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Study |

A Unique Microvascular Phenotype Shared by Juvenile Hemangiomas and Human Placenta FREE

Paula E. North, MD, PhD; Milton Waner, MD; Adam Mizeracki; Robert E. Mrak, MD, PhD; Richard Nicholas, MD; Jay Kincannon, MD; James Y. Suen, MD; Martin C. Mihm, Jr, MD
[+] Author Affiliations

From the Departments of Pathology (Drs North and Mrak and Mr Mizeracki), Otolaryngology (Drs Waner and Suen and Mr Mizeracki), Orthopedic Surgery (Dr Nicholas), and Dermatology (Dr Kincannon), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, and the Department of Veterans Affairs Medical Center, Little Rock (Dr Mrak); and the Department of Pathology, Harvard University Medical School, and Massachusetts General Hospital, Boston (Dr Mihm).


Arch Dermatol. 2001;137(5):559-570. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-137-5-dst10011.
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Background  Juvenile hemangiomas are common, benign tumors, distinctive for their perinatal presentation, rapid growth during the first year of life, and subsequent involution. We recently reported that endothelia of hemangiomas highly express GLUT1, a glucose transporter normally restricted to endothelia with blood-tissue barrier function, as in brain and placenta.

Objective  To investigate possible further similarities between hemangioma and placental vessels.

Design  In a retrospective study of a variety of vascular tumors and anomalies, we assessed lesional immunoreactivities for the placenta-associated vascular antigens FcγRII, Lewis Y antigen (LeY), merosin, and GLUT1.

Setting  A university-affiliated pediatric hospital.

Main Outcome Measure  Immunoreactivities scored for each antigen were summarized according to lesional type, compared with those of normal skin, brain, and placenta, and correlated with patient age, sex, and lesional location.

Results  All of 66 hemangiomas (patients aged 22 days to 7 years) showed intense immunoreactivity for FcγRII, merosin, LeY, and GLUT1. No immunoreactivities for these markers were seen in any of 26 vascular malformations, 4 granulation tissue specimens, 13 pyogenic granulomas, or in the tumor vasculature of 6 malignant tumors of nonvascular origin. Microvascular immunoreactivity for all 4 markers was observed in placental chorionic villi, but was absent in microvessels of normal skin and subcutis. Brain microvessels expressed only GLUT1 and merosin.

Conclusions  A distinct constellation of tissue-specific markers is uniquely coexpressed by hemangiomas and placental microvessels. These findings imply a unique relationship between hemangioma and the placenta and suggest new hypotheses concerning the origin of these tumors.

Figures in this Article

JUVENILE HEMANGIOMAS are the most common tumors of infancy, affecting approximately 10% of children. These benign vascular tumors vary from small and innocuous to large and deforming (Figure 1A-C), but share a remarkably predictable biological behavior: lesions appear within weeks of birth (or less commonly are congenital), proliferate rapidly, then spontaneously involute. Although many hemangiomas can be left to regress without intervention, even involuted lesions may be disfiguring, with loose, atrophic skin covering fatty tumor residuum (Figure 1D). Active therapeutic approaches include corticosteroid and laser therapy, surgical resection, and cosmetic surgical correction of postinvolutive residua. Pathogenesis has remained obscure.

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Figure 1.

The clinical spectrum of juvenile hemangioma. A, This 18-month-old child's small cervical hemangioma required no intervention and eventually involuted without noticeable residuum. B, This infant's periorbital hemangioma, by impinging on her visual axis, placed her at risk for development of amblyopia. Her bulging lesion was largely subcutaneous, but contiguous skin involvement imparted a red surface coloration. C, This 4-month-old infant's extensive facial and scalp hemangioma infiltrated the eyelids of one eye and threatened damage to nasal and aural cartilage. Note the ulceration of the lower lip, a common complication that usually results in scarring. D, This 3-year-old girl was left with a cosmetically significant atrophic scar despite complete involution of her lower eyelid and cheek hemangioma.

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We recently reported that the erythrocyte-type glucose transporter protein, GLUT1, is highly expressed by juvenile hemangiomas at all stages of their evolution.1 GLUT1 expression represents an intrinsic feature of the committed endothelial phenotype of these lesions and enables their immunohistochemical distinction from other histologically similar benign vascular tumors and anomalies. Use of this marker has increased diagnostic accuracy, allowing study of juvenile hemangiomas as a coherent, singular entity.

GLUT1 is immunohistochemically undetectable in the vasculature of normal skin and subcutis, but is highly expressed in normal endothelia at sites of blood-tissue barriers, including brain, eye, nerve, and placenta,26 suggesting possible pathogenic associations between juvenile hemangiomas and these tissues. We sought to further define the antigenic phenotype of juvenile hemangiomas, and to compare this with other tissues that normally demonstrate high GLUT1 expression phenotype. A panel of antibodies, directed against endothelial and basement membrane antigens selectively expressed in neural and/or placental tissues, was applied to a large series of juvenile hemangiomas—representing all stages of their evolution—and other vascular lesions, and the patterns of expression were compared with those of normal human brain, placenta, and skin. We further determined immunoreactivity of the aforementioned tissues for Lewis Y antigen (LeY), an oligosaccharide normally expressed by certain epithelia and by activated T cells, as LeY immunoreactivity has been reported in a small series of proliferative-phase hemangiomas.7 We find that capillaries of juvenile hemangioma are unique in sharing a stable, distinctive immunophenotype with placental fetal microvessels. These results suggest an exciting new paradigm for our understanding of the pathogenesis of this most common tumor of infancy.

SPECIMENS

All vascular lesions excised at Arkansas Children's Hospital, Little Rock, during the past 3 years (1997-1999), for which both frozen and paraffin-embedded tissue samples were available (111 cases), were reviewed. Hematoxylin-eosin–stained sections were reviewed blindly by 2 of us (P.E.N. and M.C.M.), and pathological diagnoses made independently.1,8 Two intracranial and 4 intramuscular lesions (all malformations) were excluded, leaving 66 juvenile hemangiomas, 26 malformations, and 13 pyogenic granulomas, with greater than 95% diagnostic concordance between reviewers. Diagnostic discrepancies, all minor, were resolved by joint review. Twenty-eight additional cases, for which only paraffin sections were available, were also included: 6 tufted angiomas, 7 epithelioid hemangioendotheliomas, 1 infantile kaposiform hemangioendothelioma, and 14 angiosarcomas. Clinical information was obtained by chart review after immunohistochemical analysis.

Samples of fresh human term placenta were taken within 30 minutes of delivery from central villus parenchyma. Samples of fresh human brain, spinal cord, and truncal skin were collected from 4 patients (aged 1-15 years) at autopsy within 4 to 8 hours post mortem. Four additional samples of normal skin were taken from margins of resected pediatric skin lesions of nonvascular origin. As examples of normal, reactive capillary proliferation, granulation tissue was collected from 1 healing surgical wound, 2 decubitus, and 1 case of ulcerative colitis. Six malignant pediatric tumors of nonvascular origin (to evaluate tumor neovasculature) included renal medullary carcinoma (n = 1), desmoplastic small blue cell tumor (n = 1), neuroblastoma (n = 2), and osteosarcoma (n = 2).

