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Roadmap for Navigating Uveal Melanoma · The Eye Believe Podcast

• 0:00
  Our guest speaker today is Doctor Jesse Berry,
• 0:02
  who is fantastic and so fun to listen to.
• 0:04
  She hails from California,
• 0:06
  and we're so grateful
• 0:07
  to have you here, Doctor Berry.
• 0:08
  just so special. Thank you.
• 0:09
  As we get started, to ask our sponsor
• 0:11
  for the webinar series, Castle Bioscience
• 0:14
  is who has helped to make this possible.
• 0:16
  So with that, I'm going to go ahead
• 0:17
  and turn the time over to Doctor Jesse Berry.
• 0:20
  Thank you so much.
• 0:21
  It's such an honor to be here
• 0:22
  and to those
• 0:23
  who are joining in or watching later.
• 0:25
  Unfortunately, I'm the tiniest bit sick,
• 0:26
  so if I call or need to stop, to take a quick
• 0:30
  break for my throat, please stick with me.
• 0:33
  So I'm going to do the first part
• 0:35
  of this, exciting webinar today
• 0:37
  talking about the navigating a Uveal
• 0:39
  melanoma diagnosis and a little bit
• 0:41
  about, the roadmap from the eye cancer,
• 0:44
  the ocular oncologist side.
• 0:45
  I do have some research funding,
• 0:47
  and I am going to talk today
• 0:48
  about some trials as well
• 0:50
  as, some companies
• 0:51
  that are in the ocular oncology space.
• 0:53
  I actually don't have
• 0:53
  relationships with any of them.
• 0:55
  I'm just sharing information.
• 0:56
  So if you're here, you likely already know
• 0:59
  this, but, Uveal Melanoma has,
• 1:02
  a whole spectrum of disease.
• 1:04
  And so you hear a lot of terms
• 1:05
  thrown around with it, including even ocular
• 1:07
  melanoma, which really includes
• 1:09
  melanoma all throughout the eye
• 1:11
  or ocular space.
• 1:12
  But when we talk about Uveal Melanoma,
• 1:14
  we're really talking about melanoma.
• 1:16
  That's involving the iris,
• 1:17
  the ciliary body, which is the structure
• 1:19
  that, produces fluid for the eye,
• 1:21
  that that hides behind the iris.
• 1:23
  And then the pigmented layer under
• 1:25
  the retina is called the choroid.
• 1:27
  and we see a lot of tumors
• 1:28
  forming there as well.
• 1:29
  So these are the structures
• 1:30
  that we're talking about when we talk about
• 1:32
  a diagnosis of Uveal Melanoma.
• 1:35
  And Uveal Melanoma
• 1:36
  actually is a minimal contributor
• 1:39
  to the total amount of melanoma that we see.
• 1:41
  Most, of course, are cutaneous
• 1:43
  or on the skin,
• 1:44
  but it does account for
• 1:45
  about 5% of melanomas, in the United States,
• 1:48
  it is the most common
• 1:49
  primary intraocular tumor in adults,
• 1:53
  and primary means it's started in the eye.
• 1:55
  It didn't come from other parts of the body.
• 1:57
  There are about
• 1:58
  six cases per million, which is about 2000,
• 2:01
  in the US.
• 2:01
  And so that means that this is a rare disease.
• 2:04
  And so anything that is rare, means
• 2:07
  that there are fewer specialists
• 2:09
  that treat this disease.
• 2:10
  I love seeing A Cure in Sight.
• 2:12
  And other groups come together to provide
• 2:14
  support for patients and resources.
• 2:16
  And for all of you showing up
• 2:17
  and spreading the word, because, again,
• 2:19
  this is a less common diagnosis and disease.
• 2:22
  And so when we think about people
• 2:23
  who are at risk for, melanoma,
• 2:26
  we often have this very
• 2:27
  stereotypical picture in our head of somebody
• 2:30
  who's maybe older than 50 years.
• 2:32
  Men and women are equally affected.
• 2:34
  But we think about people
• 2:35
  who have light hair,
• 2:36
  light eyes, and oftentimes
• 2:38
  we think about, sun exposure.
• 2:39
  although that's actually very argued.
• 2:41
  but these are the risk factors we think about
• 2:44
  when we're talking about melanomas in general.
• 2:46
  by the way,
• 2:47
  sun is not argued for skin,
• 2:49
  but who's really at risk for melanoma?
• 2:51
  Well, everyone.
• 2:52
  So in my practice in Los Angeles,
• 2:55
  I have seen, people under the age of 18.
• 2:58
  So children diagnosed with melanoma,
• 3:00
  although that's exceedingly rare,
• 3:01
  very old people every age in between.
• 3:04
  if you are an adult in your 20s,
• 3:06
  that does not mean that
• 3:07
  you cannot get melanoma.
• 3:08
  Unfortunately, I've treated many of them.
• 3:10
  And, if you are not light hair, light eyes,
• 3:14
  it does also not mean
• 3:15
  that you cannot get melanoma.
• 3:16
  unfortunately.
• 3:17
  while there, the risk may be different.
• 3:19
  The risk still exists for, all people.
• 3:22
  And so because of that,
• 3:23
  you see a lot of episodes
• 3:25
  through, this podcast.
• 3:26
  But we do recommend a dilated
• 3:28
  yearly eye exam to check for these things.
• 3:30
  And the reason we recommend a dilated
• 3:32
  yearly exam is that
• 3:33
  melanoma is really a clinical diagnosis.
• 3:36
  So what does that mean?
• 3:37
  Doctors understand what that means.
• 3:39
  But what does that mean for a patient.
• 3:40
  Well for a patient
• 3:41
  it means that you need a
• 3:42
  doctor to look in the eye
• 3:44
  and do
• 3:45
  some imaging in the eye
• 3:46
  for us to be able to diagnose melanoma.
• 3:48
  And by and large,
• 3:50
  we are about 99%
• 3:52
  accurate in diagnosing melanoma
• 3:54
  based on these features.
• 3:56
  When we decide that something
• 3:57
  has progressed to melanoma.
• 3:59
  And I'll talk about that as well.
• 4:00
  so this clinical diagnosis
• 4:02
  for ocular melanoma being so high
• 4:05
  is in comparison
• 4:06
  to cutaneous melanoma, where the biopsy
• 4:09
  positive rate for something
• 4:10
  that's possible melanoma is only 10%.
• 4:13
  But that doesn't mean that ophthalmologists
• 4:15
  are better clinicians than dermatologists.
• 4:17
  I wouldn't say such a thing,
• 4:18
  but rather
• 4:19
  that the threshold to biopsy a skin
• 4:22
  lesion is very low.
• 4:24
  You can take the whole thing off.
• 4:25
  You can take the whole thing off
• 4:27
  and get a diagnosis that way.
• 4:28
  Now there are several predisposing conditions
• 4:32
  for melanoma.
• 4:33
  there are
• 4:34
  some predisposing conditions that can lead
• 4:37
  to melanoma, and this includes Nevi.
• 4:40
  And I'm going to talk
• 4:40
  about that a little bit later.
• 4:42
  Melanoma
• 4:43
  which are sort of an aggressive looking
• 4:46
  nevus or mole in the eye,
• 4:47
  but actually have a lower risk
• 4:49
  overall of malignant transformation.
• 4:51
  And then something
• 4:52
  called Ocular Melanocytosis
• 4:54
  which you can see down here.
• 4:55
  This is also called
• 4:56
  nevus of oda
• 4:57
  patients
• 4:57
  who have this
• 4:58
  actually have a very high risk
• 4:59
  of development of melanoma.
• 5:01
  And we recommend that
• 5:02
  they are screened very frequently.
• 5:04
  now you might
• 5:05
  be referred to somebody for melanoma
• 5:06
  and not actually have melanoma.
• 5:08
  That also happens a lot.
• 5:10
  And so there are various
• 5:11
  lesions spots or dots in the eye
• 5:14
  that are not actually melanoma.
• 5:15
  These can includeChoroidal
• 5:17
  hemangioma Charpe Choroidal hemorrhages
• 5:20
  metastatic disease.
• 5:22
  You can see here
• 5:22
  this is from lung
• 5:24
  or even This is a bony tumor
• 5:26
  that can form in the eye.
• 5:27
  And so let's jump in a little bit
• 5:28
  to the path to diagnosis.
• 5:30
  So often what happens in my practice is
• 5:32
  someone is told
• 5:33
  that there's a spot in the eye
• 5:35
  and they're going to be
• 5:35
  referred to the specialist.
• 5:37
  Then they find out that the specialist
• 5:38
  is an ocular oncologist.
• 5:40
  They hear the word oncology
• 5:41
  and start to have a freak out.
• 5:43
  Although I see
• 5:43
  all different kinds of spots,
• 5:45
  including on the left here,
• 5:46
  which is a melanoma and on
• 5:48
  the right is a nevus.
• 5:49
  So just because you have a spot
• 5:51
  and just because you're referred
• 5:52
  to an ocular oncologist does not
• 5:53
  already mean that you have a melanoma.
• 5:56
  What is an ocular oncologist.
• 5:58
  Well, in ocular
• 5:58
  ecologist is an ophthalmologist
• 6:00
  which is an eye surgeon who has specific
• 6:03
  training in the management
• 6:04
  of benign and malignant tumors.
• 6:07
  Sometimes these people
• 6:07
  may also be retina trained
• 6:09
  or specifically ocular oncology trained.
• 6:12
  And so
• 6:13
  this is from a Google search
• 6:14
  that I did this morning of me
• 6:16
  to find my profile.
• 6:17
  But, Google can sometimes
• 6:18
  be a great way to find someone.
• 6:20
  But you'll see,
• 6:20
  if you look at people's profile,
• 6:22
  usually what you would see
• 6:23
  is somebody who says, like your subspecialty
• 6:26
  training in ocular oncology.
• 6:28
  Finding an
• 6:29
  ocular oncologist sometimes
• 6:30
  is the first part of,
• 6:33
  the journey to a diagnosis.
• 6:34
  Now, if you're in LA,
• 6:36
  or in the California area, there's,
• 6:37
  several of us in the state,
• 6:38
  but there are states where there are
• 6:40
  no ocular oncologists in the whole state.
• 6:42
  And so, it's important to know
• 6:43
  that there are various
• 6:44
  means or mechanisms to identify a physician
• 6:47
  who has the skill set
• 6:48
  to treat somebody with a melanoma.
• 6:51
  And so
• 6:51
  this is from a melanoma .org
• 6:53
  but it talks about all of these different areas
• 6:56
  where you can find an ocular oncologist,
• 6:58
  including from A Cure in Sight.
• 7:00
  The American Academy of Ophthalmology.
• 7:02
  There's some European sites
• 7:03
  and then also the Eye
• 7:04
  Cancer Foundation, and dare
• 7:06
  I say it, in this day and age,
• 7:07
  you can also go to Facebook or, Instagram.
• 7:10
  This again is from this morning.
• 7:11
  If you do hashtag ocular
• 7:13
  oncologist this morning this is what comes up.
• 7:15
  And actually
• 7:16
  you would see me and two of these
• 7:17
  you would direct to my profile
• 7:19
  as well as to some of my colleagues.
• 7:21
  So once you get to your appointment,
• 7:22
  what should you expect?
• 7:24
  Well, ocular oncologists love imaging.
• 7:27
  And so you should expect that you will spend
• 7:29
  a significant amount of time
• 7:31
  with your eye being imaged.
• 7:32
  And that's usually not done
• 7:34
  by the ocular oncologists themselves,
• 7:35
  but rather by a team
• 7:37
  of dedicated ophthalmic imagers.
• 7:39
  They will take photos of the eye
• 7:41
  so that we can identify the tumor
• 7:43
  and the margins of the tumor.
• 7:45
  You may have something called fluorescein
• 7:46
  angiography
• 7:47
  or a dye test,
• 7:49
  where they inject dye
• 7:50
  into the arm, or sometimes
• 7:52
  have you drink it orally
• 7:53
  so that we can see
• 7:54
  the vasculature in the tumor.
• 7:56
  And then sometimes
• 7:57
  you may also have something called
• 7:58
  optical coherence tomography or OCT
• 8:01
  This is really done for us to understand
• 8:03
  the status of the retina,
• 8:04
  which is the structure overlying the tumor,
• 8:07
  as well as the extent of fluid
• 8:08
  which you see is dark black here.
• 8:10
  And that can be very helpful,
• 8:11
  particularly in small tumors.
• 8:13
  You'll also have an ultrasound.
• 8:15
  One of the main questions
• 8:16
  my patients say to me
• 8:18
  is Doctor Barry, why did they do
• 8:20
  the ultrasound on my eye?
• 8:21
  The referring doctor did it over my eyelid.
• 8:24
  and that varies a little bit center, to center.
• 8:26
  But to get really good images, often
• 8:28
  you'll have a numbing draw placed on the eye,
• 8:30
  and the ultrasound
• 8:31
  will be done on the eye itself.
• 8:33
  Screening ultrasounds
• 8:35
  that are not quite
• 8:36
  so dedicated
• 8:37
  might be done over the eyelid,
• 8:38
  and we do the same thing.
• 8:39
  The ultrasound is a very
• 8:40
  sensitive modality
• 8:42
  for us to not only identify
• 8:44
  the location of the tumor,
• 8:45
  but to measure it, and to understand
• 8:47
  what structures are impacted by its growth.
• 8:50
  Well, this talk is not at all
• 8:52
  aboutChoroidal Nevi
• 8:53
  I felt like
• 8:54
  I should at least spend a minute on it,
• 8:56
  because so much of the very initial referral
• 8:59
  might be regarding is this a nevus?
• 9:01
  Is this a melanoma?
• 9:02
  And I think there's a lot of, anxiety
• 9:05
  and misunderstanding as it relates
• 9:06
  to this for patients.
• 9:07
  So choroid nevi by definition
• 9:11
  just like moles or freckles on the body.
• 9:13
  So nevus is a medical
• 9:14
  term for mole or freckle are benign
• 9:16
  meaning they are not malignant.
• 9:18
  And often the good nevi that we see in the eye
• 9:21
  might be dark brown or gray.
• 9:22
  They're flat
• 9:23
  and they have no high risk features.
• 9:26
  However,
• 9:26
  if they do have
• 9:27
  certain features which we'll discuss,
• 9:29
  they really need to be monitored,
• 9:30
  because all of these lesions
• 9:32
  could change at some point into a melanoma.
• 9:35
  And so Choroidal Nevi
• 9:37
  actually relatively common.
• 9:38
  This is from a prevalence
• 9:40
  study looking across multiple,
• 9:42
  multiple publications
• 9:43
  and found
• 9:44
  that about 5% of an older Caucasian
• 9:46
  population will have Choridal Nevi
• 9:48
  And most of these tumors,
• 9:50
  when nevus is still a tumor,
• 9:51
  it's just not a cancer.
