| Background:Retinoblastoma (retinoblastoma, Rb) is the most common primary infancy intraocular malignant tumors, with a serious risk of life and visual function of children. With the improving of clinical treatment, the goal of treatment is also shifted from simply limited to the protection of children’s life to a new development direction for improving the quality of life of children, that is, the eyeball preservation and keeping useful visual function. Early detection and diagnosis of children is the most critical issue to achieve this goal, because ages of Rb children generally are less than3years old, the early detection of tumors is quite difficult, not only due to the child’s poor cooperate with the fundus examination, more is the lack of clear and intuitive means of examination and imaging. Wide-field digital pediatric retinal imaging system (RetCam Ⅱ) as the most advanced children fundus imaging technology, greatly facilitates the prevention and continuous follow-up of Rb. But, for a long time, there is still a lack of collecting and collating analysis system for the complete clinical information of Rb. The recordings can only be taken by simple text description or drawing, which is not conducive to the clinical long-term follow-up observation and ongoing treatment efficacy assessment for children. In view of this, we hope to establish a integration of graphic and text information system for collecting Rb image and text using computer technology, to lay the information support for the prevention and treatment research of Rb. Through Rb graphic and text system, which combining the fundus imaging technology under inhalation anesthesia and information collection system, an ophthalmologist can obtain a full, intuitive and accurate information of children. It can promote the improvement of clinical diagnosis, treatment and follow-up in all aspects of Rb, lead a better grasp the Rb fundus manifestations and lesions progress, help clinicians to take reasonable interventions effectively, and also provide an important value for improving the survival treatment of children.In this study, a set of inspection methods and graphic and text output also has a good prospect in clinical teaching and research.With the rise of the comprehensive treatment of chemotherapy, the model of diagnosis and treatment for Rb has also undergone a huge change that conventional external radiation therapy has gradually fade out of the range of mainstream treatment, the original of Reese-Ellsworth5level staging system is no longer able to adapt to the new requirements, therefore, a new International Intraocular Retinoblastoma Classification (IIRC) has been established at the beginning of this century. In2005, a total of27centers worldwide, including Tongren Eye Center, proved the directing role of IIRC on Rb chemotherapy. However, most Rb children in China are in advanced stage when visiting hospital, lead to a relatively poor outcome of conservative treatment. Therefore, the clinical treatment is still currently the most important reality. Since January2008, an Rb professional treatment group has been found in our hospital, to carry out a comprehensive modern treatment of Rb, and has achieved good results and collected a wealth of clinical data. Based on this point of view, the topic performed a comprehensive assessment and analysis on the Rb comprehensive treatment in the past five years as well as the new treatment of23G minimally invasive vitreous surgery combined with intraocular injection chemotherapy,and by histopathological pTNM staging of children with Rb in advanced stage, we have studied potential adverse effects for patients with chemotherapy, in order to improve the level of Rb treatment, exploring individualized treatment in line with our national conditions.For a long time, prevention of relapse and metastasis of Rb is the trickiest difficulty of the treatment.40years ago, Folkman first proposed vascular dependent tumor growth and metastasis, therefore, blocking tumor blood vessels can be considered as effective cancer treatment strategy. VEGF and its related factors, as the most powerful group of cytokines that stimulate angiogenesis, occupy a central position in the process of tumor angiogenesis, and it is a key factor to mediate angiogenesis. In view of this, combining above ideas, we selected some children with successful and unsuccessful chemotherapy, extract the serum, and test the expression of43VEGF and its related cytokines in serum of children after Rb treatment using RayBiotech human angiogenic-related cytokines chip, carry out an overall, dynamic assessment of the changes of level of protein molecules, considering VEGF and its factor group as the core of tumor angiogenesis, we explore the Rb clinical prognosis, invasion and metastasis mechanism.The body’s physiological function is actually executed by protein, thus, the protein levels are particularly important for disease research. Antibody chip technology, as a high-throughput protein molecule detection technology, inherits many characteristics of the Immunofluorescence, chemiluminescence and microarray technology, and gradually develops into a research platform for the overall qualitative and quantitative detection of protein molecules, plays an important role in a variety of disease-related molecular