteoid does not disappear following tumor pelvis, scapula, and proximal femur. Tu- cult to distinguish between the two malignancies mor necrosis greater than 90% is the most impor- utilizing radiographs alone. The additional clue is Patients with osteosarcomas are followed extremely an elevated alkaline phosphatase value, which oc- carefully to rule out local recurrence or metastatic curs in 40% to 50% of all osteosarcoma patients but disease. Alkaline phos- ways results in pulmonary nodules initially, with phatase is a good tumor marker for malignant os- occasional metastatic nodules to the skeletal sys- teoid (i. Metastases from osteosarcomas are almost al- any systemic symptoms, such as anorexia, fever, or ways hematogenously spread. Sarcomas in general do not produce sys- most accurate method of evaluating the lungs for temic complaints except for Ewing sarcoma, with re- pulmonary disease. Approximately 5% to 10% of patients with utilized to confirm the diagnosis and is the preferred metastatic osteosarcomas relapse in bony sites method of definitive diagnosis. An incisional biopsy is not indicated activity signifies local recurrence or metastatic dis- due to the high likelihood of local wound contami- ease; therefore, laboratory testing should be per- nation by tumor cells. In general, 50% of pa- only when inadequate tissue is obtained with the tients with osteosarcomas have an initial elevated core needle biopsy. The biopsy for patients with suspected muscu- loskeletal tumors is the first invasive procedure, but it is extremely important. Inappropriate biopsy can contaminate tissue planes, which may jeopardize Case Continued the ability to perform a limb-sparing procedure. At this point, this patient is tained in the presence of an experienced pathologist treated with thoracotomy with resection of all four to ensure that adequate tissue is harvested. She is restarted on a chemotherapy regi- necrotic cores are obtained, requiring additional men, and at 24 months postthoracotomy she re- samples. This patient is followed for 24 when performed, should be in the line of dissection months with no evidence of additional pulmonary of any planned future incision for a resection or am- disease or metastatic bony disease. Therefore, the person performing the dle is functioning extremely well with normal el- biopsy should consult with the orthopaedic oncolo- bow and hand function. Tumors of the shoulder girdle should not be biopsied through the deltopectoral groove, because this would contaminate the pectoralis major muscle Discussion as well as the axillary space and vessels. It is strongly There are approximately 1,000 new cases of primary recommended that instead, biopsies be performed malignant bone tumors diagnosed in adolescents in through the anterior one third of the deltoid with a the United States each year. The the Musculoskeletal Tumor Society Classification Sys- changes in the development of the prostheses and tem. The primary bone to the compartment (intracompartmental or intraos- tumors that occur in adults most commonly include seous), whereas the “B” designation refers to a tumor chondrosarcoma and malignant fibrous histiocy- that arises extraosseously or extracompartmentally. Metastatic neoplasms of bone are the The patient described in this case report had a stage most common bone tumors in adults. Radiation therapy is in the mid-1970s and early 1980s, 85% of patients not utilized for spindle-cell sarcomas in children or with osteosarcomas died of their disease within 2 adults, except for palliation. The lungs are The treatment regimens of metastatic osteosar- the primary sites of metastatic spread, and 50% of coma to the lungs are variable. The patient described patients had metastatic disease within 12 to 18 in this case report developed several pulmonary nod- months. The mainstay of treatment in her this dismal prognosis for patients with pediatric pri- case was thoracotomy with the removal of all palpa- mary sarcomas of bone, especially osteosarcoma and ble disease. The reinstitution of chemotherapy or a patients includes doxorubicin (Adriamycin), cispla- change to second-line drugs has not been standard- tin, and ifosfamide, and sometimes high-dose ized at the present time.