IMMUNOHISTOCHEMISTRY

Cryosections were collected at −20°C on sialanized slides, fixed in acetone at 20°C for 1 minute, and air-dried prior to rehydration in Tris-buffered isotonic sodium chloride solution containing 0.05% Triton-X100. Paraffin sections were deparaffinized, rehydrated, and subjected to citrate buffer antigen retrieval1; all sections were protein-blocked1 before incubation with primary antibodies under optimal conditions (Table 1). Bound primary antibody was detected using a peroxidase kit (LSAB+; DAKO Corporation, Carpinteria, Calif) using diaminobutyric acid chromagen (DAB+, DAKO).1 Negative controls were processed in parallel without primary antibody. Normal tissue immunoreactivities provided internal positive controls, except for LeY, for which sections of LeY-immunopositive oral mucosa were included in each run.

Table Graphic Jump LocationTable 1. Antibodies Used for Immunohistochemical Analysis*
SCORING OF IMMUNOREACTIVITY

Immunoreactivities were scored blindly by one of us (P.E.N.) as none, weak, moderate, or intense (intense meaning greater than or equal to control immunoreactivity). For LeY, occasional weak immunoreactivity in a perinuclear, hof-type pattern was discounted. Only membranous and/or diffuse cytoplasmic-membranous LeY immunoreactivity was scored as positive. For merosin, occasional immunoreactivity in a discontinuous "stringy" pattern in connective tissue around larger veins and arteries in normal skin and subcutis and malformations, was discounted. Only circumferential, basement membrane–like patterns of merosin (and laminin) immunoreactivity were scored as positive.

ELECTRON MICROSCOPY

Tissue cubes (1 mm3) from central portions of 3 routinely submitted juvenile hemangiomas (patients aged 22 days, 5 months, and 3 years) and from terminal villus-containing portions of 2 full-term placentas were promptly fixed in glutaraldehyde and processed for electron microscopy.

PATIENTS

Patients (aged 22 days to 7 years) with both proliferative and involutive phase hemangiomas were well represented, with sex and site distributions similar to those reported in large epidemiological studies15,16 (Table 2). Age ranges for patients with other vascular lesions (excluding angiosarcoma) overlapped that of the hemangioma group.

Table Graphic Jump LocationTable 2. Vascular Lesional Immunoreactivites and Patient Characteristics
GLUT1 IMMUNOREACTIVITY

Specific microvascular GLUT1 immunoreaction was present in normal brain and placental chorionic villi (and placental trophoblast), but not in normal skin and subcutis, granulation tissue, or neovasculature of nonvascular malignant tumors (Table 2, Figure 2B and H, Figure 3B, and Figure 4B). Intense microvascular, entirely endothelial, GLUT1 immunoreactivity was present in all juvenile hemangiomas tested (Table 2, Figure 4, Figure 5A). No lesional GLUT1 expression was detected in any of the malformations, pyogenic granulomas, tufted angiomas, or hemangioendotheliomas (Table 2, Figure 6). Weak-to-moderate, focal GLUT1 immunoreaction was present in 5 of 14 angiosarcomas (Table 2, Figure 6K).

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Figure 2.

Vascular immunoreactivities in normal skin and brain. A-F, The microvasculature of normal skin lacks immunoreactivity for GLUT1 (B, solid arrows), Lewis Y antigen (LeY) (C, arrow), FcγRII (D, solid arrow), and merosin (E, solid arrows), as shown here in this normal skin margin from a resected melanocytic nevus. Note the positive internal controls provided for GLUT1 by luminal erythrocytes (B, open arrow), for FcγRII by dermal macrophages (D, open arrow), and for merosin by intradermal nerve twigs (E, open arrow) and by the epidermal basement membrane. Immunoreactivity for laminin confirmed preservation of antigenicity in vascular basement membranes (F, solid arrow) and in epithelial basement membranes (F, open arrow). G-L, Microvessels of normal brain showed strong endothelial immunoreaction for GLUT1 (H, arrows) and strong basement membrane immunoreaction for merosin (K, arrows) and laminin (L, arrow). No endothelial immunoreaction for LeY (I, arrow) or FcγRII (J, open arrow) was observed in brain, although perivascular immunoreactivity for FcγRII was frequently present in macrophages and/or microglia (J, solid arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (A-C, E, H, I) or ×400 (D, F, G, J-L).

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Figure 3.

Vascular immunoreactivities of reactive vascular proliferations (granulation tissue and pyogenic granuloma) and tumor neovasculature. Microvessels of ischial decubitus ulcer granulation tissue (A-F), of an eruptive pyogenic granuloma from the cheek of an 8-year-old girl (G-L), and of a renal medullary carcinoma metastatic to ovary (M-R) were immunonegative for GLUT1 (B; H; and N, solid arrow), Lewis Y antigen (LeY) (C; I; and O, solid arrow), FcγRII (D; J; and P, arrow), and merosin (E; K; and Q, arrow). There was normal antigenicity for laminin in vascular basement membranes (C, L, R), for merosin in epidermal basement membranes (K, arrow), for CD31 in endothelia (not shown), for GLUT1 in erythrocytes (B, arrows; and H) and in keratinocytes (H), and for FcγRII in tissue macrophages (D and J, arrows). Carcinoma cells were focally immunopositive for GLUT1 (N, open arrows) and LeY (O, open arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (C-E, G-O, Q, R) or ×400 (A, B, F, P).

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Figure 4.

Lesional immunoreactivities in full-term placenta and in proliferative and involutive phase juvenile hemangiomas. Intravillous fetal microvessels of human full-term placenta (A-F) and lesional capillaries of proliferative (G-L) and involutive (M-R) phase hemangiomas showed strong endothelial immunoreaction for GLUT1 (B, solid arrows; H, double arrows; and N, arrow), for Lewis Y antigen (LeY) (C, I, and O, arrows), for FcγRII (D, arrows; J, arrowheads; and P, arrow), and for merosin (E, K, and Q, solid arrows). There was also GLUT1 immunopositivity in syncytiotrophoblasts lining chorionic villi (B, open arrow) and dermal perineurium (H, single arrow); and strong merosin immunopositivity in trophoblastic basement membranes (E, open arrow) and dermal periarterial nerve twigs (Q, arrowheads). Native capillaries at the normal margins of hemangiomas were immunonegative for all 4 markers, as shown for FcγRII in panel J (single arrow). There was normal antigenicity for laminin in the basement membranes of all capillaries, dermis, and smooth muscle (F, solid arrow; L, R); and of trophoblast (F, open arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (A, D, G-R) or ×400 (B, C, E, F).

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Figure 5.

High-power details of lesional immunoreactivities in juvenile hemangioma. High-magnification views demonstrate the entirely endothelial, diffuse cytoplasmic and membranous distribution of GLUT1, Lewis Y antigen (LeY), and FcγRII immunoreactivity (closed arrows, A, B, and C, respectively) in juvenile hemangioma, similar to that observed in placental villous capillaries (see Figure 4B-D). Erythrocytes, as expected, also immunoreacted for the GLUT1 isoform (A, open arrow). Broad, dense bands of merosin immunoreactivity completely encircled lesional capillaries, in a basement membrane–like pattern overlying pericytes (D, black arrow). Close inspection reveals fine laminations (D, open arrow) consistent with basal lamina reduplication, seen more clearly by electron microscopy (see Figure 7). All original magnifications ×400, except D (×600).

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Figure 6.

