摘要
第一部分595nm脉冲染料激光治疗浅表性血管瘤10年回顾性分析
背景介绍：595nm脉冲染料激光(Pulsed dye laser，PDL)临床应用已10余年，脉冲染料激光治疗血管异常性皮肤病已经取得很好疗效。国内有关595nmPDL治疗浅表性血管瘤(Superficial hemangioma，SH)疗效和不良反应未见临床长期随访观察研究。
目的：通过分析随访595nmPDL治疗SH，评价595nmPDL治疗SH疗效、安全性及不良反应。
方法：回顾性分析我科2002年8月至2012年7月10年期间采用595nmPDL治疗SH病例资料。疗效评价分别采用治疗前后皮损照片的比较，由患者或患者家属、未参与治疗的资深皮肤科医师共同完成。并对患者年龄、皮肤分型、皮损部位、大小、类型、面积等进行分类，总体疗效按照痊愈、显效、有效和无效评判，应用SASS10.0统计软件统计，分析疗效及不良反应。
结果：1037例SH患者在此期间接受了595nmPDL治疗，剔除资料不完整，以及同时有2个或2个以上部位皮损的患者，资料完整且定期随访的病例资料共657例，并完成1～5年定期随访。治疗次数为1～14次，平均为3.85±2.23次；患者接受治疗时年龄0.05～60岁，平均为11.87±12.72岁；疗效分布：痊愈147例（28.00%）、显效387例（28.20%）、有效349例（27.10%）和无效153例（16.70%）；年龄越小对应的疗效越好（P=0.034）；不同部位疗效有差异，其中四肢皮损疗效明显优于其他部位(p=0.023)；皮损面积对疗效无影响。不良反应主要为接受治疗区域疼痛、紫癜（952例，91.89%）和水肿（457例，44.11%）；术后色素沉着182例(17.57%)、色素减退115例(11.10%)、萎缩性疤痕38例(3.67%)、增生性疤痕3例(0.29%)、溃疡4例(0.29%)。
结论：595nmPDL治疗SH安全有效。
第二部分595nm脉冲染料激光治疗婴幼儿浅表性血管瘤系列研究
(一)脉冲染料激光治疗婴幼儿面部与四肢浅表性血管瘤临床比较研究
研究背景：不同部位血管瘤的自然转归或在各种干预后的转归是否存在差异目前尚无研究，本研究分析595nm脉冲染料激光（PDL）治疗面部和四肢婴幼儿浅表血管瘤（SH）的疗效和不良反应是否存在差异。
方法：回顾性分析我科2002年8月至2012年7月10年期间采用595nmPDL治疗面部和四肢部位的SH病例资料。共313例SH入组，其中面部SH患儿214例（Ⅰ组），四肢SH患儿99例（Ⅱ组）。疗效评价分别采用治疗前后皮损照片比较，由患者监护人、未参与治疗的资深皮肤科医师共同完成。对患者年龄、皮肤分型、皮损部位、大小等进行分类，总体疗效按照痊愈、显效、有效和无效进行评判，并应用SASS10.0统计软件进行统计，分析疗效及不良反应在2组间的差异。
结果：Ⅰ组痊愈率35.1%，有效率88.8%，Ⅱ组痊愈率60.6%，有效率100%，两组比较差异有统计学意义（p<0.01）。Ⅰ组不良反应发生率为50%，Ⅱ组为44.4%，两组比较差异无统计学意义。
结论：四肢SH对595nmPDL治疗反应优于面部SH，不良反应无明显差异。
（二）595nm脉冲染料激光治疗不同性别婴幼儿浅表血管瘤临床研究
研究背景：婴幼儿血管瘤不同性别发病存在差异，在疾病的转归中雌激素是否发挥作用目前尚不清楚。脉冲染料激光（PDL）能安全有效治疗婴幼儿浅表血管瘤，不同性别患儿其雌激素水平存在差异，是否在血管瘤治疗过程中雌激素水平发生变化仍不清楚。本研究利用现有的595nmPDL治疗婴幼儿浅表性血管瘤10年资料，结合部分血管瘤患儿血液中雌二醇（E2）水平的测定，探讨在PDL治疗血管瘤疗中，性别是否对治疗结果发生影响。
