ocular melanoma and liver metastases
TRANSCRIPT
Eyes on a Cure:Ocular Melanoma and Liver Metastases
Maria Russell, MDAssistant Professor of Surgery
Emory UniversityMarch 6, 2016
• No Disclosures
Objectives
• Review statistics of liver metastases from ocular melanoma
• Discuss relevant anatomy• Review surgical options• Evaluate liver directed options
The Facts• Annual incidence of ocular melanoma:
– 5.1/million in the U.S. • Up to 50% of patients with primary uveal
melanoma will develop distant mets• Liver is the site of metastatic disease in 90% of
the cases• Median survival with metastatic disease 2-5
months with 1 year survival 10-15%
Predictors of Metastatic Disease
• Basal tumor diameter• Ciliary body involvement• Transcleral extension• Epithelioid melanoma cytomorphology• High mitotic rate• Extravascular matrix pattern• Chromosomal abnormalities
Options for Treatment of Liver Mets
• Surgery• Ablation• Transarterial chemoembolization• Hepatic artery infusion• Y90• Radiation• Hepatic perfusion
Anatomy
Right Hepatic Duct
Anatomy
RIGHT LOBE
2/3 Volume
LEFT LOBE
1/3 Volume
II
III
IV-A
IV-B
VIII
VVI
VII
Hepatic Veins
I
Left HV
Middle HV
Right HV
Surgical Resection• Patient Factors:
– Performance status• Technical Factors:
– Inflow/outflow– Ability to get negative margins– Future liver remnant
• Biology Factors:– Number and size of tumors– Timing/disease free interval– Extrahepatic disease
Agarwala et al. Cancer. 2015, March: 781-789.
Rye et al. JSO. 2013:108:129-135.
Median Survival:29 months
Median Survival:R0: 44 monthsR1/2: 12 months
Median Survival:Major: 70 monthsMinor: 23 months
Gomez et al. JSO. 2014;109:542-547.
Gomez et al. JSO. 2014;109:542-547.
Overall Survival:Surgery/Ablation: 27mo (14-90)Palliative: 8mo (1-30)
1/3 year survival:Surgery/Ablation: 100%, 41.4%Palliative: 31.8%, 7.4%
Recurrence:11/17 - median of 13mo (6-36)
Surgery
• Median survival 14-24 months compared to 3-12 months with non-surgical care
• 5 year overall survival ranged 19-39 months• R0 resection associated with longer OS than
R1 or R2
Problems with Surgery
• Recurrence common:– 72-75%
• Risk of morbidity and mortality:– 60day mortality 1.9% - 2.3%– Complications 15-20% historically
• Considerations:– Non-surgical candidates higher burden of disease, more
comorbidities– Some studies combine surgery with other treatments.
Non-Resection Surgical Options
Hepatic Perfusion
• Minimally invasive technique (PHP) versus open technique (IHP)
• High doses of cytotoxic agent infused into isolated liver
• Less systemic toxicity
Olofsson et al. Ann Surg Oncol. 2014; 21:466-472.
Olofsson et al. Ann Surg Oncol. 2014; 21:466-472.
P=0.029Results:• 68% radiographic response• 12% complete response• Time to progression 7
months• 68% developed EHD• Medial OS 24 months
PHP Procedure Chemofiltration
CircuitIsolation and
melphalan delivery
Isolationballoon catheter
Internal jugular returncatheter
Filtration
Veno-venobypass pump
Melphalan delivery catheter1
2
3
4
Hughes et al. Ann Surg Oncol. 2015. online.
Hughes et al. Ann Surg Oncol. 2015. online.
Hepatic Perfusion
Agarwala et al. Cancer. 2015, March: 781-789.
Radiographic Response
Reddy SK, Alexander HR. Ther Adv Med Oncol. 2014; 6(4):180-194.
COMING SOONTO A
HOSPITAL NEAR YOU!
Conclusions
• Liver metastases are too common in ocular melanoma
• Surgical resection can offer significant benefit, but few are candidates
• Hepatic perfusion is very reasonable, less invasive option with improvement in hepatic disease and survival
• Recurrence remains a problem
Eyes on a Cure:Ocular Melanoma and Liver Metastases
Maria Russell, MDAssistant Professor of Surgery
Emory UniversityMarch 6, 2016