Lesional immunoreactivities in tufted angiomas, infantile kaposiform and epithelioid hemangioendotheliomas, and angiosarcomas. A-C, Tufted angioma from the neck of a 13-year-old boy with a 4-month history of violaceous papules arising at the site of a congenital "birthmark" that had faded, shown by hematoxylin-eosin (H&E) staining (A), and by immunoreaction for GLUT1 (B) and Lewis Y antigen (LeY) (C). Review of the previous "birthmark," having undergone biopsy when the patient was 13 months old and originally diagnosed as "hemangioendothelioma with pericytic component," showed similar dermal involvement by tufts of proliferating capillaries in a distinct "cannonball" distribution. Note the lack of immunoreactivity within the capillary tufts for both GLUT1 and LeY (B and C, respectively). Positive internal controls for GLUT1 were provided by adjacent perineurium (B, arrow) and intravascular erythrocytes (B). D-F, Infantile kaposiform hemangioendothelioma (IKHE) from the head and neck of a male infant who died of Kasabach-Merritt syndrome at 6 months of age, shown by H&E staining (D) and by immunoreaction for GLUT1 (E) and LeY (F). Note the characteristic slitlike spaces containing erythrocytes and lined by spindled cells, in association with abnormal, dilated lymphatic spaces (D). Intravascular erythrocytes (E, arrow), but not tumor cells, were GLUT1 immunoreactive. Tumor cells were also LeY immunonegative (F). G-I, Epithelioid hemangioendothelioma (HE) resected from the liver of a 1-month-old girl, shown by H&E staining (G) and by immunoreaction for GLUT1 (H) and LeY (I). This example demonstrated no lesional immunoreactivity for GLUT1 (H) or LeY (I), although focal colonies of extramedullary hematopoietic cells (H, arrow) and mature erythrocytes were intensely GLUT1 immunoreactive. Some epithelioid hemangioendotheliomas (2 of 7 tested) showed focal lesional LeY (but not GLUT1) immunoreactivity in less than 5% of tumor cells (see Table 2). J-L, Angiosarcoma from the maxillary sinus of a 62-year-old man by H&E staining (J) and by immunoreaction for GLUT1 (K) and LeY (L). Focal tumor cell immunoreactivity for GLUT1 (K, arrow) and LeY (L, arrows) was present in this particular angiosarcoma, as was the case in 5 of the14 angiosarcomas tested (see Table 2). Original magnifications ×200 (A, D, E, G, I, J) or ×400 (B, C, F, H, K, L). Frozen tissue was not available for these lesional types, precluding immunoreactions for merosin, laminin, or FcγRII.

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LeY and FcγRII IMMUNOREACTIVITY

Vascular immunoreaction for LeY or FcγRII was not present in normal skin and subcutis or brain (except for perivascular macrophages and microglia)17 (Figure 2). Placental intravillous fetal capillaries showed intense endothelial immunoreactivity for LeY and FcγRII (Figure 4). Epithelia of normal and marginal skin showed variable immunoreactivity for LeY (but not for FcγRII), ranging from none (approximately 25% of cases) to moderate (in 10%). Strong LeY immunoreactivity within oral glandular and mucosal epithelia served as positive controls. Patient blood type did not affect LeY immunoreactivity (data not shown). Skin FcγRII immunoreactivity was restricted to dermal macrophages, epidermal Langerhans cells, and inflammatory cells.

Marked lesional endothelial immunoreactivity for FcγRII and LeY, in a diffuse, granular cytoplasmic-membranous pattern, similar to that seen in placenta, was present in all 66 juvenile hemangiomas (Table 2, Figure 4 and Figure 5). No LeY or FcγRII immunoreactivity was found in adjacent native dermal capillaries, or in arterioles or arteries, either within or adjacent to hemangiomas. There was no lesional immunoreaction for LeY or FcγRII in any of the malformations, pyogenic granulomas, granulation tissues, or tumor neovasculatures (Table 2, Figure 3). There was no LeY immunoreactivity in tufted angiomas or the kaposiform hemangioendothelioma, and only weak-to-moderate LeY immunoreactivity (in 2%-5% of tumor cells) in 2 of 7 epithelioid hemangioendotheliomas and 5 of 14 angiosarcomas (Table 2, Figure 6). FcγRII immunoreactivity could not be assessed in these latter lesions, for which frozen material was unavailable.

MEROSIN AND LAMININ

Strong merosin (α2-laminin) immunoreactivity was seen in vascular basement membranes of brain and placental chorionic villi but not in the vasculature of normal skin and subcutis, as reported previously1821 (Figure 2 and Figure 4). Merosin was highly expressed in nonvascular basement membranes of trophoblast, nerve, skeletal muscle, and dermal-epidermal junctions. α-Laminin ("classic" laminin), in contrast, decorated all vascular and nonvascular basement membranes (Figure 2 and Figure 4).

Intense merosin immunoreactivity was present in all juvenile hemangiomas, in a broad, continuous, bandlike pattern encircling lesional capillaries (Table 2, Figure 4 and Figure 5). Dermal capillaries of normal marginal skin, as well as intralesional and extralesional arterioles, were immunonegative for merosin, although occasional weak-to-moderate immunoreaction was seen in arterial internal elastic laminae. α-Laminin immunoreactivity was present in all basement membranes, including basement membranes of lesional capillaries and adjacent normal large and small vessels.

No lesional merosin immunoreactivity was present in malformations, pyogenic granulomas, granulation tissue, or tumor neovasculature (Table 2, Figure 3). Intense α-laminin immunoreactivity was present in all lesional and nonlesional vascular and epithelial basement membranes in these specimens (Figure 3). Frozen tissue was not available for tufted angiomas, hemangioendotheliomas, or angiosarcomas, precluding assessment of merosin or laminin immunoreactivity.

PAL-E AND CD31

Moderate-to-strong endothelial immunoreactivity for the endothelium-specific, pinocytotic vesicle-associated antigen PAL-E was observed in all specimens with available frozen tissue, except for normal brain, confirming preservation of endothelial antigenicity and findings of previous studies.14,22 Endothelial CD31 immunoreactivity, used to assess antigenicity in paraffin sections, was present in all cases.

ELECTRON MICROSCOPY

Juvenile hemangiomas (patients aged 22 days to 3 years) and placental microvessels shared ultrastructural features of (1) continuous, nonfenestrated endothelia with occasional uniform, small, subplasmalemmal vesicles; (2) small numbers of closely apposed, encircling pericytes; and (3) continuous, redundant basement membrane, varying in thickness, adjacent to or encircling interspersed collagen fibrils (Figure 7). Early hemangioma endothelia were plump, whereas those of older (involuted) lesions and of term placental capillaries were relatively thin. Basement membrane multilamination was more developed in hemangiomas of older children.

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Figure 7.

Microvascular ultrastructure in placenta and juvenile hemangioma. Normal term placenta (A), proliferating juvenile hemangiomas in patients aged 22 days (B) and 5 months (C), and an involuting hemangioma in a patient aged 3 years (D). Endothelial cells of both placental and hemangioma vessels show tight junctions (arrowheads) and occasional endocytotic vesicles but no fenestrations. Basal lamina (arrows) in the placenta and in the 22-day hemangioma appear as reduplicated layers of loose basal lamina material interspersed with collagen fibrils, and in older hemangiomas as more defined, but still reduplicated layers, again with interspersed collagen fibrils. E indicates endothelial cell; L, vascular lumen; P, pericyte; R, erythrocyte; and Leu, leukocyte.

