面部静脉畸形临床分型、病理及治疗的初步研究
|
摘要
目的 面部的静脉畸形(Venous malformation，VM)表现为显著的多样性，我们在大量的临床病例中发现静脉畸形具有一定的规律性。本研究的目的：(1)研究面部不同区域发生的静脉畸形的临床特点，根据临床特点试进行分型；(2)了解静脉畸形不同类型的病理结构；(3)探索针对不同类型静脉畸形的治疗方法。
方法 (1)对我院治疗的273例面部VM根据其发生部位、临床形态特点进行分析归类。(2)对经手术切除并经病理证实205例共213个面部VM标本经常规组织染色后，结合临床类型特点进行观察，重点观察：畸形血管形态、血管壁的厚度及管腔大小；血管外间质组织情况；病变血管组织与周围正常组织的关系(3)结合临床类型特点，采取相应的治疗方法，分析治疗效果。
结果 根据面部不同区域VM的临床表现与病理形态，可将其分为囊肿型、蜂房型、静脉湖型、海绵状静脉畸形、组织侵蚀型、肿块型六种类型。囊肿型常见于耳廓周围，临床上表现包膜完整，界限分明。病理证实VM具有完整包膜，畸形静脉构成多个囊腔。手术能够完整摘除。蜂房型见于腮腺内，VM呈蜂房型，由多个血窦组成，内含暗褐色血液，有包膜。血窦内血液与包膜外正常血管几乎无交通支。此型手术可完整或大部分切除。海绵型多见于面颊、下颌区，隆起畸形明显，范围较广，边界不清，压缩性明显，体位移动试验阳性。病理显示CVM由多量薄壁血管组成，与正常组织分界不清。此型临床多采用平阳霉素局部注射，控制后可附加局部切除以改善外形。静脉湖常发生于老年人唇、颊、舌粘膜，由少数扩
面部静脉畸形与临床分型、病理及治疗的初步研究
摘要
张迂曲的小静脉及肉芽组织构成，适于手术切除。组织侵蚀型常见于颧颖
区。这种类型临床可发现皮下组织基本为畸形血管替代，触诊时皮肤与皮
下组织菲薄，可触及受到侵蚀的颧骨或颖骨骨面，此型临床采用皮下潜行
分离，结合局部留置含平阳霉素明胶海绵的治疗方法。肿块型主要发生在
嚼肌内。通常表现为嚼肌内肿块，类似于肿瘤表现。我们对此型采用层状
切除血管病变和受累肌肉，保存面部形态，残存病变组织注射平阳霉素，
覆盖浸有平阳霉素的止血纱布。上述治疗方法使局限性病变得到根治，使
广泛病变得到控制，同时较好地恢复或保存了面部形态。
结论(l)静脉畸形在面部不同部位临床表现具有差异性，据此可以
将面部VM大体分为至少六种具体类型。(2)不同类型的VM的相应病理
表现不同。(3)对面部VM合理的分型有助于临床治疗方法的选择，提高
治疗效果。
Objective: To explore the clinical laws on the basis of the clinical situations and pathological forms of venous malformation in Oral and Maxillary Region, so as to provide the theory for selecting the optional method to treat the venous malformations.(l)Investigate the clinical manifestations of the venous malformation in Oral and Maxillary Region and Probe the pathologic structure of the venous malformation.(2) Probe the clinical typing of the venous malformations. (3) Confirm the corresponding therapy according to different venous malformations.
Methods: (1)273 cases of VM in Oral and Maxillary Region confirmed by histological study are included in our study and classified clinically. (2)213 specimens were H-E stained to observe the histological forms of VM, particularly the differences of VMs among the different locations. (3) Confirm the corresponding therapy in combination with (1) and (3). Results: (l)According to their different clinical situations and pathological forms ,VMs can be classified into 6 types which are cyst form, Honeycomb form, venous lake form, cavernous form(CVM),tissue erosion form, tumor-like form. Cyst form usually occurs in auricle region. Honeycomb form manifests in parotid gland region and consists of multi-sinusoid. Venous lake form is common in oral and lingual mucous membrane in old people over 60. Lips, cheeks and evelids are vulnerable to cavernous venous malformations. Tissue
erosion form occur in zygomatic temporal region . Tumor-like VMs mainly
appear in masticatory muscles and muscle of tongue and are similar to other
tumors in muscles on clinical behavior.
