A Decade of Bleomycin

Objective: Bleomycin’s first indication was as a chemotherapeutic agent. It has been used more recently as a sclerosant in the setting of vascular anomalies; however, there is still concern over its routine use for this indication. We aim to describe our decade-plus experience utilizing bleomycin as a sclerosant in a major vascular anomalies center across multiple lesion types that were deemed unable to be treated by other methods. Methods: We reviewed all radiology procedural reports in a retrospective fashion for the keyword bleomycin. For all procedures where the medication was used to treat a vascular anomaly, the lesion type, dosage, method of administration, and patient’s age and body-surface-area at the time of procedure were recorded. Lesions were also classified for location, focality, and indication for treatment (pain, cosmesis, etc). All subsequent clinical records were reviewed to ascertain for complications, as well as to evaluate for patient-reported improvements in clinical symptoms. Pre- and post-treatment images were compared to evaluate for resolution or lack thereof. Results: Since 2011, a total of 424 therapeutic bleomycin injection procedures were performed across 194 patients and including 210 lesions. Maximum lifetime administration was under 100 units for all patients. Lesions treated included 7 vascular tumors, 9 arteriovenous malformations (AVMs), 85 lymphatic malformations, and 109 venous malformations. Clinical improvement was seen for 89% of glomuvenous malformations, 67% of fibroadipose vascular anomalies, all lesions affecting the airway or orbit, and the subset of AVMs of the head and neck; notably, no improvement was seen in AVMs located elsewhere. For venous malformations and lymphatic malformations, clinical improvement was noted in 81% of cases. There were zero cases of skin ulceration, flagellate erythema, clinically apparent pulmonary injury (acute or chronic), anaphylaxis, respiratory compromise, or compartment syndrome. A total of 4 patients (0.9%) were noted to have significant skin hyperpigmentation after treatment. Conclusion: Bleomycin is a versatile sclerosant that allows for methods and locations of treatment that would likely lead to significant morbidity with other sclerosants, demonstrating a total complication risk under 1% (cutaneous hyperpigmentation). It also presents a novel method for the treatment of glomuvenous malformations and fibro-adipose vascular anomalies, and an adjunct or salvage therapy in AVMs.