«A Focus on Ocular Oncology Guest Expert: Miguel Materin, MD Assistant Professor of Ophthalmology Welcome to ...»
A Focus on Ocular
Miguel Materin, MD
Assistant Professor of Ophthalmology
Welcome 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 firstname.lastname@example.org and the phone number is 1888-234-4YCC. This evening Ed Chu welcomes Dr. Miguel Materin. Dr. Materin is 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.mp3 Materin 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 http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3 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.mp3 Materin 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.
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 the 12:17 into mp3 file http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3 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.
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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 small 15:36 into mp3 file http://www.yalecancercenter.org/podcast/Answers_May-31-09.mp3 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.
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.