方法：选自2002年8月到2012年7月在我科激光皮肤美容中心接受PDL治疗的婴幼儿浅表血管瘤患者，采用回顾性研究方法，分析PDL治疗中，不同性别治疗结果的差异；同期采用放免法测定部分治疗前血管瘤患儿和非血管瘤患儿血清中的E2水平，了解E2水平在不同性别血管瘤患儿和非血管瘤患儿的差异。
结果：657例血管瘤患儿入组，男261例、女396例。男性患儿痊愈率为41.61%，无效率为10.73%；女性患儿痊愈率为38.64%，无效率为7.58%。采用Wilcoxon-Ranksum test秩和检验，结果效应值Z=-19.807，P<0.001，男女两组疗效等级的差别有统计学意义。女性秩和大于男性秩和，女性患儿组疗效更好。40例血管瘤患儿（男14例，女26例），20例非血管瘤患儿入组雌二醇测定。治疗前血管瘤组E2值27.245±19.079pg/ml，非血管瘤组E2值11.385±5.506pg/ml，两组E2值差异有显著统计学意义（P＜0.001）。血管瘤组男患儿E2：18.671±8.935pg/ml，女患儿E2：31.861±21.518pg/ml，男女差异有统计学意义（P=0.01）。
结论：血清E2浓度可能与婴幼儿血管瘤发生有关，血管瘤患儿血清E2浓度高于非血管瘤患儿，女性血管瘤患儿血清E2浓度高于男性患儿。PDL治疗不同性别婴幼儿血管瘤临床疗效有差异性，女性患儿疗效优于男性患儿。
（三）595nm脉冲染料激光治疗婴幼儿浅表血管瘤预后与开始接受治疗年龄关系分析
研究背景：脉冲染料激光（PDL）是婴幼儿浅表血管瘤（SH）的一种安全有效的治疗方法，但是对血管瘤治疗时期的选择存在争议。本研究分析595nmPDL治疗SH的结果与患儿首次接受治疗时间的关系，明确是否存在合适的治疗时期。
方法：回顾性分析我科2002年8月至2012年7月10年期间采用595nmPDL开始治疗年龄在24月以内的婴幼儿SH病例资料。根据患儿首次接受治疗的年龄段，分为0-3月（A组）、4-9月（B组）、10-18月（C组）和19-24月（D组）四组。主要评价这四组之间首次接受PDL治疗的患儿，其皮损消退程度以及不良反应等之间是否存在差异。
结果：549例患儿入选，其中A组300例，121例痊愈、101例显效、49例有效、29例无效、164例发生不良反应；B组184例，72例痊愈、74例显效、29例有效、9例无效、88例发生不良反应；C组49例，23例痊愈、14例显效、8例有效、4例无效、22例发生不良反应；D组16例，8例痊愈、5例显效、3例有效、0例无效、7例发生不良反应。各组间疗效（P=0.692）及不良反应（P=0.332）均无显著差异。
结论：PDL是治疗婴幼儿浅表血管瘤的一种安全有效方法，2岁以内患儿首次接受治疗时间对其预后无明显差异性影响。
（四）光动力疗法与脉冲染料激光治疗婴幼儿浅表性血管瘤临床对照研究
研究背景：脉冲染料激光(Pulsed dye laser, PDL)和光动力疗法（photodynamictherapy, PDT）治疗婴幼儿浅表性血管瘤(Superficial Hemangioma, SH)并不能使所有患者获得满意疗效。本研究目的比较ALA局部外用后，以595nm脉冲染料激光为辐射光源（ALA-PDL），与单纯595nm脉冲染料激光（PDL）治疗SH疗效和安全性比较，评价局部外涂ALA光动力疗法与595nm脉冲染料激光治疗婴幼儿SH疗效。