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We report a constellation of shared markers of cellular specialization that imply a unique relationship between juvenile hemangioma and placental fetal microvessels. These findings characterize juvenile hemangioma as a distinct pathological entity, intrinsically different from other vascular tumors and anomalies to which it has been compared. In light of the perinatal or congenital presentation of hemangiomas and their distinctive pattern of limited growth and involution, the antigenic similarities between these lesions and placental microvessels led us to hypothesize 2 possible pathogenic mechanisms: (1) an origin from invading angioblasts that aberrantly differentiate toward the placental microvascular phenotype in the mesenchyme of skin and subcutis or (2) an origin from embolized placental cells.

The first hypothesis proposes colonization of receptive (possibly abnormal) mesenchyme by angioblasts aberrantly "switched" toward the placental endothelial phenotype by genomic alterations or abnormal inductive influences. These initially dormant cells, perhaps reflected in the blush or blanched spot of nascent hemangiomas, might be driven to proliferate on loss from the fetal circulation, coincident with late gestation or birth, of factors negatively modulating angiogenesis in utero, or in response to emerging positive angiogenic influences in the perinatal period. Alternatively, as delineated by our second hypothesis, embolic placental endothelial cells, already committed to the GLUT1/merosin/LeY/FcγRII phenotype, might reach fetal tissues from chorionic villi through right-to-left shunts characteristic of the normal fetal circulation. Because intravascular shedding of placental cells is likely increased by placental injury, this hypothesis could explain the heightened incidence of hemangiomas seen following chorionic villus sampling,2325 as well as the observation that intentional placental trauma, produced during embryoscopy prior to elective pregnancy termination, results in rapid development of fetal ecchymotic lesions.26

These hypotheses invite consideration of angiogenic control mechanisms specifically manifest in utero to explain the explosive perinatal growth phase of hemangiomas. Whereas profound angiogenesis occurs within placental villi until near term, little angiogenesis occurs in maternal tissues or in fetal tissues after organogenesis. Factors that may orchestrate this control include vascular endothelial growth factor (VEGF), placental growth factor (PlGF, a placenta-derived structural homologue of VEGF27), Flt-1 (a high-affinity transmembrane receptor for both PlGF and VEGF), and sFlt-1 (a placenta-derived, truncated, soluble form of Flt-1 produced by alternative splicing2830). Both PlGF and VEGF induce angiogenesis in vivo and induce mitotic activity in cultured endothelial cells.31 sFlt-1 is released into maternal blood and amniotic fluid during gestation, and may, as a competitive sink for both PlGF and VEGF, protect maternal and fetal tissues from overvascularization.2830 Loss of these and other placental factors at birth is likely to dramatically alter the balance of negative and positive angiogenic factors in the fetus, possibly allowing unrestrained proliferation of embolized or aberrant rests of cells expressing the placental endothelial phenotype. This idea recalls the suggestion of Boon et al32 that hemangioma growth might correlate with decreased levels of trophoblast-derived interferon. The limited period of growth and subsequent involution of hemangiomas could reflect a programmed limit to mitosis in placental-type endothelial cells, appropriate to the 9-month life span of human placenta, or perhaps vascular stabilization imposed by maturing pericytic-endothelial associations and basement membranes.

Hypotheses concerning the pathogenesis of juvenile hemangiomas must also address the strong predilection of these lesions for skin and subcutis (rarely viscera), and for the head.15,16 Tissue- and region-specific mesenchyme receptive for angioblasts or embolic placental cells might reasonably be invoked. Head mesenchyme is derived from neural crest,33 and, unlike the mesoderm-derived mesenchyme found elsewhere, does not show intrinsic angioblast development, relying instead on invasion by exogenous, migrating angioblasts and vascular sprouts from surrounding tissues for vascularization.34 Angioblast migration in chick-quail chimeras is unusually prominent in the head, suggesting heightened production of motility or chemotactic factors in that region.35

The vascular antigens co-expressed by juvenile hemangioma and placenta are probably best regarded as markers of cellular specialization, rather than of cellular proliferation or immaturity, since they persist in late-stage hemangiomas and are not associated with other forms of neovascularization. Ultrastructural studies reported herein and by others36 support this contention by demonstrating well-developed basement membrane structure and pericytic-endothelial associations, consistent with vascular stability,37 in both proliferative- and involutive-phase hemangiomas. GLUT1 is widely expressed early in embryonic development, but fetal endothelial GLUT1 expression rapidly disappears except in microvessels of developing neuroepithelial tissues, where expression increases.3,38,39 In mature brain, endothelial zonula occludens–type junctions, a component of the blood-brain barrier, necessitate high GLUT1 expression for adequate blood-brain glucose transport.40 In placenta, GLUT1 expression is required throughout gestation for adequate maternal-fetal glucose transfer,4,41 and is independent of developmental stage.42 High GLUT1 expression by juvenile hemangiomas may permit tumor growth by providing fuel for mitosis.

Merosin (α2-laminin) expression has been previously reported for 2 (of 3) juvenile hemangiomas.43 Our results show universal expression of merosin in a large series of GLUT1-positive hemangiomas representing all stages of proliferation and involution and a wide spectrum of patient ages. Vascular basement membrane merosin expression is normally restricted to the nervous system and eye19 and placenta.21 The merosin (α2) chain, 1 of at least 10 genetically distinct laminin chains, is also present in certain nonvascular basement membranes, including those of placental trophoblast, Schwann cells, striated muscle, and skin, and is abundant in the mesangial matrix of mature renal glomeruli.13,20,4446 The known heterogeneity of laminin subtypes in basement membranes and the highly restricted expression of merosin suggest tissue-specific and developmental stage–specific functional diversity. Merosin is essential, for instance, for stability and survival of fused myoblasts in vitro, apparently due to apoptosis inhibition,47 and merosin deficiency results in severe muscular dystrophy.48 This suggests that merosin might facilitate growth of hemangiomas by inhibiting apoptosis.

The selective, persistent expression of LeY and FcγRII we find in endothelia of hemangiomas and placental vessels is of unclear functional significance. LeY is a difucosylated type 2 chain oligosaccharide expressed on cell surfaces in a tissue- and stage-specific manner. Changing glycosylation patterns, mediated by differential display of LeY and other specific cell surface oligosaccharides, appear to be important in cell-cell recognition and adhesion during development and have been associated with malignant transformation and progression.4951 Expression of LeY correlates with apoptotis in some studies52,53 (but not others54); the constant LeY expression by hemangiomas throughout proliferation and involution reported herein does not support a close association with apoptosis in these lesions. FcγRII is a low-affinity Fc receptor that is normally expressed on macrophages, Langerhans cells, platelets, and various leukocytes12,55 and binds only aggregated IgG. Normal endothelial FcγRII expression is limited to placenta12,56 and hepatic sinusoidal lining cells (possibly Kupffer cells).57 This suggests that endothelial FcγRII expression may be uniquely advantageous in placenta, perhaps assisting clearance of immune complexes and/or maternal-fetal IgG transport.12,58 Its potential effect on the natural biology of hemangiomas remains obscure.

