Ocular Melanoma Treatment
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Presentation by Peter G. Hovland, MD, PhD. Presented at the 2018 Eyes on a Cure: Patient & Caregiver Symposium, hosted by the Melanoma Research Foundation's CURE OM initiative.
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Ocular Melanoma Treatment
- 1. Ocular Melanoma Treatment Peter G. Hovland MD PhD 7th Annual Eyes on a Cure: Ocular Melanoma Patient and Caregiver Symposium 21 April 2018
- 2. Welcome! • Patient advocacy can make a difference • Your fundraising helps – Improve understanding – Promotes better communication – Fosters focused research
- 3. Introduction • Dr. Peter Hovland • Ocular Oncologist and Retina Specialist • Clinical practice with Colorado Retina Associates for 12 years
- 4. Disclosure • Castle Biosciences – Advisory Board
- 5. When you hear hoof 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 in the eye wall: – Choroid - 90% – Ciliary Body – 6% – Iris – 4%
- 8. OM originates in the eye – Some OM can spread to the body
- 9. Tangent: Other cancers can spread to the eye • Adenocarcinomas – Breast, Lung, Prostate, GI, GU • Lymphoma • Sarcoma • Melanoma • Carcinoid
- 10. Journey of a New 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 we know it’s melanoma? • Diagnosis based on exam and testing • Diagnosis may be made – At initial presentation – After a period of observation • Tumor may grow
- 13. Diagnostic Testing • Initial evaluation • Periodic observation • Monitor response to treatment • Multimodal
- 15. Angiography • Evaluation of blood flow in eye tissues
- 16. Ultrasound • 3-dimensional evaluation of tumors • Measured in millimeters
- 17. Other Imaging • Laser scanning - OCT
- 18. Autofluorescence
- 20. Enhanced Depth Imaging • Measures thickness of tumor in microns
- 21. Fine Needle Biopsy • For genetic evaluation and cytology
- 22. Risk assessment for spread 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 patient experience • 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 are unique • 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 medical team: 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 • Based on: – Eye structure involvement – Size – General Medical condition – Patient preferences
- 29. Phases of patient experience • Phase 2 – Treatment of eye – Accept diagnosis – Determination to get through it – Endure discomfort
- 30. Standard treatment options for 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 • Local application 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
- 37. Radiation safety • Requires coordination with radiation department – Radiation oncologist – Radiation oncology physicist
- 38. Radiation Complications • Retinal problems • Vision loss • Cataract • Glaucoma • Inflammation • Pain
- 39. Laser treatment of tumors • 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 tumor is 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 – General Anesthesia • 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
- 42. Prosthesis
- 43. Phases of patient experience • 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
- 46. Cryotherapy • Application of freeze-thaw – Through the eye wall – Ice crystals destroy tumor
- 47. Are there a better ways to treat OM?
- 48. Research designed to improve treatment of eye tumors • Goal to replace radiation and it’s side effects
- 49. Clinical trial: Aura Biosciences • AU-011 • Currently in phase 1b clinical trial – Small to medium size melanoma
- 50. Experimental Treatment of UM • 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 of UM • 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 patient experience • 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 • Is a chronic condition. – After treatment of the eye, follow up is required.
- 54. Teamwork needed! • Patient – Unique • Support team – Family – Social • Providers – Advise – Treat