方法：采用前瞻性临床随机对照研究方法，招募SH患儿者193例，随机分为单独采用595nm脉冲染料激光治疗组（PDL组）和局部外用ALA后再应用595nm脉冲染料激光治疗组（ALA-PDL组）。在最后一次治疗6月后的随访，评价2组间疗效和不良反应差异。疗效的判定以获得完全消退或无明显改善的患者比例数为主，不良反应包括色素紊乱和皮肤萎缩等，以及局部感染和溃疡等。并对患者满意度进行调查。采用SPSS10.0软件对获得的数据进行统计分析。结果：共165例患者完成治疗和随访，其中PDL组119例、ALA-PDL组46例；所有患者年龄＜24个月，未服用其他药物。最终获得完全消退的患者在PDL组和ALA-PDL组间的分布是(44,37.0%, vs31,67.4%)、皮损几乎无改变的患者在两组间的分布是(11,22.0%vs2,1.7%)，两组疗效比较差异有显著性（X2=10.302，p=0.001），ALA-PDL组优于单纯PDL组；两组间不良反应发生无明显差异性（X2=3.32p=0.564）。
结论：与单独应用PDL相比，局部应用5-ALA后，以595nm脉冲染料激光为辐射光源治疗婴幼儿SH，可以提高临床疗效，而不良反应与单纯PDL无明显差别。
第三部分595nm脉冲染料激光对血管瘤裸鼠模型瘤体生长的影响及机制探讨
研究背景:婴幼儿血管瘤是小儿最常见的良性肿瘤，其病理机制不清楚，缺乏理想的研究模型是阻碍对血管瘤病理机制深入研究的主要原因之一。本研究将人体增生期血管瘤组织移植至裸鼠皮下制成血管瘤动物模型，采用595nm脉冲染料激光（PDL）对已经建立的血管瘤裸鼠模型作用，探讨PDL对血管瘤的作用机制。
方法：人体血管瘤取自1例2月龄男性患儿左腹壁血管瘤，迅速转移至裸鼠生活的无菌恒温实验室中行瘤体移植，自标本活体取下到移植结束不超过2h。血管瘤组织标本切成约5mm×4mm×3mm大小，分别经裸鼠双侧背部近臀部皮肤切口，植入裸鼠皮下。移植后定期观察移植瘤体生长状况，判断移植物是否成活。并于移植2月后取2个不同部位移植成活瘤体，进行组织学观察以判定是否是血管瘤组织。移植60天后，取移植成功的实验动物模型建立随机对照实验，随机分为3个实验组，A组（595nmPDL组）：以595nm PDL照射血管瘤瘤体表面一次；B组（激素组）：血管瘤瘤体内均匀注射曲安奈德混悬液0.5ml一次；C组（对照组）：不作任何处理。给予不同干预措施再连续观察2周，此时对裸鼠模型瘤体分别进行：体积测量、组织病理学分析和免疫组织化学分析。分别观察瘤体体积变化，组织病理学变化，并以免疫组织化学法检测血管内皮细胞生长因子（VEGF）、基质金属蛋白酶2（MMP-2）和组织基质金属蛋白抑制剂-2(TIMP-2)表达。使用SASS10.0统计软件对所有实验结果进行统计学分析，以P<0.05为有显著性差异。
结果：免疫组织化学检测显示移植成活的血管瘤CD31呈阳性表达, CD31定位于血管内皮细胞的细胞膜上；血管瘤裸鼠模型生长良好，瘤体体积大小均匀，A组和B组与对照组（C组）相比，体积有显著缩小；A组和B组的组织标本观察到血管减少，瘤体萎缩、退化，血管腔闭塞、破裂，血管间纤维脂肪组织浸润。对照组裸鼠模型血管瘤瘤体体积继续增大,呈增生期改变。实验处理后，A组和B组MMP-2、VEGF表达明显降低，而TIMP-2阳性表达升高。
结论：将增殖期人血管瘤组织移植于免疫缺陷的裸小鼠体内,可建成异种移植人血管瘤在体动物模型。595nmPDL可能是通过封闭血管瘤，阻止MMP-2和VEGF等的释放，从而达到治疗血管瘤目的。
PartⅠ Efficacy and Side Effect in Chinese SuperficialHemangiomaTreated by595nm Pulsed DyeLaser--Results of10-year Analysis
Background：The595nm tunable pulsed dye laser（PDL） has been used in China formore than10years clinically. However, no studies about its effect and side-effect in thetreatment of superficial hemangioma have been documented.