In summary, we report a distinct immunophenotypic pattern consisting of 4 functionally unrelated markers of cellular specialization uniquely coexpressed by fetal microvessels of human placenta and juvenile hemangiomas at all stages. We present 2 hypotheses that might explain the shared molecular differentiation of placental vessels and juvenile hemangiomas, and that might explain some of the behaviors and known associations of the latter common, sometimes devastating, lesions. These findings suggest possible new preventive strategies and therapeutic avenues, in particular the pharmacological use of angiogenic modulators that may normally decrease in the fetal circulation on separation from the placenta at birth.

Accepted for publication February 8, 2001.

This study was supported in part by the University of Arkansas for Medical Sciences, Departments of Pathology and Otolaryngology–Head and Neck Surgery.

This work was presented in part at the 89th Annual Meeting of the United States and Canadian Academy of Pathology, New Orleans, La, March 29, 2000, and at the 13th International Workshop on Vascular Anomalies in Montreal, Quebec, May 10, 2000.

Corresponding author and reprints: Paula E. North, MD, PhD, Department of Pediatric Pathology, Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202.

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Link to Article
North  PEMihm Jr  MCWaner  MedSuen  JYed The surgical pathology approach to pediatric vascular tumors and anomalies. Hemangiomas and Vascular Malformations of the Head and Neck. New York, NY John Wiley & Sons Inc1999;93- 170
Younes  MLechago  LVSomoano  JRMosharaf  MLechago  J Wide expression of the human erythrocyte glucose transporter GLUT1 in human cancers. Cancer Res. 1996;561164- 1167
Abe  KMcKibbin  JMHakomori  S The monoclonal antibody directed to difucosylated type 2 chain (Fuc alpha 1 leads to 2Gal beta 1 leads to 4[Fuc alpha 1 leads to 3]GlcNAc; Y determinant). J Biol Chem. 1983;25811793- 11797
Parums  DVCordell  JLMicklem  KHeryet  ARGatter  KCMason  DY JC70: a new monoclonal antibody that detects vascular endothelium associated antigen on routinely processed tissue sections. J Clin Pathol. 1990;43752- 757
Link to Article
Sedmak  DDDavis  DHSingh  Uvan de Winkel  JGAnderson  CL Expression of IgG Fc receptor antigens in placenta and on endothelial cells in humans: an immunohistochemical study. Am J Pathol. 1991;138175- 181
Engvall  EEarwicker  DHaaparanta  TRuoslahti  ESanes  JR Distribution and isolation of four laminin variants; tissue restricted distribution of heterotrimers assembled from five different subunits. Cell Regul. 1990;1731- 740
Schlingemann  RODingjan  GMEmeis  JJBlok  JWarnaar  SORuiter  DJ Monoclonal antibody PAL-E specific for endothelium. Lab Invest. 1985;5271- 76
Maleville  JTaieb  ARoubaud  ESarrat  PFontan  IGuillet  G Hemangiomes cutanes immatures: étude epidemiologique de 351 cas. Ann Dermatol Venereol. 1985;112603- 608
Jacobs  AH Strawberry hemangiomas: the natural history of the untreated lesion. Calif Med. 1957;868- 10
Ulvestad  EWilliams  KVedeler  C  et al.  Reactive microglia in multiple sclerosis lesions have an increased expression of receptors for the Fc part of IgG. J Neurol Sci. 1994;121125- 131
Link to Article
Sewry  CAD'Alessandro  MWilson  LA  et al.  Expression of laminin chains in skin in merosin-deficient congenital muscular dystrophy. Neuropediatrics. 1997;28217- 222
Link to Article
Villanova  MMalandrini  AToti  P  et al.  Localization of merosin in the normal human brain: implications for congenital muscular dystrophy with merosin deficiency. J Submicrosc Cytol Pathol. 1996;281- 4
Leivo  IEngvall  E Merosin, a protein specific for basement membranes of Schwann cells, striated muscle, and trophoblast, is expressed late in nerve and muscle development. Proc Natl Acad Sci U S A. 1988;851544- 1548
Link to Article
Voit  TFardeau  MTome  FM Prenatal detection of merosin expression in human placenta. Neuropediatrics. 1994;25332- 333
Link to Article
Schlingemann  ROBots  GTAMVan Duinen  SGRuiter  DJ Differential expression of endothelium-specific antigen PAL-E in vasculature of brain tumors and preexistent brain capillaries. Ann N Y Acad Sci. 1988;529111- 114
Link to Article
Kaplan  PNormandin Jr  JWilson  GNPlauchu  HLippman  AVekemans  M Malformations and minor anomalies in children whose mothers had prenatal diagnosis: comparison between CVS and amniocentesis. Am J Med Genet. 1990;37366- 370
Link to Article
Burton  BKSchulz  CJBurd  LI Spectrum of limb disruption defects associated with chorionic villus sampling. Pediatrics. 1993;91989- 993
Burton  BKSchulz  CJAngle  BBurd  LI An increased incidence of haemangiomas in infants born following chorionic villus sampling (CVS). Prenat Diagn. 1995;15209- 214
Link to Article
Quintero  RARomero  RMahoney  BSVecchio  MHolden  JHobbins  JC Fetal haemorrhagic lesions after chorionic villus sampling. Lancet. 1992;339193
Link to Article
Shore  VHWang  THWang  CLTorry  RJCaudle  MRTorry  DS Vascular endothelial growth factor, placenta growth factor and their receptors in isolated human trophoblast. Placenta. 1997;18657- 665
Link to Article
Clark  DESmith  SKHe  Y  et al.  A vascular endothelial growth factor antagonist is produced by the human placenta and released into the maternal circulation. Biol Reprod. 1998;591540- 1548
Link to Article
Hornig  CBarleon  BAhmad  SVuorela  PAhmed  AWeich  HA Release and complex formation of soluble VEGFR-1 from endothelial cells and biological fluids. Lab Invest. 2000;80443- 454
Link to Article
Banks  REForbes  MASearles  J  et al.  Evidence for the existence of a novel pregnancy-associated soluble variant of the vascular endothelial growth factor receptor, Flt-1. Mol Hum Reprod. 1998;4377- 386
Link to Article
Ziche  MMaglione  DRibatti  D  et al.  Placenta growth factor-1 is chemotactic, mitogenic, and angiogenic. Lab Invest. 1997;76517- 531
Boon  LMEnjolras  OMulliken  JB Congenital hemangioma: evidence of accelerated involution. J Pediatr. 1996;128329- 335
Link to Article
Risau  WFlamme  I Vasculogenesis. Annu Rev Cell Dev Biol. 1995;1173- 91
Link to Article
Noden  DM Embryonic origins and assembly of blood vessels. Am Rev Respir Dis. 1989;1401097- 1103
Link to Article
Noden  DMFeinberg  RNedSherer  GKedAuerbach  Red Development of craniofacial blood vessels. The Development of the Vascular System. Basel, Switzerland Karger1991;1- 23
Gonzalez-Crussi  FReyes-Mugica  M Cellular hemangiomas ("hemangioendotheliomas") in infants: light microscopic, immunohistochemical, and ultrastructural observations. Am J Surg Pathol. 1991;15769- 778
Link to Article
Darland  DCD'Amore  PA Blood vessel maturation: vascular development comes of age. J Clin Invest. 1999;103157- 158
Link to Article
Harik  SIHall  AKRichey  PAndersson  LLundahl  PPerry  G Ontogeny of the erythroid/HepG2-type glucose transporter (GLUT-1) in the rat nervous system. Brain Res Dev Brain Res. 1993;7241- 49
Link to Article
Mantych  GJHageman  GSDevaskar  SU Characterization of glucose transporter isoforms in the adult and developing human eye. Endocrinology. 1993;133600- 607
Pardridge  WMBoado  RJFarrell  CR Brain-type glucose transporter (GLUT-1) is selectively localized to the blood-brain barrier: studies with quantitative Western blotting and in situ hybridization. J Biol Chem. 1990;26518035- 18040
Carstensen  MLeichweiss  HPMolsen  GSchroder  H Evidence for a specific transport of D-hexoses across the human term placenta in vitro. Arch Gynakol. 1977;222187- 196
Link to Article
Hahn  THartmann  MBlaschitz  A  et al.  Localisation of the high affinity facilitative glucose transporter protein GLUT 1 in the placenta of human, marmoset monkey (Callithrix jacchus) and rat at different developmental stages. Cell Tissue Res. 1995;28049- 57
Martin-Padura  IDe Castellarnau  CUccini  S  et al.  Expression of VE (vascular endothelial)-cadherin and other endothelial-specific markers in haemangiomas. J Pathol. 1995;17551- 57
Link to Article
Sewry  CAPhilpot  JSorokin  LM  et al.  Diagnosis of merosin (laminin-2) deficient congenital muscular dystrophy by skin biopsy. Lancet. 1996;347582- 584
Link to Article
Sanes  JREngvall  EButkowski  RHunter  DD Molecular heterogeneity of basal laminae: isoforms of laminin and collagen IV at the neuromuscular junction and elsewhere. J Cell Biol. 1990;1111685- 1699
Link to Article
Virtanen  ILaitinen  LKorhonen  M Differential expression of laminin polypeptides in developing and adult human kidney. J Histochem Cytochem. 1995;43621- 628
Link to Article
Vachon  PHLoechel  FXu  HWewer  UMEngvall  E Merosin and laminin in myogenesis: specific requirement for merosin in myotube stability and survival. J Cell Biol. 1996;1341483- 1497
Link to Article
Tome  FMEvangelista  TLeclerc  A  et al.  Congenital muscular dystrophy with merosin deficiency. C R Acad Sci III. 1994;317351- 357
Lloyd  KO Philip Levine award lecture: blood group antigens as markers for normal differentiation and malignant change in human tissues. Am J Clin Pathol. 1987;87129- 139
Zhu  ZMKojima  NStroud  MRHakomori  SFenderson  BA Monoclonal antibody directed to Le(y) oligosaccharide inhibits implantation in the mouse. Biol Reprod. 1995;52903- 912
Link to Article
Wakabayashi  MShiro  TSeki  T  et al.  Lewis Y antigen expression in hepatocellular carcinoma: an immunohistochemical study. Cancer. 1995;752827- 2835
Link to Article
Hiraishi  KSuzuki  KHakomori  SAdachi  M Le(y) antigen expression is correlated with apoptosis (programmed cell death). Glycobiology. 1993;3381- 390
Link to Article
Minamide  SNaora  HAdachi  MOkano  A Apoptosis as a mechanism of skin renewal: Le(y)-antigen expression is involved in an early event of a cell's commitment to apoptosis. Histochem Cell Biol. 1995;103339- 343
Link to Article
Kuwashima  YKobayashi  YKawarai  A  et al.  Evaluation of apoptosis in human endometrial adenocarcinoma: comparison of nick end labeling and Le(y) antigen immunostaining method. Anticancer Res. 1996;163225- 3228
Pulford  KRalfkiaer  EMacDonald  SM  et al.  A new monoclonal antibody (KB61) recognizing a novel antigen which is selectively expressed on a subpopulation of human B lymphocytes. Immunology. 1986;5771- 76
Lang  IHartmann  MBlaschitz  ADohr  GSkofitsch  GDesoye  G Immunohistochemical evidence for the heterogeneity of maternal and fetal vascular endothelial cells in human full-term placenta. Cell Tissue Res. 1993;274211- 218
Link to Article
Micklem  KJStross  WPWillis  ACCordell  JLJones  MMason  DY Different isoforms of human FcγRII distinguished by CDw32 antibodies. J Immunol. 1990;1442295- 2303
Matre  RJohnson  PM Multiple Fc receptors in the human placenta. Acta Pathol Microbiol Scand C. 1977;85C314- 316

