Essential Eye Cancer Podcast

Tumors and cancers commonly occur on the conjunctiva and often grow onto the corneal surface. Both conjunctival melanoma and squamous carcinoma have been associated with sun (ultraviolet UV-ray) exposure, so Dr. Finger says, "Think of Sunglasses as Sunblock for your Eyes.®" Commonly treated with observation for growth, surgical removal or a combination of surgery and freezing "cryotherapy," over the last 10 years more and more patients are treated with immunotherapy or chemotherapy eye drops. Of course, your doctor may need to biopsy first, but at The New York Eye Cancer Center, most patients don't need extensive surgery. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

This Podcast takes a closer look at what I do to maximize eye radiation outcomes and minimize patient risk. Until we have a treatment for metastatic ocular melanoma, destruction of the intraocular tumor will be the best way to prevent and thus "treat" metastasis. Across the world, each eye cancer center has its own radiation methods to destroy choroidal melanomas. However, a closer look at the methods of plaque selection and implementation reveals significant differences. This Podcast discusses basic plaque design, construction, and dose calculations. I explain why certain methods/plaques are more likely to result in eye cancer control. This Podcast is targeted to help eye cancer specialists improve their results. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

This Podcase discusses a technique I introduced to ophthalmic oncology. Sometimes, when eye cancer specialists have to remove a large tumor from the surface of the eye, we created a large tissue-defect on its surface. The surgeon cannot leave it grow on its own because the eyelid can scar and stick to the eyeball (called symblepharon). This scarring can hamper the movement of the eye and doesn't look normal. So, decades ago, I used to borrow some mucus membrane tissue from the inside of the cheek (mouth). This was a second surgery that left the patient's mouth sore and swollen for a week or two. Thankfully, super-thick amniotic membranes became commercially available. These large thick pieces of donor amniotic membrane were easily sewn into place and helped the eye heal without symblepharon scarring. This PodCast describes my technique of Super-thick amniotic membrane grafting for ocular surface reconstruction. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Iris tumors are visible. Patients see them in the mirror and eye care specialists view them through the clear cornea. We use specialized ultrasound (UBM) and anterior segment OCT tests to reveal the contents, distribution, and size of these tumors. Most are benign and thus can be observed for growth prior to intervention. Others are either clinically diagnosed and treated or undergo biopsy. We review the differences between biopsy methods. In this Podcast, we will explore iris tumors, their diagnosis, and treatment. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Cancer textbooks tell us to remove or destroy primary cancers to prevent spread (metastasis) to other parts of the body. In the 1950s, most eyes with choroidal melanoma were removed. Some small anterior choroidal, ciliary body and iris melanomas were locally resected. However, The multicenter, international, Collaborative Ocular Melanoma Study taught us that removal of the eye was not necessary for moderately sized choroidal melanomas. That eye and vision sparing plaque radiation therapy was statistically equivalent for the prevention of metastatic disease. However, surgical removal, including local resection names PLSU or partial lamellar sclerouvectomy continued to be used around the world. Meanwhile, others expanded the use of plaque radiation to anterior uveal, ciliary body and iris melanomas. This PodCast compares and contrasts resection versus plaque therapy for treatment of anterior uveal melanoma. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

There are many different types of vascular tumors within the eye. In the uvea or vascular layer beneath the retina, there occur both circumscribed and diffuse hemangiomas. The latter or diffuse variant is commonly associated with the congenital neurologic disorder Sturge-Weber Syndrome (encephalotrigeminal angiomatosis). It is associated with Port-Wine skin coloration, glaucoma, seizures, intellectual disability, and ipsilateral leptomeningeal angiomas. Within the eye, both circumscribed and diffuse hemangiomas may leak causing secondary retinal detachments. Vision changes can also be due to physical displacement of the retina, cystoid retinopathy, and secondary glaucoma. Vascular tumors also occur in the retina. These include capillary hemangioma with or without Von Hippel-Landau Syndrome, cavernous retinal hemangioma, and Racemose hemangioma. Though none of these tumors spread to other parts of the body, each can be differentiated by clinical characteristics and methods of management discussed in this Podcast. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Tumors and cancers commonly occur on the eyelids. Once the clinical or pathologic diagnosis is established it is time to consider treatment. Eye cancer specialists will recommend either removal or destruction of the eyelid cancer. Depending on the type, size, and location of the tumor, different surgical or treatment strategies will be used. These treatments can range from simple surgical excision of the tumor and margins or Moh's microsurgical resection, typically followed by oculoplastic surgical repair. When tumors invade around the eye, into the orbit, brain, or sinuses, treatment becomes more complex. In these cases, orbitotomy, exenteration, radiation, and even chemotherapy may be needed. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Tumors and cancers commonly occur on the eyelids. Most have been associated with sun (ultraviolet UV-ray) exposure. The most common eyelid cancer is basal cell carcinoma, but squamous carcinoma, sebaceous carcinoma, and melanoma can occur. If the tumor doesn't have a classic, diagnostic appearance, a small biopsy for pathology evaluation may be needed. This podcast describes the clinical characteristics of these tumors, how they grow, and even spread to other parts of the body. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Oculodermal melanocytosis or the Nevus of Ota means that there are increased numbers of cells called melanocytes in the eyelid skin, sclera and uveal vascular layer of the eye. Typically presenting at birth, it can increase during puberty and pregnancy. The pigmentation can follow the distribution of the trigeminal nerve and can therefore extend to the palate. The pigmentation and be complete or partial. When the eye is affected alone, it is called ocular melanosis. The increased numbers of melanocytes cause thickening of affected tissues and increase the patients risk for choroidal melanoma. Though there is no treatment for the pigmentation, close serial surveillance for malignant transformation and secondary glaucoma is warranted. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