Conclusions: clinical situation and pathologic structure of VMs vary with the
different Oral and Maxillary Region. On the basis of these differences, VMs
can be classified into 6 types. This new classification method is significant to
diagnosis and treat VMs in Oral and Maxillary Region. The typing method can
be helpful to choice of the treatments of VMs.
方法 (1)对我院治疗的273例面部VM根据其发生部位、临床形态特点进行分析归类。(2)对经手术切除并经病理证实205例共213个面部VM标本经常规组织染色后，结合临床类型特点进行观察，重点观察：畸形血管形态、血管壁的厚度及管腔大小；血管外间质组织情况；病变血管组织与周围正常组织的关系(3)结合临床类型特点，采取相应的治疗方法，分析治疗效果。
结果 根据面部不同区域VM的临床表现与病理形态，可将其分为囊肿型、蜂房型、静脉湖型、海绵状静脉畸形、组织侵蚀型、肿块型六种类型。囊肿型常见于耳廓周围，临床上表现包膜完整，界限分明。病理证实VM具有完整包膜，畸形静脉构成多个囊腔。手术能够完整摘除。蜂房型见于腮腺内，VM呈蜂房型，由多个血窦组成，内含暗褐色血液，有包膜。血窦内血液与包膜外正常血管几乎无交通支。此型手术可完整或大部分切除。海绵型多见于面颊、下颌区，隆起畸形明显，范围较广，边界不清，压缩性明显，体位移动试验阳性。病理显示CVM由多量薄壁血管组成，与正常组织分界不清。此型临床多采用平阳霉素局部注射，控制后可附加局部切除以改善外形。静脉湖常发生于老年人唇、颊、舌粘膜，由少数扩
面部静脉畸形与临床分型、病理及治疗的初步研究
摘要
张迂曲的小静脉及肉芽组织构成，适于手术切除。组织侵蚀型常见于颧颖
区。这种类型临床可发现皮下组织基本为畸形血管替代，触诊时皮肤与皮
下组织菲薄，可触及受到侵蚀的颧骨或颖骨骨面，此型临床采用皮下潜行
分离，结合局部留置含平阳霉素明胶海绵的治疗方法。肿块型主要发生在
嚼肌内。通常表现为嚼肌内肿块，类似于肿瘤表现。我们对此型采用层状
切除血管病变和受累肌肉，保存面部形态，残存病变组织注射平阳霉素，
覆盖浸有平阳霉素的止血纱布。上述治疗方法使局限性病变得到根治，使
广泛病变得到控制，同时较好地恢复或保存了面部形态。
结论(l)静脉畸形在面部不同部位临床表现具有差异性，据此可以
将面部VM大体分为至少六种具体类型。(2)不同类型的VM的相应病理
表现不同。(3)对面部VM合理的分型有助于临床治疗方法的选择，提高
治疗效果。
Objective: To explore the clinical laws on the basis of the clinical situations and pathological forms of venous malformation in Oral and Maxillary Region, so as to provide the theory for selecting the optional method to treat the venous malformations.(l)Investigate the clinical manifestations of the venous malformation in Oral and Maxillary Region and Probe the pathologic structure of the venous malformation.(2) Probe the clinical typing of the venous malformations. (3) Confirm the corresponding therapy according to different venous malformations.
Methods: (1)273 cases of VM in Oral and Maxillary Region confirmed by histological study are included in our study and classified clinically. (2)213 specimens were H-E stained to observe the histological forms of VM, particularly the differences of VMs among the different locations. (3) Confirm the corresponding therapy in combination with (1) and (3). Results: (l)According to their different clinical situations and pathological forms ,VMs can be classified into 6 types which are cyst form, Honeycomb form, venous lake form, cavernous form(CVM),tissue erosion form, tumor-like form. Cyst form usually occurs in auricle region. Honeycomb form manifests in parotid gland region and consists of multi-sinusoid. Venous lake form is common in oral and lingual mucous membrane in old people over 60. Lips, cheeks and evelids are vulnerable to cavernous venous malformations. Tissue
erosion form occur in zygomatic temporal region . Tumor-like VMs mainly
appear in masticatory muscles and muscle of tongue and are similar to other
tumors in muscles on clinical behavior.