Thus buy 50mg minocin overnight delivery antibiotics for sinus infection in pregnancy, their sur- study purchase minocin line antimicrobial quiet collar sink baffle, the investigators use discretion order minocin without prescription oral antibiotics for acne vulgaris, and this can vary vival rate would not be suffciently “pure” to be compared from person to person and from time to time. Modern with the survival of those who were screened by the test clinical trial protocols and associated guidelines usually procedures. In a feld situation, contamination in a control give very clear and detailed instructions regarding trial group can occur if the control group is in close proximity conduct. In another situation, a neighboring area may on prevalent cases rather than incident cases. Prevalence not be the test area of the research, but some other pro- is dominated by those who survive for a longer duration. Berkson bias: Comparison of hospital cases with hospital disproportionately more of those who are healthier and controls can be biased if exposure increases the chance survive longer. Cases of injury in motor vehi- since there would be more cases in whom disease progres- cle accidents can suffer from this kind of bias. Bias in ascertainment or assessment: This bias occurs sion of the disease and early death. Bias in detection of cases: Error can occur in diagnostic or the investigators are more thorough with cases than with screening criteria. A similar problem can also occur when subjects tion study, if prostate biopsies are not performed on men belonging to a particular social group have records but with normal results after screening, the true sensitivity others have to depend on recall. Interviewer bias or observer bias: Interviewer bias occurs is less prone to error in the detection of cases compared when one is able to elicit better responses from one group to one carried out in a feld setting. Detection bias also of patients (say, those who are better educated) relative to occurs when cases with mild disease do not report or are another (such as illiterates). If this is inadvertent, the results would the observer unwittingly (or even intentionally) exercises be biased without anybody knowing that such a bias was more care about one type of response or measurement than present. Lead-time bias: Not all cases are detected at the same esis versus those opposing the hypothesis. With regard to cancers, some may can also occur if, for example, the observer is not fully be detected by screening before they are clinically appar- alert when listening to Korotkoff sounds while measuring ent, for example, by Pap smear, whereas some may not be blood pressure or not able to properly rotate the endoscope detected until clinical manifestation of the disease starts to get an all-around view of, say, the duodenum in a sus- appearing. Instrument bias: This occurs when the measuring instru- is generally from the time of detection. Another kind of inclusion criteria in terms of stage of disease at detection instrument bias occurs when a device does not provide a and/or by stratifying subjects according to the stage of dis- complete picture of the target organ, thereby giving false ease at detection. For example, an endoscope backward elimination 45 butterfy effect might not reach the site of interest. Another example is profession, people living close together, family members, Likert scale assessment, where +3 may be a more frequent etc. When members of such response on a scale of −5 to +5 than +8 on a scale of 0 to groups are study subjects by design, use design effect to 10, although both are same. If clustering occurs by B bias occurs when an instrument is considered the gold chance, you may not even know that it is there, and the standard because this is acknowledged as the best while results would be biased. Hawthorne effect: When subjects know that they are the population being observed for a study, the response being observed or being investigated, they often alter their may alter. In fact, this is the basis for includ- same population, one may contaminate the other. The usual responses of sub- unexpected event such as a disease outbreak can alter the jects are not the same as when they are under a scanner. Diseases such as arthritis and asthma from better recall of recent events than those that occurred have natural periods of remission that may look like the a long time ago. Bias due to digit preference: It is well known that events much more easily than healthy controls. A person aged 69 or 71 is likely to report his/ more correct responses regarding history and current ail- her age as 70 years. Blood recall but also because patients with serious illness tend glucose level categories would be commonly chosen as to keep meticulous records. Thus, intervals such as 88–92, 93–97, and 98–102, tion because of the stigma attached to these diseases. Bias due to nonresponse: In most medical studies, par- might even become nearly uniform. An unexpected ill- ticularly those requiring follow-up, some subjects refuse ness, death in the family, or any such drastic event may to cooperate, suffer an injury, die, or become untraceable. Response