• 9:53
  are asymptomatic.
• 9:54
  Again,
• 9:55
  this is another reason why you need to have
• 9:57
  that dilated yearly exam,
• 9:58
  because you might have a nevus
• 9:59
  and not know the growth
• 10:01
  or change of this nevus might cause,
• 10:03
  different changes that we see in the eye,
• 10:05
  which include Drusen in changes
• 10:07
  in pigmentation, the presence of fluid,
• 10:09
  or the presence of something
• 10:10
  called Lipofuscin or orange pigment is
• 10:12
  how we often describe it to our patients.
• 10:14
  And size
• 10:15
  also matters, but
• 10:16
  is not the definitive defining feature.
• 10:19
  So, if you
• 10:20
  look in textbooks,
• 10:21
  most textbooks will say that
• 10:23
  a lesion, around five by one
• 10:26
  millimeters is by definition
• 10:27
  a Chorodial nevus.
• 10:28
  Although all of us who have treated
• 10:30
  melanoma have seen very
• 10:31
  small tumors, in that range as well,
• 10:33
  that are worrisome.
• 10:34
  And you can also have giant Chorodidal Nevi
• 10:37
  as you see here, that have been followed
• 10:40
  and are stable in the eye for years.
• 10:42
  And years and years.
• 10:43
  however, they're quite large,
• 10:44
  so size alone does not diagnose
• 10:47
  someone as having a nevus
• 10:49
  or a melanoma by any means.
• 10:51
  but these nevi need to be monitored.
• 10:53
  And this is from a study,
• 10:54
  by the shields, who are, ocular
• 10:56
  oncologists in Philadelphia.
• 10:58
  And there are some factors
• 10:59
  that tell us that there's an increased
• 11:01
  risk of a nevus turning into a melanoma,
• 11:03
  and that includes thickness greater
• 11:05
  than two millimeters,
• 11:06
  the presence of some retinal fluid,
• 11:09
  the patient noticing symptoms.
• 11:11
  Symptoms are usually a sign
• 11:12
  that something is growing or changing.
• 11:14
  The presence of orange pigment,
• 11:16
  and whether the tumor is close to the disk
• 11:18
  or on ultrasound looks hollow.
• 11:20
  So some of these features, as people
• 11:23
  who are listening, patients
• 11:24
  listening to this, podcast might know
• 11:27
  because they're being
• 11:27
  followed for a nevus,
• 11:28
  and that includes
• 11:29
  the idea that it could be thick,
• 11:31
  especially thicker than two millimeters,
• 11:33
  whether it has fluid or orange pigmentation.
• 11:35
  And these are factors that to me
• 11:38
  mean, if possible, if you're in a place
• 11:40
  where
• 11:40
  a retina specialist or an ocular oncologist
• 11:43
  with training in melanoma
• 11:45
  can monitor you, they should.
• 11:46
  And the reason they should
• 11:47
  is that these grow.
• 11:49
  And so if you have
• 11:50
  five risk factors, you have a 27 times
• 11:54
  the risk that this nevus will grow.
• 11:56
  Growth is not a guarantee
• 11:58
  that it's turning into a melanoma.
• 12:00
  Again you can have these larger nearby.
• 12:01
  But growth is very concerning
• 12:03
  for metastatic change.
• 12:05
  excuse me for malignant change.
• 12:06
  And we don't want to see
• 12:07
  growth unchecked and unfettered
• 12:10
  for this metastatic risk.
• 12:12
  So a growing nevus
• 12:13
  absolutely needs to be referred.
• 12:15
  And so again
• 12:16
  just showing,
• 12:17
  how important it is for you as the patient
• 12:20
  to understand these risk factors,
• 12:22
  and to
• 12:22
  interact with your doctor
• 12:24
  to make sure that you're
• 12:25
  referred appropriately,
• 12:26
  if you have one or more.
• 12:28
  Many times when I get a patient
• 12:30
  referred for this nevus melanoma question,
• 12:33
  the first question they ask me is
• 12:35
  what about a biopsy?
• 12:36
  And again
• 12:37
  I think this comes
• 12:38
  from the fact
• 12:39
  that 95% of the
• 12:40
  melanomas that we hear and talk about
• 12:42
  are these cutaneous melanomas.
• 12:44
  And so it's
• 12:45
  very well understood in the by patients
• 12:48
  that if you have an atypical mole
• 12:50
  or a mole that's changing,
• 12:51
  your dermatologist will take that mole out
• 12:54
  and have it biopsied for evaluation.
• 12:56
  And that works
• 12:57
  really well for moles on the skin,
• 12:59
  because while you might have a small scar,
• 13:01
  you're otherwise okay in the eye.
• 13:04
  I hope you see my, mouse moving,
• 13:05
  but in the eye there's the optic nerve.
• 13:07
  And here's the phobia.
• 13:08
  And this mole.
• 13:10
  this was actually a nevus
• 13:11
  that's been stable now for a long time.
• 13:13
  But this mole
• 13:14
  is in between the two
• 13:16
  most critical structures for vision in the eye.
• 13:18
  So one, I can't take that out.
• 13:21
  If I take that out,
• 13:22
  I permanently destroy vision.
• 13:24
  And frankly,
• 13:24
  to take the whole thing out,
• 13:25
  I would permanently destroy the eye itself.
• 13:27
  So I cannot remove this easily.
• 13:30
  I could do a biopsy where I take a needle
• 13:33
  and take a few cells for analysis.
• 13:36
  It's still a very small
• 13:37
  tumor in a very critical spot,
• 13:39
  and so there's risks to the patient.
• 13:41
  But even if I do
• 13:42
  a small biopsy at that moment in time
• 13:45
  and they tell me that the nevus
• 13:47
  is a nevus and it's benign,
• 13:49
  it doesn't mean that it doesn't need
• 13:50
  to be monitored, because in two years
• 13:52
  or five years or ten years,
• 13:54
  it could still transform into a melanoma
• 13:56
  because it hasn't been removed.
• 13:58
  And so
• 13:58
  I spent a lot of time
• 13:59
  explaining this to my patients
• 14:01
  and making sure they understand this.
• 14:03
  I hope that in the future,
• 14:04
  we will actually use liquid biopsy
• 14:06
  to better follow these, and to give some more
• 14:09
  definitive information to our patients.
• 14:11
  I'm not going to talk about that,
• 14:13
  any more on this podcast.
• 14:14
  but we did a podcast already on this.
• 14:16
  And so you can listen to this
• 14:18
  a little bit more if you're interested.
• 14:19
  So because
• 14:20
  we don't biopsy these currently,
• 14:22
  we monitor these closely.
• 14:24
  And why do we monitor these closely?
• 14:25
  Well, here is,
• 14:27
  one of my favorite examples of this.
• 14:28
  So these are
• 14:29
  eight patients that all have high risk nevi.
• 14:33
  So that means a nevus or caudal
• 14:35
  tumor in the eye that shows some features
• 14:37
  that are concerning.
• 14:38
  We as even as ocular
• 14:40
  oncologists are not sure 100%.
• 14:42
  Is it a melanoma. Is it not.
• 14:43
  So we watch for a short interval
• 14:45
  and you can see here
• 14:46
  some of these half will be completely stable
• 14:50
  and not change.
• 14:51
  And the others will go on to change or grow.
• 14:53
  And that
• 14:54
  change or growth tells us definitively
• 14:56
  this is an ocular melanoma.
• 14:58
  This is a patient who needs treatment.
• 14:59
  So when to ask for a referral,
• 15:02
  if you have any of
• 15:02
  those risk factors
• 15:03
  or if you have any associated
• 15:05
  systemic disorders.
• 15:06
  So now
• 15:06
  that we've discussed
• 15:07
  the early diagnosis and the nevus versus
• 15:10
  melanoma, tension,
• 15:12
  let's talk about some Uveal
• 15:13
  Melanoma treatments.
• 15:14
  And I thought I would give
• 15:16
  just a quick overview
• 15:18
  on the treatment timeline
• 15:19
  and the history of treatment of melanoma.
• 15:21
  So prior to the 1960s,
• 15:23
  a enucleation was the primary
• 15:25
  diagnosis in the US.
• 15:26
  And I like reminding people
• 15:28
  that because the 1960s
• 15:29
  weren't really that long ago. Right.
• 15:31
  And so a lot has changed in this rare disease
• 15:34
  in a short period of time.
• 15:35
  And even in the 1960s, unfortunately,
• 15:38
  there was about a 20% misdiagnosis rate.
• 15:40
  Might have been other things
• 15:41
  that were growing or changing, in the eye.
• 15:44
  So we've gotten better at diagnosis
• 15:45
  and better at treatment.
• 15:47
  In the 1970s,
• 15:48
  there was some thought
• 15:49
  that the enucleation itself, the
• 15:51
  the manipulation of the eye,
• 15:52
  caused tumor spread.
• 15:54
  Now, that has been completely debunked.
• 15:56
  I don't want anyone to worry about that.
• 15:57
  We know that that's not true.
• 15:59
  But that led
• 16:00
  people to think, okay,
• 16:01
  is there something that we can do
• 16:04
  that is not going to cause tumor spread?
• 16:06
  Again, take home
• 16:07
  it was not causing tumor spread,
• 16:09
  but they wanted to see
• 16:10
  if there were any other options
• 16:11
  to manipulate the eye less.
• 16:12
  And in Europe, people were doing plaque
• 16:14
  brachytherapy or various forms
• 16:16
  of radiation therapy to the eye in order to
• 16:19
  save, these eyes with melanoma.
• 16:23
  So in the mid 1980s, again,
• 16:24
  not that long ago, I was alive, right.
• 16:26
  we designed NEI
• 16:28
  in the United States, designed
• 16:29
  the collaborative ocular melanoma studies
• 16:32
  in order to specifically evaluate
• 16:34
  whether it was safe to treat patients
• 16:36
  with this form of radiation,
• 16:38
  where you take a plaque loaded with radioactive
• 16:41
  beads in order to save the eye.
• 16:43
  And these were very well designed,
• 16:45
  long prospective studies
• 16:47
  funded by the National Institute.
• 16:49
  and there are many collaborative
• 16:50
  ocular melanoma studies,
• 16:52
  but the three main ones
• 16:53
  were basically the large, the medium
• 16:56
  and the small tumor trial.
• 16:58
  And the idea between the
• 16:59
  for the large tumor trial was does a patient
• 17:02
  after they have, eye removal need radiation
• 17:06
  because a lot of radiation
• 17:07
  was being done at that time
• 17:09
  and we found that there was no added
• 17:11
  benefit to radiation.
• 17:12
  So this is why we do studies right.
• 17:14
  To really understand
• 17:15
  is something helping a patient.
• 17:17
  Is it hurting a patient.
• 17:18
  Is it not doing anything.
• 17:19
  What should we do as a group.
• 17:21
  And so the large study
• 17:23
  helped us move away from radiation.
• 17:25
  After the eye was removed,
• 17:26
  the medium study
• 17:28
  ushered in a whole new,
• 17:30
  era of saving these eyes again.
• 17:32
  Prior to this,
• 17:33
  the treatment was to remove the eye.
• 17:35
  They looked head to head at eye
• 17:37
  removal versus brachytherapy
• 17:39
  and found that the outcomes overall
• 17:41
  in terms of the patient surviving
• 17:43
  not the eye, but the patient
• 17:45
  surviving or equivalent,
• 17:46
  and that it was safe to offer eye
• 17:48
  salvage therapy for patients
• 17:50
  with medium sized tumor.
• 17:51
  And then for the small tumors, again,
• 17:53
  specifically, because of this tension
• 17:56
  in some of the small tumor studies,
• 17:58
  the idea was can you safely
• 17:59
  watch and monitor these?
• 18:01
  And the answer was yes.
• 18:03
  The risk at five years in terms
• 18:05
  of overall patient survival is low.
• 18:07
  We know we can monitor them
• 18:08
  to make very sure that we're dealing
• 18:10
  with a melanoma before treatment.
• 18:12
  Around that same time in the 70s to 80s,
• 18:15
  proton beam,
• 18:16
  which is another form of radiation
• 18:18
  that is, external it's charged
• 18:20
  particle radiation and a beam of that
• 18:22
  is literally placed
• 18:23
  into the eye to target
• 18:25
  the tumor
• 18:25
  was also gaining popularity in the first,
• 18:28
  was the Harvard Cyclotron.
• 18:30
  And by the mid 2000s and now even passers,
• 18:32
  you know, 20 or more centers
• 18:34
  that do this type of, radiation
• 18:36
  therapy for ocular tumors.
• 18:38
  So the charged particle
• 18:39
  radiation has
• 18:40
  some advantages
• 18:41
  to bring you therapy in that
• 18:43
  you don't have to have two surgeries.
• 18:45
  And the surgery that you do
• 18:46
  have is somewhat smaller
• 18:47
  to place clips in the eye.
• 18:49
  it gives a very uniform dose of radiation,
• 18:52
  but it also radiates all structures
• 18:53
  from the front, to the back of the eye,
• 18:56
  where the brachytherapy
• 18:58
  radiates the structures local to the tumor
• 19:00
  and not so much to the front of the eye,
• 19:02
  unless you're tumor is in the front of the eye.
• 19:04
  In the late
• 19:05
  80s, two current people, including, USC,
• 19:09
  where I have my ocular
• 19:10
  melanoma practice, started
• 19:12
  to look at various forms of plaque
• 19:15
  brachytherapy to make the treatment
• 19:17
  of brachytherapy even better
• 19:19
  and even more localized.
• 19:20
  And they designed the USC
• 19:22
  Eye Physics plaques, which are,
• 19:23
  frankly,
• 19:24
  one of the most common plaques
• 19:25
  now done throughout the US in the world.
• 19:27
  And again,
• 19:27
  I played no part of that,
• 19:28
  but I get to benefit from using them.
• 19:30
  We call these, personalized
• 19:32
  eye plaques.
• 19:33
  So you talk about personalized medicine.
• 19:35
  It means you take information
• 19:36
  about the patient.
• 19:37
  You design your treatment to, that.
• 19:40
  These personalized plaques are similar.
• 19:43
  So we take imaging from the patient,
• 19:46
  make a 3D model
• 19:48
  and design the plaque around the patient.
• 19:50
  So it is not a one size fits all plaque.
• 19:52
  You are not getting the same plaque
• 19:54
  as the person, who was treated
• 19:56
  several weeks before.
• 19:57
  The size, shape and dosage is
• 19:59
  really, is really for the patient
• 20:01
  and for the patient's, tumor.
• 20:03
  And that's done
• 20:04
  to limit radiation toxicity
• 20:06
  to other structures in the eye.