Conclusions: clinical situation and pathologic structure of VMs vary with the
different Oral and Maxillary Region. On the basis of these differences, VMs
can be classified into 6 types. This new classification method is significant to
diagnosis and treat VMs in Oral and Maxillary Region. The typing method can
be helpful to choice of the treatments of VMs.
引文
1 Mulliken JB, Glowacki J. Hemangiomas and vascular malformation in infants and children, a classification based on endothelial characteristics. Plas Reconstr Surg 1982;69:412.
2 Achauer BM, Vanderkam VM. Capillary hemangioma (strawberry mark) of infancy: comparison of argon and Nd:YAG laser treatment. Plast Reconstr Surg 1989; 84:60-69
3 White, C. W., Wolf, S. J., Korones, D. N., Sondheimer, H. M., Tosi, M. F., and Yu, A. Treatment of childhood angiomatous diseases with recombinant interferon alfa-2a. J. Pediatr. 1991,118:59
4 Greinwald, J. H., Jr., Burke, D. K., Bonthius, D. J., Bauman, N. M., and Smith, R. J. An update on the treatment of hemangiomas in children with interferon alpha-2a. Arch. Otolaryngol. Head Neck Surg. 1999,125: 21.
5 Siniluoto TM, Svendsen PA, Wikholm GM, Fogdestam I, Edstrom S: Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecyl sulphate (sotradecol). Scand J Plast Reconstr Hand Surg 1997, 31: 145-150.
6 寿柏泉，杨震，孟昭业，等．平阳霉素治疗口腔面部血管瘤 450 例临床分析．口腔面外科杂志，2000，10(4)：302-304
7 Wirth FA, Lowitt MH: Diagnosis and treatment of cutaneous vascular lesions. Am Fam Physician 1998, 57: 765-773.
8 Achauer BM, Celikoz B, VanderKam VM: Intralesional bare fiber laser treatment of hemangioma of infancy. Plast Reconstr Surg 1998, 101: 1212-1217.
9 J.A.Bartlett, K.H.Riding.Management of hemangiomas of the head and neck in children.J Otol,1998,17(2);111-120
10 Jackson IT, Carreno R, Potparic Z, et al. Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment. Plast Reconstr Surg. 1993 Jun;91(7):1216-30.
11 林晓曦．先天性动静脉畸形的分期与治疗．第一届上海国际整形外科会议文献，2003，67．
12 Very M, Nagy M, Carr M, Hemangiomas and vascular malformations: analysis of diagnostic accuracy. Laryngoscope. 2002 Apr; 112(4):612-5.
13 张连仲，董长宪，吴刚，等 彩色多普勒超声鉴别小儿皮肤软组织血管瘤与血管畸形，中华超声影像学杂志，2000，9(8)：475-477．
14 陈衣敏，张武．周围海绵状血管瘤的彩色超声表现．中国超声医学杂志
1997,13:833. 13 Paltiel H, Barrows P, Kozakewich H, et al.: Soft-tissue vascular anomolies: utility of US for diagnosis. Radiology 2000, 214:747-754.
15 范新东，邱蔚六，罗济程，等．头颈部血管畸形的磁共振成像特征．临床放射学杂志，2000，19(3)：140-142．
16 Fordham L, Chung C, Donnelly L: Imaging of congenital vascular and lymphatic anomalies of the head and neck. Neuroimaging Clin N Am 2000, 10:117-136.
17 Jones B, Koch B: Magnetic resonance imaging of the pediatric head and neck. Top Magn Reson Imaging 1999, 10:348-361.
19 Allen, P. W., and Enzinger, F. M. Hemangioma of skeletal muscle: An analysis of 89 cases. Cancer, 1972,29: 8.
20 Steve S, Milten W, Stephen F, et al. Port-wine Stains, An Assessment of 5 years of Treatment. Arch Otolaryngol Head neck Surg, 1996,12(11); 1174-79
21 Svendsen, P., Wikholm, G., Fogdestam, I., Naredi, S., and Eden, E. Instillation of alcohol into venous malformations of the head and neck. Scand. J. Plast, Reconstr. Surg. Hand Surg. 1994, 28: 279.