Objective: This study was designed to retrospectively summarize595nm PDL usage inChinese patients.
Methods: Infant patients with superficial hemangioma, who had received595nmtunable pulsed dye laser treatment in our laser center in the last10years, were recruited.Detailed demographics, results of assessment about their degree of clearance andclinical examination for treatment complications were entered into SASS10.0versiondatabase, and statistical analyses were conducted.
Results:657cases with superficial hemangioma were recruited from the total1037cases treated by595nm PDL during the period time. The overall effectiveness rate was91.17%. Female patients respond better than male, the difference was statisticallysignificant (P<0.001). Lesions at different part of the body respond differently to thetreatment with lesions on extremities show the best result. The response rate does notincrease with time of treatments. The most common side-effects were pigment changesand skin atrophy, which usually resolve spontaneously and disappear completely in afew months. Conclusions: Our experience confirmed the satisfactory clinical efficacy and safety ofthe595nm tunable pulse dye laser in the treatment of childhood superficialhemangioma.
PART Ⅱ Series research of595nm pulsed dye laser inthe treatment of superficial hemangioma
PARTⅡ.1Pulsed dye laser in the treatment of infants withsuperficial hemangioma located on facial andlimb:a clinical comparative study
Objective: There is no research about the natural outcome or prognosis afterintervention in the patients with hemangioma in different parts. The aim of this study isto compare efficacy and adverse reaction of hemangioma located on facial and limbtreated by595nm pulsed dye laser.
Methods: Retrospective analysis of595nmPDL in the treatment of superficialhemangioma cases in our department from August2002to July2012with period of10years. A total of313cases were enrolled, including214cases which lesion located onface (Group I),99cases on limbs (Group II). Evaluation of curative effect was used tocompare skin photo before and after treatment, completed by the patients`guardian, andsenior dermatologists who did not participate in the treatment. The patient age, skin type,lesion site, size et al was also analyzed. The treatment results were classified according to recur, excellence, valid and invalid, and analyzed using SASS10.0statistical softwareduring two groups, and adverse reaction was also analyzed.
Results: In group I, the cure rate was35.1%, effective rate was88.8%; and in group II,the cure rate was60.6%, effective rate was100%, there was significant differencebetween two groups (p<0.01). There was no significant difference about adversereaction between two groups (50%vs44.4%).
Conclusion: Limb SH response to595nmPDL treatment is better than that of facial SH,there is no significant difference about adverse reaction between two groups.
PartⅡ.2A study of gender affect the curative ofhemangioma treated by595nm Pulsed dye laser
Objective：There is difference about morbidity in the patients with infantile superficialhemangioma between the sexes, whether estrogen play a role is unclear. Pulsed dyelaser (PDL) can be safe and effective in the treatment of superficial hemangioma ininfants, but the gender does play a role in the disease process is not clear. This studywas a retrospective analysis10years of data, uses595nm PDL for treatment of infantilesuperficial hemangioma, in our department, especially the difference result existedbetween the sexes, and combined with blood estradiol levels part with hemangiomawere measured. The aim of this study is to explore whether gender affects the progressand prognosis of hemangioma.
