Dr. Miguel Materin, A Focus on Ocular Oncology
May 31, 2009

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 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?

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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?

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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?

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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.

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 the

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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 small

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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.

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Chu               
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 is

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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 also

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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.

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Chu
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.