22 Yakes, W. F., Haas, D. K., Parker, S. H., et al. Symptomatic vascular malformations: Ethanol embolotherapy. Radiology, 1989,170: 1059.
23 Patan S.Vasculogenesis and angiogenesis as mechanisms of vascular network formation, growth and remodeling.J Neurooncol,2000,50(1-2): 1-15
24 郑勤田，伍连康，容文星，等．平阳霉素局部注射治疗小儿血管瘤．中华外科杂志1991，29(5)：290．
25 刘树发，谷永安，杜晓岩．平阳霉素注射治疗口腔面部海绵状血管瘤．现代口腔医学杂志，1999，13(1)：3．
23 王昌美，高庆红，付风华，等．平阳霉素局部注射治疗口腔面部血管瘤．华西口腔医学杂志，2000，18(5)：317-319．
24 Yakes, W. F., and Baker, R. Cardiopulmonary collapse: Sequelae of ethanol embolotherapy. Radiology 189: 145, 1993.9,10,16,21,24
25 Kane, W. J., Morris, S., Jackson, I. T., and Woods, J. E. Significant hemangiomas and vascular malformations of the head and neck: Clinical management and treatment outcomes. Ann. Plast. Surg. 35: 133, 1995.
26 Pappas, C. D., Jr., Persky, M. S., and Berenstein, A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J. 77: 914, 1998.
27 Siniluoto, T. M., Svendsen, P. A., Wikholm, G. M., Fogdestam, Ⅰ., and Edstrom, S. Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecylsulfate (Sotradecol). Scand. J. Plast. Reconstr. Surg. Hand Surg. 31: 145, 1997.
28 Larsen PE,Peterson LJ. A systematic approach to management of high-flow vascular
malformations of the mandible. J Oral maxillofacial Surg, 1993;51:1083
29 Walter J W, Blei F, Anderson, et al. Genetic mapping of a novel familial form of infantile hemangioma. Am J Med Genet, 1999, 82:77
30 Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children. N Engl J Med, 1999,341:173
31 Feitelbaum GP, Halbach VV, Fraser KW, et al.Direct Puncture coil embolization of maxillofacial high flow vascular malformations. J Laryngoscope, 1994,52:1083.
2 Achauer BM, Vanderkam VM. Capillary hemangioma (strawberry mark) of infancy: comparison of argon and Nd:YAG laser treatment. Plast Reconstr Surg 1989; 84:60-69
3 White, C. W., Wolf, S. J., Korones, D. N., Sondheimer, H. M., Tosi, M. F., and Yu, A. Treatment of childhood angiomatous diseases with recombinant interferon alfa-2a. J. Pediatr. 1991,118:59
4 Greinwald, J. H., Jr., Burke, D. K., Bonthius, D. J., Bauman, N. M., and Smith, R. J. An update on the treatment of hemangiomas in children with interferon alpha-2a. Arch. Otolaryngol. Head Neck Surg. 1999,125: 21.
5 Siniluoto TM, Svendsen PA, Wikholm GM, Fogdestam I, Edstrom S: Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecyl sulphate (sotradecol). Scand J Plast Reconstr Hand Surg 1997, 31: 145-150.
6 寿柏泉，杨震，孟昭业，等．平阳霉素治疗口腔面部血管瘤 450 例临床分析．口腔面外科杂志，2000，10(4)：302-304
7 Wirth FA, Lowitt MH: Diagnosis and treatment of cutaneous vascular lesions. Am Fam Physician 1998, 57: 765-773.
8 Achauer BM, Celikoz B, VanderKam VM: Intralesional bare fiber laser treatment of hemangioma of infancy. Plast Reconstr Surg 1998, 101: 1212-1217.
9 J.A.Bartlett, K.H.Riding.Management of hemangiomas of the head and neck in children.J Otol,1998,17(2);111-120
10 Jackson IT, Carreno R, Potparic Z, et al. Hemangiomas, vascular malformations, and lymphovenous malformations: classification and methods of treatment. Plast Reconstr Surg. 1993 Jun;91(7):1216-30.
