The wait and see approach

The "wait and see" approach.

For many years in the past, the management of hemangiomas was directed towards the "benign neglect"policy. Observation of the lesion's clinical course was considered enough for this medical condition. The "wait and see" approach, had an obvious reason to be applied; "the hemangioma will eventually shrink, so what is the reason of treating a lesion that will disappear"?

Even today, a significant percentage of physicians, around the world, are still in favor of this approach. They suggest to "wait and see" and try to reassure the parents that, there is no reason for treatment.

We have to analyze this approach and try to determine if this 'benign neglect" can be applied safely.

One of the main reasons to support the 'do nothing" approach is the fact that the lesion will eventually disappear. This is the obvious argument in favor of this opinion.

There may have been other reasons, though.

Operating on a little patient with a vascular lesion requires specialized training, certain surgical skills and expertise. There is always the fear of extensive uncontrollable bleeding that may lead to hemorrhagic shock, if it is not controlled efficiently. Remember that the amount of blood loss, that a patient is able to tolerate, is proportional to the patient's weight. Babies have small weight and small blood volume, indeed!

Creating a scar, by excising a hemangioma of the face, could also be fearsome. When the extent of the scar is estimated preoperatively, there is always the fear that this will be a reminder of the lesion to the patient and the peers forever.
Utilizing other treatment modalities such as lasers or systemic and local medications also requires some experience. This experience was and to a certain extent still is limited, among otherwise very competent physicians, just because the treatment of hemangiomas was not widespread.
So what is the right thing to do when having a patient with a hemangioma?

It is true that not at all cases are the same, nor the appropriate treatment is applied in the same manner. The physician has to recognize the reasons in order to decide to treat or not. The decision should not be based just on whether if he/she is capable of treating the lesion. It should be based on the indications for treatment.
One of the main reasons for avoiding treatment was the fact that hemangiomas will eventually involute. Accumulating experience shows that, even when the lesion shrinks, there may be some elements left behind such as epidermal atrophy, scars from previous ulceration or residual telangiectasia. Studies have proved that 40% of the lesions involuting by the age of six and 80% of the lesions involuting by the age of twelve will require some form of corrective intervention.

It is of paramount importance to realize that a child with a prominent facial lesion at early childhood will most likely develop a psychological trauma. This fact is one of the most definite reasons to intervene early. Early intervention is defined as treatment before the development of self awareness (18-24 months), or if this is not possible, at least before entering into school environment. Children with a facial hemangioma will develop multiple emotional, educational, social and intellectual sequelae.
At this point we have to realize that the child is not able to take the decision for treatment on its own. It is the doctor with the parents that will take the decision for the child. This fact makes any decision even more difficult, because it will affect the child's life. This is one of the reasons why, in many cases, decision of not treating may not be the right one.

In many cases hemangiomas are associated with significant functional complications. Astigmatism and amblyopia from a periorbital lesion, skeletal distortion of the facial skeleton, airway obstruction, hemorrhage, high output cardiac failure, consumption of platelets and clotting factors, ulceration and epidermal atrophy, just to mention some. All these factors are definite indications for treatment. It is not acceptable to approach, for example, a periorbital hemangioma with the 'wait and see approach'. The child will end up with visual impairment, which will most likely affect the rest of his/her life. It is also unjustified to "observe" the gradual skeletal distortion that will lead to bony developmental abnormalities, which will require extensive surgical corrections in the future.

The fear of an uncontrollable intraoperative bleeding played also a key role in the 'wait and see approach'. Many parents are still advised that the risk to benefit ratio of performing a surgical excision is not favorable. This opinion of course will make the parents decide against surgical treatment. The advances in surgical techniques, surgical expertise and training made the possibility of uncontrolled bleeding minimal. Surgical protocols upon the optimal way to surgically approach a hemangioma have been developed. Specialized training aims to provide the surgeon with all the necessary knowledge to safely perform the excision. With the aid of advanced technological instrumentation the specialist is able to operate and remove the hemangioma with minimal blood loss. The absence of intraoperative hemorrhage when patients are treated by well trained surgeons is an undoubtful fact.

Regarding the post operative surgical scar, the discussion should be focused on the unique healing characteristics of babies' skin. The skin elasticity and collagen fiber concentration is by far more prominent in little children. These facts have a favorable outcome when operating early on a baby's face. The resulting scar will be inconspicuous. The surgeon, is able to direct and "hide" the scar in certain natural lines of the face. Finally let's think that by removing a hemangioma, we "exchange" a disfiguring facial lesion, with a surgical scar which of course is by far less visible, having at the same time corrected the vascular anomaly.

For all these and many other individualized reasons, the old wait and see approach has to be reconsidered.

• Now days, vascular malformation clinics have been developed in many countries.
• The level of experience has considerably risen.
• The treatment modalities are, by far, improved.
• The advances of technology in lasers and surgical instrumentation were remarkable during the last few years.
• Propranolol has prevented many children from undergoing extensive surgeries.
• A lot of information is available through the internet.
• Many medical conferences are directed specifically in exchanging ideas and experience in this type of lesions.
• Many physicians work exclusively on this field.
• An enormous ongoing research is trying to reveal the pathogenesis of hemangiomas.

It is obvious that so many efforts are well under way, from all different aspects of the medical community, towards the quality of care for our little hemangioma patients.

• Why should we insist on doing nothing, when there are so many things to do?
• Who can deny a treatment option if this option exists?
• Who doesn't agree THAT EVERY CHILD DESERVES A NORMAL APPEARANCE?

Dr. Stavros Tombris

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