• 20:07
  And so there's a 3D modeling, process
• 20:10
  that's used for this
• 20:11
  to overlay the plaque on to the tumor
• 20:14
  in the eye
• 20:15
  using both the ultrasound
• 20:16
  and either a CT scan or an MRI of the area
• 20:20
  of the called the orbits,
• 20:21
  which is the area around the eye.
• 20:22
  Again,
• 20:23
  to make sure that that plaque is fitting
• 20:25
  within the patient's
• 20:26
  ocular space to best treat their tumor.
• 20:29
  And then we use very specific markers
• 20:31
  to make sure that during the surgery,
• 20:33
  we know exactly where to put
• 20:34
  the plaque in the eye.
• 20:35
  So I'm going to share I think I have time.
• 20:38
  Yep. I still have time despite a little cough.
• 20:40
  sorry again about that, but I'm going to share,
• 20:43
  a two minute surgical video,
• 20:45
  of placing a plaque.
• 20:46
  So if you are sensitive,
• 20:48
  you don't want to see an eye surgery.
• 20:50
  please close your eyes or turn away.
• 20:52
  Once it's done, I'll let you know.
• 20:54
  And it moves fast.
• 20:54
  This is four times speed.
• 20:56
  I don't actually operate this fast.
• 20:57
  So this is
• 20:58
  showing the 3D process of taking the images
• 21:02
  from the CT or MRI and the ultrasound
• 21:05
  to perfectly design a plaque
• 21:07
  for that patient's eye and that patient's tumor
• 21:10
  to give the highest dose of radiation
• 21:13
  to kill the melanoma
• 21:14
  without as much radiation
• 21:16
  to other ocular structures.
• 21:18
  It's not zero.
• 21:18
  But we try to limit
• 21:20
  people ask, how do you get into the eye?
• 21:21
  Well, you have a skin on
• 21:23
  the eye called the conjunctiva.
• 21:24
  And we open that up.
• 21:26
  And then very delicately,
• 21:27
  we mark the exact location.
• 21:29
  This is an ocular muscle.
• 21:31
  I don't always have to take these off,
• 21:33
  but I like to show that sometimes you do,
• 21:35
  and then you mark again using the plan.
• 21:38
  It's all planned out.
• 21:39
  You know exactly where the patient's tumor is.
• 21:41
  You mark where the plaque is
• 21:43
  going to go on the eye wall.
• 21:45
  That white part of the eye wall
• 21:46
  is called the sclera.
• 21:47
  And it's about a millimeter or so thick.
• 21:49
  It depends on
• 21:50
  on which part of the eye you're
• 21:52
  placing those sutures.
• 21:53
  But you place that just there on the eye wall.
• 21:56
  And the first thing
• 21:56
  we do is put a dummy plaque in
• 21:58
  you saw that was hollow in the center.
• 22:01
  You make sure
• 22:01
  with ultrasound that that plaque
• 22:03
  is exactly where you want it to go.
• 22:05
  It's covering the tumor nicely.
• 22:07
  And that's when you put the heat on.
• 22:09
  You put the hot plaque on
• 22:10
  that has the radiation seeds.
• 22:12
  You suture or tie it down in place.
• 22:15
  You close everything up
• 22:17
  and then the patient goes home.
• 22:19
  The timing of plaque is dependent
• 22:21
  a little bit facility to facility,
• 22:23
  but then the patient comes back
• 22:24
  and it's removed in the O.R.
• 22:27
  several days or a week later.
• 22:29
  And here you can see
• 22:30
  gently releasing those sutures,
• 22:32
  the plaque removal.
• 22:33
  I do my plaque removals in the O.R..
• 22:35
  I think it's more comfortable
• 22:36
  for patients, but that's not done
• 22:38
  everywhere. You remove that plaque.
• 22:40
  So again, a very quick thing.
• 22:42
  You close everything up
• 22:43
  and the patients heal up really nicely.
• 22:45
  So let's talk about some options
• 22:48
  for treatment today based on size of tumor.
• 22:52
  So for patients
• 22:53
  who have small tumors again
• 22:55
  brachytherapy or proton beam.
• 22:57
  We've just gone over
• 22:58
  the history of both of those.
• 23:00
  and the way those two mechanisms
• 23:01
  of, of radiation are applied,
• 23:03
  our standard of care
• 23:05
  treatments for small, medium
• 23:07
  and even large, tumors.
• 23:09
  However, we're in an era
• 23:10
  now where we have more trials,
• 23:12
  which is really exciting.
• 23:13
  And as somebody
• 23:14
  who treats these tumors, these don't exist.
• 23:17
  You know, ten or more years ago
• 23:18
  when I started my practice.
• 23:19
  And so I'm really excited about them.
• 23:22
  One such
• 23:22
  trial is the CoMpass
• 23:23
  Trial again, I am not sponsored by or
• 23:26
  I don't work for or I'm just sharing
• 23:28
  information, about this trial,
• 23:30
  and I actually,
• 23:31
  if one of my patients
• 23:32
  is interested in this trial,
• 23:34
  I send them out to an enrolling center.
• 23:36
  So what happens in this trial
• 23:38
  is there's an injection,
• 23:39
  of a medication into the I called Bel-sar.
• 23:42
  It's a novel, therapeutic.
• 23:45
  That's, sort of has a virus component to it
• 23:48
  that, allows an affinity for these tumors.
• 23:52
  And then there's a laser.
• 23:53
  And the laser actually
• 23:54
  activates the drug, right? In the tumor.
• 23:56
  As ophthalmologist, we're all very good
• 23:58
  at, aiming laser beams into the eye.
• 24:00
  We do this for lots of indications.
• 24:02
  And so we can
• 24:03
  then very specifically activate,
• 24:05
  the drug over the tumor.
• 24:07
  However, for you to be,
• 24:09
  eligible for a trial like this,
• 24:11
  you need to have a small, tumor.
• 24:13
  The tumor thickness
• 24:14
  needs to be
• 24:14
  less than 2.5, but also more than, zero.
• 24:18
  We want to make sure that we're actually,
• 24:20
  treating these, high risk early,
• 24:22
  lesions and small melanomas.
• 24:23
  And you also need to have some documented
• 24:25
  tumor growth again for that same reason.
• 24:27
  So you can follow the QR code
• 24:29
  to find out more about that trial here.
• 24:31
  In general, for the medium,
• 24:32
  tumor trials again, brachytherapy
• 24:34
  and proton beam are standard of care.
• 24:37
  Although this is
• 24:38
  changing a little bit as well.
• 24:40
  with an early, some early news
• 24:42
  from some of our large tumors.
• 24:43
  And this includes, a trial
• 24:45
  from Ideya Biosciences.
• 24:47
  And so in this trial, they're using, Daro
• 24:50
  which is an oral medication.
• 24:52
  It's a small molecule inhibitor of protein
• 24:56
  which is something that we
• 24:57
  know to be activated in these melanoma cells.
• 25:00
  And so you can turn it off.
• 25:01
  this is also actively
• 25:03
  enrolling, for patients
• 25:04
  who have tumors that are planned
• 25:06
  for a enucleation or brachytherapy
• 25:09
  and hot off the press.
• 25:10
  As of June third,
• 25:12
  the company released some early results from
• 25:15
  their initial trial.
• 25:16
  And what they found
• 25:17
  is that from 12 patients
• 25:19
  who are planned for a enucleation
• 25:21
  or eye removal, nine of them were able
• 25:23
  to, preserve their eye by taking, Daro for six
• 25:27
  months beforehand.
• 25:28
  And so their take home was that
• 25:30
  this is not taking the melanoma away,
• 25:32
  but it's providing meaningful
• 25:34
  shrinkage of the tumor.
• 25:35
  to either
• 25:36
  avoid a nucleation
• 25:37
  or provide a smaller dose,
• 25:39
  for Brachytherapy therapy.
• 25:40
  And so this is evolving
• 25:42
  lots of more information
• 25:43
  and will be released, I'm sure, in the future.
• 25:46
  At the time of whichever treatment you choose,
• 25:49
  most physicians,
• 25:51
  we'll talk to you about a biopsy.
• 25:53
  Now, it is my practice
• 25:54
  to offer a patient a biopsy.
• 25:56
  but let them choose
• 25:57
  whether or not they want it.
• 25:59
  Most of my patients, but not all of them do.
• 26:01
  and for very, very small tumors like less than
• 26:05
  two millimeters that are right next to the
• 26:07
  I might not want to biopsy those patients
• 26:10
  because I think the risk
• 26:12
  may be greater than the benefit
• 26:14
  or the likelihood of
• 26:15
  them having a high risk, tumor profile is low,
• 26:18
  but this is all something
• 26:19
  that you need
• 26:20
  to understand it
• 26:21
  to talk to your doctor about,
• 26:22
  because there are options here.
• 26:24
  And as the patient, you should be, empowered
• 26:27
  to activate those options
• 26:28
  and make a choice that's right for you.
• 26:30
  So the biopsy that's done is usually in FNAB
• 26:34
  That means fine needle aspiration biopsy.
• 26:36
  So again,
• 26:37
  doesn't mean we cut the whole tumor out,
• 26:39
  but instead it means we take a small
• 26:41
  to, small needle
• 26:42
  about the size of, I don't know, ten
• 26:44
  or more human hairs put together.
• 26:46
  Place it in the tumor
• 26:47
  just to take some cells out.
• 26:49
  It is in general, again,
• 26:51
  not done for diagnosis.
• 26:52
  We already talked
• 26:53
  about that as it relates
• 26:54
  to the nevus versus melanoma question,
• 26:57
  but rather it's done for prognosis.
• 27:00
  And the prognosis
• 27:01
  that we're looking at
• 27:02
  right now is the prognosis
• 27:04
  that this tumor
• 27:05
  will show up in the body in the future.
• 27:07
  So prognosis for metastatic disease
• 27:10
  in my practice, the, the biopsy, mechanism
• 27:14
  that I choose to identify
• 27:15
  prognosis is use of Castle
• 27:17
  Bioscience is again
• 27:18
  I have no I don't work for, Castle Biosciences,
• 27:22
  but Castle Bioscience is uses
• 27:23
  a gene expression profiling assay,
• 27:26
  which basically means it tells us
• 27:28
  which genes are turned on
• 27:29
  and which genes are turned off in the tumor.
• 27:32
  And we know from
• 27:33
  very good studies
• 27:34
  that this helps us prognosticate
• 27:37
  how likely it is
• 27:38
  that the tumor might show up in the body.
• 27:40
  There are also, aside from class
• 27:42
  one and class two,
• 27:43
  there's also BAP one, monosomy 3 and Prame .
• 27:47
  This is other information
• 27:49
  that you may get.
• 27:50
  Some of this comes from, Castle.
• 27:51
  Some of this comes from
• 27:52
  other types
• 27:54
  of biopsy, like Cytogenetics
• 27:56
  that may be offered to you at your center.
• 27:59
  So just understand
• 28:00
  if a biopsy is offered to you, it's not.
• 28:02
  You should consider
• 28:03
  asking for a biopsy
• 28:05
  and understand
• 28:06
  what kind of biopsy it is
• 28:07
  and what are the biomarkers
• 28:08
  that you are going to get from Castle.
• 28:11
  this is the kind of results
• 28:12
  that are given to the patient, patients
• 28:14
  with class two, of course,
• 28:16
  have a higher risk of developing
• 28:18
  metastatic disease.
• 28:19
  and then
• 28:19
  you're in a good
• 28:21
  position to really understand
• 28:23
  what sort of surveillance
• 28:24
  you need as a patient.
• 28:25
  And so, other factors that are clinical
• 28:28
  also impact, your risk of metastatic
• 28:31
  metastatic disease as a patient.
• 28:33
  And that includes
• 28:34
  age involvement of the ciliary body,
• 28:37
  the size of the tumor,
• 28:38
  both the thickness
• 28:39
  and the diameter of the tumor.
• 28:41
  And again, that chromosome three,
• 28:43
  status is only three is higher risk.
• 28:45
  But what has shown in several studies
• 28:47
  to be
• 28:48
  the most predictive is in fact
• 28:50
  this gene expression profiling class.
• 28:52
  And so that is why in my hands
• 28:54
  this is the test that I use.
• 28:55
  I also at diagnosis stage my patients.
• 28:59
  So I cannot tell you how often I'm asked.
• 29:02
  Well Doctor Barry, I already have
• 29:03
  an ocular oncologist.
• 29:04
  Why do I need another oncologist.
• 29:06
  Well, cancer in the eye, I believe,
• 29:08
  should be staged
• 29:09
  in the same way that cancer
• 29:11
  or anywhere else in the body is staged.
• 29:14
  And so the American joint
• 29:15
  Committee on Cancer is, the,
• 29:17
  group of researchers and physicians
• 29:19
  that come together
• 29:20
  to provide staging guidelines
• 29:22
  for patients with cancer.
• 29:24
  And those guidelines are specific
• 29:26
  to each type of cancer.
• 29:28
  And so for melanoma,
• 29:29
  the staging is based on the size
• 29:31
  and extent of the primary tumor,
• 29:33
  but also whether or not there's
• 29:34
  any sort of metastatic disease
• 29:36
  found in the body at that time.
• 29:38
  To determine that,
• 29:40
  you need to have baseline staging scans.
• 29:43
  In my hands, I generally do a CT
• 29:45
  of the chest, abdomen and pelvis.
• 29:47
  Other places
• 29:48
  might do something different,
• 29:49
  but that's my preference.
• 29:50
  And then again, particularly
• 29:52
  if I'm planning brachytherapy,
• 29:53
  I will get that imaging around the orbits.
• 29:56
  Now, I have heard some, via some patients
• 29:59
  who come to me or at academic meetings.
• 30:01
  People will say, you know,
• 30:02
  we don't need to stage
• 30:03
  these patients with melanoma
• 30:05
  because the risk of them having metastatic
• 30:07
  disease at diagnosis is very low.
• 30:09
  And that's true.
• 30:10
  Thankfully, the vast
• 30:12
  majority of our patients do not have
• 30:13
  any metastatic disease at diagnosis.
• 30:16
  However, we do know that with this, cancer,
• 30:19
  many patients unfortunately
• 30:21
  will go on to develop metastatic disease.
• 30:23
  So I believe that it is important
• 30:25
  to have that baseline staging
• 30:27
  and to partner
• 30:28
  with a medical oncologist
• 30:30
  and have the patient followed
• 30:32
  with a medical oncologist.
• 30:33
  I don't want to get a 5 p.m.
• 30:35
  Friday call Doctor Berry.
• 30:38
  You know, the ultrasound
• 30:39
  showed something in my liver
• 30:40
  and I don't have someone to call to help me.
• 30:43
  I can't treat liver disease.
