A Focus on Ocular Oncology

Dr. Miguel Materin, A Focus on Ocular
Oncology
 May 31, 2009Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy Director
and Chief of Medical Oncology at Yale Cancer Center and he is an
internationally recognized expert on colorectal cancer.  Dr.
Foss is a Professor of Medical Oncology and Dermatology and she is
an expert in the treatment of lymphomas.  If you would like to
join the discussion, you can contact the doctors directly. 
The address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening Ed Chu
welcomes Dr. Miguel Materin.  Dr. Materinis an
Assistant Professor of Ophthalmology at Yale School of
Medicine.Chu
Dr. Materin's specialty, in addition to the general field of
ophthalmology, is focusing on eye cancers; cancers that
specifically involve the eye.  I would guess that many of our
listeners probably aren't aware that the eye is an area of the body
where cancer can develop.  Miguel, let's start off by telling
our listeners how commonly the eye is involved in terms of
cancer.Materin
 First of all, I would like to emphasize that eye cancer is a rare
condition.  It's not very common; however, it can affect
patients at any age and it can affect male or females equally.Chu
What types of eye cancers are there?Materin
 Well, if we need to make a big division, we can divide eye tumors
between primary tumors from the eye, which means that the tumor
originates in the eye, and tumors coming from other sites of the
body.Chu
The purpose of our discussion this evening will be focusing on the
primary eye cancers, but just briefly, can you mention a little bit
about what types of cancer can spread to the eye that one would
need to be aware of?Materin
 The most common cancers that can affect, or spread to the eye, are
breast, lung, and skin cancers, skin melanoma, but I think that any
cancer can spread into the eye.Chu
Interesting.  Let's focus on the primary eye cancers. What
would be the most common primary eye cancers that you see?Materin
 I would like to say that 50% of the time that patient's are
referred with the possibility of an eye cancer, they don't have an
eye cancer.  The most common intraocular cancer in adults is
melanoma.  The most common intraocular cancer in children is
called retinoblastoma.Chu
Are there any types of say chronic eye conditions that are
associated with or can develop into an eye cancer?3:23 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3Materin  
      
 Let's use the example of a nevus on the skin, they need to be
checked by the dermatologist sometimes for life, most of the time
for life.  Well 6% of the white population can have a nevus in
the back of the eye; only six out of a million can develop a
melanoma.Chu
You mentioned Caucasian's, how about say, African Americans?Materin
 We have seen melanomas in African Americans, in Hispanics, and
even in Asians, but it is not as common as Caucasian's with blue
eyes.Chu
What would be the typical symptoms that an individual would present
with?Materin
 Well, this is the hard part. I want to be very clear with
everybody who is listening to this conversation.  Sometimes
there are no symptoms, sometimes the tumors can be found in a
routine eye examination, or they can have any common ophthalmic
symptoms.  Now, I want to be clear, most of the time these
symptoms are not due to a cancer.Chu
You had mentioned that a large majority of the patient's who would
be referred to you don't have an eye cancer.  What would be
the reason for them being referred to you?Materin
 Most patients will go if they have a symptom, they will go to
their local doctor, to the general ophthalmologist, and the general
ophthalmologist will find the tumor and then they will refer the
patient to the specialist in eye tumors.Chu
Let's focus a little bit on ocular melanoma, which you say is the
most common eye cancer in adults.  When would it typically
occur?Materin
 Usually it occurs at around 50 years of age.  We have seen it
in young kids and we have seen it in older people too, but the
average age is around 50.Chu
We typically think of melanoma as occurring on the skin.  Is
there a relationship between the melanoma in the eye, the ocular
melanoma, and the skin melanoma?Materin
 That's a very important question, because even though they have
the same name, they do not behave the same. 80% of the time
melanoma occurs on the skin, and maybe 15% of the time they can
occur in the eye. Most of the time they are intraocular, but they
can affect any part of the eye.Chu
And is the risk for developing ocular melanoma the same as the risk
for developing skin melanoma?6:36 into mp3 file 
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 Materin         No,
because to my knowledge there is a good relationship between sun
exposure and skin melanoma, or any skin cancer, and it has not been
proven that that is the same risk factor for ocular melanoma.Chu
Do we know what causes ocular melanoma?Materin
 We don't know.  There are certain rare conditions where the
patient is at a higher risk of having a melanoma, but they are
rare.Chu
Are there moles, or nevus, discolorations within the eye that could
predispose someone to melanoma of the eye?Materin
 There is a condition called melanocytosis and that's when patients
have skin areas on the surface of the eye or in the back of the
eye, and they have a higher risk of developing melanomas, but in
general there are no other conditions.Chu
We know for skin melanoma that there is a genetic component. 