discovery, molecular diagnostics and efficacy evaluation. and has good application prospects. In this study, we hope to take advantage of this technology, from the macro point of view, make an overall understanding of the complex cytokine network regulation mechanisms in new biochemical micro-environment of the tumor vasculature, in order to explore the potential new interventional means and intervention strategies of the Rb treatment in the future.Objective:1. Establish the clinical graphic and text information collection system for Rb, collecte and manage all clinical information and fundus images of Rb children, to lay foundations for mastering the pathogenesis and laws of Rb, and summarizing and exploring Rb treatment characteristics.2. Explore the clinical diagnosis and treatment of retinoblastoma and IIRC staging characteristics3. Study the characteristics of comprehensive treatment on Rb and to investigate the related clinical factors, to explore the patterns for the individualized treatment; preliminarily summarize the clinical experience and prognostic effect of23G minimally invasive vitreous surgery combined with intraocular injection chemotherapy for Rb treatment, fumble new treatment methods for advanced Rb; and study the correlation between chemotherapy and cancer metastasis and mortality of advanced Rb children.4. Using cytokine antibody chip technology, for children in the same stage who succeed or failed in eyeball preservation by comprehensive treatment, determine the changes in expression of43angiogenesis-related cytokines in serum after the treatment. Considering tumor angiogenesis, we explore the Rb clinical treatment, and invasion and metastasis mechanism.Methods:1. Use the JAVA software or language, establish the Rb clinical information acquisition system, and collect Rb clinical data over the past ten years, to provide information support for the analysis of clinic characteristics and laws of Rb.2. Perform a retrospective analysis on the clinical data of116cases of Rb children in our hospital over the past ten years from2003to2012.3. Analyze75cases of Rb children’s clinical data with comprehensive treatment in our hospital from2009to2012, the comprehensive treatment methods include: chemotherapy, local treatment (laser or cryotherapy), enucleation, vitreous surgery combined with injection. In which,65cases have taken chemotherapy-based joint topical treatment+enucleation, while the remaining10cases have taken surgical intervention by23G minimally invasive vitreous surgery combined with intraocular infusion chemotherapy.4. By pTNM staging and disease-specific survival (DSS) methods, study on the correlation between chemotherapy before enucleation and cancer metastasis and mortality of the children with advanced Rb.5. Using RayBiotech angiogenesis-related cytokine chip, determine the changes in expression of43angiogenesis-related cytokines in serum of children with different prognosis after the treatment.6. Data analyses were performed with R2.15.1version software. Chi-square test, T test, Fisher’s exact test, Wilcoxon rank sum test and survival analysis were performed. A P-value≤0.05was chosen to define statistical significance.Results:1. The Rb clinical information collection system has been established, mainly consisting of three modules:the text report module, graphic image module and case query module, and the system can generate a complete graphic and text report information for Rb children.2. Analyze on clinical information of116cases of Rb children, in which,79 cases with unilateral Rb (68.1%),37cases with bilateral Rb (31.9%); in children with a genetic family history,1case was unilateral (1.27%),5cases were bilateral (13.51%), there were significant differences in statistical analysis (P<0.05); most common symptoms in initial diagnosed Rb children were leukocoria (78.4%); On gender aspect,74males (63.79%) and42females (36.21%); for those children, overall initial diagnosed time, diagnostic delay time and follow-up time were21.49months,5.14weeks and30.72months, respectively. The initial diagnosed time of unilateral Rbs in children were24.27months, bilateral Rbs were15.1months, there were significant differences in statistical analysis between the two groups, P≤0.05; In all children,75%had single tumor,25%had more than one tumor; For IIRC of Rb children, of all153affected eyes,5in group A (3.27%),7in group B (4.58%),11in group C (7.19%),56in group D (36.6%),69in group E (45.10%), and4with spontaneous degeneration (2.61%), another1eye removed from the other hospital and the stage was unknown; in all eyes with Rb,97performed enucleation (63.4%), the overall eyeball preservation rate was36.6%; considering the eyeball preservation rate of different staging,5in group A (100%),7in group B (100%),9in group C (81.82%),24in group D (42.86%),10in group E (14.49%),3of4spontaneous degenerative eyeballs were removed due to atrophy. The statistical analysis of the groups A, B, C showed no statistically significant difference (P>0.05); Group A, B, C and Group D, E showed a significant difference (P<0.05).3. With chemotherapy combined topical treatment+enucleation, in all65cases (92eyes,27bilateral cases,38unilateral cases) of Rb children,4-year total survival rate was92.3%, in groups A-E, the survival rates were100%,100%,100%,95%and90.00%, the