for Cancer that has Spread
If your cancer has spread to other organs in the body there
are two approaches - local treatment and systemic treatment.
Local treatment involves directly attacking
the tumours where they are situated, for example with surgery, whereas systemic treatment involves treating the patient's
entire body, for example with chemotherapy.
Your oncologist will advise you on the best treatment for you,
but it is likely to involve a mixture of both local and systemic treatment.
The most common place for ocular melanoma to spread is into the liver. Other common sites of metastases
include the lungs, bone and the brain, although tumours can be anywhere in the body as they are spread via the blood stream.
Local Treatment Options
For Disease in the Liver
Ocular melanoma within the liver can multiply extremely quickly. Tumours can double in size in as little as four weeks,
so patients can get ill very quickly if the liver is not brought under control with some kind of targeted local treatment.
Resection offers the best outcome of all the liver treatments, giving on average an extra 27
months of life expectancy. There have been occasions when removal of a single tumour or patch of tumours has led to
many cancer-free years.
Liver surgery is best for patients with small numbers of tumours and easiest if only one side of the liver is involved, however even very
large lesions may be removed if there is enough clear and healthy liver that can be left behind.
surgery is done as open surgery, but in some centres keyhole surgery is also available. The results are the same for the two
types of surgery, but recovery is usually much faster with key hole surgery.
There are also many patients
with diffuse disease in the liver for which surgery is unsuitable.
SIRT is available for diffuse disease. The brand name is Sirspheres
and the treatment involves tiny radioactive beads inserted into the liver via the femoral artery.
routinely available on the NHS (for ocular melanoma) it can be accessed via the patient's PCT (Primary Care Trust) using
an application for funding.
It is as yet unclear how much this treatment extends life expectancy,
however, if patients are rendered NED (No Evidence of Disease) it is considered be comparable to resection in effectiveness.
At the very least, SIRT is thought to de-bulk the liver, which in turn may improve the sufferer's quality
SIRT is available at a number of centres around the country, so if you want to be considered for it ask your oncologist to refer you.
Ablation (RFA) or Micro Wave Ablation (MWA) and Chemoembolisation (TACE) are other
treatments you can access through your liver surgeon and interventional radiologist.
RFA and MWA work by
placing a probe into the tumour and heating it up to kill the cancer cells, they are most effective for small numbers of small
to medium sized tumours (<5cm diameter) in cases where surgery cannot be offered.
TACE involves placing
a fine catheter up through the arteries from the top of the leg all the way up to the liver under X-ray guidance. Once in
place particles impregnated with chemotherapy drugs are released directly into the blood vessels supplying the tumours to
block their blood supply and release chemotherapy directly into the tumours. This can be useful for multiple small and medium
sized tumours, but is less effective for very big tumours.
TACE is usually done under local anaesthetic with
the patient awake. RFA and MWA are usually done under a full general anaesthetic, or occasionally under heavy sedation.
PHP (Percutaneous Hepatic Perfusion) is a technology offering a unique approach for
the treatment of liver cancers. In patients suffering with liver cancer which cannot be treated surgically, PHP can be a good
alternative option. The treatment isolates the liver from the patient's circulatory system and allows for the targeted
administration of anti-cancer drugs at dramatically increased doses.
PHP is currently available in Southampton by contacting their interventional radiologist.
The treatment is given via an infusion catheter is inserted through the skin into the femoral artery. The catheter
is guided so that its tip is positioned within the hepatic artery to deliver the drug. Then a double balloon catheter is inserted
into the femoral vein and guided into the inferior vena cava. A third catheter is inserted into the internal jugular vein.
Within the inferior vena cava the two balloons are separately inflated to block the normal flow of blood from the liver to
the heart. A small channel within the catheter allows some blood to continue to flow normally from the lower body back to
the heart and bypass the occluded section of the inferior vena cava.
Contrast media is pushed through the double balloon
catheter to confirm organ isolation. High doses of chemotherapy are delivered directly to the liver over a period of 30 minutes.
The catheter collects the blood as it exits the liver in the region between the two inflated balloons and then directs it
out of the body via the double balloon catheter. The blood passes through a filtration system which removes the toxic drug.
The cleansed blood is then returned to the patient's body through the catheter in the internal jugular vein.Early
trials utilising this technology with ocular melanoma patients have shown a lot of promise.
For Disease in the Lungs
It is not uncommon
to develop lung metastases and these can be picked up by X-ray or CT scan.
Initially they may be unproblematic
to the patient, but if they multiply or increase in size, they can cause symptoms such as coughing, pain in the chest and
back and shortness of breath.