Obviously, if a family member develops skin melanoma, then another
relative is at higher risk potentially.  What do we known
about the genetics of ocular melanoma?Materin
 That's another important question.  There are a lot of
studies that are underway these days to find out if there is any
genetic relationship.  What I want to emphasize is that if a
father or a mother has a melanoma, that does not mean that their
offspring will have a melanoma.  What has been studied is that
there are some gene mutations, gene alternations, within the tumor,
that look like they are a very important prognostic factor for the
future of that patient.Chu
Again, what are the typical symptoms that an individual who has
ocular melanoma presents with?Materin
 There are no typical symptoms.  No blurry vision, floaters,
flashes, because they are very common symptoms in
ophthalmology.Chu
Unfortunately I see some of those floaters every day, so hopefully
I don't have ocular melanoma.Materin
 I know, you don't.Chu
But if someone has change in their vision, blurriness of vision, or
floaters that just seem unusual in character, what should an
individual then do?9:21 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3Materin
 Go to their ophthalmologist and see the ophthalmologist, have a
complete eye examination with dilation of the pupils and in a
routine eye examination, if there is a tumor, it can be found.Chu
So if the ophthalmologist sees something suspicious, then would
that ophthalmologist make the diagnosis, or would that individual
then be referred to you, who specializes in these types of eye
cancers?Materin
 It depends on the referring doctor, but my guess is that most
doctors will be referring patients to a center that specializes in
eye tumors, yes.Chu
What would you do in that situation?Materin
 In general, we will repeat the complete eye exam and depending on
what the patient has, we will use different diagnostic methods to
make the correct diagnosis.  Most of the time, the correct
diagnosis is made in the clinic.  In general, it does not
require any invasive tests to make a diagnosis.  However,
sometimes it is not that easy, and then yes, we will need to do a
biopsy, but those are the minority of the cases.Chu
That's interesting, because I would have assumed that in all cases
you need to do a biopsy to make the diagnosis.Materin
 No, we don't.Chu
On a simplistic level, what are these diagnostic tests that you
would perform?Materin
 We will see the patient, again do a complete eye exam including
evaluation of the vision, intraocular pressure, examination with a
slit lamp, the fundus examination, ultrasound, and a dye test
called retino fluorescent angiography, which is an injection in the
vein in the arm and we take fundus photos of that.  We use a
test called optical coherence tomography, it is simple test, and it
takes few minutes to do.  There are many different
possibilities, but most of the time, yes, we can make the diagnosis
the day we see the patient.Chu
If an individual is given the diagnosis of ocular melanoma, do you
worry about the spread of that melanoma to other parts of the body,
or it's just confined to the eye?Materin
 No, we are always concerned about that and it depends on the
location of the tumor, the size of the tumor in both diameter and
thickness, the genetic analysis, and other features of the12:17 into mp3 file 
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 tumor that will tell us how aggressive the tumor is.  With
melanoma we are always concerned about spreading and that's why
with any patient it is not just Dr. Materin treating the patient,
it's a whole team of doctors, ocular oncologists, medical
oncologists, cytogenetics, the pathologist, we are all involved in
the care of these patients.  Chu
Is there any general recommendations as to whether or not children
or adults should wear sunglasses to try to prevent sun exposure to
the eyes, just like we talk about using sunscreen and sun block to
prevent the damaging effects of the sun on the skin?Materin
 To my knowledge there is a no proof of that for eye cancer. 
