目的 探讨经导管眼动脉灌注化疗(TOAC)治疗化疗失败的眼内晚期视网膜母细胞瘤(RB)的价值.方法 对70例(95眼)全身化疗失败,且国际眼内视网膜母细胞瘤分级为D期或E期的RB患儿行TOAC治疗.造影确认微导管在眼动脉内且脉络膜显影清晰后,行眼动脉灌注化疗.术中化疗方案采用美法仑5 mg及卡铂20 mg.每隔4周重复一次TOAC术,方法同前.每次TOAC术后均观察患儿一般情况及术后不良反应.每次TOAC术后4周行超声检查测量瘤体最大径(即眼球赤道平面的最长径)以及厚度(即瘤体前后径)的变化,行眼底检查评价瘤体的消退情况,观察是否出现钙化或瘢痕.瘤体最大径及厚度的比较采用配对样本t检验.结果 对70例(95眼)术中尝试行眼动脉插管209次,平均(2.2±0.4)次/眼,其中197次操作成功.患儿TOAC术后随访2～ 28个月,中位随访时间为13个月.62例患儿的84眼随访资料完整.散在的较小瘤体(最大径≤3 mm)经过1或2次TOAC术治疗后瘤体完全消失.最大径＞3 mm的主瘤体,每次TOAC术后瘤体均有不同程度的缩小,直至最后钙化或形成瘢痕.70例患儿(95眼)RB瘤体术前瘤体最大径和厚度分别为(10.9±2.1)和(6.3±1.6) mm,第1次TOAC术后分别为(6.8±1.6)和(3.4±1.2) mm,差异均有统计学意义(t值分别为23.600和27.351,P值均＜0.01).随访资料完整的62例(84眼) RB患儿4次TOAC术后瘤体最大径和厚度均较术前减小,差异也均有统计学意义(P均＜0.01).62例(84眼)随访资料完整的患儿中,25眼瘤体完全消失,局部形成钙化斑块;其余59眼行眼球摘除术,其中肿瘤复发31眼、广泛玻璃体种植12眼、视网膜下种植9眼、玻璃体出血7眼.5例因视神经侵犯伴颅内转移或肿瘤复发死亡.术后不良反应包括一过性的眼周不适及轻度骨髓抑制.结论 TOAC术治疗眼内晚期化疗失败的RB患儿安全有效.%Objective To evaluate the value of transcatheter ophthalmic arterial chemotherapy (TOAC) for chemotherapy failure of advanced intraocular retinoblastoma(RB).Methods TOAC was performed in 70 cases(95 eyes) with systemic chemotherapy failure.All cases were in accordance with the international intraocular retinoblastoma classification(IIRC) for stage D or E.Ophthalmic arterial perfusion chemotherapy would be performed when angiography confirmed the position of micro catheter in the ophthalmic artery and choroid development was clear.The chemotherapy regimen was Melphalan combined with Carboplatin.TOAC was repeated once every 4 weeks.Postoperative observation projects included patients' general conditions and adverse reactions after each TOAC.Changes of largest diameter and thickness of the tumors were measured by ultrasound 4 weeks after each TOAC.Tumors regression such as calcification or scar was evaluated by funduscopy.The preoperative and postoperative changes of the largest diameter and the thickness of the tumors were compared by paired sample t test.Results Opthalmic arterial catheterization was applied within 70 cases(95 eyes) of surgery for 209 times.Follow-up period was from 2 to 28 months(mean time 13 months).There were 84 eyes of 62 cases with complete follow-up data.Scattered small tumors(maximum diameter ≤3 mm) had completely disappeared after 1 or 2 TOAC.Primary tumors(biggest diameter＞ 3 mm) had different degrees of regression after TOAC up to calcification or scar.Preoperative argest diameter and thickness of all tumors were(l0.9±2.1) mm and(6.3± 1.6) mm,respectively.The largest diameter and thickness of all tumors were regressed to(6.8± 1.6) mm and(3.4± 1.2) mm when 1 TOAC was finished,respectively,which had statistical significance(t values were 23.600 and 27.351,P＜ 0.01).When 62 cases(84 eyes) finished all TOAC,postoperative tumors' largest diameter and thickness were smaller than preoperative tumors,which had statistical significance(all P＜ 0.01).Of 62 cases(84 eyes) with complete follow-up data,25 eyes tumors had completely disappeared,forming local calcified plaque.The causes of the remaining 59 eyes of eyeball enucleation include 31 eyes of tumor recurrence,12 eyes of widely vitreous planting,9 eyes of subretinal planting,7 eyes of vitreous hemorrhage.Five cases died of tumor recurrence or intracranial metastases associated with optic nerve invasion.Postoperative adverse reactions include transient eye discomfort and mild bone marrow suppression.Conclusion TOAC is a safe and effective method to treat advanced intraocular RB in patients with chemotherapy failure.
展开▼