Figures

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Figure 1.

The clinical spectrum of juvenile hemangioma. A, This 18-month-old child's small cervical hemangioma required no intervention and eventually involuted without noticeable residuum. B, This infant's periorbital hemangioma, by impinging on her visual axis, placed her at risk for development of amblyopia. Her bulging lesion was largely subcutaneous, but contiguous skin involvement imparted a red surface coloration. C, This 4-month-old infant's extensive facial and scalp hemangioma infiltrated the eyelids of one eye and threatened damage to nasal and aural cartilage. Note the ulceration of the lower lip, a common complication that usually results in scarring. D, This 3-year-old girl was left with a cosmetically significant atrophic scar despite complete involution of her lower eyelid and cheek hemangioma.

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Figure 2.

Vascular immunoreactivities in normal skin and brain. A-F, The microvasculature of normal skin lacks immunoreactivity for GLUT1 (B, solid arrows), Lewis Y antigen (LeY) (C, arrow), FcγRII (D, solid arrow), and merosin (E, solid arrows), as shown here in this normal skin margin from a resected melanocytic nevus. Note the positive internal controls provided for GLUT1 by luminal erythrocytes (B, open arrow), for FcγRII by dermal macrophages (D, open arrow), and for merosin by intradermal nerve twigs (E, open arrow) and by the epidermal basement membrane. Immunoreactivity for laminin confirmed preservation of antigenicity in vascular basement membranes (F, solid arrow) and in epithelial basement membranes (F, open arrow). G-L, Microvessels of normal brain showed strong endothelial immunoreaction for GLUT1 (H, arrows) and strong basement membrane immunoreaction for merosin (K, arrows) and laminin (L, arrow). No endothelial immunoreaction for LeY (I, arrow) or FcγRII (J, open arrow) was observed in brain, although perivascular immunoreactivity for FcγRII was frequently present in macrophages and/or microglia (J, solid arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (A-C, E, H, I) or ×400 (D, F, G, J-L).

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Figure 3.

Vascular immunoreactivities of reactive vascular proliferations (granulation tissue and pyogenic granuloma) and tumor neovasculature. Microvessels of ischial decubitus ulcer granulation tissue (A-F), of an eruptive pyogenic granuloma from the cheek of an 8-year-old girl (G-L), and of a renal medullary carcinoma metastatic to ovary (M-R) were immunonegative for GLUT1 (B; H; and N, solid arrow), Lewis Y antigen (LeY) (C; I; and O, solid arrow), FcγRII (D; J; and P, arrow), and merosin (E; K; and Q, arrow). There was normal antigenicity for laminin in vascular basement membranes (C, L, R), for merosin in epidermal basement membranes (K, arrow), for CD31 in endothelia (not shown), for GLUT1 in erythrocytes (B, arrows; and H) and in keratinocytes (H), and for FcγRII in tissue macrophages (D and J, arrows). Carcinoma cells were focally immunopositive for GLUT1 (N, open arrows) and LeY (O, open arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (C-E, G-O, Q, R) or ×400 (A, B, F, P).