Any answer that I give you will be personal, but not
scientific.Chu
Great.  You have been listening to Yale Cancer Center Answers
and I am here in the studio this evening discussing eye cancer with
our special guest expert Dr. Miguel Materin from Yale Cancer Center
in the Yale School of Medicine.Chu
Welcome back to Yale Cancer Center Answers.  This is Dr. Ed
Chu and I am joined by Dr. Miguel Materin, Assistant Professor of
Ophthalmology at the Yale School of Medicine. Before the break we
were talking about ocular melanoma, which is the most common form
of eye cancer in adults.  Miguel, let's talk a little bit
about once ocular melanoma is diagnosed. What are the different
types of treatments that you would consider?Materin
 Well, it depends on several factors. I will try to make a good
summary of the options for treatment.  One option, probably
the most common option in the world, is cryotherpay. Cryotherpay
can be applied in two different forms, one is with what is called
the plaque cryotherpay, or brachytherapy, and that consists of the
application of the suture of a small15:36 into mp3 file 
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 device the size of a penny on the surface of the eye where the
tumor is located. The plaque will stay in place for four or five
days, depending on the size of the tumor and the amount of
radiation required, and then on the second surgery the plaque is
removed.  Most of the time a few months later a laser called
transpupillary thermotherapy will be done in the office, and that
is done between two and four times; that is for local cryotherpay.
The other option to develop cryotherpay to the eyes is an external
cryotherpay and that is done by a radiation oncologist. 
Another option, unfortunately that we have to do sometimes, and
it's an important option, is to remove the eye.Chu
What would make you consider removal of the eye as opposed to
radiation therapy?Materin
 Well, if the tumor is very large, for example filling 50% of the
eye, or if there is no chance for vision in the future, then we
will advise removing the eye. But the important thing here is that
ophthalmology is the field to take care of vision.  In ocular
oncology, we have different priorities.  The life is number
one, the eye is number two, and vision is the third one.Chu
With radiation therapy, is there a possibility that vision can be
maintained or restored?Materin
 It depends on different factors such as location of the tumor, and
size of the tumor, but on average, we expect that 50% of patient's
will have some damage in that region.Chu
Obviously if the patient needs to have their eye removed there is
complete loss of vision, but is there anything that can be done
afterwards in terms of cosmetics?Materin
 Yes, the patient will be referred to an ocularist who is an artist
who will make the artificial eye, the plastic eye, trying to look
make it look as much as possible like the opposite eye, and these
days they have very good cosmetics.Chu
For surgery, can this be done as an outpatient procedure or do
patients need to be admitted as an inpatient?Materin
 Regarding removal of the eye, it can be done as an outpatient
procedure.Chu
Wow.Materin
 Regarding the plaques, that depends on the state regulations, some
states require patients with the radioactive device to be in the
hospital, in the room, and some states allow the patients to go
home or to a hotel where they can be in the room for four or five
days.18:58 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3Chu 
             
 What would be the general followup process, say for instance for
either radiation therapy that has been done, or removal of the
eye?Materin
 Well, since we are talking about melanoma, melanoma of the eye is
a very strange condition, and my advice today would be to follow
these patients for life.Chu
How frequently would you as the ocular ophthalmologist be seeing
these patient's in follow-up?Materin
 We like to work with the referring doctors.  We like to see
that the patient is being treated and that the early follow-ups are
taken care of, then the patient needs to be seen twice a year.Chu
We talked about the potential risk of ocular melanoma and skin
melanoma. I am curious, since the eye is right there near the
brain, is there ever an increased risk for those patients to
develop the metastasis to the brain?Materin
 Patient's with intraocular melanoma, when they develop, metastasis
90% of the time, and the first metastasis is usually the liver, not
in the brain.  The second place is the lungs, and the third
place is the skin.Chu
It's curious because one wouldn't think about some kind of
connection between the eye and the liver.  Is it known why, as
you say, 90% of patients may present with metastatic involvement of
the liver?Materin
 The spreading is through the blood, and it will go wherever it
can; tumors can develop easily. I am not sure the reason why the
liver is more common, but it spreads through the blood stream.Chu
We have talked about ocular melanoma, let's talk briefly about the
most common form of cancer in kids, which as you say is
retinoblastoma.  What age group do we need to worry about?Materin
 The most common age is the first two years of life.  However,
we have seen it in older kids, it's not common, but we have seen