statistical analysis showed that survival rate in different groups was not statistically significant (P>0.05); total eyeball preservation rate of all children was51%, in group A to E, eyeball preservation rates were100%,100%,85.70%,77.10% and10%, respectively, using the chi-square test of two independent samples among the groups, the eyeball preservation rates among A, B, C, D groups showed no significant difference, P>0.05; but eyeball preservation rates between group E and other groups showed significant difference, P<0.05; the comprehensive treatment outcomes in low-risk Rb children:with15eyes in groups A, B, C,14eyes successful and1eye failed, success rate was93.3%; the comprehensive treatment outcomes in high-risk Rb children:with a total of60cases of Rb children in groups D, E, a total of42cases were treated with chemotherapy combined local therapy,18in group D and24in group E, the eyeball preservation treatment success rate of group D was61.1%(11/18), in group E was16.7%(4/24), the remaining18cases were simple eyeball enucleation or eyeball enucleation after chemotherapy. Perform further analysis on the correlation of conservative treatment and clinical factors of42cases in groups D and E, in children with successful and failed treatment, respectively, the initial diagnosed time were12and16.1months, follow-up time was22.47and28months, there were no statistical significant difference, P>0.05; perform relevance analysis to the location of the tumor,42patients were divided into three groups according to the location of the tumors in the eye:the posterior pole retina, peripheral retina(include the mid-peripheral retina) and the posterior pole+peripheral retina, the number of patients with successful treatment in the three groups were4cases,6cases,5cases; success rate of23.50%,85.70%,27.80%, using chi-square analysis on posterior pole and the peripheral portion, the peripheral group and posterior pole+peripheral group, there were significant differences, P<0.05;4of42patients have died, all with the location of the tumors in the posterior pole retina, groups of the other two locations, no deaths, there were statistical significant differences between posterior pole group and posterior pole+peripheral group, P<0.05; for other groups, there was no significant difference, P>0.05. 4.10cases of Rb children were treated with23G minimally invasive vitreous surgery combined with injection chemotherapy, an average postoperative follow-up time was6.4months,4cases performed surgery with silicone oil tamponade, the silicone oil removed from2cases, for visual acuity,7cases improved,1case the same as preoperative,2cases declined, eyeballs of all children were preserved, and the eyeball preservation rate was100%, no extraocular transfer was found, the tumor focus was almost calcification and atrophy,1case had a small amount of postoperative vitreous hemorrhage,2cases had mild choroidal detachment,1case had persistent chemosis, improved after treatment and found no other serious complications.5. By pTNM staging and disease-specific survival (DSS) analysis methods, study on the Rb histopathology report of41cases (26males,15females,16bilateral cases,25unilateral cases,13group D eyes and28group E eyes performed enucleation). Only count the phase of one eye for each patient into statistical, for patients with bilateral Rb, count worse side in the study.16eyes used enucleation as the preferred treatment,25eyes was carried out chemotherapy treatment before enucleation. There were no significant statistical difference between two groups in the incidence of gender, unilateral and bilateral, international staging or diagnostic age, P>0.05.5deaths were all in the group E with chemotherapy before enucleation,2were bilateral and3were unilateral. Overall average diagnosis age of bilateral children was19.3months (range2-54months), overall average diagnosis age of unilateral children was25.5months (range4-72months); Followed up time of the survival children with enucleation as the first choice treatment (average time31.1months, range11-52months) was longer than the followed up time of the ones with chemotherapy before enucleation (average time26.4months, range10-50months). Average time from diagnosis to enucleation of the children with enucleation as the first choice treatment was0.9months, while median time from diagnosis to enucleation of the children with chemotherapy before enucleation was5.7months, There are significant differences in the statistical analysis, P≤0.05.Disease-specific survival analysis of children:children’s survival time was calculated from the time of diagnosis, up to the date of death of the death of children. Since the deaths are all the group E children, therefore, comparing the DSS between the enucleation children with no chemotherapy and the children with chemotherapy before enucleation, there are near significant differences by statistical analysis, P=0.05. There was significant difference between DDS of children whose enucleation delayed for more than3months and children whose enucleation performed within3months (P≤0.05).Analyze the PTNM staging of the pathological tissue pieces from enucleation of41cases. Overall, in pTNM risk comparison of children with and without chemotherapy before enucleation, there was no significant difference (P>0.05); in