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Medical Efforts from Life Saving to Vision Saving
Writing | Yan Xiaoliu
Source | “Medical Community” Public Account
“Can you wait? Can you afford it?” After the outbreak of the epidemic in Shanghai, dozens of Sichuan and Sichuan parents kept asking themselves.
They have the same reason to go to Shanghai as soon as possible: the child was diagnosed with retinoblastoma (RB) in Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine (hereinafter referred to as Shanghai Xinhua Hospital). This is a special and most common malignant tumor of the eye of children. It has a high recurrence and systemic metastasis rate. Treatment is a race against time.
Most of these children have completed the previous treatment, but they need to be reviewed every 1-2 months to find and deal with new lesions as soon as possible.
Ms. Guang’s son Liangliang was due for a review in March. His trip to Shanghai dragged on for nearly a month, but it still hasn’t happened.
Ms. Guang said that she was in a good mood, but she was always in a hurry. “My child is in stable condition. Other children treated at the same time have relapses or metastases, we have not. However, the disease is uncertain.”
The turnaround occurred in mid-April. Ms. Guang and others learned from the patient’s WeChat group that Shanghai Xinhua Hospital and a hospital in Zibo, Shandong have reached a cooperation, and dozens of local children will be transferred to Zibo for re-examination.
“Can there be a point in the southwest region?” In the WeChat group, Sichuan and Shu parents asked.
The Ophthalmology Department of Sichuan Provincial People’s Hospital connected with Shanghai Xinhua Hospital through remote 5G video to discuss the next treatment plan. /respondent provided
Review road cut off by the epidemic
September 2020, Liangliang is one and a half years old. One day, the child’s father found that one of Liangliang’s eyes looked like a “cat’s eye”, with bright pupils and flickering white spots. This is medically known as “white pupils” and is a typical symptom of RB.
“How can a child get cancer when he is so young?” This is a common question shared by many parents of children with children.
“RB is most common in infants and young children under the age of 3. 95% of children have the disease before the age of 5.” Zhong Jie, chief physician of the Department of Ophthalmology of Sichuan Provincial People’s Hospital, told the “medical community” that RB The incidence is “rare”, with only 1 in every 15,000 to 20,000 births.
Liangliang’s treatment in Shanghai went smoothly. Ms. Guang found that the wards were full of infants and young children, the youngest being only three or four months old. “The child is too young and has a low degree of cooperation. Every treatment and reexamination requires general anesthesia, water and food for several hours. After the treatment, he has to stop eating and drinking for 4 hours. Xinhua Hospital has opened a green channel, and the procedures are well arranged. Compact. The child suffers a lot less.”
From September to December 2020, Liangliang completed 4 times of ophthalmic artery interventional perfusion chemotherapy (IAC). Since then, due to the stable condition, the review interval has been extended to every 10 weeks. Until March this year, the review was interrupted due to the epidemic.
Anxiously awaiting the re-examination, there are also Ms. Yang from Sichuan and her son Qiu Qiu.
This year, Qiu Qiu, 2 years and 5 months old, was diagnosed with RB in October 2021. “(At that time) it was found that there was a white spot on his black eyeball.” Ms. Yang recalled that in order to protect the eyeball, they came to Shanghai Xinhua Hospital for treatment.
Currently, Qiu Qiu is in the critical early postoperative period. “It was originally planned to fly to Shanghai for re-examination every 4 weeks. If there is an epidemic, we can’t go there. We were very anxious at that time.” Ms. Yang said.
In mid-April, you all waited for good news.
“The doctors of Xinhua Hospital announced in the patient’s WeChat group that they have contacted the Ophthalmology Department of Sichuan Provincial People’s Hospital and can arrange for the children to be reexamined locally. The doctors of Xinhua Hospital will ‘consult’ online, and the whole process will not leave the diagnosis and treatment. . Everyone agreed immediately.” Ms. Guang said.