it.  We could talk for days about retinoblastoma, but I will
try to make things very simple for the audience.  There are
two different types of retinoblastoma and everything is based on
the mutation in these patients.  One type of mutation is
called somatic mutation, and that means that the gene is wrong only
in the retina.  The other type of mutation is called germ line
mutation, and that means that the mutation occurs very, very early
and it can affect any cell of the body of those kids.  This
is22:27 into mp3 file 
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 important because patients with the somatic mutation, it's only in
the eye, and they do well.  The patients who have the germ
line mutation, they are at higher risk for other problems. I want
to say that one hundred years ago, all these kids died.  These
days, more than 95% of these kids in first world countries will
survive.Chu
What has made such a big difference in that 100 year period?Materin
 The improvement in diagnosis and treatment.  Sometimes, yes,
we need to remove the eye in these kids, but we are saving the kids
life, and they can have a very normal life seeing with one
eye.  They just need to wear protective glass, but they can
play sports and they can have a normal life.  The other
options of treatment are chemotherapy, radiation, laser, and
cryotherpay, and each patient, each eye, each tumor, will be
treated accordingly based on the need.  We are dealing with
families who have reason to be concerned and to be anxious, but its
teamwork and it involves the family, the pediatric oncologist, the
radiation oncologist, and us.Chu
Now, as you mentioned, there is a germ line mutation.Materin
 Yes.Chu
In the retinoblastoma gene, so in theory that diagnosis could be
made in the prenatal stage, or no?Materin
 Yes, there is debate about that too, but yes, the blood can be
studied and there are good ultrasounds that can make a diagnosis
early in life and everybody will be ready. But most of the time, if
the father or the mother have a retinoblastoma, the kid should be
seen early in life.  It could be the first week, or the first
month.  The parents usually know they need to go to the eye
doctor.Chu
Miguel, could you tell our listeners, if in fact there is a concern
about eye cancer or some eye condition associated with the
treatment, how can they get in touch with you, how can they see you
in your clinic?Materin
 I work at the Yale Eye Center, which is located on Temple Street
in New Haven, and there is a website where they can look for the
department of ophthalmology and there is a section for ocular
oncology. I also think in the near future we will be part of Yale
Cancer Center's website too.Chu
In addition to seeing patients with eye cancer, we have talked in
the past about how you also26:01 into mp3 file 
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 are actively involved in seeing our cancer patients who are
getting various treatments that develop various eye
disorders.  Can you tell us a little bit about that?Materin
 Yes, that's the second part of ocular oncology.  The patients
with systemic cancers that can spread to the eye, or they can have
side effects from treatment; either radiotherapy or
chemotherapy.  They can have ocular side effects and we want,
we would like, to take care of them too.Chu
One of the common side effects that I see in patient's with
colorectal cancers, are patients who develop very dry eyes, or
conjunctivitis of the eyes. What are your general recommendations
in that setting?Materin
 We will be working again as a team, everything in ocular oncology
is a team. The cornea specialist will be involved if the orbit is
involved, and I need to mention Dr. Bernardino as part of the
ocular oncology team, he takes care of the orbit and eyelids, and I
could mention the entire team.  If we see a patient with
retinoblastoma, we will be working, for example, with Dr. Salchow,
who is the pediatric ophthalmologist at the eye center.  If
the patient has glaucoma, we will be working with Dr. Tsai, Dr.
Mayer, and Dr. Shields, and I could continue with all the
names.  But yes, the entire group will be involved.Chu
Again, as you say, just as we deal with our disease specific
cancers, with eye cancers it really is a multidisciplinary,
interdisciplinary team that's involved.Materin
 Yes.  Absolutely.Chu
Which I think is critically important in trying to optimize the
care of these patients.Materin
 Yes absolutely, we totally agree with that and we spoke about this
a lot and we are ready to go.Chu
Great.  Real quick, what is the location of your clinic?Materin
 It's 40 Temple Street, on the third floor, in New Haven.Chu     
        
 At the Yale Eye Center?Materin
 Yes, at the Yale Eye Center.28:16 into mp3 file 
http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3Chu
 You have been listening to Yale Cancer Center Answers and I would
like to thank our guest expert this evening Dr. Miguel Materin for
joining us.Materin
 Thank you.Chu
Until next time, I am Ed Chu from Yale Cancer Center wishing you a
safe and healthy week.If you have questions or would like to share your comments,
go to yalecancercenter.org where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum from
Connecticut Public Radio.