• 30:44
  So I feel that it's really important
• 30:46
  to have a team based approach.
• 30:47
  And thankfully, one of my colleagues
• 30:49
  from the
• 30:50
  other side of the country,
• 30:51
  and we'll be talking to
• 30:52
  you guys about this shortly.
• 30:54
  The last thing that I'd like
• 30:55
  to, talk about before, we move on to some Q&A
• 30:59
  and then
• 30:59
  before I hand off to Doctor Orloff
• 31:01
  for her part of this, webinar
• 31:03
  is another really
• 31:04
  common question I get for my patients.
• 31:06
  So their question is, well, what treatment?
• 31:09
  You know, all this sounds great,
• 31:10
  Doctor Berry,
• 31:11
  but which of these treatments
• 31:12
  is going to bring my vision back to 2020?
• 31:15
  And unfortunately, the answer right now
• 31:17
  is that we do not have a treatment
• 31:19
  that is going to restore
• 31:20
  someone's vision to 2020.
• 31:22
  And in fact, unfortunately,
• 31:24
  the radiation therapy that we do
• 31:25
  is really very good, 98% or better
• 31:29
  at killing the main tumor in the eye,
• 31:32
  the melanoma that's formed in the
• 31:35
  Uveal tract and maintaining it.
• 31:37
  So that's really high success.
• 31:39
  We're really good at that.
• 31:40
  But the dose that needs
• 31:42
  to be used to kill
• 31:43
  the tumor is a dose that can cause damage
• 31:46
  to structures in the ocular space.
• 31:48
  So as I discussed,
• 31:49
  there are many people, around the country,
• 31:52
  in the world
• 31:53
  that are working on different ways
• 31:54
  to maximize the dose of radiation
• 31:57
  that's needed
• 31:58
  to the tumor itself,
• 31:59
  but to decrease it to the ocular structures.
• 32:02
  And so we've done that with the USC eye
• 32:04
  physics plaques,
• 32:05
  the Ideaya trial that I discussed.
• 32:08
  So the idea there is you shrink
• 32:09
  the tumor down again to prevent enucleation,
• 32:12
  facilitate radiation,
• 32:13
  and to decrease the dose of radiation
• 32:16
  that might be, needed for an eye,
• 32:18
  all with the goal of maintaining
• 32:20
  as much vision as possible.
• 32:22
  Other things like diabetes, young age,
• 32:24
  use of chemotherapy might impact vision.
• 32:26
  And there are also some ongoing
• 32:28
  trials, including some
• 32:29
  that I hope will be opening
• 32:31
  up, later this year or in 2025,
• 32:33
  looking at injections
• 32:34
  or other therapy for patients unchecked.
• 32:37
  You can see that radiation can continue
• 32:39
  to cause damage in the eye.
• 32:41
  So again,
• 32:42
  this is why it's
• 32:43
  really important
• 32:44
  to be in a place where you can partner
• 32:45
  with your ocular oncologist,
• 32:47
  the retina specialist who's treating you
• 32:49
  to maintain the vision,
• 32:50
  and with the medical oncologist
• 32:53
  to monitor the body.
• 32:54
  So in conclusion,
• 32:55
  uveal melanoma as a rare tumor.
• 32:57
  You need a team and you need a team
• 32:59
  with training for this rare disease,
• 33:01
  including an ocular oncologist
• 33:03
  to diagnose and manage the eye,
• 33:05
  including the treatment sequelae
• 33:07
  as it relates to vision.
• 33:09
  Thankfully, we have new trials
• 33:10
  for better treatments, salvage.
• 33:12
  And I think it's really important
• 33:13
  that, each patient understands
• 33:15
  the role of biopsy,
• 33:17
  whether they want a biopsy
• 33:18
  and if a biopsy is being done,
• 33:20
  what in their case is it looking for?
• 33:22
  This is from our team
• 33:23
  and my two daughters, Daphne and Lilly.
• 33:26
  It's a real honor for me to be part
• 33:28
  of the ocular oncology community.
• 33:30
  I spend my days doing
• 33:32
  melanoma in adults,
• 33:33
  and then retinoblastoma, in children.
• 33:35
  It's very rare to basically focus
• 33:37
  on two diseases as a physician,
• 33:39
  but I love it. Our team loves it.
• 33:41
  And we're so honored
• 33:42
  to take care of these patients
• 33:44
  and to be here
• 33:44
  and share our experience with you all.
• 33:46
  Thank you. Doctor Berry, this was fabulous.
• 33:49
  I absolutely loved everything.
• 33:51
  I feel like I learned
• 33:52
  a ton, even as a, you know,
• 33:53
  patient four years into my diagnosis, who
• 33:56
  my job is, you know, to
• 33:57
  be as immersed in this as some of you guys are.
• 33:59
  And so I love this. Thank you so much.
• 34:02
  please
• 34:02
  make sure that if you are asking questions
• 34:04
  that we are not, able
• 34:06
  to give personal medical advice,
• 34:07
  but we can't give
• 34:08
  generalized medical advice,
• 34:09
  so we'll do our best
• 34:10
  to answer those questions as we go
• 34:11
  I am a physician that treats, diseases
• 34:13
  and or these diseases.
• 34:15
  And, you know, I treat them at USC
• 34:16
  because I share that.
• 34:17
  But I'm not speaking to you
• 34:18
  today as your USC physician.
• 34:21
  I'm speaking to you generally to provide
• 34:22
  education to the melanoma community.
• 34:24
  So I can't answer
• 34:25
  more specific questions,
• 34:27
  but I can give some
• 34:27
  general advice on education.
• 34:30
  Wonderful.
• 34:31
  Kevin says, hi, Doctor Berry
• 34:32
  Next Tuesday will be my five year
• 34:34
  anniversary, of biopsy for ciliary body.
• 34:37
  I had Castle GEP, and next gen sequencing
• 34:40
  resulting in class one A and only one small
• 34:43
  in Gianna AQ.
• 34:44
  That's great.
• 34:45
  That means that you have
• 34:45
  a very low risk profile.
• 34:47
  It says still no.
• 34:49
  That's also really good news.
• 34:50
  Now at five years,
• 34:52
  what is your recommendation
• 34:53
  to patients on Castle prognostic
• 34:55
  genomic testing at first biopsy.
• 34:58
  So yes
• 34:59
  this is my recommendation
• 35:01
  as it relates to my practice
• 35:03
  is that I do use this
• 35:05
  prognostic genomic testing.
• 35:07
  again, I have patients
• 35:08
  who do not want this information.
• 35:10
  I do not force it,
• 35:12
  but I do provide it as something
• 35:13
  that I can do for them.
• 35:15
  When I started out,
• 35:16
  we didn't have adjuvant trials.
• 35:18
  Adjuvant means trials
• 35:20
  after the primary therapy.
• 35:22
  But we do now.
• 35:24
  And some of those trials want to know
• 35:26
  that the patient has these high risk markers.
• 35:28
  So for example,
• 35:29
  they would want to enroll somebody
• 35:31
  with a class two disease
• 35:33
  because it may make sense
• 35:34
  for someone who's high risk
• 35:36
  to have further therapy
• 35:38
  after their primary ocular therapy.
• 35:40
  So I make sure
• 35:41
  my patients are informed about that.
• 35:43
  We have the trials
• 35:44
  that are available, in the office,
• 35:46
  and I can share it with them.
• 35:47
  I also recommend, again,
• 35:49
  that anyone, particularly
• 35:51
  who has a high risk biopsy,
• 35:52
  but really all my patients partner
• 35:54
  with medical oncology.
• 35:55
  There is also a question
• 35:56
  and maybe you're getting to it.
• 35:58
  What do you do after, five years?
• 36:00
  Well,
• 36:00
  I think it depends
• 36:01
  also a little bit on patient's age.
• 36:03
  So if I have a 27 year old who's now 32,
• 36:07
  five years out, I'm
• 36:08
  absolutely going to, strongly recommend
• 36:10
  that they continue, surveillance.
• 36:13
  I am lucky that I also get to treat
• 36:15
  people who might be 105.
• 36:16
  And so they might say,
• 36:18
  you know, I'm kind of over this.
• 36:19
  And I think that's okay, really.
• 36:21
  Just like we I like to personalize our plaques.
• 36:24
  I like to personalize my medicine
• 36:26
  for what the patient needs.
• 36:27
  But this is it's good
• 36:28
  news for you and I'm glad to hear that.
• 36:30
  So our next question is from, Heather.
• 36:32
  And Heather says, is one eye
• 36:33
  injection better than another?
• 36:36
  That is a great question
• 36:37
  and we are studying that.
• 36:39
  So again,
• 36:39
  the ocular oncology community
• 36:41
  is coming forward to do a prospective,
• 36:44
  trial of this.
• 36:45
  The, lead, person
• 36:46
  who's looking at this is Doctor
• 36:49
  so if any of you have
• 36:50
  been treated by him or know him,
• 36:51
  he's a big name in the melanoma community.
• 36:54
  we honestly don't know for sure when you should
• 36:58
  start injections.
• 36:59
  Should the injections
• 37:00
  be steroids or should they be
• 37:02
  an anti-medication?
• 37:04
  How often should you give injections?
• 37:06
  How long should you continue injections?
• 37:08
  Should you do the laser?
• 37:10
  Every single bit of information
• 37:12
  that we have as it relates to
• 37:13
  that are from small studies
• 37:16
  that are often retrospective.
• 37:17
  They're center by center.
• 37:19
  And even among my colleagues.
• 37:20
  our approach to this is different.
• 37:22
  We don't have
• 37:23
  a good head
• 37:24
  to head prospective trial,
• 37:25
  but we will have one soon,
• 37:27
  and I think it will give some good information
• 37:29
  in my hands.
• 37:31
  For most patients, I don't treat it
• 37:33
  until I see signs of retinopathy.
• 37:36
  Some treat earlier.
• 37:37
  There are multiple reasons for that.
• 37:39
  That's just my practice.
• 37:40
  Although in very young patients or patients who
• 37:43
  who ask about it, we talk about it
• 37:45
  and then we talk about, you know,
• 37:46
  some of the real life stuff,
• 37:47
  like what are the insurance implications?
• 37:50
  They might not, cover an injection
• 37:52
  if you don't actually have signs of treatment.
• 37:54
  So doctors hate talking about things like this.
• 37:56
  we just like to provide care,
• 37:58
  but I think it's
• 37:59
  an important dialog with patients.
• 38:00
  So the answer is we don't know.
• 38:02
  think you kind of covered,
• 38:03
  it's about Avastin and injections.
• 38:05
  We kind of covered that one already.
• 38:07
  But if there's anything else
• 38:07
  you want to add feel free.
• 38:09
  Yeah I think,
• 38:10
  you know, when patients do start to show
• 38:12
  signs of radiation changes in the.
• 38:14
  I think it's very reasonable
• 38:16
  to try, Avastin.
• 38:17
  That's usually my first line or another.
• 38:20
  and again, no company.
• 38:22
  I don't work
• 38:23
  with any of the companies
• 38:24
  that do any of the injections.
• 38:25
  So that just is my practice.
• 38:27
  And, you can also use, steroids.
• 38:30
  So sometimes if there's been a really big tumor
• 38:33
  and quickly, the eye is showing a lot of fluid.
• 38:36
  It's something called tumor necrosis syndrome.
• 38:39
  It means your surgeon did a great job.
• 38:41
  Your tumor is dying, but as it's dying,
• 38:43
  it causes a lot of inflammation.
• 38:44
  And so an injected steroid
• 38:46
  can sometimes help there.
• 38:47
  But talk to your doctor
• 38:48
  about what the options are. Okay.
• 38:50
  So Sandra asks, why is cytology
• 38:52
  not done with the biopsy taken
• 38:53
  during brachytherapy to determine malignancy?
• 38:56
  So that's also a great question.
• 38:58
  there's a couple of reasons for this.
• 39:00
  So first of all, the tumor
• 39:02
  biopsy is again small.
• 39:04
  You're taking just a couple of cells.
• 39:06
  We generally
• 39:07
  want to prioritize
• 39:09
  getting the prognostic information.
• 39:11
  And so again sending for genetic or
• 39:13
  genomic
• 39:14
  alteration is via whichever company
• 39:17
  your surgeon likes to use.
• 39:18
  And they can talk to you about that.
• 39:19
  I was just.
• 39:20
  Going to ask
• 39:20
  can we define the word cytology?
• 39:22
  Oh yeah, that's a great question.
• 39:24
  So cytology means
• 39:25
  I'm looking at cells like a cell prep.
• 39:27
  like, for women
• 39:28
  if you've had a pap smear.
• 39:29
  basically, what they're doing
• 39:30
  is taking cells off the service
• 39:32
  and then
• 39:32
  looking at the cells under the microscope
• 39:35
  to see if they're, malignant.
• 39:36
  And so for the tumors in the eye,
• 39:39
  you would then have to go in again
• 39:41
  and do a separate biopsy.
• 39:43
  If you have a big tumor, that's
• 39:44
  probably not that big of a deal.
• 39:46
  But if you have a smaller tumor
• 39:48
  and during multiple times
• 39:49
  with the needle does cause increase risk
• 39:52
  and you've already been diagnosed, right.
• 39:55
  The ocular and call just
• 39:56
  is doing the treatment.
• 39:57
  They've already made
• 39:59
  the decision that you show
• 40:00
  the clinical signs of a melanoma.
• 40:02
  and the worst
• 40:04
  thing that can happen
• 40:05
  is sometimes
• 40:06
  the cytology goes off and they say we didn't
• 40:09
  get enough cells or we're not sure
• 40:12
  or, melanoma cells, nevus versus melanoma
• 40:16
  correlate clinically. That's a common report.
• 40:18
  We get well correlate clinically.
• 40:20
  Are we already correlated clinically.
• 40:22
  And so that's why it's often not done.
• 40:25
  Again my liquid biopsy work
• 40:26
  will not look at cells.
• 40:28
  It'll look at markers from cells.
• 40:29
  But I'm hoping in years to come definitely
• 40:32
  within the next 5 to 10 years, it'll be
• 40:34
  a more frequent thing that's done clinically.
• 40:37
  Well.
• 40:37
  Roger Shaw,
• 40:38
  what is your recommendation
• 40:40
  about follow up
• 40:41
  MRI's to monitor potential Mets?
• 40:43
  So I work with, ocular
• 40:45
  oncologists most of the time.
• 40:46
  Excuse me,
• 40:46
  an oncologist, Geno in at Norris Cancer Center.
• 40:50
  And he has expertise in melanoma.
• 40:53
  And we make
• 40:53
  these decisions together based on the patient.
• 40:56
  So based on how high risk
• 40:58
  the patient is from their biopsy,
• 41:00
  if they are higher risk, we recommend MRI's.
