Abstract
An ultrasound-guided intralesional photocoagulation (ILP) technique using a laser is described for treatment of deep venous malformations in the oral cavity. ILP is basically a blind operation and has a risk of unintended destruction of surrounding normal tissue, therefore the authors now routinely use guidance by ultrasonography using a mini-probe to improve the safety and reliability of ILP. This approach enables safe fibre insertion, appropriate laser irradiation, and intraoperative assessment of coagulation. The use of this technique is described in 8 patients. The authors conclude that ultrasound-guided ILP with a laser is a promising technique for less-invasive treatment of a vascular malformation in the oral cavity.
Numerous treatments have been proposed for vascular lesions, including surgery, embolization, sclerotherapy, steroids, and laser therapy. Treatment of vascular lesions in the oral cavity and other regions remains an unresolved problem. Recently, promising results have been obtained for large deep vascular lesions using intralesional photocoagulation (ILP) laser treatment. This technique allows laser energy to be delivered into thick, deep lesions via a bare fibre delivery system, thereby maximizing the effect on deep components and minimizing cutaneous damage by eliminating direct contact with the skin surface.
To date, the authors have obtained satisfactory results in all cases in which they have used ILP for treating large or deep vascular lesions in the oral cavity. Since the ILP technique is partly a blind operation, there is a risk of unintended destruction of surrounding tissue. Such a risk must be minimized. To make ILP safer and more reliable, the authors introduced ultrasound (US) navigation into the treatment, using a mini-probe ( Fig. 1 ). They authors have previously described their experiences with ILP for vascular lesions in the oral cavity, including their first trial of US-guided ILP.
The authors have now established US-guided ILP as a routine approach that they use in all cases. Here, they report the surgical procedure and the results of US-navigated ILP for 8 patients in whom safe and satisfactory regression of lesions was achieved. The advantages of this method compared with other treatments for vascular lesions and with intralesional laser treatment without US guidance are discussed.
Patients and methods
The study subjects were 8 patients (6 males and 2 females) aged 17–78 years, who were treated for a large vascular lesion in the oral cavity at the Department of Oral and Maxillofacial Surgery, Gunma University Hospital. The minimum and average follow-up periods were 13 months and 19.1 months, respectively. All the cases presented here had an expansion of 2 cm in at least two dimensions. Diagnosis was based on the International Society for the Study of Vascular Anomalies (ISSVA) classification, and for all 8 patients, the lesions were considered to be a venous malformation (VM), based on their medical history and age, and the findings of magnetic resonance imaging (MRI), dynamic MRI, and power or colour Doppler imaging.
The lesions could not be treated by excision, because total excision would leave unacceptable dysfunction. All potential modalities for treating vascular lesions were explained to the patients. In all cases, the patient did not want wide excision, but agreed to laser treatment. Age, gender, previous illness, chief complaint, clinical diagnosis, and the size of the lesion are shown in Table 1 . Written informed consent was obtained from all patients prior to the operation.
| Patients | Age | Gender | Previous illness | Chief complaint | Clinical diagnosis | Size (mm) |
|---|---|---|---|---|---|---|
| 1 | 36 | F | – | Swelling, pain and recurrent bleeding | VM of left tongue | 30 × 24 × 20 |
| 2 | 74 | M | Hypertension, chronic hepatitis | Difficulty with speech | VM of left tongue | 32 × 23 × 14 |
| 3 | 54 | F | – | Misbiting the buccal mucosa | VM of right buccal mucosa | 37 × 25 × 14 |
| 4 | 64 | M | – | Swelling | VM of left tongue | 50 × 40 × 30 |
| 5 | 31 | M | – | Swelling | VM of upper lip | 27 × 23 × 13 |
| 6 | 30 | F | – | Swelling, difficulty with speech | VM of right tongue | 20 × 20 × 14 |
| 7 | 34 | M | – | Difficulty with swallowing and speech, pain | VM of right tongue | 23 × 20 × 10 |
| 8 | 17 | M | – | Swelling, enlarging of mass | VM of left tongue | 27 × 22 × 15 |
The extent of the lesion was determined by MRI and US, and the velocity of blood flow in the lesion was determined by dynamic MRI and power or colour Doppler imaging. Diagnostic imaging ultrasonic apparatuses with linear probes (Hitachi Hivision Avius with EUP-O54J) ( Fig. 2 ) at a frequency of 13 MHz (Hitachi Medical Corporation, Chiba, Japan); or LOGIQ P5 (GE Ultrasound Korea, Korea) with i12L at a maximum frequency (GE Parallel Inc., USA) were used in the study. US was performed to examine the intraoral lesions, with 2% xylocaine jelly (a water-based gel with 2% lidocaine hydrochloride) used to couple the ultrasound between the probe and the lesion. The scanning plane was moved horizontally across the mucosa of the tongue or buccal mucosa.