Methods：A retrospective study method was used to analysis gender differences resultsfor PDL in the treatment patients with superficial hemangioma from2002August to2012July in our hospital. During the same period, serum E2level was detected withradioimmunoassay method in some children with hemangioma and children with lungdiseases, but non hemangiomas.
Results：657cases of hemangiomas were enrolled, including261male cases,396female cases. Male patients’ cure rate was41.61%, inefficiency was10.73%; femalepatients’ cure rate was38.64%, inefficiency was7.58%. Wilcoxon-Rank sum test wasused, because grouping variable are unordered data, and target variable are ordered data,result shown effect value Z=-19.807, P<0.001, sum of ranks in female> male, it issuggested that there is statistical significance between female and male gorup, femalepatients are more effect than male.40cases of hemangioma in children (male14, female26) and20cases of non hemangiomas in children enrolled for serum E2level weredetermination.E2value were27.245±19.079pg/ml vs11.385±5.506pg/ml correspondto the group hemangioma vs non hemangioma group. There was statistically significantdifference between two groups (P <0.001). And there was statistically significantdifference about serum E2level between male hemangioma and female hemangioma(P=0.01).
Conclusion: The estradiol may play a role in hemangioma proliferation, differentgender differences may be effect results in the children with hemangioma treated withPDL.
PartⅡ.3Study on therapeutic outcome for superficialhemangioma treated by595nm Pulsed dye laseraffected by the timing of starting treatment
Objective: Pulsed dye laser (PDL) is the infantile superficial hemangioma (SH) of asafe and effective treatment, but the treatment period hemangioma choice iscontroversial. This study analyzed the relationship between595nmPDL treatmentresults of the SH and the timing of starting treatment, clear whether there areappropriate treatment period.
Methods: Retrospective analysis of595nmPDL in treatment of infant SH cases in ourdepartment from2002August to the2012July period of10years according to startingtreatment age within24months. According to the timing of starting treatment age,divided into0-3month (group A),4-9month (group B),10-18month (group C) and19-24month (group D) of four groups. The main evaluation between the four groups forthe first time in PDL treated patients; the lesions subsided whether there are differencesbetween the degree and adverse reaction.
Results:549patients were selected, the A group of300cases,121cases were cured,101cases markedly effective,49cases effective,29cases invalid,164cases of adversereactions occur;184cases in group B,72cases were cured,74cases markedly effective,29cases effective,9cases invalid,88cases of adverse reactions occur; C group of49cases,23cases were cured,14cases markedly effective,8cases effective,4casesinvalid,22cases of adverse reactions occur;16cases in group D,8cases were cured,5cases markedly effective,3cases effective,0cases invalid,7cases of adverse reactionsoccur. There are no significant differences among the groups about effect (P=0.692) andadverse reactions (P=0.332).
Conclusion: PDL is a safe and effective method for the treatment of infantile SH, butwithin2years old children, timing of starting treatment has little influence on theprognosis.
PartⅡ.4Topical ALA administration followed by irradiationwith PDL and PDL in treatment of superficialhemangioma—a controlled clinical study
Objectives: The role of pulsed dye lasers (PDL) and photodynamic therapy (PDT) inthe treatment of superficial hemangioma (SH) are not satisfactory for all patients. Thepurpose of this study was to evaluate the safety and efficacy of the method that topicalapplication of ALA spreading followed by595-nm PDL compared with595-nm PDLalone in treatment of SH.
Methods: We did a prospective, randomized controlled trial in which193patients withSH were enrolled. We assigned patients to receive PDL treatment (PDL group) or local5-ALA application and then irradiation with595nm PDL(ALA-PDL group), followedup6months after last treatment session, and evaluate the differences of the curativeeffect and the adverse reaction between the two groups. The main outcome measureswere assessed according to the proportion of the patients whose lesions were completelycleared or not significantly improved, adverse reactions including pigmentarydisturbance, skin atrophy, ulceration, infection and so on. Questionnaires were used to investigate the patients' satisfactory degree. The data obtained are computed andanalyzed via SPSS Version17.0.