Zhong Jie told the “medical community” that it plans to accept 40-50 children with RB. As of May 7, 3 batches and more than 30 children have completed the re-examination. The youngest is only 11 months old, the oldest is 6 years old, and the average age is about 3 years old.
Dr. Zhong Jie examines the child in the dark room. /respondent provided
Provincial People’s Hospital Ophthalmology Department’s routine workdays are saturated. After discussing with his colleagues, Zhong Jie decided to arrange these RB children on weekends. After completing the anesthesia evaluation and other work in the early stage, the children will arrive at the hospital in the morning, and they will be able to complete the examination and be discharged home in the afternoon.
Zhong Jie pointed out that more than 90% of the children who took over had completed 3-4 interventional treatments, and 2-3 cases needed to continue conventional chemotherapy in the Provincial People’s Hospital. “When parents come, they bring their children’s previous diagnosis and treatment records with them. During the inspection process, we have a real-time video connection with Xinhua Hospital to compare the results of the last two inspections online and discuss the next steps together.”
Not long ago, Liangliang and Qiu Qiu’s re-examination continued. This is more than two weeks later than originally planned. “Fortunately, the results were good.” Ms. Guang breathed a sigh of relief.
The child with retinoblastoma in the right eye shrank significantly after three interventional treatments. /respondent provided
“Going around and back”
Zhong Jie took a close look at the children’s data and found that many children’s path of diagnosis and treatment has been very twists and turns.
For example, Qiu Qiu followed her mother to many hospitals in Sichuan Province.
Liangliang, accompanied by the whole family, was transferred from the first-level county hospital to the top. After queuing up for a few days in a well-known tertiary hospital in Sichuan Province, he still could not wait for the examination. Later, he was diagnosed in the ophthalmology department of Sichuan Provincial People’s Hospital and was referred to Shanghai for treatment.
“Several children were diagnosed here and then transferred out. After a circle, they returned to the people of the province.” Zhong Jie said.
Recalling the referral of patients, he admits that he has some regrets.
The ophthalmology department of Sichuan Provincial People’s Hospital has a very good reputation in the southwest region. It is the first batch of first-class key disciplines in Sichuan Province, and it is also the eye disease prevention and treatment center of Sichuan Province. The department has several sub-specialty groups such as cataract, optometry, fundus diseases, glaucoma, and ocular surface diseases, and routinely conducts advanced eye surgery and treatment at home and abroad.
Zhong Jie is the leader of the fundus disease group. In 2008, he and his team pioneered the treatment of retinopathy of prematurity in Southwest China.
In recent years, Zhong Jie and his team have been able to successfully treat difficult eye diseases such as retinopathy of prematurity, hereditary familial exudative vitreoretinopathy, and persistent embryonic vascular disease.
Retinoblastoma was once an “exception.” Zhong Jie and team members can diagnose, but most of the children who meet the indications for eye protection will be transferred to Shanghai.
Zhong Jie said frankly that the core reason is that RB treatment is difficult and risky. “We don’t want to start when the pre-preparation is not enough.”
Under general anesthesia, Dr. Dong Wentao, an ophthalmologist, performed a fundus examination for the child. /respondent provided
He introduced that RB treatment methods include IAC, systemic intravenous chemotherapy, intravitreal chemotherapy, laser cryotherapy, and enucleation.
The conventional treatment in the past was to shrink the tumor through systemic intravenous chemotherapy, and then to eradicate the tumor through local treatments such as lasers and cryotherapy. The systemic side effects of this treatment are large, and it will cause bone marrow suppression and so on. Many children suffer, and the final outcome is still loss of vision and removal of the eyeball.
In recent years, IAC has become the treatment of choice for RB. It uses an ultra-thin catheter to enter the ophthalmic artery on the affected side through the internal carotid artery, and infuses chemotherapy drugs by bolus injection to “poison” the tumor.
This can increase the local drug concentration in the tumor with less systemic side effects. Compared with the traditional surgical operation “de-meat and deboning”, the internal medicine radiotherapy and chemotherapy “kill one thousand enemies and self-destruct eight hundred”, IAC can be described as a green minimally invasive.
