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Ocular Melanoma Treatment
Dr. Peter G. Hovland discusses ocular melanoma, a rare eye cancer that affects around 2,000 people in the U.S. each year, primarily in Caucasians with lighter eye colors. Treatment options include radiation, laser therapy, and enucleation, with ongoing research into new therapies such as clinical trials for alternative treatments. The presentation emphasizes the importance of personalized patient care and a supportive healthcare team throughout the patient's journey.
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Ocular Melanoma Treatment
- 1. Ocular Melanoma Treatment PeterG. Hovland MD PhD 7th Annual Eyes on a Cure: Ocular Melanoma Patient and Caregiver Symposium 21 April 2018
- 2. Welcome! • Patient advocacycan make a difference • Your fundraising helps – Improve understanding – Promotes better communication – Fosters focused research
- 3. Introduction • Dr. PeterHovland • Ocular Oncologist and Retina Specialist • Clinical practice with Colorado Retina Associates for 12 years
- 4. Disclosure • Castle Biosciences– Advisory Board
- 5. When you hearhoof steps… • You think of horses not zebras! • Common things are seen more commonly. • This talk is about zebras however. Common Rare
- 6. Ocular Melanoma • Rare –About 2000 new cases per year in US – About 7000 new cases per year world – “Orphan” disease • Mostly affects adults – M = F – More common in Caucasians • Especially Blue/hazel eyes • Familial 1% • Cause unknown – Genetic mutations - random
- 7. Ocular Melanoma Starts inthe eye wall: – Choroid - 90% – Ciliary Body – 6% – Iris – 4%
- 8. OM originates inthe eye – Some OM can spread to the body
- 9. Tangent: Other cancerscan spread to the eye • Adenocarcinomas – Breast, Lung, Prostate, GI, GU • Lymphoma • Sarcoma • Melanoma • Carcinoid
- 10. Journey of aNew patient • Symptoms or Routine Eye exam • Eye doctor -> Specialist -> Ocular Oncologist • Diagnosis • Evaluation of Body • Treatment of Eye • Wait for response to treatment
- 11. How do weknow it’s melanoma? • Diagnosis based on exam and testing • Diagnosis may be made – At initial presentation – After a period of observation • Tumor may grow
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- 13. Diagnostic Testing • Initialevaluation • Periodic observation • Monitor response to treatment • Multimodal
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- 15. Angiography • Evaluation ofblood flow in eye tissues
- 16. Ultrasound • 3-dimensional evaluationof tumors • Measured in millimeters
- 17. Other Imaging • Laserscanning - OCT
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- 20. Enhanced Depth Imaging •Measures thickness of tumor in microns
- 21. Fine Needle Biopsy •For genetic evaluation and cytology
- 22. Risk assessment forspread of disease into body (metastasis) High risk Low risk Tumor size Large Small Genetics Class 2 Class 1 Eye location Ciliary Body Iris
- 23. Phases of patientexperience • Phase 1 – Diagnosis – “Shock and Awe” – Unexpected and Unwelcome – Anxiety – Why me? – Loss of Control – Confusion – Fear of Unknown – Work up • Systemic screen for metastatic disease
- 24. Discovery: you areunique • Not all OM patients are the same • Differ in – Genetics – Location in the Eye – Impact of disease • Sight • Involvement of body – threat to health
- 25. Challenge for medicalteam: Find the best solution for the patient • Eliminate cancer – Locally – Systemically • Preserve vision • Preserve eye
- 26. • You choose,providers inform, guide • Three principles – Life • highest priority – Vision • can be damaged by treatment • Can be improved or stabilized with other treatment – Quality of life • Pain • Anxiety • Appearance Decisions – what to do?
- 27. Treatments for OM •Toolbox – Enucleation – Radiation – Laser – Cryotherapy – Excision
- 28. Treatment recommendation • Basedon: – Eye structure involvement – Size – General Medical condition – Patient preferences
- 29. Phases of patientexperience • Phase 2 – Treatment of eye – Accept diagnosis – Determination to get through it – Endure discomfort
- 30. Standard treatment optionsfor OM • Radiation – Proton beam – Brachytherapy • Laser – Diode (TTT) – PDT – photosensitized dye – Argon • Enucleation
- 31. Radiation treatment • Brachytherapy –Most common treatment – Usually “medium” sized tumors – Up to 98% effective in controlling the tumor in the eye
- 32. Radiation: Brachytherapy • Localapplication of radiation to tumor • Iodine 125 is usually used • Two surgeries – Implantation – Removal • Reattach muscle if necessary
- 33. Plaque Brachytherapy Pre-op –Anxiety due to recent diagnosis • Need for treatment • Loss of vision – Pain usually not an issue
- 35. Uveal Melanoma Brachytherapy •Radioactive iodine plaque placement
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- 37. Radiation safety • Requirescoordination with radiation department – Radiation oncologist – Radiation oncology physicist
- 38. Radiation Complications • Retinalproblems • Vision loss • Cataract • Glaucoma • Inflammation • Pain
- 39. Laser treatment oftumors • Smaller tumors • Different types of lasers – Tissue burning lasers • Argon laser • TTT – diode laser – 85% effective – Light activated dye (PDT) • Better in light colored tumors
- 40. If the tumoris too big… • Enucleation – Salvage of the eye is impossible – The eye may be painful – The eye may be blind – Psychology • Mourn loss of limb
- 41. Enucleation • Procedure – GeneralAnesthesia • And a retrobulbar block • About 1 hour – The eye is removed in a standard fashion • Muscles are disinserted • Optic nerve is cut. • Eye is processed for biopsy and pathology – Implant is placed, eye muscles attached – Layered closure with conformer
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- 43. Phases of patientexperience • Phase 3 - Recovery • Healing from surgery – Vision issues • Adjusting to the “new” you • May need additional treatments to eye – Prosthesis – Intraocular shots – Laser – Additional surgery
- 44. Intraoperative procedures • Enucleation •Plaque Brachytherapy • Vitrectomy • Cryothermy • Laser • Biopsy
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- 46. Cryotherapy • Application offreeze-thaw – Through the eye wall – Ice crystals destroy tumor
- 47. Are there abetter ways to treat OM?
- 48. Research designed toimprove treatment of eye tumors • Goal to replace radiation and it’s side effects
- 49. Clinical trial: AuraBiosciences • AU-011 • Currently in phase 1b clinical trial – Small to medium size melanoma
- 50. Experimental Treatment ofUM • AU-011 Aura Biosciences – Photoreactive modified viral capsid protein • Modeled on Human Papilloma Virus – Tumor selective binding – Intravitreal delivery – Targeted activation • Attached chromophore • Light activation – 689nm wavelength laser (same as PDT) – Local tissue necrosis • Cell membrane disruption
- 51. Experimental Treatment ofUM • Iconic therapeutics – Intravitreal injection – Anti-tissue factor (TF) antibody – TF expressed at high levels • On tumor surface • Tumor vasculature • Associated with aggressive tumor behavior • Trial now closed, awaiting analysis
- 52. Phases of patientexperience • Phase 4 – Long term issues – Surveillance after treatment • Body Imaging – What kinds? – How often? – Genetic information from Biopsy • Low risk – Are you cured? • High risk – Adjuvant trials » Is it right for you? – What if you have metastatic disease?
- 53. Ocular Melanoma • Isa chronic condition. – After treatment of the eye, follow up is required.
- 54. Teamwork needed! • Patient –Unique • Support team – Family – Social • Providers – Advise – Treat
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