In 2014, the first multicenter, international consensus guidelines for ophthalmic plaque radiation therapy was "open access" published in the journal "Brachytherapy." Dr. Finger was selected to Chair the Ophthalmic Oncology Task Force which he assembled to discuss, survey, and create these guidelines. In total, this committee included 47 eye cancer specialists from 10 countries. In this Podcast, Dr. Finger summarizes their most important findings. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Lasers have long been used to treat eye diseases. Though largely unsuccessful as primary treatment for intraocular cancers, laser continues to play an important role in ophthalmic oncology care. This podcast presents the history of ophthalmic laser treatment as well as a disease by disease analysis of its efficacy. Herein, is described its use to successfully treat subretinal neovascularization, exudative retinal detachment, retinoblastoma, and retinal capillary hemangioma. Clearly, laser therapy continues to play a role in ophthalmic oncology care. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Orbital radiation therapy has long provided eye and vision sparing treatments for patients with benign and malignant tumors. These include tumors that originate in the orbit and those that extend from the central nervous system, skin, sinuses, and conjunctiva. Each tumor is characterized by an inherent radiation sensitivity. Each orbital location will require a customized approach. However, there exists a multitude of radiation modalities for each purpose. Careful source selection based on creating a conformal treatment zone with relative sparing of normal ocular structures will provide each patient with an optimal chance for globe salvage, vision retention, and local tumor control. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

There exists a multitude of radiation modalities used to treat ocular, orbital, and adnexal tumors. Each type of radiation machine or method has a characteristic pattern of dose distribution within the eye and orbit. The specific pattern and amount of radiation dose delivered to the eye and orbit can be used to predict radiation-related side-effects. Therefore, some methods are better than others. This podcast provides an overview of radiation sources and explains their differences from an ophthalmic perspective. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

The American Joint Committee on Cancer along with the International Union for Cancer Care have long supported the use of a standard language to define patients with cancer. The 7th and 8th editions of the AJCC-UICC staging systems have now been adopted and function to improve eye cancer research and clinical care. The major ophthalmic journals now require its use for research publications as to allow them to be compared and or combined in multivariate analysis. The largest ophthalmic societies now expect both tumor and patient staging in presentation. Clearly, the use of AJCC-UICC tumor staging has brought ophthalmic oncology into the mainstream of world-wide cancer care.