Generally, after 3-5 IAC treatments, the tumor size can be significantly reduced. If the cancer cells are observed to spread to the vitreous cavity later, targeted anticancer drug injections can be performed.
Data show that the eye preservation rate of IAC treatment for advanced RB can reach 70%. Keep the eyeballs, and it will be possible for the children to regain their sight in the future.
But IAC treatment must rely on a multidisciplinary approach.
The internal carotid artery to the ophthalmic artery is a right angle, and it is difficult to bend after the catheter is inserted. A little careless operation may lead to blood vessel rupture and spasm. At this point, the neurosurgery needs to plan the route to ensure the smooth arrival of the catheter.
At the same time, most children are young. Oncology and pediatrics should also participate in the study of drug ratio, calculation of dosage, and balance between eye protection and life protection.
“The medical team that can successfully carry out IAC must be mature in multiple disciplines.” Zhong Jie said.
On January 7, 2022, the rare disease retinoblastoma multidisciplinary team of Sichuan Provincial People’s Hospital successfully completed the first IAC treatment in the hospital. Ophthalmology, Neurosurgery Interventional Group, Oncology, Pediatrics are all involved.
Zhong Jie and others have been preparing for this day for many years. During this period, the hospital successively dispatched young backbone physicians such as Dong Wentao from the Department of Ophthalmology and Cheng Meixiong from the Department of Neurosurgery to be apprentices in Shanghai Xinhua Hospital. The two young doctors brought back a complete set of SOPs for IAC treatment, and in the internal sharing, they also focused on the various accidents they encountered.
The “medical community” learned from Shanghai Xinhua Hospital that this time, the reexamination of children with RB was placed on the people of the province, not only because of the large number of children in the southwest area and the urgent needs, but also because of two There are many academic exchanges in the hospital, “We know very well that the Provincial People’s Hospital has complete inspection equipment and good treatment skills.”
Dr. Cheng Meixiong of the Neurosurgery Intervention Group is performing interventional treatment for the child. /respondent provided
After overcoming technical difficulties, learn comprehensive management skills
“No worries at all.” Zhong Jie said that when he communicated with Xinhua to accept the child, his first reaction was “this is a good thing”.
From the perspective of the patient, Zhong Jie felt that it was necessary to pick up, and the sooner the better. It is a doctor’s duty to save lives.
From the hospital and department level, this is a very good learning and experience accumulation process. “We have overcome technical difficulties, but we still need to learn comprehensive management capabilities like Xinhua Hospital, especially long-term follow-up and disease management.”
According to the “Guidelines for the Diagnosis and Treatment of Retinoblastoma in Children (2019 Edition)”, children with RB in both eyes should be re-examined at least 3 times every 3-4 weeks for inactive tumors, which can be adjusted to every 6-8 weeks Review until age 3, and thereafter every 4-6 months until age 10. For monocular children, review every 6-8 weeks, transition to review every 4-6 months, until 10 years of age.
Zhong Jie pointed out that during the review process, if there is a need for treatment, parents can have it in Sichuan Provincial People’s Hospital, or they can choose to go back to Shanghai Xinhua Hospital. “I talked to a parent. The other person said that if the people of the province get well, they will definitely want to stay in the province.”
Ms. Yang said that in the past, to go to Shanghai for a re-examination, it required 2 adults to bring a child. Air tickets, accommodation, meals, plus the re-examination fee, cost at least seven or eight thousand. This time I saw it in Sichuan Provincial People’s Hospital, and the cost was saved by more than half.
There are also parents who are still considering it. “The doctors in the province are very good, the communication is very smooth, and the investigation is very meticulous. It may be because the number of children admitted is not the same as that in Shanghai.” Ms. Guang told the “medical community”.
“By taking over the children this time, we may be able to sell the brand that we have IAC technology and treat RB. After we see more children, we will get better and better.” Zhong Jie said.
Source: Medicine
Editor in charge: Tian Wei
Proofreading: Zang Hengjia