Photodiagnosis and Photodynamic Therapy (2015) 12, 143—145
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pdpdt
CASE REPORT/RESEARCH LETTER
18 years long-term results of facial port-wine stain (PWS) after photodynamic therapy (PDT) — A case report Wenxin Yu a, Gang Ma a, Yajing Qiu a, Hui Chen a, Yunbo Jin a, Xi Yang a, Xiaojie Hu a, Lei Chang a, Tianyou Wang a, Henghua Zhou b, Wei Li a, Xiaoxi Lin MD, PhD a,∗ a
Department of Plastic and Reconstructive Surgery, Department of Laser Center, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, School of Medicine, China b Department of Pathology, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, School of Medicine, China Available online 25 October 2014
KEYWORDS Port-wine stain; Photodynamic Therapy; Efficacy; Long-term; PDT
Abstract Port-wine stain (PWS) is still a challenging condition for clinician to treat, because in the majority of cases, the stains are not lifted fully by treatment with laser therapy. Photodynamic therapy (PDT) was considered recently as a promising alternative treatment for PWS. We report here long-term follow-up measures 18 years on PWS lesion treated with PDT and the histological data of residual PWS. © 2014 Elsevier B.V. All rights reserved.
Port-wine stain (PWS) is still a challenging condition for clinician to treat, because in the majority of cases, the stains are not lifted fully by treatment with laser therapy. Photodynamic therapy (PDT) was considered recently as a promising alternative treatment for PWS. We report here long-term follow-up measures 18 years on PWS lesion treated with PDT and the histological data of residual PWS. A 18 years old female patient with untreated PWS involved in V2 distribution at left cheek was treated by PDT (Fig. 1A). The PDT setting was a PDT combination of PsD-007 (provided by the 523 Institute of Medical Materials, China) and copper vapor laser (CVL-5, China).
∗
Corresponding author. Tel.: +86 13701997136. E-mail address: [email protected] (X. Lin).
http://dx.doi.org/10.1016/j.pdpdt.2014.09.004 1572-1000/© 2014 Elsevier B.V. All rights reserved.
Immediately to 1 h after PsD-007 injection (4—7 mg/kg), the laser radiation range from 40 to 90 mW/cm2 irradiated the PWS lesion. The laser emitted a wavelength of 578 nm and the length of irradiation was 30 min. After PDT, the patient was advised to avoid sunlight exposure for 4 weeks. To evaluate the relationship between the efficacy of PDT and its histologic manifestation and change of facial PWS and had biopsies: (1) residual PWS lesion (resisted PWS site) after PDT, (2) the completely blanch site after PDT. After a single PDT treatment, this patient exhibited blanching of PWS lesion 1 year post-treatment (Fig. 1B). Long-term follow-up (18 years later) showed stable results (Fig. 1C). PWS lesions showed no obvious recurrence and were blanched completely in the completely blanch site.
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Figure 1 A female patient with untreated facial PWS before PDT therapy (A). The blanching of PWS lesion 1 year posttreatment (B). The follow up examination, 18 years after PDT treatment, showed stable results in the PWS lesion, with no obvious recurrence of PWS in the completely blanched site (C).
Histological examination revealed there were a number of slightly telangiectatic dermal vessels in residual PWS sites after PDT therapy (Fig. 2A). Ectatic capillaries were almost destroyed and the lumen of the ectatic caliber capillaries was occluded with fibrin in the completely blanching site (Fig. 2B). Pulsed dye laser was developed for the treatment of PWS based on the principle of selective photothermolysis [1]. There have been significant advances in the development of PDL, however, PDL has its limitations, including the need for multiple treatments, and its inability to treat lesions that are particularly deep or thick [2]; therefore, complete remove of a PWS lesion is hard to achieve by PDL [3]. Moreover, it should be noted that some patients exhib-
ited re-darkening of their PWS at their long term follow-up, after receiving treatment with PDL [4]. PDT’s efficacy in treating vascular lesions is vasculartargeted, which involves a photosensitizer that is selectively activated by visible light. The resulting production of oxygen creates cytotoxic free radicals, which then causes direct endothelial cells to be injured during the photochemical reaction. The light irradiation is performed while the photosensitizer is circulating in the vascular compartment, and the oxygenated cytotoxic free radicals cause selective vascular damage, resulting in thrombosis and vascular occlusion. In 1997, our previous study reported the first study of PWS treated by PDT which showed that after one PDT session, the therapeutic outcome of PWS showed more significant
Figure 2 The histological examination revealed slightly telangiectatic dermal vessels in the residual PWS site after PDT therapy (A). The ectatic capillaries were almost destroyed, and the ectatic caliber capillaries’ lumen was occluded with fibrin in the blanching site (B). (All hematoxylin—eosin, original magnifications ×100.).
