Metastatic Eye Cancer

M. D. Anderson Cancer Center
Date: August 02, 2010

Return to Cancer Newsline

Metastatic Eye Cancer

Dan Gombos, M.D., Associate Professor of the Dept. of Head and Neck Surgery, Section of Ophthalmology at MD Anderson Cancer Center, continues the conversation on eye cancer focusing on metastatic tumors.

Lisa Garvin:

Welcome to Cancer Newsline, a weekly podcast series from the University of Texas M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, prevention, and treatment providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today we welcome Dr. Dan Gombos back to our studio. He is an associate professor in the section of ophthalmology in the Department of Head and Neck Surgery at M.D. Anderson. Welcome back Dr. Gombos.

Dr. Dan Gombos:


Thanks. And thanks for having me back.

Lisa Garvin:

Our first conversation was about primary eye cancers, are these cancers that originate in the eye or orbital section. Today we're gonna talk about cancers that spread or metastasize to the eye.

Dr. Dan Gombos:

Yes, it's an interesting phenomenon. In fact, if you look statistically, cancers that spread to the eye from other organ systems are in fact more common than tumors that arise from the eye itself.

Garvin:

What are the most common areas that the eye cancers will spread from?

Gombos:

So, as you might expect the most common cancers that we see nationally and internationally are those from the breast and lung. And so, those in fact are the most common tumors that spread to the eye. In women, breast cancer is the most common tumor that we see involving the intraocular structures. And they tend to spread to this vascular layer called the uvea, and the largest are of the uvea is called the choroid. And so, the most common area of the eye that's involved is the choroid. And these represent tumors that have spread through the bloodstream to this layer of the eye.

Garvin:

How common is that in breast and lung patients, a metastasis to the eye area?

Gombos:

Well, if you look at all the areas that patients can develop metastastic disease it's obviously not a common finding, but if you compare all the tumors that occur in the eye, metastatic tumors are the most common ones that we as ophthalmologists see. So, if we're going to see a tumor in a patient, statistically it's most likely to be a tumor from another organ, and in a female patient it's going to be most likely from the breast. And in fact, it sometimes does occur that the ophthalmologist is the first person who will diagnose a tumor. It seems not a likely scenario but for some patients who have undiagnosed metastatic disease, the ophthalmologists will the first person who will diagnose this problem. And it maybe from nothing more than blurry vision that the patient notices, maybe has been putting off for a while. Finally goes and sees a eye care specialist, and they'll get referred for what is thought to be a retinal detachment but on further investigation is actually a tumor.

Garvin:

So, you're actually finding the site of metastasis first rather than the primary?

Gombos:

Sometimes it is the ophthalmologist who is the first person who will diagnose a cancer or what is not uncommon for us here at M.D. Anderson is that we will be the first service that demonstrate significant metastatic disease to the eye and central nervous system. As you might expect, the eye is really an extension of the brain and the central nervous system. And there is a high correlation between tumors that spread to the eye and tumors that spread to the brain and central nervous system. So, a patient maybe thought to be disease free for quite sometime, and then they present to their eye care practitioner with a mass, they get referred to M.D. Anderson and we in fact see that the eye is involve as well as the brain or other organ systems.

Garvin:

How do you as an ophthalmologist know that this is a secondary cancer as opposed to a primary site?

Gombos:

That's an excellent question because eye cancers especially intraocular cancers are often not diagnosed with tissue. And this kind of goes against what is often done in this institution which is a biopsy is obtained. But within the field of ocular oncology we're able to make a lot of these diagnoses based on primary examinations. So we examine the eye, we actually are able to look at these tumors unlike other organ systems where you maybe be able to palpate something. We're actually, with our instrument, able to look inside the eye. And then we have a series of non-invasive diagnostics tests that we can do to further facilitate and confirm our clinical suspicion. One of the tests that we look at quite routinely is eye ultrasounds. Just like you can ultrasound a baby, you can ultrasound the eye. And this is something we routinely do in the eye clinic. And we've become very facile in our field by looking at an eye, examining it with ultrasounds, and sometimes doing a sort of angiogram test which are dye tests to look inside the vascular structure of these tumors. All those things come together and they really do provide us with the opportunity to make the diagnosis in most patients.

Garvin:

How does eye ultrasound work? I mean, we think of the paddle and the gel that obviously doesn't work on the eye? Or does it? How do you do an ultrasound of the eye?

Gombos:

The concept is the same, you know, you have a probe that vibrates at a frequency and basically just with nothing but sound waves allows us to visualize the organ. But it's a small probe we keep in the eye clinic. It's designed specifically for the eye. And eye ultrasounds are use in many facets of eye care, you know, many patients will never have an eye cancer and therefore will never need an eye ultrasound. But many patients will need to have their cataracts removed. And we routinely use eye ultrasounds to measure the length of the eye so we know what kind of implant to put in the eye when we remove a cataract. So same kind of machinery generally is used, it's a small probe that's placed on the eye itself with some topical anesthetic and a little bit of a specialized gel, we can assess these tumors. And we can see not only the type of sort of wave pattern they give or sound wave pattern they give but we can also quite accurately assess the size of these tumors in tenths of millimeters, that's how accurate these measurements are. And in fact, sometimes an eye ultrasound provides us greater sensitivity than even an MRI or a CT scan. So, as it relates to eye tumors, eye ultrasounds are really the standard of care.