the high risk comparison, the proportion of children with chemotherapy before enucleation was12%, while the proportion of children without chemotherapy before enucleation was37.5%, the high risk was significantly less in the former; in the staging comparison, the groups in group D had a significant difference, P≤0.05, i.e. the risk of chemotherapy group is lower than no chemotherapy group; but no significant difference in the risk of the children in the two groups in group E, P>0.056. Drawing peripheral blood of children who succeed or failed in eyeball preservation by comprehensive treatment, determine the43angiogenesis-related cytokines in serum by antibody chip, and found that the expression of11cytokines change, there was a significant difference. In which:2kinds were upregulated:IFN-y and Endostatin;9kinds were downregulated:ENA-78, Angiopoietin-2, VEGFR2, MCP-1, VEGF, MMP-9, IL-1β, PIGF and Tie-2. Conclusion:1. A graphic and text collection system for clinical information of Rb children were created using the Java language, it can collect and collate information of children completely, and output data in the form of EXECL table, at the same time, form a graphic and text report containing the disease and diagnosis and treat of children.2. The leukocoria is the most common clinical manifestations of the symptoms of the Rb children with initial diagnosed, accounting for more than3/4of the total number of children; compared with foreign countries, the time and cause of Chinese children with initial diagnosed Rb when first visiting hospital were generally late, and single tumor accounted for main proportion, the ratio reached75%; For staging, mainly were the advanced patients in groups D and E, which was more than80%.For treatment, eyeball preservation rate was36.6%, and closely related to enucleation rate and staging. It suggested that Rb diagnosis and treatment is still relatively low in our country, patients are found with more serious illness, the prognosis is poor, and need to strengthen the public awareness on the Rb health education, to raise the level of Rb early diagnosis, improve the treatment of disease, and to explore a new effective and economic individualized treatment method.3. Comprehensive treatment of chemotherapy combined with local treatment+enucleation improved the survival and eyeball preservation rate of children with Rb, but the survival rate of patients and eyeball preservation rate was closely related to its clinical stage, the treatment of advanced cases was ineffective with a higher rate of enucleation; at the same time, there is a high degree of correlation between treatment prognosis and tumor location. The location of the tumor has a guiding significance for the choice of clinical treatment; it is also an important factor affecting the clinical Rb comprehensive treatment efficacy. 4. To Rb advanced children with failed or ineffective chemotherapy, vitreous surgery combined with intraocular injection of drugs, as a new treatment method with observed effects in the short term, had an eyeball preservation rate was100%, and postoperative no serious complications. It is a safe and effective treatment, but also need long-term future observation and assessment on large sample.5. If the time from diagnosis to enucleation is more than three months, chemotherapy treatment before enucleation in serious group E of those histopathological poor staging Rb children, and there is no close monitoring and appropriate high-risk factors processing, and which will likely lead to increased mortality caused by metastasis or recurrence. The findings suggest that, the advanced Rb treatment should be in appropriate measure, that is, how to avoid the problem of possible tumor metastasis brought by eyeball preservation treatment, and under what circumstances should we resolute to carry out enucleation or eyeball preservation treatment timely. How to grasp the balance between the two is the key issue requiring in-depth study and summarize.6. Using cytokine antibody chip, we can determine the changes in expression of43angiogenesis-related cytokines in serum of children with different prognosis after the comprehensive treatment. The tumor vascularization with a core of VEGF/VEGFR2and Ang2/Tie2is important influencing factor to prognosis of Rb comprehensive treatment, the tumor prognosis outcome is a complex pathophysiological process, vascular generated at the core, involved in immunity, inflammation, metastasis invasion and apoptosis. VEGF/VEGFR2and the Ang2/Tie2, as Rb new treatment targets, have tremendous potential clinical value.Innovations:1. Established a set of effective retinoblastoma graphic and text information collection system. 2. Proposed a new idea of23G minimally invasive vitreous surgery combined with injection chemotherapy for advanced retinoblastoma, and made a preliminary summary, provided a new means for the comprehensive treatment of Rb.3. Proposed that the excessive chemotherapy or eyeball preservation treatment may cause an increase in mortality or elevated risk in transference in children with advanced retinoblastoma.4. Proposed that the core of prognosis on Rb is tumor angiogenesis, and the VEGF/VEGF R2and Ang2/Tie2can be considered as a new target for future Rb treatment. |
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