Results: All165patients with SH completed the study, which included119patientswho were in PDL group and46patients who were in ALA-PDL group. The number ofpatients whose lesions showed complete clearance or minimum residual signs at0.5year follow up was significantly different in the PDL group and ALA-PDL group(44,37.0%, vs31,67.4%). Lesions showed no obvious change was significantly differentin the PDL group and ALA-PDL group (2,1.7%, vs11,22.0%). There were significantdifferences about effect between the two groups, ALA-PDL was better than PDL alonein the treatment of SH.(X2=10.302, p=0.001) Adverse reactions between the twogroups had no obvious difference (42.9%vs47.8%, X2=3.32, p=0.654).
Conclusion: Topical ALA administration followed by irradiation with a595nm PDL ismore effective in the treatment for SH, compared with PDL alone.
Part Ⅲ Investigation of595nm PDL on the growth ofhemangioma in nude mice and its mechanism
Objective: Infantile hemangioma is the most common benign tumor in children, itspathological mechanism is not clear; lack of an ideal model for studying is one of themain reasons hindering the in-depth study on the pathogenesis of hemangioma. Thepurpose of this study is to investigate the role and mechanism of PDL on hemangioma by establishment of vascular tumor in nude mice animal model, and using595nmpulsed dye laser (PDL) on hemangioma in established nude mice models.
Methods: Using tissue transplantation, infant’s proliferative phase capillaryhemangioma surgical specimens were cut into small pieces under sterile conditions,implanted subcutaneously into nude mice, made of infantile hemangiomas in nude micexenograft animal models. Transplant60days later, take the transplants were successfulexperimental animal model of randomized controlled trials, divided into3experimentalgroups were given different interventions. A group intervened by595nm PDL, B groupintervened by Triamcinolone Acetonide0.05ml, and C group without intervention.Given different interventions, hemangioma xenograft model of tumor volumemeasurement, monitoring of vascular tumor growth in nude mice model in vivo;experimental nude mouse model were sacrificed2weeks after treatment to remove thehemangioma made of slices, HE staining for histological analysis, and forimmunohistochemistry staining of the expression of VEGF、MMP-2、TIMP-2. Using theSPSS17.0statistical software for all experimental results were analyzed statistically, P<0.05was thought to be significant difference.
Results: Immunohistochemistry revealed CD31and CD34were positive expression ingrafted hemangioma tissue, CD31and CD34localized in the membrane of vascularendothelial cells. Produced by hemangioma xenograft model of growth is good, thecontrol group nude mouse model of vascular aneurysm volume continues to increase,the gross and microscopic observation of vascular aneurysm was the proliferation ofchange of the specimen; the others groups nude mouse model of vascular aneurysmvolume were reduced. The hemangioma tumor volume between groups were significantdifferences, tissue observed reduced vascular density, tumor atrophy, degeneration,occlusion of the vessel lumen, rupture, fat and fibrous tissues in the vascular infiltrationwere observed both A and B groups. The positive expression of MMP-2, VEGF in control group was significantly higher than that in A group and B group. The positiverate of TIMP-2was lower in group C than in the A and B group.
Conclusion: Planting of human subeutnaeous hemnagiomas onto nude micesubeutnaeously is a feasible way to establish a model of human hemnagioma. The studyconfirmed that action of595nmPDL on vascular can reduced MMP-2and VEGFreleasing by action of blocking vessel.
引文
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11) Liu H, Dang Y, Chai X, Wang Z, Ma L, Ren Q. Treatment of port-wine stainswith the595-nm pulsed dye laser: a pilot study in Chinese patients. Clin ExpDermatol.2007;32(6):646-9.
12) Wei Chen, Chunjun Yang, Shengxiu Liu,Sen Yang. Curative effect study ofpulsed dye laser in the treatment of43patients with hand infantile hemangioma.Eur J Dermatol.2013,(accepted).
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