18 years long-term results of facial PWS after PDT - A case report improvements in large areas compared to other methods [4]. Moreover, Gao K. et al. reported that the side-by-side comparison for PDT and PDL treatments of PWS showed that PDT was safer and more potent, improving PWS lesions more effectively when compared to PDL [5]. Another study showed that PWS were treated by PDT and received satisfactory results, with no recurrence of their PWS [6]. In our study, this patient received follow-up examinations 18 years after PDT treatment. The study demonstrated that the patient presented stable results, and observed no obvious recurrence of PWS in the completely blanched site at long term follow-up, which may indicated that PWS would not recur after a complete lesion removal (one in which where a completely normal skin appearance is reached). The histological manifestation showed that the smaller vessels in the residual PWS lesions posttreatment. The photosensitizer may more easily enter the vascular compartment, circulating in the larger lumen of a PWS and allowing the photosensitized distribution of these large PWS vessels, while light radiation and production of cytotoxic oxygen free radicals injure endothelial cells during the photochemical reaction, therefore, the photosensitizer does not easily enter the smaller capillaries’ lumens, not photosensitizing enough to cause injury to the endothelial cells during the photochemical reaction. The variations in the structure and anatomical manifestation of vessels, such as skin thickness and vessel diameter and depth, may affect the treatment’s efficacy. Which indicated that the efficacy of PDT may be limited by wave length of laser. For example, a study showed a histological manifestation of PDT indicating positive responses to treatment in lesions less than 830 m, but poor or no responses when the depth of the lesions are 1000 m or greater, due to the limitation of the light’s penetration [6].
Summary PDT may be considered an effective alternative for the treatment of PWS. Its potential should be emphasized due to the relatively stable results showed in the long term. However, the present limitations of PDT in different histologic structures of PWS lesions needed be solved, more precise
145
and selective systems of PDT such as new photosensitizers and matching wavelengths with deeper penetration, may be important considerations in the future treatment of PWS.
Conflict of interest The authors declare that they have no conflicts of interest to disclose.
Acknowledgement This study was supported by a grant of the Shanghai Health System Important Disease Joint Research Project (2013ZYJB0014).
References [1] Anderson RR, Parish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524. [2] Onizuka K, Tsuneda K, Ito S, Sekine I. Efficacy of flash lamppumped pulsed dye laser therapy of port wine stains: clinical assessment and histopathological characteristics. Br J Plast Surg 1995;48:271—9. [3] Huikeshoven M, Koster PH, de Borgie CA, Beek JF, van Gemert MJ, van der Horst CM. Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment. N Engl J Med 2007;356(March (12)):1235—40. [4] Lin XX, Wang W, Wu SF, Yang C, Chang TS. Treatment of capillary vascular malformation (port-wine stains) with photo chemotherapy. Plast Reconstr Surg 1997;99(June (7)): 1826—30. [5] Gao K, Huang Z, Yuan KH, Zhang B, Hu ZQ. Side-by-side comparison of photodynamic therapy and pulsed-dye laser treatment of port-wine stain birthmarks. Br J Dermatol 2013;168(May (5)):1040—6, http://dx.doi.org/10.1111/bjd.12130. [6] Xiao Q, Li Q, Yuan KH, Cheng B. Photodynamic therapy of port-wine stains: long-term efficacy and complication in Chinese patients. J Dermatol 2011;38(December (12)):1146—52, http://dx.doi.org/10.1111/j.1346-8138.2011.01292.x. Epub October 27.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pdpdt
CASE REPORT/RESEARCH LETTER
18 years long-term results of facial port-wine stain (PWS) after photodynamic therapy (PDT) — A case report Wenxin Yu a, Gang Ma a, Yajing Qiu a, Hui Chen a, Yunbo Jin a, Xi Yang a, Xiaojie Hu a, Lei Chang a, Tianyou Wang a, Henghua Zhou b, Wei Li a, Xiaoxi Lin MD, PhD a,∗ a
Department of Plastic and Reconstructive Surgery, Department of Laser Center, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, School of Medicine, China b Department of Pathology, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University, School of Medicine, China Available online 25 October 2014
KEYWORDS Port-wine stain; Photodynamic Therapy; Efficacy; Long-term; PDT
Abstract Port-wine stain (PWS) is still a challenging condition for clinician to treat, because in the majority of cases, the stains are not lifted fully by treatment with laser therapy. Photodynamic therapy (PDT) was considered recently as a promising alternative treatment for PWS. We report here long-term follow-up measures 18 years on PWS lesion treated with PDT and the histological data of residual PWS. © 2014 Elsevier B.V. All rights reserved.
