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Treatments
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. Most liver 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. Currently not 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 of life. 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. Radiofrequency 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. 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. 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 Resection The surgical removal of part of the affected organ. http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Liversecondary/Treatingsecondarylivercancer/Surgery.aspx Selective Internal 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 onto it. http://www.sirtex.com/files/Patient%20Information%20Leaflet%20EU%20English%20147-MAR-LEAF%20rev%202.pdf Radiofrequency Ablation (RFA) 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. http://www.cancerhelp.org.uk/about-cancer/cancer-questions/radiofrequency-ablation Chemoembolisation 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. http://www.medicinenet.com/chemo_infusion_and_chemoembolization_of_liver/article.htm 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. http://www.irsa.org/radiosurgery.html Stereotactic Resection Tumour removal is performed via microsurgical techniques with the aid of the stereotactic computer system, lasers and other techniques as needed. http://www.buffaloneuro.com/stereo/stereo.html Cryoablation A technique for removing cancerous tissue by killing it with extreme cold. http://medical-dictionary.thefreedictionary.com/Cryoablation Embolisation 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: http://en.wikipedia.org/wiki/Embolization Systemic (Drug) Therapies Systemic therapies
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.
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