11 林晓曦．先天性动静脉畸形的分期与治疗．第一届上海国际整形外科会议文献，2003，67．
12 Very M, Nagy M, Carr M, Hemangiomas and vascular malformations: analysis of diagnostic accuracy. Laryngoscope. 2002 Apr; 112(4):612-5.
13 张连仲，董长宪，吴刚，等 彩色多普勒超声鉴别小儿皮肤软组织血管瘤与血管畸形，中华超声影像学杂志，2000，9(8)：475-477．
14 陈衣敏，张武．周围海绵状血管瘤的彩色超声表现．中国超声医学杂志
1997,13:833. 13 Paltiel H, Barrows P, Kozakewich H, et al.: Soft-tissue vascular anomolies: utility of US for diagnosis. Radiology 2000, 214:747-754.
15 范新东，邱蔚六，罗济程，等．头颈部血管畸形的磁共振成像特征．临床放射学杂志，2000，19(3)：140-142．
16 Fordham L, Chung C, Donnelly L: Imaging of congenital vascular and lymphatic anomalies of the head and neck. Neuroimaging Clin N Am 2000, 10:117-136.
17 Jones B, Koch B: Magnetic resonance imaging of the pediatric head and neck. Top Magn Reson Imaging 1999, 10:348-361.
19 Allen, P. W., and Enzinger, F. M. Hemangioma of skeletal muscle: An analysis of 89 cases. Cancer, 1972,29: 8.
20 Steve S, Milten W, Stephen F, et al. Port-wine Stains, An Assessment of 5 years of Treatment. Arch Otolaryngol Head neck Surg, 1996,12(11); 1174-79
21 Svendsen, P., Wikholm, G., Fogdestam, I., Naredi, S., and Eden, E. Instillation of alcohol into venous malformations of the head and neck. Scand. J. Plast, Reconstr. Surg. Hand Surg. 1994, 28: 279.
22 Yakes, W. F., Haas, D. K., Parker, S. H., et al. Symptomatic vascular malformations: Ethanol embolotherapy. Radiology, 1989,170: 1059.
23 Patan S.Vasculogenesis and angiogenesis as mechanisms of vascular network formation, growth and remodeling.J Neurooncol,2000,50(1-2): 1-15
24 郑勤田，伍连康，容文星，等．平阳霉素局部注射治疗小儿血管瘤．中华外科杂志1991，29(5)：290．
25 刘树发，谷永安，杜晓岩．平阳霉素注射治疗口腔面部海绵状血管瘤．现代口腔医学杂志，1999，13(1)：3．
23 王昌美，高庆红，付风华，等．平阳霉素局部注射治疗口腔面部血管瘤．华西口腔医学杂志，2000，18(5)：317-319．
24 Yakes, W. F., and Baker, R. Cardiopulmonary collapse: Sequelae of ethanol embolotherapy. Radiology 189: 145, 1993.9,10,16,21,24
25 Kane, W. J., Morris, S., Jackson, I. T., and Woods, J. E. Significant hemangiomas and vascular malformations of the head and neck: Clinical management and treatment outcomes. Ann. Plast. Surg. 35: 133, 1995.
26 Pappas, C. D., Jr., Persky, M. S., and Berenstein, A. Evaluation and treatment of head and neck venous vascular malformations. Ear Nose Throat J. 77: 914, 1998.
27 Siniluoto, T. M., Svendsen, P. A., Wikholm, G. M., Fogdestam, Ⅰ., and Edstrom, S. Percutaneous sclerotherapy of venous malformations of the head and neck using sodium tetradecylsulfate (Sotradecol). Scand. J. Plast. Reconstr. Surg. Hand Surg. 31: 145, 1997.
28 Larsen PE,Peterson LJ. A systematic approach to management of high-flow vascular
malformations of the mandible. J Oral maxillofacial Surg, 1993;51:1083
29 Walter J W, Blei F, Anderson, et al. Genetic mapping of a novel familial form of infantile hemangioma. Am J Med Genet, 1999, 82:77
30 Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children. N Engl J Med, 1999,341:173
31 Feitelbaum GP, Halbach VV, Fraser KW, et al.Direct Puncture coil embolization of maxillofacial high flow vascular malformations. J Laryngoscope, 1994,52:1083.