Port-wine stain (PWS) is still a challenging condition for clinician to treat, because in the majority of cases, the stains are not lifted fully by treatment with laser therapy. Photodynamic therapy (PDT) was considered recently as a promising alternative treatment for PWS. We report here long-term follow-up measures 18 years on PWS lesion treated with PDT and the histological data of residual PWS. A 18 years old female patient with untreated PWS involved in V2 distribution at left cheek was treated by PDT (Fig. 1A). The PDT setting was a PDT combination of PsD-007 (provided by the 523 Institute of Medical Materials, China) and copper vapor laser (CVL-5, China).
∗
Corresponding author. Tel.: +86 13701997136. E-mail address: [email protected] (X. Lin).
http://dx.doi.org/10.1016/j.pdpdt.2014.09.004 1572-1000/© 2014 Elsevier B.V. All rights reserved.
Immediately to 1 h after PsD-007 injection (4—7 mg/kg), the laser radiation range from 40 to 90 mW/cm2 irradiated the PWS lesion. The laser emitted a wavelength of 578 nm and the length of irradiation was 30 min. After PDT, the patient was advised to avoid sunlight exposure for 4 weeks. To evaluate the relationship between the efficacy of PDT and its histologic manifestation and change of facial PWS and had biopsies: (1) residual PWS lesion (resisted PWS site) after PDT, (2) the completely blanch site after PDT. After a single PDT treatment, this patient exhibited blanching of PWS lesion 1 year post-treatment (Fig. 1B). Long-term follow-up (18 years later) showed stable results (Fig. 1C). PWS lesions showed no obvious recurrence and were blanched completely in the completely blanch site.
144
W. Yu et al.
Figure 1 A female patient with untreated facial PWS before PDT therapy (A). The blanching of PWS lesion 1 year posttreatment (B). The follow up examination, 18 years after PDT treatment, showed stable results in the PWS lesion, with no obvious recurrence of PWS in the completely blanched site (C).
Histological examination revealed there were a number of slightly telangiectatic dermal vessels in residual PWS sites after PDT therapy (Fig. 2A). Ectatic capillaries were almost destroyed and the lumen of the ectatic caliber capillaries was occluded with fibrin in the completely blanching site (Fig. 2B). Pulsed dye laser was developed for the treatment of PWS based on the principle of selective photothermolysis [1]. There have been significant advances in the development of PDL, however, PDL has its limitations, including the need for multiple treatments, and its inability to treat lesions that are particularly deep or thick [2]; therefore, complete remove of a PWS lesion is hard to achieve by PDL [3]. Moreover, it should be noted that some patients exhib-
ited re-darkening of their PWS at their long term follow-up, after receiving treatment with PDL [4]. PDT’s efficacy in treating vascular lesions is vasculartargeted, which involves a photosensitizer that is selectively activated by visible light. The resulting production of oxygen creates cytotoxic free radicals, which then causes direct endothelial cells to be injured during the photochemical reaction. The light irradiation is performed while the photosensitizer is circulating in the vascular compartment, and the oxygenated cytotoxic free radicals cause selective vascular damage, resulting in thrombosis and vascular occlusion. In 1997, our previous study reported the first study of PWS treated by PDT which showed that after one PDT session, the therapeutic outcome of PWS showed more significant
Figure 2 The histological examination revealed slightly telangiectatic dermal vessels in the residual PWS site after PDT therapy (A). The ectatic capillaries were almost destroyed, and the ectatic caliber capillaries’ lumen was occluded with fibrin in the blanching site (B). (All hematoxylin—eosin, original magnifications ×100.).