bias can also be Nonrespondents have two types of effects on the results. Bias due to protocol violation: It is not uncommon in a and their exclusion can lead to biased results. Second, clinical trial that some subjects do not receive the full nonresponse reduces the sample size and can result in intervention or the correct intervention, or some ineligi- substantial differences between the numbers in different ble subjects are randomly allocated in error. This occurs groups, both of which can decrease the power of the study when the study protocol is not faithfully followed, some- to detect specifed differences or associations. Repeat testing bias: In a pretest–posttest situation, the between subgroups in the sense that in one subgroup, more subjects tend to remember some of the previous ques- severe cases drop out, whereas in another group, mostly tions, and they may no longer commit previous errors mild cases drop out. In a rheumatoid arthritis databank in the posttest—thus doing better for reasons other than study, attrition during follow-up was high in patients of the intervention. The observer may acquire expertise to young age, who were less educated, and were non-whites elicit the correct response on the second or third occasion. Everything possible should be done to convince the Conversely, fatigue may set in with repeat testing, which subjects to respond. Bias in handling outliers: No objective rule can defne a surements have a strong tendency toward the mean (see value as an outlier other than that the value must be far regression to the mean): extremely high scorers tend to away from the mainstream values. If the duration of hospi- score lower in subsequent testing, and extremely low scor- tal stay after a particular surgery is mostly between 6 and ers tend to do better in a subsequent test, whereas mid- 10 days, some researchers would call 18 days an outlier range scores remain similar. For example, people in one subjective and essentially arbitrary defnition of an outlier, backward elimination 46 butterfy effect many would not exclude any extreme value, howsoever 1. Thus, the results would vary depend- that you are in the occupation of a relentless search for truth. Assess the validity of the identifed target population and B suspected outlier from analysis unless there is convincing the groups to be included in the study in the context of objec- reason to label it as an outlier. The inclusion and exclusion cri- exclusions is performed, an analysis without any exclu- teria should be precisely worded to address this problem. Recording bias: At least two types of errors can occur in viding the correct answer to your questions. Beware of epistemic uncertainties arising from the limi- erly decipher the writing on case sheets, particularly since tation of scientifc knowledge. This can randomized controlled trials goes a long way toward mini- happen particularly with similar-looking digits such as 1 mize this bias. Evaluate the reliability and validity of the measurements The second arises due to the carelessness of the investiga- required to assess the antecedents and outcomes, as well tor. A diastolic level of 87 can be wrongly recorded as 78, as of the other tools you plan to deploy.
When the hypercalcaemia is at least tion of phosphate; it increases calcium absorption from partly due to mobilisation from bone purchase minocin 50 mg with visa antibiotics walgreens, calcitonin the gut buy 50 mg minocin mastercard infection red line up arm, indirectly minocin 50mg without a prescription treatment for uti from chemist, by stimulating the renal synthesis of (4 units/kg) can be used to inhibit bone resorption, 1a,25-vitamin D (see above and Fig. It acts on bone (inhibit- secondary to intoxication or granulomatous disease, ing osteoclasts) to reduce the rate of bone turnover, and on e. Corticosteroid may be effective in the the kidney to reduce reabsorption of calcium and phos- hypercalcaemia of malignancy where the disease itself phate. Antibodies develop particularly to • Dialysis is quick and effective and is likely to be needed pork calcitonin and neutralise its effect; synthetic salmon in severe cases or in those with renal failure. Calcitonin is used (subcutaneously, intramuscularly or intranasally) for Paget’s disease of bone (relief of pain, Longer-term treatment and compression of nerves, e. Bisphosphonates are synthetic, non-hydrolysable analogues It is of particular use for hypercalcaemia resulting from of pyrophosphate (an inhibitor of bone mineralisation) in increased intestinal absorption of calcium, e. Intravenous administration that rapidly target exposed bone mineral surfaces, are im- can cause acute ’flu-like symptoms (fever, myalgia, mal- bibed by bone-resorbing osteoclasts, inhibit their function aise). An additional action may for treatment of hypercalcaemia of malignancy is associ- be to stimulate bone formation by osteoblasts, but the ther- ated with increased risk of osteonecrosis of the jaw in pa- apeutic utility of bisphosphonates rests on their capacity to tients with metastatic bone disease or multiple myeloma. The risk may be slightly greater with zoledronic acid com- Bisphosphonate binding to hydroxyapatite crystals can, pared with pamidronate. This disadvantageous Osteoporosis effect, prominent with non-nitrogen containing bis- phosphonates, is less with newer nitrogen containing Osteoporosis is a disease characterised by increased skeletal members. It occurs most Pharmacokinetics commonly in post-menopausal women and patients tak- Bisphosphonates are poorly absorbed after ingestion. Exclude underlying causes sorption is further impaired by food, drinks, and drugs such as hyperthyroidism, hyperparathyroidism and hypo- containing calcium, magnesium, iron or aluminium salts. A proportion of bisphosphonate that is absorbed is Post-menopausal osteoporosis is due to gonadal defi- rapidly incorporated into bone; the remaining fraction ciency; it can be prevented. Once incorporated in their sixties and one in two in their seventies experience into the skeleton, bisphosphonates are released only an osteoporotic fracture. They may gen–progestogen therapy was widespread until data from be given orally or intravenously. Now, patients at risk of osteoporosis are advised to in- crease daily exercise, stop smoking and optimise diet to en- sure sufficient calories and an adequate intake of calcium Indications and vitamin D. Increased Age (years) bone pain (as well as relief) and fractures (high dose, pro- longed use only) can occur due to bone demineralisation. Potential nephrotoxicity is a concern with bisphosphonate The shaded area represents two standard deviations above and therapy although zoledronic acid has been used in patients below the mean for bone mineral density. The mode of administration (subcutaneous, Pharmacotherapy intramuscular or nasal) and possible tachyphylaxis make Bisphosphonates are the first-line treatment for post- calcitonin a less suitable choice for treatment of osteoporo- menopausal osteoporosis. Alendronate (10 mg once daily or 70 mg once Fracture (usually assessed by vertebral and hip fractures) weekly) and risedronate (5 mg daily or 35 mg once weekly) is the only important outcome of osteoporosis. Patients taking dronate is effective as a once-monthly preparation, or the equivalent of prednisolone 7. Ibandronate has been shown to have effi- lactic treatment, and it is mandatory in those aged over cacy in reducing the risk of new vertebral fractures; however, 65 years. All patients should receive vitamin D and cal- randomised controlled trials conducted with ibandronate did cium supplements. Bisphosphonates are first line for both not have sufficient power to demonstrate efficacy in hip frac- prophylaxis and treatment; calcitonin may be considered tures All post-menopausal women with a history of hip or where bisphosphonates are contraindicated or not verterbral fracture, or with osteoporosis based on bone min- tolerated. It is probably less effective than combined contribution of hyperphosphataemia, vitamin bisphosphonates but no direct comparisons have been D deficiency and secondary hyperparathyroidism. Raloxifene reduces the risk of breast cancer (see D deficiency in chronic renal failure results from reduced p. It In addition, reduced calcitriol results in decreased intesti- is indicated for severe post-menopausal osteoporosis or nal absorption of calcium and the subsequent hypocalcae- where bisphosphonates have proved to be ineffective. The aim of treatment is to maintain normal serum phosphate and calcium Oestrogen–progestogen. Though now out of favour (see levels and suppress secondary hyperparathyroidism in or- above), oestrogen–progestogen therapy may yet be indi- der to prevent disordered bone metabolism. Phosphate binders are the first step in the management of hyperphosphataemia and prevention of renal osteody- 3In a pivitol 19-month trial, teriparatide increased bone mineral density in strophy. The aim of treatment has been to prevent the spine and femoral neck, and rates of new vertebral fractures and non-vertebral fractures were 5% and 6. It is indicated for patients with end- hyperphosphataemia and adverse clinical outcomes, pos- stage renal disease with secondary hyperparathyroidism sible secondary to accelerated vascular calcification, pro- refractory to standard treatment. Calcium-based phosphate binders, such as calcium