Garvin:

How do you treat a metastasis of the eye? I mean, are we treating the primary cancer first? Are we treating the primary and secondary concurrently? How do you devise a treatment regimen?

Gombos:

So, that's the beauty of being at a place like M.D. Anderson, everything is multidisciplinary and you can't simply state that we treat all of these cancers in a certain fashion. The patient's entire medical situation is reviewed and it's very significant to us whether this represents a patient who's never seen chemotherapy, or is newly diagnosed with breast cancer, or is a patient who is thought to be in remission and now develops a new metastatic lesion, or the unfortunate patient who is known to have progressive metastatic disease who has not responded to other forms of therapy and this represents a further extension of disease. Broadly, we have a series of things that we can treat the patient with. Radiation therapy is among the most common approaches that are used. In select patients systemic chemotherapy can be used. And then for some patients we have alternative treatment modalities like laser--laser hyperthermia, specifically. But I would say the most common approach particularly for breast cancer patients would be external beam radiotherapy.

Garvin:

Now, are they treating the primary and the secondary cancer at the same time or is it a targeted detect for both the primary and metastasis?

Gombos:

So, again, it depends on the state of the patient's primary disease. If the patient was thought to--had the primary side already treated, the breast cancer, and now they have a new metastatic focus we will often treat the eye with radiotherapy. Unfortunately, many of these lesions are associated with brain metastasis as well. So, it becomes critical for us to know, what's the situation of the brain? Are these new lesions within the brain? If they decide to treat the whole brain they'll include the eye in the radiation fields. The positive thing I'd like to say about metastatic breast cancer in particular is if you look at historic reviews the life prognosis for patients who develop metastatic eye cancer was very poor. But I can tell you one of my experiences being here now almost a decade is to see how long patients can live, and particularly patients with breast cancer. I've seen patients live five, six, seven years with metastatic breast cancer to the eye. Historically that was not the life prognosis that we were usually able to offer. In many patient particularly breast cancer patients, these tumors are often very radiation sensitive. And so a lesion that we see even in the center vision area can respond quite beautifully. Poor vision can sometimes results in very good vision if the tumor is responsive.

Garvin:

What about recurrence? Like distant recurrence after somebody's been treated successfully for breast cancer? Would a recurrence perhaps go to eye or does sit go back to the breast? How does that work?

Gombos:

You know, we're talking about metastatic disease and sometimes we have patients for whom the patient has been thought to be in remission for many years and occasionally the eye will be a site of metastatic recurrent disease that does happen occasional. We generally encourage all patients with cancer to get a dilated eye exam at least once a year for many reasons. Patients have often been exposed to systemic medications that may have ocular toxicities but it's generally a good check up to have the eyes assessed every one to two years, to be properly assessed. And I would encourage patients to make sure they get a proper dilated exam which means that they put those nasty drops in the eyes and make the pupils big and you can't see for a while, and also to be seen by an ophthalmologist so they can asses all the potential complications that may occur. Occasionally, metastatic lesions are asymptomatic and those patients will come to us. And if it looks like an inactive lesion we'll just watch it but if it's an active one, we may choose to treat it.

Garvin:

So, any cancer patient in active treatment who suffers any kind of vision changes should have that checked into?

Gombos:

Absolutely, never ignore any vision changes that you might have. You may assume it's nothing more than needing reading glasses, and you maybe correct. But there are a number of things that can occur in patients who've been treated for active disease. Sometimes some of the medications we've put patients on we know will have long term toxicities, that's one thing to look at. Patients who've been treated with radiation are known to be at risk for things like cataracts and dry eye, and of course, there are patients who subsequently develop metastatic lesions to the eye. Even if we have a patient who was seen a few months back and we have good documentation that their exam was completely normal, that's very helpful for us in the ophthalmology clinics in the M.D. Anderson because a new lesion represents change, and that change is important for us to be aware of.

Garvin:

Great! Thank you very much. Any final thoughts before we go?

Gombos:

Well, I would tell patients that, you know, historically metastatic lesions were associated with a poor prognosis but that's very patient dependent. And I would say that, you know, nothing continues to encourage me more than the advances that we've seen in this institution. We work in a multidisciplinary fashion. We interact with the oncologists, the radiation therapists, and so hope is probably the most positive thing that I continue to encourage patients about. Everyone as an individual and I have clearly seen patients live many, many years even after metastatic disease to the eye. So, it's important to keep a positive attitude and to remember that everyone's looking at the entire picture not just the eye itself.

Garvin:

Thank you. If you have questions about anything you've heard today on Cancer Newsline, contact ask M.D. Anderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.


Return to Cancer Newsline