• 41:03
  If they are lower risk
• 41:05
  they might still get an MRI,
• 41:06
  but not as frequently.
• 41:07
  If a patient is fit
• 41:09
  and can have a liver ultrasound
• 41:11
  and they're low risk.
• 41:12
  Sometimes we choose that.
• 41:14
  It really just depends on the patient.
• 41:16
  You'll have patients who can't tolerate
• 41:18
  MRI's for one reason or another.
• 41:20
  and so you really have to
• 41:22
  discuss with the doctor
• 41:23
  your specific risk. Yes.
• 41:25
  Just to add to this question,
• 41:27
  in your opinion, is it
• 41:28
  best, best practice
• 41:30
  to have
• 41:30
  both an ocular oncologist
• 41:32
  and a medical oncologist who, you know,
• 41:34
  specifically is focused on the scan monitoring?
• 41:36
  I just know that
• 41:37
  sometimes I hear about patients who
• 41:38
  their ocular oncologist
• 41:39
  is the one ordering their scans
• 41:41
  for like five, six years.
• 41:42
  And while I, you know, I just
• 41:44
  I kind of I'm curious,
• 41:45
  do you think that that's okay.
• 41:46
  Do you think there's
• 41:47
  a benefit or a risk to that. Yeah.
• 41:49
  So that is not my practice. Yes.
• 41:51
  And and the reason that I gave
• 41:53
  earlier is why
• 41:54
  when I first started out,
• 41:56
  that had been my training.
• 41:57
  And so I did that.
• 41:58
  And like you feel good like you're
• 41:59
  the doctor taking care of the patient.
• 42:01
  You're doing everything.
• 42:02
  And then a patient
• 42:04
  will call you on Friday at 5 p.m.
• 42:06
  and say, there's a new lesion on my scans.
• 42:09
  What do I do?
• 42:10
  Well, now
• 42:11
  you're scrambling to get the patient
• 42:13
  into a medical oncologist
• 42:14
  scrambling to set up a relationship.
• 42:17
  It's highly anxiety
• 42:18
  inducing for the patient.
• 42:20
  And frankly,
• 42:20
  I mean,
• 42:21
  ocular oncologists,
• 42:22
  who are practicing in this field like
• 42:23
  we care about you guys.
• 42:25
  So it's anxiety inducing for us as well.
• 42:28
  I want my patients
• 42:30
  to have an established relationship.
• 42:32
  I will say, I probably shouldn't
• 42:34
  I don't want to get into trouble.
• 42:35
  But I will say
• 42:36
  insurance dictates
• 42:38
  a lot of this, and it can be hard.
• 42:39
  So I have many patients
• 42:41
  whose insurance will not allow them
• 42:43
  to see my medical oncologist.
• 42:45
  The medical oncologist
• 42:46
  that they see might not be as well
• 42:48
  versed in these rare melanomas.
• 42:50
  That's not their fault, right?
• 42:52
  They're probably a wonderful
• 42:53
  medical oncologist.
• 42:55
  They just don't treat these rare diseases.
• 42:57
  And then you find yourself
• 42:58
  in a tough situation.
• 43:00
  I had a, recent experience,
• 43:02
  and I know the patient would be okay
• 43:03
  with me, anonymously sharing these details.
• 43:06
  But the patient was being treated
• 43:08
  with an older protocol.
• 43:11
  for metastatic disease.
• 43:13
  And there had been no discussion
• 43:14
  whatsoever about track.
• 43:16
  no testing for HLA.
• 43:18
  And again, it
• 43:18
  it really is not the oncologists
• 43:20
  fault that that person does not.
• 43:22
  Do you feel melanoma is not an expert in it?
• 43:25
  They are put in an
• 43:26
  uncomfortable situation as well.
• 43:28
  And so
• 43:28
  we really had to
• 43:29
  work together
• 43:29
  to get the patient in with a medical
• 43:31
  oncologist like Doctor Orloff,
• 43:33
  who understands, the current
• 43:35
  best practices for Uveal melanoma.
• 43:37
  So important for you
• 43:39
  all to understand that as well.
• 43:40
  Oh, I feel like that's such a nuanced answer.
• 43:42
  Like it's it's very particular,
• 43:44
  very unique to each patient.
• 43:45
  So thank you.
• 43:46
  we we have time for one more question.
• 43:48
  So if you want to take a look
• 43:49
  at the three that you see and pick
• 43:50
  the one that you want to answer the most,
• 43:52
  and then the other two,
• 43:53
  I will, send those over to you
• 43:54
  if you're willing to
• 43:55
  send an email response and an answer.
• 43:57
  Yeah, sure.
• 43:58
  Well, it seems like
• 43:59
  I can answer
• 44:00
  all of them, I think, in one answer
• 44:01
  because they're sort of
• 44:02
  like they're large tumors.
• 44:04
  How fast do they grow?
• 44:05
  So in general,
• 44:06
  we don't think these tumors grow very fast.
• 44:09
  That being said, you know,
• 44:10
  people really get stuck on this idea
• 44:13
  that if my tumor had been diagnosed
• 44:16
  three months
• 44:16
  or four months earlier, I would have
• 44:18
  a completely different outcome.
• 44:20
  And a lot of good studies
• 44:22
  have shown that that's just not true.
• 44:24
  That is unlikely to be true.
• 44:26
  So a delay in diagnosis of years.
• 44:29
  And by the way, I'm saying
• 44:30
  multiple years surely is impactful.
• 44:32
  A delay in diagnosis of months is
• 44:34
  is very unlikely to be impactful.
• 44:37
  These are not fast or rapidly growing tumors.
• 44:40
  And yes, we do know
• 44:41
  that some tumors are heterogeneous,
• 44:44
  but by and large there is a dominant clone.
• 44:48
  And that dominant clone
• 44:49
  is what's driving your risk.
• 44:51
  And so that's why we believe
• 44:52
  that biopsies,
• 44:53
  not just for this tumor but for every cancer
• 44:56
  have a role.
• 44:56
  So people like to kind of pounce
• 44:58
  sometimes on heterogeneity.
• 45:00
  But then you look at our breast cancer
• 45:01
  patients, all of our patients
• 45:03
  we use biopsy and we use markers
• 45:05
  to prognosticate risk.
• 45:07
  And to I'm hoping
• 45:08
  we'll get there to identify a treatment
• 45:11
  that is best for those tumors.
• 45:13
  We don't stop doing that
• 45:14
  just because there might
• 45:15
  be some small levels of heterogeneity.
• 45:17
  What's dominant is dominant.
• 45:19
  Just like
• 45:20
  you might have some changes
• 45:21
  in your personality.
• 45:22
  You might be shy sometimes
• 45:24
  and not shy other times.
• 45:25
  But how you are in general,
• 45:26
  that's your dominant clone.
• 45:27
  And so you can think about tumors
• 45:28
  the same way.
• 45:29
  I think that's such a good way to explain.
• 45:31
  Well, Doctor Berry,
• 45:32
  thank you
• 45:32
  so much for answering all these questions
• 45:34
  for this presentation,
• 45:36
  for the information you shared.
• 45:37
  If anyone has specific questions
• 45:39
  or wants to get in touch with you directly,
• 45:40
  is there a good way for them to do so?
• 45:42
  Yeah, absolutely.
• 45:43
  So, I am online,
• 45:45
  so I blog
• 45:46
  and I talk as much
• 45:47
  as I can about ocular oncology at on Instagram
• 45:50
  @Moda underscore moda underscore MD.
• 45:54
  I cannot provide medical advice there,
• 45:56
  but I can provide education
• 45:58
  or you can reach out to me, via USC
• 46:01
  I do accept, patients
• 46:02
  for specific questions there as well.
• 46:04
  Excellent.
• 46:05
  Well, Doctor Berry, we thank you for your time.
• 46:07
  Thank you.
• 46:07
  For those of you who tuned in live
• 46:09
  and this will be recorded.
• 46:10
  You can catch the recording
• 46:11
  on our YouTube channel and on the Eye
• 46:13
  Believe podcast at your listening channels.
• 46:15
  at your pleasure.
• 46:16
  For now, though, I'm going to go ahead
• 46:17
  and let Doctor Berry back to her day,
• 46:19
  and we're going to bring on Doctor
• 46:20
  Marlena Orloff from the other
• 46:22
  side of the country here. Right.
• 46:23
  Thank you all.
• 46:24
  You're going to end this
• 46:25
  wonderfully with my colleague.
• 46:26
  And I really appreciate you guys
• 46:28
  sticking with my cough, and letting me be here.
• 46:30
  Bye we have Doctor Orloff. Hello.
• 46:33
  How are you, Doctor Orloff? Hi, everybody.
• 46:35
  All right, well, like I said,
• 46:37
  this is Doctor Marlena Orloff.
• 46:38
  She is joining us all the way
• 46:39
  from the other side of the country
• 46:41
  on the East coast in Philadelphia,
• 46:43
  at Thomas Jefferson Hospital
• 46:45
  with the Sidney Kimmel Cancer Center.
• 46:46
  So Doctor
• 46:47
  Orloff is a medical oncologist,
• 46:49
  and we are thrilled to have her here
• 46:51
  to talk about navigating
• 46:52
  a Uveal melanoma metastatic diagnosis.
• 46:55
  I think Doctor Berry, you know,
• 46:56
  summed up, things great there just in the last
• 46:59
  few minutes that, you know, that
• 47:00
  there is a little bit of a baton pass,
• 47:02
  you know, that that happens,
• 47:04
  after a patient has a new diagnosis
• 47:07
  of metastatic melanoma.
• 47:08
  normally that baton passes
• 47:10
  kind of most
• 47:11
  seamless when,
• 47:12
  the patient already has a relationship
• 47:14
  with a medical oncologist.
• 47:15
  And I'll talk a little bit about that, but,
• 47:17
  we certainly are grateful
• 47:18
  for our ocular oncology
• 47:20
  colleagues
• 47:20
  who, will also pick up the phone
• 47:22
  and call us if, one of their patients,
• 47:24
  has a new has a new concern.
• 47:26
  So thank you, doctor Barry,
• 47:27
  for kind of setting the stage.
• 47:29
  And we will jump right in.
• 47:30
  So, as,
• 47:31
  as the name mentioned,
• 47:33
  the title of my talk is navigating
• 47:34
  a Metastatic Uveal melanoma diagnosis.
• 47:37
  So what I wanted to do, is, is really kind
• 47:40
  of set this talk up in chronological order,
• 47:44
  kind of based on
• 47:45
  how one actually experiences
• 47:48
  a new metastatic diagnosis.
• 47:50
  so I don't necessarily go into detail
• 47:52
  about surveillance and what,
• 47:54
  you know, leads up to to the suspicion.
• 47:57
  I think part of that
• 47:57
  was part of Doctor Berry's talk.
• 47:59
  and then also today is really not meant
• 48:01
  to be a, discussion of the,
• 48:02
  of all of the data, including recently
• 48:04
  reported trials or trials in progress.
• 48:06
  I actually encourage
• 48:07
  you, there's lots of other webinars,
• 48:09
  I think, that have been on on this topic,
• 48:11
  and I will say that
• 48:13
  actually, here at Jefferson,
• 48:14
  we're having a patient symposium,
• 48:16
  for which
• 48:16
  a Cure In Sight
• 48:16
  actually going to be there,
• 48:17
  just tomorrow,
• 48:18
  you can only attend in person,
• 48:20
  but it will be recorded and then,
• 48:21
  available online as well.
• 48:23
  we're kind of each of the,
• 48:24
  treatment approaches to metastatic disease
• 48:26
  actually has its own session.
• 48:28
  so a lot of the information
• 48:29
  can be reported there and has been
• 48:31
  also detailed elsewhere in other webinars.
• 48:33
  So really, like I said,
• 48:34
  today is really just kind of going through,
• 48:36
  you know, the navigation
• 48:37
  checklist of kind of what the steps are,
• 48:39
  that someone may experience
• 48:41
  and kind of how to think about those,
• 48:43
  if you're in the middle of going through this,
• 48:45
  or certainly,
• 48:46
  unfortunately, you have to
• 48:47
  go through it in the future.
• 48:48
  so here you can see
• 48:49
  kind of an outline for the talk.
• 48:51
  So, you know, with things
• 48:53
  like epic, and other electronic
• 48:56
  medical records, it is honestly often
• 48:59
  the patient who gets an alert on their phone
• 49:02
  that a radiology read is available for review
• 49:06
  and may actually see
• 49:08
  the report before the physician.
• 49:09
  certainly, if my patients
• 49:11
  are getting their scans, outside of Jefferson,
• 49:14
  it's going to end up in whatever
• 49:15
  local portal, exists there
• 49:18
  before it ends up getting either
• 49:19
  electronically sent over
• 49:21
  to my in basket
• 49:22
  or even old school
• 49:24
  paper fax and then upload it.
• 49:26
  And so,
• 49:27
  you know what I, what I wanted to kind of
• 49:29
  kind of highlight here
• 49:31
  is that, you know,
• 49:32
  that you get the alert
• 49:33
  that the MRI report is ready for review.
• 49:36
  and for those of you
• 49:37
  who've had the experience
• 49:38
  of of reading MRI reports, you know,
• 49:40
  you want to scroll down,
• 49:41
  you want to see the impression saying,
• 49:43
  you know, no evidence
• 49:44
  of metastatic disease in the liver. Right?
• 49:46
  That's what we all want to see.
• 49:47
  You know, every time we get a scan.
• 49:49
  but unfortunately, there are times where
• 49:51
  even if you've
• 49:52
  had a bunch of negative scans,
• 49:54
  you know, the impression is not that.
• 49:55
  And the impression
• 49:57
  may be something as kind of definitive
• 49:59
  as, you know,
• 50:00
  extensive hepatic metastatic
• 50:02
  metastasis with,
• 50:03
  you know, a large mass, it may even suggest
• 50:05
  that there's cancer outside of the liver.
• 50:08
  you know, in and what that translates
• 50:10
  to is,
• 50:10
  what you can see here
• 50:11
  on the right is, you know, this
• 50:13
  being an MRI, this being the liver
• 50:15
  here, the brighter white
• 50:16
  being normal to,
• 50:18
  normal liver and then the dark spots
• 50:19
  here, these circles being tumor.
• 50:21
  And then
• 50:21
  actually this whole left lobe, here is a tumor.
• 50:24
  So this is not subtle.
• 50:25
  There's no,
• 50:26
  kind of clinical confusion
• 50:27
  about what's happening here.
• 50:29
  we would still offer
• 50:30
  biopsy for this patient to confirm,
• 50:32
  which we'll talk about in a second.
• 50:33
  but but this is pretty obvious.
• 50:35
  on the client, on the opposite end.
• 50:37
  there are times where patients
• 50:38
  could have had an MRI.