carbonate and calcium acetate,arethemostcom- Osteomalacia monly used agents with similar efficacy. Newer non cal- cium-based phosphate binders include the anion Osteomalacia is due to primary or secondary vitamin D de- exchange resins sevelamer hydrocholoride and sevelamer car- ficiency (see above). These have a similar phosphate lowering effect compared to calcium based agents but are associated with reduced risk of hypercalcaemia. Sevelamer hydrochloride Paget’s disease of bone may worsen metabolic acidosis thus sevelamer carbonate This disease is characterised by increased bone turnover (re- is the preferred agent. Lanthanum carbonate is a non-alu- sorption and formation) – as much as 50 times normal. The newer nitrogen-containing bispho- uating lanthanum; short-term trials suggest increased ad- sphonates (pamidronate, zoledronic acid, risedronate, alendro- verse effects compared with other binders. These bisphosphonates Phosphate binders alone may not be sufficient to control suppress bone turnover without impairing bone mineralisa- phosphate levels and prevent secondary hyperparathyroid- tion. Single fetus, longitudinal lie, cephalic presentation, 3/5th of the head is palpable P/A. Any woman who has been supervised (examined and advised) during pregnancy in an institution at least three times. What investigations are commonly advised to a pregnant woman in the antenatal clinic? Ultrasound examination in the frst trimester and/or routine anomaly scan at 18–20 weeks. Generally a pregnant woman is seen at an interval of 4 weeks upto 28 weeks, at interval of 2 weeks upto 36 weeks and thereafter weekly till the expected date of delivery. To detect any high-risk factor from the history, examination and investigations, each time she attends the clinic. Live virus vaccines (rubella, measles, mumps, varicella, yellow fever) are contraindicated. The top of the centralized uterine fundus is measured from the superior border of the symphysis pubis with a measuring tape. Engagement (by palpating the sincipital and occipital poles in cephalic presentation). Detailed fetal anatomy, viability, number of fetuses liquor volume and placental localization can be assessed. In cephalic presentation, it is heard by placing the fetoscope or the bell of the stethoscope on the spinoumbilical line depending on the side where the fetal back is. In occipitoposterior position, it is more towards the flank and is difficult to locate.
Management Management is complete excision; incomplete removal is asso- ciated with eventual recurrence and more aggressive behavior (3–5) purchase 50mg minocin bacteria 4 conditions. This lesion was also previously managed elsewhere by cessful removal of the lesion order minocin 50 mg mastercard antibiotics dogs can take. Regional lymph noted dissection generic minocin 50 mg without prescription medicine for uti boots, irradiation, and from specialized neuroendocrine receptor cells of the skin and chemotherapy are believed to improve the prognosis mucous membranes, known as Merkel cells. Radiotherapy (50 Gy) has been reported to achieve appear to mediate touch sensation and are thought to be complete tumor control after 24 months (20). It is an aggressive malignant Concerning prognosis, Merkel cell carcinoma often tumor that can exhibit local recurrence and distant metasta- exhibits early regional lymph node metastasis and distant sis. As mentioned, the 5-year survival for all Merkel to develop regional or distant metastasis (4). The specific prognosis for eye- cinoma can occur on the trunk, extremities, and face. Clinical Features Approximately 10% of all cases of Merkel cell carcinomas affect the eyelid and periocular skin (4). Of those, the upper eyelid is involved in 64%, lower eyelid in 13%, canthi in 11%, and unspecified eyelid sites in 13% of cases (1). Clinically, eyelid Merkel cell carcinoma usually occurs as a painless pro- gressive, red or violaceous, reddish-blue nodule near the eye- lid margin. It has a predilection for elderly women but has been recognized in a 22-year-old woman (18). Like seba- ceous carcinoma, Merkel cell carcinoma can masquerade as a chalazion, resulting in serious delay in diagnosis (9,15). Differential Diagnosis Differential diagnosis includes lymphoma, plasmacytoma, leukemic infiltration, sebaceous carcinoma, squamous cell car- cinoma, basal cell carcinoma, and amelanotic melanoma. Its reddish-blue color and lack of ulceration should arouse suspi- cion of the diagnosis and to help differentiate it from most of these lesions (11). Pathology Histopathologically, Merkel cell carcinoma is composed of lob- ules of poorly differentiated malignant cells with round to oval nuclei with finely dispersed chromatin and