If these symptoms start to affect the patient's quality of life or if
they represent the only site of metastatic disease, Resection, Radiofrequency Ablation and Stereotactic Radiosurgery are all
options which your thoracic surgeon will consider.
For Disease of the Bone
Bone metastases can cause
considerable pain if left untreated. Radiating the tumours will not kill them, but can halt the pain they cause, so
this is often a good alternative to painkilling drugs.
If patients need more aggressive therapy, Cryoablation
and Embolisation are available. If you develop bone tumours they will be picked up by CT scan and your medical, surgical
and radiation oncologists will work together to decide on the best course of action.
You may be given a
Bisphosphonate drug such as Zolendronic Acid to help protect your bones.
Disease in the Brain
Brain metastases will not generally be screened for unless
there is reason to suspect them.
Troublesome symptoms include weakness, difficulty walking,
headaches, nausea, and blurred vision. More serious symptoms include seizures and changes in the patient's alertness,
mental capacity, speech or personality.
Brain tumours can be treated with Stereotactic Radiosurgery and
Stereotactic Resection depending on what your neurosurgeon decides is appropriate.
Local Treatments Glossary
The surgical removal of part of the affected organ.
Radiation Therapy (SIRT)
Putting radiation into the patient's liver to kill the
cancer cells. Tiny radioactive ‘beads' are injected into the artery that supplies blood to the liver (the hepatic
artery). The beads become trapped (embolise) in the tiny blood vessels surrounding the cancer, releasing radiation directly
A minimally invasive treatment that heats and destroys cancer
cells. Imaging techniques such as ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) are
used to help guide a needle electrode into a cancerous tumour. High-frequency electrical currents are then passed through
the electrode, creating heat that destroys the abnormal cells.
A procedure in
which the blood supply to the tumour is blocked surgically or mechanically and anticancer drugs are administered directly
into the tumour. This permits a higher concentration of drug to be in contact with the tumour for a longer period of time.
Stereotactic Radiosurgery (SRS)
A treatment that precisely delivers a single, high dose of radiation in a one-day session. Focused radiation beams are delivered
to a specific area of the brain to treat tumours.
Tumour removal is performed via microsurgical techniques with the aid of the stereotactic computer system, lasers and
other techniques as needed.
A technique for removing cancerous tissue by killing it with extreme cold.
A non-surgical, minimally-invasive procedure performed by an interventional radiologist. It involves the selective
occlusion of blood vessels by purposely introducing emboli. The treatment is used to slow or stop blood supply thus
reducing the size of the tumour:
can be divided into two groups; those that are given in addition to the primary treatment to help increase the patient's
chances of survival (adjuvant) and those that are used to improve symptoms once the cancer has become terminal (palliative).
There are currently no chemotherapy drugs suitable for use in an adjuvant setting for ocular melanoma.
Traditionally Dacarbazine (or DTIC) given as an IV infusion has been used to treat ocular melanoma that has spread
from the eye to other parts of the body. Unfortunately, there is no evidence to prove that this drug has any effect
in ocular melanoma. In spite of this and in the absence of any other proven therapies, it is still the drug commonly
prescribed for ocular melanoma.
There are a number of experimental drugs currently being developed and many of these have had success in skin
melanoma and other cancers. Often patients will need to participate in a trial to receive them.
read about different types of cancer drugs click here. To search for current cancer trials, or
to find out more about what the different phases of trials signify, go to the Cancer Research UK website.
Ocular melanoma is genetically different to skin melanoma so most melanoma trials exclude ocular patients. If
you have a medical oncologist who specialises in ocular melanoma he or she will be best placed to advise you.
Please find below details of the drugs UK patients are currently accessing:
until 14th July 2011, Ipilimumab (Yervoy) was available to ocular melanoma patients on compassionate use then via an expanded
access programme. The drug has now been approved in the EU for patients with previously treated advanced melanoma.
The expanded access programme has now been suspended but patients can currently get the drug through their medical
oncologist. The oncologist has to apply for funding on behalf of the patient, and we haven't heard of anyone being
turned down so far.
The effect of ipilimumab on ocular melanoma is not fully known
although it appears to be about the same as cutaneous melanoma at 8%. More studies are currently taking place which
will tell us about ocular melanoma specifically.
In the people who have responded so far it seems to have had
a significant benefit. However, the drug is best used early on in the course of advanced disease as it can take
anything up to a year to see a response.
If you take the drug you should also be aware of the potentially lethal side
effects, although with close supervision from your oncologist and being aware yourself of the issues these are generally
This is a global trial currently
recruiting at 5 sites - one of which is the Royal Marsden here in the UK. It is a phase 1 trial but the dose is established.
The trial is available to patients with or without any prior systemic treatment. To find out more click here or email Dr James Larkin.