• 50:39
  Multiple,
• 50:40
  you know, many multiple MRI,
• 50:42
  or maybe their first MRI.
• 50:43
  and the impression is
• 50:45
  there appears to be
• 50:45
  a new lesion in the lobe, left lobe
• 50:47
  measuring often under a centimeter.
• 50:50
  but given the history of malignancy,
• 50:52
  Mets cannot be excluded.
• 50:53
  Close interval follow up is recommended.
• 50:56
  So here
• 50:56
  the radiologist is actually saying
• 50:58
  well we think this could be match.
• 51:00
  You know close interval
• 51:01
  follow up is recommended.
• 51:02
  And there are times
• 51:04
  where close follow up is recommended.
• 51:06
  But you know often times
• 51:08
  we do actually aim to biopsy.
• 51:11
  So if someone's undergoing
• 51:12
  close surveillance.
• 51:13
  So certainly
• 51:14
  the high risk, patients who are being followed
• 51:16
  say every three months with, with MRI,
• 51:19
  it is not unlikely, uncommon for an MRI
• 51:23
  to pick up something
• 51:24
  that's new under a centimeter,
• 51:26
  in which case biopsy may be difficult.
• 51:28
  sometimes the urgency
• 51:29
  for a biopsy may be dependent
• 51:31
  on how suspicious something looks,
• 51:33
  the size of it, the location.
• 51:35
  Though we tend to say that
• 51:36
  anything new or growing,
• 51:38
  certainly in the liver, needs to be evaluated.
• 51:40
  It and biopsy at least attempted,
• 51:43
  if it's outside the liver,
• 51:44
  and it's a lung nodule, we often actually
• 51:47
  monitor those,
• 51:48
  I would say for for longer,
• 51:49
  you know,
• 51:50
  someone may have a couple of new three,
• 51:52
  four millimeter lung nodules.
• 51:54
  It is unlikely
• 51:55
  that's usually related to Uveal melanoma.
• 51:57
  Not to say that it's, you know,
• 51:59
  never Uveal melanoma
• 52:00
  because we certainly have patients
• 52:01
  who present with lung, metastasis first.
• 52:04
  and that's like a whole different kind
• 52:05
  of subset of patients.
• 52:06
  But there's also a lot of other things
• 52:08
  that can cause lung nodules, you know,
• 52:10
  bad bronchitis or, you know, certainly
• 52:12
  we were seeing it a lot during times of Covid.
• 52:15
  so not every lung lesion is Uveal melanoma.
• 52:17
  but, you know, in
• 52:19
  someone with a history of melanoma,
• 52:20
  it's usually any newer growing
• 52:22
  liver lesion really is Uveal
• 52:24
  until proven otherwise.
• 52:25
  Lung lesions,
• 52:26
  if they get big enough over a centimeter,
• 52:28
  and we will often recommend a Pet scan,
• 52:30
  which we normally don't, do at least
• 52:31
  in my practice for the liver.
• 52:33
  And I would say
• 52:34
  if all the patients
• 52:34
  that I've evaluated for melanoma
• 52:36
  who's had a new lung lesion,
• 52:38
  I probably actually picked up,
• 52:40
  incidental lung cancer, probably more than
• 52:43
  first diagnosis, metastatic melanoma.
• 52:45
  So they still need to be worked
• 52:47
  up, still needs to be biopsied if suspicious.
• 52:49
  but they are a little bit
• 52:50
  of a different breed.
• 52:51
  in our practice, basically because we,
• 52:54
  you know,
• 52:55
  I have an interventional radiologist
• 52:56
  who's very good, at ultrasound
• 52:58
  guided biopsy,
• 52:59
  if a lesion is greater than seven
• 53:01
  millimeters, and location appropriate
• 53:03
  biopsy is often feasible,
• 53:04
  if it's sizable, but the location is hard
• 53:07
  for ultrasound and percutaneous biopsy,
• 53:09
  we sometimes sent to a surgeon
• 53:10
  for an exploratory kind of laparoscopy
• 53:13
  where they can look at the liver,
• 53:14
  and get to area,
• 53:15
  sometimes even use intraoperative
• 53:16
  ultrasound to get a biopsy there.
• 53:18
  but if it's small or hard to access,
• 53:20
  then actually scans at two months interval.
• 53:22
  So that close interval follow up that
• 53:23
  the radiology suggested, can be reasonable.
• 53:26
  Even if we can prove
• 53:29
  metastatic melanoma for a lesion
• 53:31
  under one centimeter,
• 53:32
  it does actually pose some challenges
• 53:34
  for treatment decisions.
• 53:35
  So often
• 53:36
  things under a centimeter
• 53:37
  are too small for clinical trial,
• 53:39
  sometimes even too small.
• 53:40
  for certain liver directed therapies.
• 53:42
  And, you know,
• 53:43
  we certainly have patients where we may
• 53:46
  say, you know what, let's
• 53:47
  wait until it's over a centimeter to biopsy.
• 53:49
  Or even if we biopsy it
• 53:51
  at seven millimeters, we say, oh,
• 53:53
  but there's a first line clinical trial
• 53:54
  that we really want,
• 53:55
  you know, to, to, to wait for.
• 53:57
  So we may get another scan
• 53:59
  and wait for it to get over
• 54:00
  a centimeter, which I know seems crazy.
• 54:02
  and for those of you
• 54:03
  who listening, who you've kind of been
• 54:04
  in that limbo, it's
• 54:05
  an uncomfortable place to be.
• 54:07
  But, it is a little bit of kind of a diagnostic
• 54:09
  and then kind of treatment conundrum
• 54:11
  that we sometimes find, that
• 54:12
  we sometimes find ourselves in, in.
• 54:14
  The truth is, though,
• 54:14
  if lesions are multiple and sizable,
• 54:16
  you know, you shouldn't be waiting to biopsy.
• 54:19
  And I guess this also goes to the point
• 54:21
  I did put a bullet here,
• 54:22
  but it is our practice that we do not treat
• 54:25
  without biopsy confirmation.
• 54:26
  There have been patients over the years
• 54:28
  that, you know,
• 54:29
  even though it looks like you feel melanoma,
• 54:32
  it turns out to be something else.
• 54:33
  So sometimes you pick up things like,
• 54:35
  chronic granulomatous disease,
• 54:37
  which is kind of a
• 54:38
  type of inflammatory process
• 54:39
  that can happen, in the liver,
• 54:41
  in which case, you know, we obviously would not
• 54:43
  then treat for metastatic melanoma.
• 54:44
  So biopsies are necessary
• 54:47
  certainly required for, for clinical trials.
• 54:49
  And they're required for
• 54:50
  in our practice for treatment.
• 54:51
  So the next thing
• 54:52
  kind of in the checklist that I had
• 54:54
  mentioned, is something called HLA testing.
• 54:56
  So I think for those of you
• 54:58
  who are not new to that, to the UVM
• 54:59
  melanoma community,
• 55:00
  I've heard about HLA testing.
• 55:02
  what is HLA and why does it matter?
• 55:04
  We'll talk about that.
• 55:05
  so HLA stands for human leukocyte
• 55:07
  antigen, also called MHC.
• 55:09
  it encodes cell surface molecules
• 55:12
  that are basically responsible
• 55:13
  for presenting bits of antigen to T cells.
• 55:16
  So antigen can be the, you know,
• 55:18
  bacteria, antigen can also be tumor.
• 55:20
  and the immune system really kind of uses
• 55:22
  HLA to differentiate self versus non-self.
• 55:25
  but here in kind of cancer fighting terms,
• 55:28
  it's really the MHC or the HLA that presents
• 55:30
  bits of cancer to the immune system.
• 55:33
  And then in theory, the immune system
• 55:35
  should recognize that as being a bad guy
• 55:37
  and, and kill it, as you can see by the,
• 55:38
  the diagram there.
• 55:40
  So why does it matter in Uveal melanoma?
• 55:42
  well, because, really the only systemic, drug
• 55:45
  that's specifically approved
• 55:46
  for Uveal melanoma, something called to
• 55:49
  is what we call HLA restricted.
• 55:51
  so, in order to be eligible for,
• 55:54
  you need to be, specifically hla A2O1.
• 55:57
  and so testing for this
• 55:58
  really should be offered
• 55:58
  to all patients either
• 55:59
  in the surveillance period
• 56:01
  or at first, metastatic diagnosis.
• 56:03
  before treatment, decisions are made.
• 56:05
  there are many different types of HLA.
• 56:07
  And so in order to develop
• 56:09
  kind of this drug,
• 56:10
  the you can kind of, see here, it's
• 56:12
  kind of the this, this intact,
• 56:14
  this blue guy here,
• 56:15
  it needed to basically be engineered
• 56:17
  to interact with a particular
• 56:19
  HLA that would present the peptide,
• 56:21
  because there's kind of
• 56:22
  this, there's this linking
• 56:23
  that has to happen in order for the T-cell
• 56:25
  to then kill the cancer.
• 56:26
  So, and HLA A2 is the most common
• 56:28
  found in all ethnic groups.
• 56:30
  And 0201 is
• 56:31
  is the most common in Caucasians,
• 56:33
  and of European descent
• 56:34
  which make up a bulk of patients
• 56:36
  who are diagnosed
• 56:36
  with, uveal melanoma so,
• 56:38
  I just wanted to kind of take a step back.
• 56:40
  And I think Doctor
• 56:41
  Berry started
• 56:42
  to kind of allude to this,
• 56:43
  and that why it's so important to
• 56:45
  to seek care in an expert center
• 56:48
  or have a medical oncologist
• 56:49
  who's in touch with
• 56:50
  folks at an expert center,
• 56:52
  or even if
• 56:53
  you have a local oncologist,
• 56:54
  you know, to kind of
• 56:55
  have your foot in the door.
• 56:57
  in an expert center.
• 56:58
  And, and that's really because, you know,
• 57:00
  and Uveal melanoma, you know, it's rare.
• 57:02
  You know,
• 57:03
  you've probably heard about the incidence
• 57:05
  and prevalence not only in Doctor
• 57:07
  Berry's talk, but but elsewhere.
• 57:08
  But in the metastatic realm,
• 57:10
  there's really growing complexity,
• 57:12
  in, in the treatment landscape.
• 57:14
  and so I think it's
• 57:15
  really important to be at a center
• 57:16
  that has knowledge at least
• 57:17
  of the broad landscape.
• 57:19
  So, you know, not only knowledge of
• 57:21
  melanoma as distinct melanoma subtype,
• 57:23
  you know, obviously different
• 57:24
  from skin melanoma, knowledge of treatment
• 57:26
  indications and criteria.
• 57:28
  So, you know, knowledge
• 57:29
  of what HLA is and why having
• 57:32
  that information is important.
• 57:33
  knowledge of standard of care
• 57:34
  treatments and ability to offer
• 57:36
  or refer when unable to offer.
• 57:38
  So, you know,
• 57:39
  not every oncologist in the US
• 57:41
  is able to offer to many of us,
• 57:43
  it is a little bit quirky and unique
• 57:45
  in that there's,
• 57:45
  you know,
• 57:46
  some inpatient hospitalizations
• 57:47
  and for a long monitoring period
• 57:49
  with the first three doses.
• 57:50
  But at least if if a site is aware
• 57:52
  that the drug exists,
• 57:53
  if they can't offer it
• 57:54
  themselves
• 57:55
  or at least be able to refer to a site
• 57:56
  that can knowledge of clinical trials
• 57:58
  that are open now
• 57:59
  and in the near future,
• 58:00
  and really knowledge of inclusion
• 58:01
  and exclusion criteria of those trials.
• 58:03
  So, you know, the, the,
• 58:05
  the last thing we want
• 58:06
  patients to do
• 58:07
  is to get a treatment, say, you know,
• 58:09
  immune checkpoint and inhibition
• 58:11
  kind of
• 58:12
  as a first choice because the medical
• 58:15
  oncologist may not be aware
• 58:16
  of what's out there.
• 58:17
  That then makes them ineligible for a trial.
• 58:20
  there we do have a first line trial right now.
• 58:22
  that's that I'm going to detail
• 58:23
  that's very specific
• 58:24
  to HIV negative patients,
• 58:25
  but you can't have had prior immunotherapy
• 58:27
  because that's actually a comparator arm.
• 58:29
  So, you know,
• 58:30
  you don't want to be somewhere where,
• 58:33
  you know, something may be offered.
• 58:34
  The thing could exclude
• 58:35
  from from treatments down the line.
• 58:37
  And you don't always have a crystal ball.
• 58:38
  but at least,
• 58:39
  someone who's, you know, willing to,
• 58:40
  like I said, reach out to an expert center
• 58:43
  who may have that those ideas.
• 58:45
  And, there are opportunities
• 58:47
  to seek recommendations
• 58:48
  from a, an expert center
• 58:50
  and then get treatment closer to home.
• 58:51
  So, I gave the example of
• 58:54
  So there's a lot of sites
• 58:55
  that may not offer
• 58:55
  the first
• 58:56
  few doses
• 58:57
  because of the, complexity
• 58:58
  of the prolonged monitoring period.
• 59:00
  but we have
• 59:01
  a number of patients actually, probably
• 59:03
  almost three quarters
• 59:04
  of our patients who come get
• 59:05
  induction at our site.
• 59:07
  we then actually refer to an oncologist
• 59:09
  closer to where they live.
• 59:10
  and that works out really well.
• 59:11
  you know, standard of care,
• 59:12
  immune checkpoint inhibitors.
• 59:14
  So if, if things like
• 59:16
  are recommended, those can certainly be
• 59:18
  done closer to home.
• 59:19
  There are some liver directed therapies
• 59:21
  that can be done closer to home.
• 59:23
  you know, obviously
• 59:23
  now with being, FDA approved, in theory,
• 59:27
  it could be done kind of anywhere.
• 59:28
  But it's also,
• 59:29
  kind of a unique treatment
• 59:30
  and it's not necessarily
• 59:31
  being offered everywhere,
• 59:32
  but things like radio embolization in y 90?
• 59:35
  because it's offered
• 59:35
  for other cancers often can be, offered
• 59:37
  at a local at a local hospital.
• 59:39
  however, despite kind of having
• 59:41
  some of those options, as many of you know,
• 59:43
  there are still often a need
• 59:44
  to travel, for clinical trials
• 59:46
  or even sometimes just basic treatment
• 59:48
  and just sometimes
• 59:49
  really just the comfort of being somewhere
• 59:51
  where you know that
• 59:52
  even if you start on treatment,
• 59:53
  A, they could
• 59:54
  potentially offer you that treatment
• 59:55
  B and then treatment C,
• 59:56
  and not have to be kind of go into to multiple,
• 1:00:00
  multiple sites.