inconspicuous nucleoli (1). Electron microscopy and immunohistochemistry may be helpful in confirming the diagnosis. Immunohistochemistry can assist in the diagnosis, showing positive reactions to neuron-specific enolase, cytokeratins, and neurosecretory granules (14,19,29). Primary neuroendocrine carci- noma (“Merkel cell tumor”) of the eyelid: a report of two cases. Merkel cell carcinoma: clini- copathologic correlation, management, and follow-up in five patients. Merkel cell carcinoma of the eyelid: his- tological and immunohistochemical features with special respect to differ- ential diagnosis. Parotid metastasis of Merkel cell carci- noma in a young patient with ectodermal dysplasia. Fine needle aspiration cytologic diag- nosis of metastatic Merkel cell carcinoma in the parotid gland. Primary neuroendocrine carcinoma of the eyelid, immunohistochemical and ultrastructural study. Typical Merkel cell carcinoma of the upper eyelid showing reddish, sausage-shaped mass. Low-magnification photomicrograph of eyelid showing basophilic tumor located near eyelid margin. Chapter 7 Neural Tumors of the Eyelid 129 ■ Eyelid Merkel Cell Carcinoma: Pathology Figure 7. These Congenital cutaneous capillary hemangioma (infantile heman- are discussed further in the Atlas of orbital Tumors. It can be located superficially, deep, Histopathologically, capillary hemangioma consists of lobules or both. There is a tendency for this lesion to occur in siblings of capillaries that are separated by fibrous tissue septa. Rarely, cuta- proliferating endothelial cells may obliterate the capillaries neous capillary hemangioma can be associated with extensive (6). As a capillary hemangioma undergoes regression, it hemangiomatosis that can involve the viscera and other becomes less cellular and less vascular, and is replaced by organs. This condition, called the Kasabach-Merritt syn- Pathogenesis drome, is sometimes fatal (3). The pathogenesis of cutaneous capillary hemangioma, previ- ously unknown, has been the subject of recent interest. It has Clinical Features been recognized that placenta and cutaneous capillary heman- The superficial eyelid and periocular capillary hemangioma giomas share unique immunohistochemical similarities. This (strawberry hemangioma) appears initially as a red vascular has led to speculation that infantile hemangiomas could be of macule that progressively enlarges and becomes more ele- placental origin. Two theories have been proposed to explain vated for 3 to 6 months after diagnosis. It has proliferate toward placental tissue in the site where the been estimated that about 30% of cutaneous capillary heman- hemangioma develops. A second intriguing theory is that cells giomas regress completely by age 3 years and 75% to 90% by of placental origin could embolize to the target areas and pro- age 7 years (4). Almost complete regression usually occurs by liferate into the tumor (“metastatic placenta”) (8,9). Although it may have a very bothersome cosmetic appearance early in its course, the eventual regression is often Management dramatic, leaving little cosmetic defect. In contrast to the superficial form, the deep capillary Because most infantile capillary hemangiomas regress sponta- hemangioma lies in the subcutaneous tissues with little or no neously, it is generally appropriate to follow the tumor with involvement of the epidermis. However, it is palpation, and becomes more prominent with crying or strain- important to check visual acuity and do a refraction. A tumor that extends deeper in the orbit can produce amblyopia or potential amblyopia should be treated with proptosis and displacement of the globe, and is important in patching the opposite eye. Most authorities also use local or the differential diagnosis of infantile orbital tumors. Its natu- systemic corticosteroids or intralesional injection of cortico- ral course is similar to the superficial variant, with fairly rapid steroids to hasten regression of capillary hemangioma of the growth followed by regression. However, occasional complications of Complications intralesional corticosteroids include central retinal artery obstruction (16,17), linear perilymphatic subcutaneous fat The main complications of periocular capillary hemangioma atrophy (18,19), eyelid depigmentation (20), eyelid necrosis are strabismus and amblyopia. As an alterna- ondary to tumor impingement on the rectus muscles or sec- tive, topical corticosteroids have been occasionally used ondary to amblyopia. Intralesional interferon -2a and -2b have also been tumor obstructing the pupil or a result of the anisometropia used for capillary hemangioma that is unresponsive to corti- induced by the compression of the globe by the tumor.