18 years long-term results of facial PWS after PDT - A case report improvements in large areas compared to other methods [4]. Moreover, Gao K. et al. reported that the side-by-side comparison for PDT and PDL treatments of PWS showed that PDT was safer and more potent, improving PWS lesions more effectively when compared to PDL [5]. Another study showed that PWS were treated by PDT and received satisfactory results, with no recurrence of their PWS [6]. In our study, this patient received follow-up examinations 18 years after PDT treatment. The study demonstrated that the patient presented stable results, and observed no obvious recurrence of PWS in the completely blanched site at long term follow-up, which may indicated that PWS would not recur after a complete lesion removal (one in which where a completely normal skin appearance is reached). The histological manifestation showed that the smaller vessels in the residual PWS lesions posttreatment. The photosensitizer may more easily enter the vascular compartment, circulating in the larger lumen of a PWS and allowing the photosensitized distribution of these large PWS vessels, while light radiation and production of cytotoxic oxygen free radicals injure endothelial cells during the photochemical reaction, therefore, the photosensitizer does not easily enter the smaller capillaries’ lumens, not photosensitizing enough to cause injury to the endothelial cells during the photochemical reaction. The variations in the structure and anatomical manifestation of vessels, such as skin thickness and vessel diameter and depth, may affect the treatment’s efficacy. Which indicated that the efficacy of PDT may be limited by wave length of laser. For example, a study showed a histological manifestation of PDT indicating positive responses to treatment in lesions less than 830 m, but poor or no responses when the depth of the lesions are 1000 m or greater, due to the limitation of the light’s penetration [6].
Summary PDT may be considered an effective alternative for the treatment of PWS. Its potential should be emphasized due to the relatively stable results showed in the long term. However, the present limitations of PDT in different histologic structures of PWS lesions needed be solved, more precise
145
and selective systems of PDT such as new photosensitizers and matching wavelengths with deeper penetration, may be important considerations in the future treatment of PWS.
Conflict of interest The authors declare that they have no conflicts of interest to disclose.
Acknowledgement This study was supported by a grant of the Shanghai Health System Important Disease Joint Research Project (2013ZYJB0014).
References [1] Anderson RR, Parish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983;220:524. [2] Onizuka K, Tsuneda K, Ito S, Sekine I. Efficacy of flash lamppumped pulsed dye laser therapy of port wine stains: clinical assessment and histopathological characteristics. Br J Plast Surg 1995;48:271—9. [3] Huikeshoven M, Koster PH, de Borgie CA, Beek JF, van Gemert MJ, van der Horst CM. Redarkening of port-wine stains 10 years after pulsed-dye-laser treatment. N Engl J Med 2007;356(March (12)):1235—40. [4] Lin XX, Wang W, Wu SF, Yang C, Chang TS. Treatment of capillary vascular malformation (port-wine stains) with photo chemotherapy. Plast Reconstr Surg 1997;99(June (7)): 1826—30. [5] Gao K, Huang Z, Yuan KH, Zhang B, Hu ZQ. Side-by-side comparison of photodynamic therapy and pulsed-dye laser treatment of port-wine stain birthmarks. Br J Dermatol 2013;168(May (5)):1040—6, http://dx.doi.org/10.1111/bjd.12130. [6] Xiao Q, Li Q, Yuan KH, Cheng B. Photodynamic therapy of port-wine stains: long-term efficacy and complication in Chinese patients. J Dermatol 2011;38(December (12)):1146—52, http://dx.doi.org/10.1111/j.1346-8138.2011.01292.x. Epub October 27.