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Figure 4.

Lesional immunoreactivities in full-term placenta and in proliferative and involutive phase juvenile hemangiomas. Intravillous fetal microvessels of human full-term placenta (A-F) and lesional capillaries of proliferative (G-L) and involutive (M-R) phase hemangiomas showed strong endothelial immunoreaction for GLUT1 (B, solid arrows; H, double arrows; and N, arrow), for Lewis Y antigen (LeY) (C, I, and O, arrows), for FcγRII (D, arrows; J, arrowheads; and P, arrow), and for merosin (E, K, and Q, solid arrows). There was also GLUT1 immunopositivity in syncytiotrophoblasts lining chorionic villi (B, open arrow) and dermal perineurium (H, single arrow); and strong merosin immunopositivity in trophoblastic basement membranes (E, open arrow) and dermal periarterial nerve twigs (Q, arrowheads). Native capillaries at the normal margins of hemangiomas were immunonegative for all 4 markers, as shown for FcγRII in panel J (single arrow). There was normal antigenicity for laminin in the basement membranes of all capillaries, dermis, and smooth muscle (F, solid arrow; L, R); and of trophoblast (F, open arrow). H&E indicates hematoxylin-eosin. Original magnifications ×200 (A, D, G-R) or ×400 (B, C, E, F).

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Figure 5.

High-power details of lesional immunoreactivities in juvenile hemangioma. High-magnification views demonstrate the entirely endothelial, diffuse cytoplasmic and membranous distribution of GLUT1, Lewis Y antigen (LeY), and FcγRII immunoreactivity (closed arrows, A, B, and C, respectively) in juvenile hemangioma, similar to that observed in placental villous capillaries (see Figure 4B-D). Erythrocytes, as expected, also immunoreacted for the GLUT1 isoform (A, open arrow). Broad, dense bands of merosin immunoreactivity completely encircled lesional capillaries, in a basement membrane–like pattern overlying pericytes (D, black arrow). Close inspection reveals fine laminations (D, open arrow) consistent with basal lamina reduplication, seen more clearly by electron microscopy (see Figure 7). All original magnifications ×400, except D (×600).

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Figure 6.

Lesional immunoreactivities in tufted angiomas, infantile kaposiform and epithelioid hemangioendotheliomas, and angiosarcomas. A-C, Tufted angioma from the neck of a 13-year-old boy with a 4-month history of violaceous papules arising at the site of a congenital "birthmark" that had faded, shown by hematoxylin-eosin (H&E) staining (A), and by immunoreaction for GLUT1 (B) and Lewis Y antigen (LeY) (C). Review of the previous "birthmark," having undergone biopsy when the patient was 13 months old and originally diagnosed as "hemangioendothelioma with pericytic component," showed similar dermal involvement by tufts of proliferating capillaries in a distinct "cannonball" distribution. Note the lack of immunoreactivity within the capillary tufts for both GLUT1 and LeY (B and C, respectively). Positive internal controls for GLUT1 were provided by adjacent perineurium (B, arrow) and intravascular erythrocytes (B). D-F, Infantile kaposiform hemangioendothelioma (IKHE) from the head and neck of a male infant who died of Kasabach-Merritt syndrome at 6 months of age, shown by H&E staining (D) and by immunoreaction for GLUT1 (E) and LeY (F). Note the characteristic slitlike spaces containing erythrocytes and lined by spindled cells, in association with abnormal, dilated lymphatic spaces (D). Intravascular erythrocytes (E, arrow), but not tumor cells, were GLUT1 immunoreactive. Tumor cells were also LeY immunonegative (F). G-I, Epithelioid hemangioendothelioma (HE) resected from the liver of a 1-month-old girl, shown by H&E staining (G) and by immunoreaction for GLUT1 (H) and LeY (I). This example demonstrated no lesional immunoreactivity for GLUT1 (H) or LeY (I), although focal colonies of extramedullary hematopoietic cells (H, arrow) and mature erythrocytes were intensely GLUT1 immunoreactive. Some epithelioid hemangioendotheliomas (2 of 7 tested) showed focal lesional LeY (but not GLUT1) immunoreactivity in less than 5% of tumor cells (see Table 2). J-L, Angiosarcoma from the maxillary sinus of a 62-year-old man by H&E staining (J) and by immunoreaction for GLUT1 (K) and LeY (L). Focal tumor cell immunoreactivity for GLUT1 (K, arrow) and LeY (L, arrows) was present in this particular angiosarcoma, as was the case in 5 of the14 angiosarcomas tested (see Table 2). Original magnifications ×200 (A, D, E, G, I, J) or ×400 (B, C, F, H, K, L). Frozen tissue was not available for these lesional types, precluding immunoreactions for merosin, laminin, or FcγRII.

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Figure 7.

Microvascular ultrastructure in placenta and juvenile hemangioma. Normal term placenta (A), proliferating juvenile hemangiomas in patients aged 22 days (B) and 5 months (C), and an involuting hemangioma in a patient aged 3 years (D). Endothelial cells of both placental and hemangioma vessels show tight junctions (arrowheads) and occasional endocytotic vesicles but no fenestrations. Basal lamina (arrows) in the placenta and in the 22-day hemangioma appear as reduplicated layers of loose basal lamina material interspersed with collagen fibrils, and in older hemangiomas as more defined, but still reduplicated layers, again with interspersed collagen fibrils. E indicates endothelial cell; L, vascular lumen; P, pericyte; R, erythrocyte; and Leu, leukocyte.

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Tables

Table Graphic Jump LocationTable 1. Antibodies Used for Immunohistochemical Analysis*
Table Graphic Jump LocationTable 2. Vascular Lesional Immunoreactivites and Patient Characteristics