The goal of the treatment was control of symptoms, as described by Dixon et al. or Enjolars et al., since these lesions are often not progressive and are not truly neoplastic. Therefore, a focus on control of symptoms, rather than wide resection of the lesion, seems to be appropriate.
Treatment was performed on an outpatient basis with local anaesthesia. All patients were warned about the potential for postoperative swelling and obstruction. A Nd:YAG laser of wavelength 1064 nm was used between 10 and 13 W, a KTP laser of wavelength 532 nm was used between 2 and 3 W (KTP/YAG Laser Surgical System, Model 20/50, Laserscope, San Jose, CA, USA), and a diode laser of wavelength 880 nm was used between 2 and 3 W (Light Surge Square Osada, Osada Electric Co., Ltd., Tokyo, Japan). The power was adjusted as needed. The outline of the lesion was marked with ink (Case 1, Fig. 3 A ) and 2% lidocaine without epinephrine was infiltrated around the lesion. To access the submucosal lesion, the mucosa was pierced with an 18-gauge intravascular catheter adjacent to the lesion ( Fig. 3 B and F) and a 0.6 mm fibre was inserted into the lesion through the catheter with US guidance ( Fig. 3 G). Several mucosal perforations were needed to access the entire lesion in some cases. Intralesional treatment was performed in continuous mode under US monitoring ( Fig. 3 C). The laser was applied to the vascular lesion while the fibre was slowly withdrawn. The fibre tip was moved as soon as the echo level on the US scan increased ( Fig. 3 G–I). The treatment session was finished when visible shrinkage of the lesion was apparent and an induration was palpable ( Fig. 3 D), and all parts of the lesion showed an increase in the homogenous echo level on the US scan ( Fig. 3 J). To improve assessment of the intralesional laser application by US, treatment of the deep layers of the vascular lesion was carried out first and subsequently the laser was applied to the upper parts of the lesion. A minimal distance of about 5 mm between the mucosa and fibre tip was maintained to avoid heat-induced erosion. After irradiation, the lesion was protected with application of ice cubes for >30 min. To limit postoperative swelling and infection, steroids were given for 3 days and antibiotics for 5 days. The patient was followed closely for 1 month and then monthly to determine the response and to assess any complications.
Response was determined by clinical examination by a single observer and comparisons of photographic records, US, and MRI at 3–6 months after laser treatment. Outcome was assessed by measuring the change in the size of the lesion and was classified by Vlachakis’ criteria as ‘excellent’, 90–100% area reduction; ‘good’, 50–89% area reduction; ‘moderate’, 20–49% area reduction; or ‘poor’, 0–19% area reduction.
Results
The results are summarized in Table 2 . The 8 patients were followed for an average of 19.1 months after receiving their first treatment. All treated lesions were reduced in size, with no increases in the size of lesions after initial inflammatory swelling and oedema subsided, and they showed more than 80% regression after the first or second ILP session. There were no infections, hematomas, or damage to vital structures, and ulceration from the burn healed with minimal scars. The laser irradiation time was <3 min and the entire operative time was <10 min in all cases. All procedures were performed on an outpatient basis under local anaesthesia.
| Patients | Location | Size (mm) | Laser | Power (W), mode | (J) | Complication after treatment | Healing process | Follow-up duration (M) | Assessment of treatment |
|---|---|---|---|---|---|---|---|---|---|
| 1 | Tongue | 30 × 24 × 20 | Nd:YAG | 10–13 W, CW | 1157 | Transient paresthesia Ulcer formation | Good | 20 | Good |
| 2 | Tongue | 32 × 23 × 14 | Nd:YAG | 12 W, CW | 265 | – | Good | 20 | Excellent |
| 3 | Buccal mucosa | 37 × 25 × 14 | Nd:YAG | ILP: 10 W, CW non-contact: 13 W, single pulse (pulse duration: 200 ms) | 850 | – | Good | 13 | Good |
| 4 | Tongue | 50 × 40 × 30 | Nd:YAG | First session: 10 W, CW | 1466 | – | Good | – | |
| Second session: 10 W, CW | 1333 | – | Good | 20 | Good | ||||
| 5 | Upper lip | 27 × 23 × 13 | Diode | 3 W, CW | 285 | Ulcer formation | Good | 18 | Excellent |
| 6 | Tongue | 20 × 20 × 14 | Nd:YAG | 10 W, CW | 356 | – | Good | 20 | Excellent |
| 7 | Tongue | 23 × 20 × 10 | KTP | 3 W, CW | 215 | Transient paresthesia | Good | 26 | Good |
| 8 | Tongue | 27 × 22 × 15 | Nd:YAG | 10 W, CW | 759 | Ulcer formation | Good | 16 | Good |
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