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Medical Minute 8-10: Blindsiding Eye Cancer

By: Vanessa Welch Email
By: Vanessa Welch Email

You could call 54-year-old Marilyn Nakama's eye patch a badge of courage. For the last several months, she's been fighting adenoid cystic carcinoma -- a tumor growing deep inside her eye socket.

Instead of cutting open the skull to remove these tumors, Doctor David Tse at the University of Miami's Bascom Palmer Eye Institute pioneered a new treatment. Using a catheter, he infused a high dose of chemotherapy into the artery that was feeding the tumor -- much more than what could be delivered through the veins.

"By putting a catheter into the artery that supplies the blood to the lacrimal gland, we could perfuse high concentrations of chemotherapy that the concentration normally would be lethal to the patient," said David T. Tse, M.D., F.A.C.S., Ophthalmic Plastic and Orbital Surgeon at Bascom Palmer Eye Inst. at the University of Miami Miller School of Medicine.

The procedure shrunk the tumor -- making surgery to remove all cancer cells more effective. Though Marilyn lost her eye, she still feels lucky.

"I had an MRI about two weeks ago, and they said I was cancer-free, so that's really, really good news," said Marilyn Nakama, Eye Cancer Survivor.

Steve Downey was the first to undergo Doctor Tse's experimental cancer procedure.

"Short-term and long-term, he saved my life, I guess you could say."

Steve now wears a removable prosthesis matched to his eye and skin color.

"Just like taking out contacts in the morning, putting them in at night."

And he never forgets what could have been. A grateful patient looking forward to a long, cancer-free future.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: Adenoid cystic carcinoma of the lacrimal gland is the most deadly orbital tumor. The cancer arises from the cells within the lacrimal gland, which is a structure that produces tears. Orbital adenoid cystic carcinoma usually occurs in patients between 20 and 50 years old. When an adenoid cystic carcinoma of the lacrimal gland grows, it typically pushes the eye down, towards the nose and forward. It can cause bulging of the eye. Adenoid cystic carcinoma also invades local nerves, causing pain. Pain and bulging are the most common symptoms.
(SOURCE: www.eyecancer.com)

DIAGNOSIS: Doctors must perform a complete eye exam with a clinical history and ophthalmic exam to diagnose adenoid cystic carcinoma of the lacrimal gland. Other tests such as CAT scans, MRIs and ultrasounds are also helpful in determining the diagnosis of adenoid cystic carcinoma of the lacrimal gland.
(SOURCE: www.eyecancer.com)

TREATMENT: If possible, an adenoid cystic carcinoma should be completely removed. This surgery is often called a lateral orbitotomy. However, total removal is often impossible because of the tumor's size, shape and presence of invasion.
(SOURCE: www.eyecancer.com)

A NEW OPTION: David Tse, M.D., from the University of Miami Miller School of Medicine, is using a new treatment called intra-arterial cytoreductive chemotherapy. A catheter is inserted into a large artery in the groin and is advanced toward the artery in the eye socket that feeds the tumor. Infusion of chemotherapy through the artery allows the doctor to deliver a very high dose of chemo that cannot be given through the vein. As the chemotherapy goes through the tumor, the drug is absorbed by the cancer cells, and the drug dosage becomes much less after perfusing through the tumor mass. This delivery system causes the tumor to shrink. Once the tumor shrinks, surgery becomes more effective in removing all cancer cells within the socket. The 10-year survival rate for adenoid cystic carcinoma of the lacrimal gland is 20 percent. The new treatment protocol developed at the University of Miami improves survival to more than 80 percent.
(SOURCE: Dr. David Tse, University of Miami)

FOR MORE INFORMATION, PLEASE CONTACT:
Omar Montejo, Media Relations
University of Miami Miller School of Medicine
(305) 243-5654
OMontejo@med.miami.edu

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David T. Tse, MD, FACS, an ophthalmic plastic and orbital surgeon from the Bascom Palmer Eye Inst. at the University of Miami Miller School of Medicine, talks about a new way to treat a deadly eye cancer.

As I understand it this whole mindset came into your head when Steve came into see you.

David Tse, M.D: Steve came in with a very rare orbital tumor called adenoid cystic carcinoma of the lachrymal gland. Historically, this tumor has a very high mortality rate in general despite radical surgery, removing the tumor, removing the bone, removing the eye. The survival rate in five years is about 50% and 20% survival in ten years. So, it’s a very, very lethal disease for which we don’t have a very effective form of therapy. When Steve came in, he was quite young, 21 years old. He just had his first child. I thought that, given the extensive nature of his tumor, if we followed the conventional therapy his life expectancy would not be very high. So, he was the first patient whom I offered a new treatment to try to shrink the tumor down before we address the cancer itself. The aim in here is called intra-arterial cytoreductive chemotherapy and that is to pass a catheter into the artery that’s serving the lachrymal gland and that’s a unique anatomical feature of this organ in the socket. The lachrymal gland produces tears for the surface of the eye and is served by one single artery and one vein coming out. So, by putting the catheter into the artery that supplies the blood to the lachrymal gland we could perfuse high concentration of chemotherapy that the concentration would normally be lethal to the patient. But once chemotherapy goes through the tumor bed most of the chemotherapy is absorbed by the tumor. So, that when it comes out of the tumor the concentration is quite low so the patient can tolerate that. The concept here is to deliver a high concentration of chemotherapy to kill the cancer cell and to shrink the tumor down so as to make the surgery easier so that we can, hopefully, get the margins of the tumor clear.

Once you’ve done the chemo, then you go in to do the surgery. Is the surgery essentially the same surgery, or is it different?