References

North  PEWaner  MMizeracki  AMihm Jr  MC GLUT1: a newly discovered immunohistochemical marker for juvenile hemangiomas. Hum Pathol. 2000;3111- 22
Link to Article
Harik  SIKalaria  RNAndersson  LLundahl  PPerry  G Immunocytochemical localization of the erythroid glucose transporter: abundance in tissues with barrier functions. J Neurosci. 1990;103862- 3872
Froehner  SCDavies  ABaldwin  SALienhard  GE The blood-nerve barrier is rich in glucose transporter. J Neurocytol. 1988;17173- 178
Link to Article
Jansson  TWennergren  MIllsley  NP Glucose transporter protein expression in human placenta throughout gestation and in intrauterine growth retardation. J Clin Endocrinol Metab. 1993;771554- 1562
Schlingemann  ROHofman  PKlooster  JBlaauwgeers  HGVan der Gaag  RVrensen  GF Ciliary muscle capillaries have blood-tissue barrier characteristics. Exp Eye Res. 1998;66747- 754
Link to Article
Farrell  CLYang  JPardridge  WM GLUT-1 glucose transporter is present within apical and basolateral membranes of brain epithelial interfaces and in microvascular endothelia with and without tight junctions. J Histochem Cytochem. 1992;40193- 199
Link to Article
Iwata  JSonobe  HFurihata  MIdo  EOhtsuki  Y High frequency of apoptosis in infantile capillary haemangioma. J Pathol. 1996;179403- 408
Link to Article
North  PEMihm Jr  MCWaner  MedSuen  JYed The surgical pathology approach to pediatric vascular tumors and anomalies. Hemangiomas and Vascular Malformations of the Head and Neck. New York, NY John Wiley & Sons Inc1999;93- 170
Younes  MLechago  LVSomoano  JRMosharaf  MLechago  J Wide expression of the human erythrocyte glucose transporter GLUT1 in human cancers. Cancer Res. 1996;561164- 1167
Abe  KMcKibbin  JMHakomori  S The monoclonal antibody directed to difucosylated type 2 chain (Fuc alpha 1 leads to 2Gal beta 1 leads to 4[Fuc alpha 1 leads to 3]GlcNAc; Y determinant). J Biol Chem. 1983;25811793- 11797
Parums  DVCordell  JLMicklem  KHeryet  ARGatter  KCMason  DY JC70: a new monoclonal antibody that detects vascular endothelium associated antigen on routinely processed tissue sections. J Clin Pathol. 1990;43752- 757
Link to Article
Sedmak  DDDavis  DHSingh  Uvan de Winkel  JGAnderson  CL Expression of IgG Fc receptor antigens in placenta and on endothelial cells in humans: an immunohistochemical study. Am J Pathol. 1991;138175- 181
Engvall  EEarwicker  DHaaparanta  TRuoslahti  ESanes  JR Distribution and isolation of four laminin variants; tissue restricted distribution of heterotrimers assembled from five different subunits. Cell Regul. 1990;1731- 740
Schlingemann  RODingjan  GMEmeis  JJBlok  JWarnaar  SORuiter  DJ Monoclonal antibody PAL-E specific for endothelium. Lab Invest. 1985;5271- 76
Maleville  JTaieb  ARoubaud  ESarrat  PFontan  IGuillet  G Hemangiomes cutanes immatures: étude epidemiologique de 351 cas. Ann Dermatol Venereol. 1985;112603- 608
Jacobs  AH Strawberry hemangiomas: the natural history of the untreated lesion. Calif Med. 1957;868- 10
Ulvestad  EWilliams  KVedeler  C  et al.  Reactive microglia in multiple sclerosis lesions have an increased expression of receptors for the Fc part of IgG. J Neurol Sci. 1994;121125- 131
Link to Article
Sewry  CAD'Alessandro  MWilson  LA  et al.  Expression of laminin chains in skin in merosin-deficient congenital muscular dystrophy. Neuropediatrics. 1997;28217- 222
Link to Article
Villanova  MMalandrini  AToti  P  et al.  Localization of merosin in the normal human brain: implications for congenital muscular dystrophy with merosin deficiency. J Submicrosc Cytol Pathol. 1996;281- 4
Leivo  IEngvall  E Merosin, a protein specific for basement membranes of Schwann cells, striated muscle, and trophoblast, is expressed late in nerve and muscle development. Proc Natl Acad Sci U S A. 1988;851544- 1548
Link to Article
Voit  TFardeau  MTome  FM Prenatal detection of merosin expression in human placenta. Neuropediatrics. 1994;25332- 333
Link to Article
Schlingemann  ROBots  GTAMVan Duinen  SGRuiter  DJ Differential expression of endothelium-specific antigen PAL-E in vasculature of brain tumors and preexistent brain capillaries. Ann N Y Acad Sci. 1988;529111- 114
Link to Article
Kaplan  PNormandin Jr  JWilson  GNPlauchu  HLippman  AVekemans  M Malformations and minor anomalies in children whose mothers had prenatal diagnosis: comparison between CVS and amniocentesis. Am J Med Genet. 1990;37366- 370
Link to Article
Burton  BKSchulz  CJBurd  LI Spectrum of limb disruption defects associated with chorionic villus sampling. Pediatrics. 1993;91989- 993
Burton  BKSchulz  CJAngle  BBurd  LI An increased incidence of haemangiomas in infants born following chorionic villus sampling (CVS). Prenat Diagn. 1995;15209- 214
Link to Article
Quintero  RARomero  RMahoney  BSVecchio  MHolden  JHobbins  JC Fetal haemorrhagic lesions after chorionic villus sampling. Lancet. 1992;339193
Link to Article
Shore  VHWang  THWang  CLTorry  RJCaudle  MRTorry  DS Vascular endothelial growth factor, placenta growth factor and their receptors in isolated human trophoblast. Placenta. 1997;18657- 665
Link to Article
Clark  DESmith  SKHe  Y  et al.  A vascular endothelial growth factor antagonist is produced by the human placenta and released into the maternal circulation. Biol Reprod. 1998;591540- 1548
Link to Article
Hornig  CBarleon  BAhmad  SVuorela  PAhmed  AWeich  HA Release and complex formation of soluble VEGFR-1 from endothelial cells and biological fluids. Lab Invest. 2000;80443- 454
Link to Article
Banks  REForbes  MASearles  J  et al.  Evidence for the existence of a novel pregnancy-associated soluble variant of the vascular endothelial growth factor receptor, Flt-1. Mol Hum Reprod. 1998;4377- 386
Link to Article
Ziche  MMaglione  DRibatti  D  et al.  Placenta growth factor-1 is chemotactic, mitogenic, and angiogenic. Lab Invest. 1997;76517- 531
Boon  LMEnjolras  OMulliken  JB Congenital hemangioma: evidence of accelerated involution. J Pediatr. 1996;128329- 335
Link to Article
Risau  WFlamme  I Vasculogenesis. Annu Rev Cell Dev Biol. 1995;1173- 91
Link to Article
Noden  DM Embryonic origins and assembly of blood vessels. Am Rev Respir Dis. 1989;1401097- 1103
Link to Article
Noden  DMFeinberg  RNedSherer  GKedAuerbach  Red Development of craniofacial blood vessels. The Development of the Vascular System. Basel, Switzerland Karger1991;1- 23
Gonzalez-Crussi  FReyes-Mugica  M Cellular hemangiomas ("hemangioendotheliomas") in infants: light microscopic, immunohistochemical, and ultrastructural observations. Am J Surg Pathol. 1991;15769- 778
Link to Article
Darland  DCD'Amore  PA Blood vessel maturation: vascular development comes of age. J Clin Invest. 1999;103157- 158
Link to Article
Harik  SIHall  AKRichey  PAndersson  LLundahl  PPerry  G Ontogeny of the erythroid/HepG2-type glucose transporter (GLUT-1) in the rat nervous system. Brain Res Dev Brain Res. 1993;7241- 49
Link to Article
Mantych  GJHageman  GSDevaskar  SU Characterization of glucose transporter isoforms in the adult and developing human eye. Endocrinology. 1993;133600- 607
Pardridge  WMBoado  RJFarrell  CR Brain-type glucose transporter (GLUT-1) is selectively localized to the blood-brain barrier: studies with quantitative Western blotting and in situ hybridization. J Biol Chem. 1990;26518035- 18040
Carstensen  MLeichweiss  HPMolsen  GSchroder  H Evidence for a specific transport of D-hexoses across the human term placenta in vitro. Arch Gynakol. 1977;222187- 196
Link to Article
Hahn  THartmann  MBlaschitz  A  et al.  Localisation of the high affinity facilitative glucose transporter protein GLUT 1 in the placenta of human, marmoset monkey (Callithrix jacchus) and rat at different developmental stages. Cell Tissue Res. 1995;28049- 57
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