My name is John Mulliken. I’m one of the three co-directors of the Vascular Anomalies Center. The separation of the field of vascular anomalies from pediatric diseases began in the 1970’s. We used to see these children with vascular lesions in the plastic surgery clinic; in the 80’s, we initiated a vascular anomalies clinic. I had only one colleague at the time, Dr. Ken Fellows, a radiologist. Dr. Julie Glowacki and I were examining vascular lesions in the late Dr. Judah Folkman’s laboratory. We published a paper in 1982 that separated vascular anomalies into two major categories: tumors and malformations. In the 1990’s, we began to treat hemangiomas with Interferon. We instituted weekly meetings to go over consults from different parts of the country. We decided to call ourselves a Vascular Anomalies Center, as other specialists joined the team: Dr. Burrows, interventional radiologist; Dr. Fishman, pediatric surgeon; and Dr. Kozakewich, pathologist. Dermatologists were the last to come on board. I function as a diagnostician and make recommendations for management. As a plastic surgeon, I care for kids who need operative correction of various vascular anomalies.
How did you get interested in this pediatric population?
I was curious about these vascular lesions and disturbed that they weren’t well-described and understood in the textbooks. So I began to look at resected tissues and with the help of Dr. Julie Glowacki working on weekends, our goal was to correlate clinical behavior and what we saw through the microscope. We started to see some patterns; however, the most important question was suggested to us by Judah Folkman. He wondered, “What cells are upregulated in these tissues?” So we started to separate lesions out into those in which cells were turning over rapidly and those in which cells were stable, not turning over at all. That’s how we came up with a very simple binomial classification of vascular anomalies into tumors and malformations. It took a long time for people to understand this nosology. At the same time a colleague, Tony Young from London, and I started a workshop group which eventually became the International Society for the Study of Vascular Anomalies. The participants met every two years from different countries, particularly in Europe. In 1996, in Rome, there was a consensus that my interpretation of mother nature’s schema in terms of tumors and malformations was correct, and the classification has the imprimatur of the International Society for the Study of Vascular Anomalies.
Is there a particular anomaly or group of anomalies that you specialize in?
I see all of them. I have colleagues who specialize in anomalies of the limbs, usually plastic surgeons and orthopedic surgeons. Steve Fishman, a pediatric surgeon is focused on the viscera, the bowels and the chest. Neurosurgeons care for vascular anomalies in the brain. Dermatologists work with me in the skin which is the largest organ in the body. I suppose if there was one that fascinates me, it would be infantile hemangioma. These children are normal at birth and then they develop a tumor, and although the tumor eventually start to regress, it can cause deformities of the face, bleeding, scarring, impingement on vital structures such as vision and swallowing and breathing. I’m particularly interested in hemangiomas because I think believe it’s a solvable problem. We should be able to figure out what causes the tumor, and as soon as there’s the first sign give a drug that prevents its growth so I don’t have to operate or treat them later. That’s what drives all good surgeons. Prevents the disorder so as to put themselves out of business. Then I can go on to other problems.
What is the most rewarding part about working with this population?
The most rewarding, of course, is to understand what causes a vascular anomaly. Particularly exciting for me is finding the gene responsible, because once you have the gene, then you’ve got a handle on the disease and can figure out how that gene acts. We know the gene, for example, for glomuvenous malformation, the most common familial venous malformation. Nevertheless we haven’t been able to use the knowledge yet. I am privileged to work with basic scientists in Brussels, Finland, and our group at the Boston Children’s Dental School and Harvard. We meet every month by video conference. So what’s most rewarding is to discover molecular mechanisms and then be able to treat a patient based on what you have learned in wringing Mother Nature’s neck for answers that are not in the textbooks. My biggest reward would be to try and prevent hemangiomas. I imagine someday when every newborn gets a pill so they don’t get hemangiomas, just like a vaccine. Then I could retire a happy man.
What are some of the challenges and rewards of working with this population?
The greatest challenges are to understand how vascular malformations arise and the associated issues of overgrowth issues and recurrence. Why is one side of your body the same as the other side of your body? Why is one side of the thyroid bigger than the other? In some of these kids with a vascular malformation, one leg is three times the size of the other one. To discover what causes the overgrowth will help us to understand how it occurs in the presence of fat and nerves and different tissues. That’s a whole new horizon that I envision will come from understanding vascular anomalies.