• 1:00:01
  So, I started
• 1:00:02
  really framing a lot of my talks
• 1:00:04
  kind of around this,
• 1:00:05
  because this is really what,
• 1:00:06
  ends up
• 1:00:07
  going into the decision making,
• 1:00:08
  both kind of with the patient
• 1:00:10
  and then also actually behind the scenes,
• 1:00:11
  you know,
• 1:00:12
  when we talk about patients
• 1:00:13
  and talk about, you know, what
• 1:00:14
  treatment approach may be best,
• 1:00:16
  there's really five things.
• 1:00:17
  So hla status,
• 1:00:18
  which I'll go
• 1:00:19
  into a little bit
• 1:00:20
  more that we already talked about it,
• 1:00:21
  the sites of metastatic disease,
• 1:00:23
  how quickly
• 1:00:24
  things are going or growing,
• 1:00:26
  and how much tumor there is.
• 1:00:27
  So what I call burden and kinetics,
• 1:00:29
  clinical trial availability.
• 1:00:30
  And then
• 1:00:31
  and then really some of the
• 1:00:32
  I've kind of title is logistics.
• 1:00:34
  And so these are
• 1:00:35
  all kind of things
• 1:00:36
  that we kind of throw in the pot.
• 1:00:37
  But you know,
• 1:00:38
  when we're trying to decide what,
• 1:00:40
  what treatment may be best for a patient.
• 1:00:41
  So one of the first break points,
• 1:00:43
  as we noted,
• 1:00:44
  is HLA status because of the
• 1:00:46
  availability of of fast.
• 1:00:48
  So if someone is H1n1 positive,
• 1:00:50
  they are eligible for to bed to fast.
• 1:00:52
  There are other HLA restricted options.
• 1:00:55
  so there are other clinical trials
• 1:00:57
  that may and role specifically a 201.
• 1:00:59
  and then there are actually also trials now
• 1:01:01
  or soon to be enrolling
• 1:01:03
  for another subtype called 824
• 1:01:05
  which is kind of one of the more common
• 1:01:06
  subtypes as well.
• 1:01:08
  So having your HLA type, not just knowing
• 1:01:11
  if your
• 1:01:12
  positive or negative, but actually
• 1:01:13
  knowing kind of what hla
• 1:01:15
  you have,
• 1:01:16
  could be helpful for, for treatment options.
• 1:01:19
  And then if you're a 201 negative, in theory,
• 1:01:22
  all of the other options,
• 1:01:23
  outside of those that are restricted to
• 1:01:25
  a 201 an option.
• 1:01:26
  And then very specifically,
• 1:01:27
  there are trials for patients
• 1:01:29
  who are HLA, A201, a one negative.
• 1:01:31
  So having that information out front,
• 1:01:34
  right before it, you know, before
• 1:01:36
  first line treatment is really important.
• 1:01:38
  so the current options to treat them
• 1:01:39
  kind of based on HLA status,
• 1:01:41
  you know, I already kind of
• 1:01:42
  said this and so many terms
• 1:01:44
  you can see it, you can see it here.
• 1:01:46
  And you know, again, I'm not going to go
• 1:01:48
  too much in detail.
• 1:01:49
  There are full hours available online.
• 1:01:52
  We can learn all about another webinars.
• 1:01:54
  But more recently we did published
• 1:01:56
  a three year overall survival
• 1:01:58
  was compared
• 1:01:59
  to the control arm, which was single agent,
• 1:02:02
  you know, therapy or chemotherapy.
• 1:02:04
  and what you can kind of take home from here
• 1:02:05
  is that even going out now?
• 1:02:07
  three years or more?
• 1:02:08
  there's still kind of a
• 1:02:10
  break in there, in the survival curve.
• 1:02:12
  So with more patients alive in the first arm,
• 1:02:15
  that then
• 1:02:15
  the control arm, you know,
• 1:02:17
  some of the
• 1:02:17
  other things,
• 1:02:18
  you know,
• 1:02:18
  that were originally reported
• 1:02:19
  haven't changed a whole heck of a lot.
• 1:02:21
  You know,
• 1:02:21
  we still don't see a ton of response,
• 1:02:25
  so you can see, you know,
• 1:02:26
  only one patient, had a complete response.
• 1:02:28
  patients have had partial response,
• 1:02:30
  but a lot of patients having stable disease,
• 1:02:32
  especially when you compare it
• 1:02:33
  to the control group.
• 1:02:34
  And it's really these patients too,
• 1:02:35
  with stable disease.
• 1:02:36
  Or even if their best response
• 1:02:37
  was progressive disease
• 1:02:38
  and they kind of
• 1:02:39
  plateau, still showing kind of an improvement
• 1:02:41
  in, in overall survival compared.
• 1:02:43
  and then this is again, just showing that,
• 1:02:46
  even patients
• 1:02:47
  who have progressive disease,
• 1:02:48
  do tend to do
• 1:02:48
  better than those
• 1:02:49
  who had progressive disease in the control,
• 1:02:51
  probably due to phenomenon,
• 1:02:52
  sometimes progression before kind of plateau,
• 1:02:55
  or other things that we still haven't
• 1:02:56
  totally, figured, figured out.
• 1:02:58
  and then what
• 1:02:59
  you see here is, in case
• 1:03:00
  this has come up in discussion
• 1:03:01
  with any of your medical oncologists,
• 1:03:03
  is that at least on the trial,
• 1:03:04
  we looked at something
• 1:03:05
  called circulating tumor DNA,
• 1:03:07
  and there was a thought that correlation
• 1:03:09
  of kind of outcome
• 1:03:10
  and survival with log reduction
• 1:03:13
  in circulating tumor DNA correlated
• 1:03:15
  better than actually radiographic response.
• 1:03:17
  so there are some folks that are checking ctDNA
• 1:03:20
  kind of in, in practice, the platform
• 1:03:22
  that was used in
• 1:03:22
  the trial is a bit
• 1:03:23
  different than the one that's
• 1:03:24
  commercially available, so it's hard to know
• 1:03:27
  if it'll kind of stand stand up.
• 1:03:29
  compared to what was done in the trial.
• 1:03:30
  But for some patients, it can be a useful tool.
• 1:03:33
  so like I mentioned, there are other
• 1:03:34
  HLA restricted considerations.
• 1:03:36
  the most common HLA in most of the trials
• 1:03:38
  will restrict for a 201.
• 1:03:40
  but they'll
• 1:03:41
  look out for an expansion to,
• 1:03:42
  to A24 and potentially even other HLA types.
• 1:03:45
  So even if you are not
• 1:03:46
  A2O1 positive, like I mentioned,
• 1:03:48
  there is a first line
• 1:03:49
  trial that's actually enrolling
• 1:03:51
  specifically A2 negative patients.
• 1:03:53
  so this is the, randomized
• 1:03:55
  trial looking, to get kind of
• 1:03:57
  registration or FDA approval
• 1:03:58
  of the combination of drive
• 1:04:00
  assertive and present in IB.
• 1:04:01
  so it's a 2 to 1 randomization.
• 1:04:03
  you need to be a two, one negative.
• 1:04:05
  and then you're
• 1:04:05
  randomized to either get, draw
• 1:04:07
  a sort of an active or investigators, choice,
• 1:04:09
  which I think for the
• 1:04:10
  most part, at least in the US, is your boy and
• 1:04:14
  so why, are we excited
• 1:04:18
  and that's because, you know,
• 1:04:19
  we've been doing the trials
• 1:04:20
  for actually quite a long time
• 1:04:22
  initially with just also called,
• 1:04:24
  some of you may have heard is Id1 96.
• 1:04:27
  and then in combination
• 1:04:27
  with which is actually a
• 1:04:29
  drug that's approved in, lung cancer.
• 1:04:31
  and when we were doing the,
• 1:04:33
  the other trials in patients
• 1:04:34
  who'd been previously treated, you know,
• 1:04:36
  you can see
• 1:04:36
  by these waterfall plots
• 1:04:37
  that the majority of
• 1:04:38
  the patients were going down.
• 1:04:40
  So that means
• 1:04:41
  the majority of the patients
• 1:04:42
  had some shrinkage of tumor.
• 1:04:43
  Anyone kind of over this -30%,
• 1:04:46
  that's considered a response.
• 1:04:47
  So you see an overall response of 45%.
• 1:04:50
  This is first line, 95% of patients
• 1:04:52
  had shrinkage, disease control 90%.
• 1:04:55
  and here,
• 1:04:55
  this is any line to patients
• 1:04:57
  even who've been previously treated,
• 1:04:58
  here in overall response of 30 at 92%
• 1:05:01
  at tumor shrinkage disease control of 89%.
• 1:05:04
  So you know, these these are numbers
• 1:05:06
  that we've never seen
• 1:05:07
  before in melanoma and metastatic melanoma.
• 1:05:10
  so it's a it's very exciting.
• 1:05:11
  so the hope is that this drug,
• 1:05:13
  will get approved, following this trial.
• 1:05:16
  you know, I will say
• 1:05:16
  and some of you have heard
• 1:05:17
  and I, I think it's been shared
• 1:05:19
  kind of in
• 1:05:19
  some of the, in the, online support groups
• 1:05:21
  and whatnot that,
• 1:05:22
  even though the first line trial
• 1:05:23
  is restricted to a to positive
• 1:05:25
  or a negative patients, there
• 1:05:27
  may be an opportunity soon for patients
• 1:05:29
  who are A2 positive who, got to
• 1:05:32
  be enrolled, not on this trial,
• 1:05:34
  but actually on
• 1:05:34
  an arm of the, of the original, trial
• 1:05:37
  that that is actually shown here.
• 1:05:39
  so more to come on that.
• 1:05:40
  so the other thing that, I like to consider,
• 1:05:42
  you know, when deciding which treatment option
• 1:05:45
  first, is where the tumors are.
• 1:05:47
  So, as many of you know, patients
• 1:05:49
  with metastatic
• 1:05:50
  melanoma,
• 1:05:50
  the first place that it likes to go,
• 1:05:52
  and often the place that can become life
• 1:05:54
  threatening is in the liver.
• 1:05:55
  but there are patients
• 1:05:56
  who have either extra paddock
• 1:05:58
  only or extra paddock dominant.
• 1:06:00
  you know,
• 1:06:00
  they may have a couple little ugly
• 1:06:01
  liver lesions, but they, you know, have
• 1:06:03
  a whole lot of stuff going on the line.
• 1:06:05
  So that is a that is a decision point.
• 1:06:07
  So if they're
• 1:06:08
  hepatic dominant you may want to consider
• 1:06:09
  liver directed therapy.
• 1:06:10
  You can also consider
• 1:06:11
  systemic therapy or even combination.
• 1:06:13
  And and then extra paddock dominant.
• 1:06:15
  You're probably going
• 1:06:16
  to want to choose a systemic therapy.
• 1:06:17
  So as I mentioned, you know,
• 1:06:19
  I would say more than 90% of the time,
• 1:06:21
  liver metastatic burden is really
• 1:06:22
  what's dictating survival.
• 1:06:24
  some treatments have some restrictions
• 1:06:26
  regarding sites of disease. so
• 1:06:30
  really limits the sites of
• 1:06:31
  extra paddock disease.
• 1:06:32
  So you can't really have
• 1:06:33
  like a whole lot going on in the lung
• 1:06:35
  or a whole lot going on in the bone.
• 1:06:37
  You can have some sites
• 1:06:38
  that may be amenable to radiation,
• 1:06:39
  but not not a lot going on.
• 1:06:41
  other liver directed therapies.
• 1:06:42
  we tend to be less stringent.
• 1:06:44
  there are trials coming
• 1:06:45
  that you need kind of injectable disease.
• 1:06:47
  so that all kind of be a, any a parameter that,
• 1:06:50
  that needs to be considered,
• 1:06:51
  rare to have extra paddock disease only.
• 1:06:54
  often it can be associated
• 1:06:55
  with, you know,
• 1:06:56
  long as the primary site,
• 1:06:57
  there's a specific mutation called SF 31.
• 1:07:00
  where sometimes we see in those patients,
• 1:07:02
  tend to have lung first, at least.
• 1:07:04
  In. There tends to be kind of a better
• 1:07:05
  prognosis overall.
• 1:07:07
  and though many patients
• 1:07:08
  may start with extra paddock only, most,
• 1:07:10
  if not all kind of eventually
• 1:07:12
  develop liver metastasis,
• 1:07:13
  which even if you started with stuff
• 1:07:15
  outside the liver, it's
• 1:07:16
  still sometimes the liver that becomes
• 1:07:18
  what's, what's life threatening.
• 1:07:20
  and then the important thing
• 1:07:21
  is that there's a number of trials
• 1:07:22
  that are coming out
• 1:07:23
  to address groups of patients
• 1:07:25
  with combination
• 1:07:25
  hepatic and extra paddock disease.
• 1:07:27
  I mean, it's just the reality
• 1:07:28
  that that often, what we see
• 1:07:30
  and we need treatments
• 1:07:31
  and trials that, address that.
• 1:07:33
  So, just a few slides on PHP and Hablado.
• 1:07:36
  this has been discussed kind of for years.
• 1:07:38
  most recently, was FDA approved,
• 1:07:40
  last, almost a year ago now.
• 1:07:42
  and, and then the publication
• 1:07:43
  actually just, recently,
• 1:07:45
  came out, looking at the efficacy
• 1:07:46
  and safety, really, of just a single arm.
• 1:07:49
  so there was kind of two arms in the trial,
• 1:07:51
  but this is really a publication on the
• 1:07:52
  on the patients who got, who that got
• 1:07:54
  PHP so, you know,
• 1:07:55
  here, on the left
• 1:07:56
  hand corner, is
• 1:07:57
  just kind of an illustration of what
• 1:07:59
  PHP is.
• 1:08:00
  it's a catheter system, essentially
• 1:08:02
  that kind of closed circuits the liver
• 1:08:04
  so that you can perfused the liver
• 1:08:06
  with chemotherapy through the artery.
• 1:08:08
  Then the blood, kind of goes
• 1:08:09
  through the liver, collected
• 1:08:10
  in the, in the big vein.
• 1:08:12
  but because there's a balloon
• 1:08:13
  at the top of the bottom, the,
• 1:08:14
  the blood just kind of goes in the middle
• 1:08:16
  so it doesn't go to the rest of the body,
• 1:08:18
  then that blood is kind
• 1:08:18
  of sucked out,
• 1:08:19
  put through a filter system,
• 1:08:21
  and then put back into the body.
• 1:08:23
  and this can be done, up
• 1:08:24
  to six times, typically every,
• 1:08:26
  every six, every 6 to 8 weeks.
• 1:08:28
  so here you can just see a snapshot.
• 1:08:30
  And again, this, this at this publication
• 1:08:32
  is now out, of how patients did.