There exist many different types of orbital cancers. Typically diagnosed by biopsy, few can be completely removed. In these cases, radiation therapy offers a method to treat residual and even clinically undetectable microscopic left over tumor cells. Most of these orbital cancers can be safely cured with relatively low dose radiation that is easily tolerated by the eye. In those cases, the tumor is cured and the eye continues to function. These patient need to be monitored with periodic eye examinations for late occurring radiation complications (eg. cataract, retinopathy, optic neuropathy). However, there also exists orbital cancers that cannot be controlled with low dose irradiation. Many of those cancers will treated by removal of entire orbit (including the eye). This results in no possibility of vision and a poor cosmetic result. When high dose irradiation is needed to spare the eye, vision and improve cosmesis, Dr. Finger utilizes a specialized technique called “Brachytherapy Boost.” This involves temporary surgical placement of radiation sources into part of the orbit to increase treatment of the tumor bed. Then an overlay of external radiation treats the entire orbit. These two types of radiation overlap in the implanted radiation zone, effectively increasing the dose where is it is needed while decreasing irradiation to the normal parts of the eye. Finger’s brachytherapy boost technique has allowed Dr. Finger to improve cosmesis, spare vision and preserve eyes for patients with radiation resistant orbital tumors. This podcast discusses Dr. Finger’s experience with Brachytherapy Boost for tumor control in patients. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Many kinds of radiation have been used to treat choroidal melanoma. However, they can be divided into two main categories, implanted radiation plaques and externally administered radiation beams. While the most common radiation plaques include: ruthenium-106, iodine-125 and palladium-103, external beam is dominated by proton therapy. The literature suggests that both plaques and proton beam can be used to destroy intraocular tumors. However, they are very different in their radiation dose distribution within the eye and orbit. These differences result in a different pattern, incidence and distribution of radiation side-effects. This episode examines how each form of radiation is applied, the ability of each form of radiation to compensate for eye movements as well as what results the patient and doctor should expect over time. This podcast episode presents Dr. Finger’s decades of experience with ophthalmic radiation therapy, his knowledge gained working with the American Academy of Physicists in Medicine and as Chair of the 2014 AJCC-OOTF Ophthalmic Plaque Radiation Therapy Guideline Initiative for the American Brachytherapy Society. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

One of the most difficult subjects is second opinions. Dr. Finger says, "second opinions are great as long as both doctors agree." When they don't, sometimes they create more problems than expected. So, what is the patient to do when their two opinions don't agree? Typically, the patient will want a second opinion because they didn't like what they heard from the first opinion. Second, albeit less commonly, they want confirmation of the first opinion. Lastly, they have a relative who wants the patient to see "their" person. Dr. Finger's suggestion is to go to each opinion with a checklist of what is important to you. For example, ask which doctor will perform the surgery, ask who will answer the phone if the patient has an emergency, and ask what the likely outcomes will be for sight and life? Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

This podcast describes the methods used at The New York Eye Cancer Center to show and thus teach patients about their disease, need for treatment and probable outcomes (for sight and life). For example, each examination room has a 55" 4K screen to display clinical photographs of tumors, radiation side effects and 3D OCT images of inside the eye. Images of important photographs and figures from publications are framed and displayed to show risk of tumor spread and methods of treatment. Model eyes with plastic intraocular tumors, laminated photographs and devices can be used to show exactly what is involved during surgery. They say a picture is worth a thousand words! Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

Though the optic nerve is a relatively radiation-resistant tissue; both plaque and external beam irradiation for eye cancer can cause radiation optic nerve damage. Divided by location, anterior radiation optic neuropathy and radiation papillitis has been most commonly seen after plaque and proton beam therapy. In contrast, posterior radiation optic neuropathy can be seen after external beam radiation therapy for orbital, sinus and brain tumors. Posterior radiation optic neuropathy is best seen as optic nerve illumination during gadolinium-enhanced magnetic resonance imaging (MRI). Such is a sign of extravasation of dye into the optic nerve sheath and orbit. In those cases, the intraocular optic disc can appear normal, there is no known effective treatment and vision loss occurs within 4-8 weeks. In contrast, anterior radiation optic neuropathy typically presents with disc-swelling, hemorrhages and retinal exudates. Early treatment with periodic intravitreal anti-VEGF therapy offer the best chance for years of vision preservation. However, it is important to consider that anterior radiation optic neuropathy is a chronic disease that requires long-term anti-VEGF therapy. This PodCast reviews Dr. Finger’s experience with the pathophysiology and methods used to preserve vision in eyes affected by radiation optic neuropathy. Paul T. Finger, MD, FACS The New York Eye Cancer Center 115 East 61st Street New York City, New York, USA 10065 E-mail: pfinger@eyecancer.com Telephone: (011) 212 832 8170

The best way to prevent metastatic melanoma is to destroy the primary intraocular cancer during the first treatment. Dr. Finger explains why the American Brachytherapy Societry Eye Plaque Guidelines defines normal plaque placement as covering the entire tumor and at least a 2-3 mm free margin of normal-appearing tissue. In order to make sure that happens, it is important to make sure all the muscles on the outside of the eye are temporarily moved away from the plaque. Simply, the radiation plaque should not be pushed to the side or lifted away from the eye by an extraocular muscle. Even if the patient has secondary double vision that must be later fixed, it is better than local regrowth that has been proven to be associated with a 6.3 Hazard of metastatic disease.