WAIKOLOA, HAWAII – The term "hemangioma" is used erroneously in 70% of cases of vascular anomalies, a study has shown.
"We’re not doing so well. That’s a high rate of misses," Dr. Moise L. Levy said in highlighting the findings.
The study, conducted by investigators at Harvard Medical School, Boston, involved an analysis of all 320 English language articles in PubMed that were published in 2009 with the word "hemangioma" in the title or abstract.
Dr. Moise L. Levy
The investigators sought to learn whether the approved binary classification system for vascular anomalies introduced by the International Society for the Study of Vascular Anomalies (ISSVA) 15 years ago was being utilized by physicians and the consequences, in terms of treatment appropriateness, when it wasn’t.
Overall, the term "hemangioma" was used incorrectly in 71% of cases. Improper use of the term diagnostically was associated with a 21% rate of erroneous treatment. In contrast, patients whose lesions were described using ISSVA terminology had a 0% rate of improper treatment.
Physicians in some specialties did better than others. Radiologists used the term inappropriately in 84% of cases. Pediatricians, internists, general surgeons, ob.gyns., and pathologists who authored papers misused the term "hemangioma" in 60%-70% of cases. And, dermatologists, plastic surgeons, pediatric surgeons, and otolaryngologists used the term inappropriately in 32% of cases.
The investigators noted that the 71% incidence of incorrect nomenclature and 21% rate of incorrect treatment probably underestimate the true rates in clinical practice (Plast. Reconstr. Surg. 2011;127:347-51).
Dr. Levy said the study results indicate most physicians still use the antiquated method of classifying vascular anomalies learned during training. They’re using the term "hemangioma" to describe a wide variety of vascular birthmarks with differing etiologies and behavior patterns, ranging from strawberry hemangiomas to port wine stains, capillary hemangiomas, infantile hemangiomas, and lower-segment hemangiomas, he said.
The ISSVA system of classification divides vascular anomalies into two categories: tumors and malformations. Tumors show rapid growth in the neonatal period, followed in most cases by slow involution. These lesions are comprised of biologically active tissues that procreate in culture. Examples include infantile hemangioma, tufted angioma, and pyogenic granuloma.
Malformations are by definition present at birth. Their growth rate is commensurate with that of the child. Examples include capillary, venous, and lymphatic malformations, explained Dr. Levy, a pediatric dermatologist at Dell Children’s Medical Center of Central Texas in Austin.
In the Harvard study, misdiagnosis of malformations occurred significantly more often than for vascular tumors. The high misdiagnosis rates underscore a key point: Nonspecialists should consider referral of any patient with a complicated lesion, or one raising aesthetic concern, or when the diagnosis is unclear, Dr. Levy said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).
"The bottom line is we need to encourage our primary care providers to get cases to us early rather than after a problem is discovered," he said.
Infantile hemangiomas are the most common type of vascular tumors in infancy. They vary tremendously in their threat level. The first weeks to months of life are a critical time in the growth of these lesions. Useful guidance as to when to refer children with infantile hemangiomas and when reassurance can be offered is provided by a multicenter prospective study published by pediatric dermatologists several years ago, Dr. Levy continued.
The investigators concluded that infantile hemangiomas posing the greatest risk for serious morbidity based upon morphology and/or anatomic site include large, segmented facial lesions because of the possibility of PHACES syndrome (posterior fossa malformations, hemangiomas, arterial anomalies, cardiac defects, eye abnormalities, and sternal clefting).
Other red flag infantile hemangiomas identified in the study as warranting referral included perioral, periocular, perineal, axillary, or retrobulbar lesions; segmental lesions on the central neck, or what in later life would be called the beard area; and segmental lesions overlying the lumbosacral spine (Pediatrics 2008;122:360-7).
Dr. Levy reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.