David Tse, M.D: What we are doing is we are not deviating from the conventional method of management, which would be exoneration, removing the tumor and the eye. What we are doing is augmenting a combination of procedures that has proven to be ineffective and by shrinking the tumor down first and the surgery would be essentially the same. The exonerate, the socket, removing the eyelid, the cancer cell and the eye as well as the bone surrounding the cancer. So, to try to get the local disease controlled we can assure ourselves there are no residual cancer cells in the orbit.

But, by doing the intense chemo ahead of time, you’re really changing the surgery a little bit. In the old days it was probably going to be a much bigger deal because of where these tumors go...back into the brain.

David Tse, M.D: Correct, it downstages the tumor. You prevent the tumor from becoming larger by shutting it down and that’s the intent, to downstage the tumor.

Why is it so important to stop this cancer fast? Tell me what it is and what it does.

David Tse, M.D: We still do not understand the biological behavior of this tumor. What we do know is that it confers the worst prognosis of all the tumors we see. And so, we know that the conventional therapies will not prolong life. So, the aim of this regimen, this combination of cytoreductive chemotherapy and surgery and then postoperative radiation, this whole combination or regiment, is aimed at saving life. Unfortunately, we cannot save the eye at this point. The aim is to save life, to improve the dismal mortality rate of this cancer first. Ultimately, as we gain more knowledge through translation of research and we understand the genomics of the cancer we can tailor our therapy a little bit in hopes of saving the eye. We would then be able to get rid of the cancer and not have to sacrifice the eye. That’s the ultimate aim of research. But, at this time, we are trying to prolong life first.

You were telling me that this cancer gets into everything. Once you get it, it doesn’t just limit itself to the eye. Tell me about that.

David Tse, M.D: Well, the principal cause of death with this cancer is a metastasis to the brain. This tumor has a tendency of getting into nerves around the lachrymal gland and then in a retrograde manner migrates to the brain. The eye is not too far from the brain so it gets back to the brain very quickly and that’s the principal cause of death. Additionally, this tumor can also get into blood vessels and metastasize to other organs, the lung and the liver. It gets into lymph nodes, because it invades the lymphatic channels, it also invades into adjacent bones, for example. And so, this the kind of tumor that infiltrates all tissue planes. That’s why making local disease control is hard. Making the control of fisted metastatic disease is also very, very hard. Hopefully this combination of therapies will interact. Lowering the local disease control, in other words, get rid of the cancer in the socket. I’d also address any kind of metastasis, so that we are not recognizing in the beginning elsewhere in the body, in the lung, in the liver and elsewhere.

How would you be able to impact ten years of survival to cancer free with your procedure?

David Tse, M.D: Well, I mentioned early the previous survival rate is about 20% in ten years. We have survival now of better than 85% in ten years.

Is the procedure still considered experimental, or is it standard of care?

David Tse, M.D: It’s not experimental anymore. We have published our data and now we have good introspective patients. It is not an experimental technique. It is a proven and validated by patient care, by studies, to be effective in prolonging life.

The prosthetic is interesting too.

David Tse, M.D: The prosthesis is the unfortunate part of this whole technique. While it saves patient’s lives, this whole concept is not an elegant approach. It is an inelegant approach. It is almost like trying to get rid of a condemned house with dynamite and then the rest of the neighborhood gets affected as well. So, the aim in here, we want to have a controlled removal of the cancer, while saving the eye. That’s our ultimate aim. For Steve we had to follow the conventional method and that is to remove the tumor, remove the eye because the cancer affected the tissues surrounding the eye as well. Unfortunately, we couldn’t save the eye. Once you remove the tumor and the eye and the patient is cancer free, then we fit them with a prosthesis that will simulate the appearance of the other normal eye. The only difference is they cannot blink.

But it’s not just the eye that what I thought was the interesting part.

David Tse, M.D: The prosthesis including the fabrication of the eyelid with eyelashes and everything. It looks very life like and with a pair of glasses in front of it sometimes you can’t tell.

That’s because you didn’t just remove the eye. Most prosthesis is just like an eye. Tell me why this one is different.

David Tse, M.D: Well, I think that most of us are accustomed to seeing a patient that has lost an eye with intact eyelids and eye muscles so they have a very functional eyelid. It blinks normally and closes normally and that’s a nucleation, removing the eye only. In Steve’s case the tumor is outside of the eye in the socket and it affects the adjacent bone, it affects the eye and it affects the surround tissue. So, all those tissues come in contact with this tumor. They need to be removed en bloc including the eye. So, you have an empty socket in there. We fix a prosthesis that will return the appearance very similar to the other side. So, the prosthesis includes the fabrication of eyelid as well as the eye.

And you also do some kind of a graft. They were talking about grafting skin off their leg.

David Tse, M.D: Well, we do one of two things. Once you pick the content of the socket out you basically have exposed bone and so, we resurface the bone with a skin graft first to make the inside of the socket very much like the skin elsewhere, the cheek, for example. The socket would feel very smooth and clean. Another option: A lot of times we have to do a lot more extensive surgery. Like getting into the sinuses for example. You then create a much larger space and you need to fill the space. In that case, we fill with a free graft, a lot more bulky tissue to fill in the socket and sinuses.

How gratifying is it for you to not have to do that old procedure anymore? Do you think about this every time one of these patients comes in the door?

David Tse, M.D: I do. I think the work is still not done. It’s not important to get the answer, it’s more important to look for the question. The question is, “how can we save the eye?” Hopefully, by getting some specimens from the tumors we remove and unraveling the genetics of this tumor and finding a more inventive way of beating the cancer with the ultimate aim of just removing the cancer and not the eye.


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