• 1:08:34
  So there were seven patients
• 1:08:35
  who actually had
• 1:08:37
  a, a complete response,
• 1:08:38
  26% that had partial response.
• 1:08:41
  and then another 34%,
• 1:08:42
  that had some stable disease.
• 1:08:44
  you can see duration of response.
• 1:08:46
  you know, the one year
• 1:08:46
  overall survival, 80%, which is
• 1:08:48
  is pretty impressive here.
• 1:08:50
  overall survival two years, 43%.
• 1:08:53
  and so, you know, and then there
• 1:08:54
  specifically, hepatic kind of end points.
• 1:08:56
  So really just looking, at the liver,
• 1:08:58
  and so with an overall response rate,
• 1:09:00
  so kind of
• 1:09:01
  percentage of patients
• 1:09:02
  in which the tumor did shrink, 3,636%.
• 1:09:05
  and then this is a, survival
• 1:09:07
  curve of showing patients
• 1:09:09
  who had that complete response.
• 1:09:10
  You know, obviously, they, they
• 1:09:12
  their survival
• 1:09:12
  was much better compared to those
• 1:09:14
  that even
• 1:09:14
  just had
• 1:09:15
  a partial response
• 1:09:16
  or stable disease,
• 1:09:16
  but being better than patients who would
• 1:09:19
  only had progression.
• 1:09:20
  and, you know,
• 1:09:21
  while it's
• 1:09:22
  not in this current publication,
• 1:09:24
  in some of the original
• 1:09:25
  presentations that are available,
• 1:09:27
  I think online, this this looked better than
• 1:09:30
  the patients who were treated,
• 1:09:31
  the comparator arm,
• 1:09:32
  which was mostly just chemo, embolization,
• 1:09:35
  but of various kind of types
• 1:09:36
  because it was dependent on the location.
• 1:09:38
  So, you know,
• 1:09:39
  I would say
• 1:09:39
  other than HLA in that first breakpoint
• 1:09:42
  and maybe even more so,
• 1:09:44
  at least at our institution,
• 1:09:46
  kind of overall tumor burden
• 1:09:48
  and how quickly things are growing
• 1:09:50
  probably, weighs the most in, in how
• 1:09:53
  we decide on treatment,
• 1:09:54
  because
• 1:09:55
  if you have a patient who has bulky tumors,
• 1:09:58
  you know, large
• 1:09:59
  tumors, tumors that are growing quickly, you
• 1:10:01
  sometimes you got one chance.
• 1:10:03
  and so, you know, you don't want to delay,
• 1:10:05
  you don't want to kind
• 1:10:06
  of make the wrong first move
• 1:10:07
  because that can really affect
• 1:10:09
  what happens down the line.
• 1:10:10
  So, you know,
• 1:10:11
  we often
• 1:10:11
  take this parameter very seriously
• 1:10:14
  and in making recommendations.
• 1:10:15
  So if,
• 1:10:16
  if tumors are big
• 1:10:17
  or growing quickly,
• 1:10:18
  you know, really want to be able
• 1:10:20
  to start something quickly.
• 1:10:22
  So unlike what Doctor
• 1:10:23
  Berry said
• 1:10:23
  about the primary eye tumor, where,
• 1:10:25
  you know, a delay of a couple of months,
• 1:10:27
  probably not going to change much here
• 1:10:29
  inUveal The amount
• 1:10:30
  metastatic, Uveal melanoma,
• 1:10:32
  you know, sometimes tumors
• 1:10:33
  can double in a week.
• 1:10:33
  and so if we have a couple of time points
• 1:10:35
  that are telling us that's
• 1:10:36
  how quickly things are growing,
• 1:10:38
  you know, you need to start something quickly.
• 1:10:39
  And ideally we would also start
• 1:10:41
  something that has a higher response rate.
• 1:10:42
  Right.
• 1:10:43
  If you're starting out with a lot of tumor,
• 1:10:44
  you want to be able to shrink that tumor.
• 1:10:46
  Whereas if there's limited tumor burden
• 1:10:48
  or you now
• 1:10:48
  have a couple of scans
• 1:10:49
  where things aren't growing slowly
• 1:10:51
  because that does also happen,
• 1:10:52
  you know,
• 1:10:53
  then it really
• 1:10:53
  all option should be considered
• 1:10:54
  and you should be looking at all
• 1:10:55
  the other parameters that I mentioned.
• 1:10:57
  And so going back to those two,
• 1:10:59
  kind of cases here, you know,
• 1:11:00
  if it's really just a solitary tumor
• 1:11:02
  and not even a centimeter, you know,
• 1:11:04
  some treatments may actually be reserved,
• 1:11:06
  you know, meaning
• 1:11:07
  if it's not quite a centimeter,
• 1:11:08
  you may not have a clinical trial.
• 1:11:10
  you know, certainly,
• 1:11:11
  if there is a positive first line
• 1:11:13
  for these patients, makes sense.
• 1:11:14
  There are certain liver
• 1:11:15
  directed therapies
• 1:11:16
  that we don't necessarily recommend
• 1:11:17
  if there's really just one solitary,
• 1:11:19
  you know, one centimeter tumor.
• 1:11:20
  and then the thing that does
• 1:11:21
  sometimes come into play here is
• 1:11:22
  if there's really one tumor,
• 1:11:24
  and we always kind of make the rule, you know,
• 1:11:27
  there needs to be
• 1:11:27
  a little bit of time between the eye
• 1:11:29
  diagnosis and the scan,
• 1:11:30
  because sometimes
• 1:11:31
  you just want to make sure it's not like,
• 1:11:32
  you know, just the tip of
• 1:11:33
  the iceberg type thing.
• 1:11:34
  and also like to see it at least on a couple
• 1:11:36
  of scans, that there's really just one.
• 1:11:38
  That's when things like
• 1:11:39
  ablation can be appropriate.
• 1:11:41
  so, you know,
• 1:11:42
  and I say ablation
• 1:11:42
  almost kind of loosely here now
• 1:11:44
  because there's a number
• 1:11:45
  of different things you can do. So true.
• 1:11:47
  Kind of microwave radiofrequency ablation.
• 1:11:49
  there's other new strategies
• 1:11:50
  for kind of targeting, solitary lesions
• 1:11:54
  sometimes just focus radiation
• 1:11:55
  if ablation
• 1:11:56
  that able to be done accessed,
• 1:11:58
  that those can all be, offered
• 1:11:59
  if the tumors are large and growing quickly.
• 1:12:02
  Want to start something immediately?
• 1:12:04
  percutaneous hepatic
• 1:12:05
  perfusion does have an exclusion
• 1:12:06
  for greater than 50% involvement.
• 1:12:08
  clinical trials.
• 1:12:09
  While we love clinical trials,
• 1:12:11
  you know,
• 1:12:11
  there are patients that can't
• 1:12:13
  wait a month, necessarily.
• 1:12:15
  and we of all, you know, as
• 1:12:17
  you know,
• 1:12:17
  who do clinical trials
• 1:12:18
  in this space have all seen patients
• 1:12:20
  that were referred for clinical trial.
• 1:12:21
  And the time
• 1:12:22
  it kind of takes to kind of
• 1:12:23
  get the patient there
• 1:12:24
  to do a little bit of the screening, you know,
• 1:12:26
  all of a sudden you've,
• 1:12:27
  you've lost control of, of the liver.
• 1:12:28
  And that can be an issue here.
• 1:12:30
  You know, watching liver function
• 1:12:31
  very closely in these patients.
• 1:12:33
  you can offer
• 1:12:34
  with chemo embolization,
• 1:12:35
  which is often kind of, at our institution,
• 1:12:38
  what we offer patients with very large
• 1:12:40
  tumors, who, who are growing quickly,
• 1:12:42
  because that's sometimes our best chance
• 1:12:44
  of kind
• 1:12:44
  of stopping things
• 1:12:45
  until we have a very effective
• 1:12:46
  systemic therapy.
• 1:12:48
  which going back to just,
• 1:12:49
  you know, bring up the Daro story.
• 1:12:51
  You know,
• 1:12:51
  if these
• 1:12:52
  pills really show us
• 1:12:53
  that we can shrink tumors
• 1:12:54
  in that percent of patients,
• 1:12:56
  you know,
• 1:12:56
  that may also be
• 1:12:57
  a good option for those patients in the future.
• 1:12:59
  We know that patients,
• 1:13:00
  who were on the trial, who had bulky disease.
• 1:13:03
  So we call M1 C disease, which means largest
• 1:13:05
  tumor greater than eight centimeters.
• 1:13:07
  those patients did not do well with
• 1:13:09
  out of the gate.
• 1:13:10
  has, you know,
• 1:13:12
  kind of a lower overall response rate
• 1:13:14
  than we would like to see,
• 1:13:15
  patients can get that locally.
• 1:13:17
  so normally, if there's a patient
• 1:13:19
  who has a lot of tumor, tumors progressing,
• 1:13:22
  maybe symptomatic, if they can't get to,
• 1:13:25
  you know, an expert center for,
• 1:13:27
  you know, something else.
• 1:13:28
  Sometimes those are the patients
• 1:13:29
  will recommend just start nivo locally.
• 1:13:31
  because normally that can be
• 1:13:33
  started within days or a week.
• 1:13:34
  larger liver tumors,
• 1:13:36
  those patients could be symptomatic.
• 1:13:37
  So we also want to make
• 1:13:39
  sure that they're not having nausea
• 1:13:40
  or vomiting or pain.
• 1:13:41
  And and may refer to, palliative
• 1:13:43
  care for, for help with management of that.
• 1:13:45
  So, just a little note,
• 1:13:47
  you know, about chemo embolization again we,
• 1:13:50
  we offer that
• 1:13:50
  quite a bit for patients
• 1:13:52
  with really large,
• 1:13:53
  tumors
• 1:13:53
  who are progressing quickly, and have shown
• 1:13:55
  in various, publications over the years,
• 1:13:58
  you know, patients with, you know, here
• 1:14:00
  the darker spots or tumors.
• 1:14:02
  this is a before kind of in
• 1:14:03
  after you don't really see that big guy
• 1:14:05
  kind of shrunk down here.
• 1:14:06
  here's another one that was treated with
• 1:14:08
  something called
• 1:14:08
  dead docs, which is a type of chemo
• 1:14:10
  embolization followed by more standard.
• 1:14:12
  So this is a big oh, sorry,
• 1:14:14
  my cursor is on the wrong side
• 1:14:15
  is a big tumor right here.
• 1:14:17
  and then this is 15 months later.
• 1:14:18
  The tumor shrank, kind of significantly there.
• 1:14:20
  so, so this is, an option
• 1:14:22
  for some of our patients with larger tumors.
• 1:14:24
  and I mentioned ablation for kind of solitary
• 1:14:26
  tumors or, you know,
• 1:14:28
  I think what we also say is patients
• 1:14:30
  who have kind of oligo metastatic progression.
• 1:14:32
  So, so they had, you know, ten tumors
• 1:14:34
  and only one was growing.
• 1:14:36
  sometimes also oblate, oblate, those and we,
• 1:14:39
  we often, like I said, typically reserve.
• 1:14:41
  You know,
• 1:14:41
  I think this three year mark is probably a
• 1:14:43
  little more liberal now.
• 1:14:44
  but certainly if a patient, say, just
• 1:14:46
  had plaque radiation or nucleation,
• 1:14:48
  you know, say two months ago
• 1:14:50
  and now they have a solitary lesion,
• 1:14:52
  it's normally not a great sign.
• 1:14:53
  Normally other lesions are
• 1:14:54
  going to pop up soon,
• 1:14:55
  but if it's been two, 3 to 5, seven, ten years
• 1:14:59
  and really just seeing
• 1:15:00
  one solitary lesion and then often they're,
• 1:15:02
  a good potentially ablation candidate.
• 1:15:04
  and we looked at a small cohort
• 1:15:06
  of those patients here, who had metastatic
• 1:15:08
  or what we call kind of that rogue lesion.
• 1:15:10
  and it actually they had a two year OS of 76%.
• 1:15:13
  so some patients went
• 1:15:13
  almost three years
• 1:15:14
  without needing any other therapy
• 1:15:16
  after management of just that, that one tumor.
• 1:15:18
  and here's an example of a patient.
• 1:15:20
  So here's this here was ablated.
• 1:15:22
  That's what it looks like.
• 1:15:23
  Oh it's called diffusion.
• 1:15:24
  So it's bright white post.
• 1:15:25
  You can see it almost looks like it's bigger.
• 1:15:27
  But that's actually just the ablation cavity.
• 1:15:29
  It's kind of just like a crater.
• 1:15:30
  And then you don't see anything
• 1:15:31
  active here on diffusion.
• 1:15:33
  there are like
• 1:15:33
  I mentioned, there's other ablation
• 1:15:34
  like techniques being explored.
• 1:15:36
  None yet have a whole lot of data
• 1:15:38
  in metastatic melanoma.
• 1:15:40
  and then also focus
• 1:15:40
  radiation can also be used
• 1:15:42
  when lesions can't be
• 1:15:43
  easily accessed, by other modalities.
• 1:15:46
  So Pivoting now to, to clinical trials.
• 1:15:48
  you know,
• 1:15:49
  I was trying to figure out
• 1:15:50
  which graphic, really was most appropriate
• 1:15:53
  for illustrating all of the layers
• 1:15:56
  that we think about when we talk
• 1:15:58
  about clinical trials with patients.
• 1:16:00
  So, you know, the availability,
• 1:16:02
  is there just a trial that exists?
• 1:16:04
  what is the inclusion criteria?
• 1:16:05
  What is the exclusion criteria?
• 1:16:07
  What phase of the trial is it a phase one trial
• 1:16:10
  where we're
• 1:16:11
  only going to get one
• 1:16:12
  slot every month or two,
• 1:16:14
  because you need to clear a cohort
• 1:16:16
  to see if
• 1:16:17
  and a safe dose,
• 1:16:18
  and then they'll only allow
• 1:16:18
  three more patients on
• 1:16:20
  is it a phase three trial
• 1:16:22
  where there's a randomization arm?
• 1:16:23
  the trial logistics, the schedule,
• 1:16:26
  how frequently do you have to be there?
• 1:16:27
  Are there do you just come in,
• 1:16:29
  take your pill, go home or get your infusion?
• 1:16:31
  Or are you here for 14 hours?
• 1:16:33
  you know, all that kind of stuff.
• 1:16:34
  Are there biopsies involved?
• 1:16:35
  you know,
• 1:16:36
  what are the side effects
• 1:16:37
  and are they in line with, you know,
• 1:16:39
  what a patient is, is willing to experience
• 1:16:42
  and then, you know,
• 1:16:43
  really just
• 1:16:44
  very, just practically the
• 1:16:46
  time to start treatment.
• 1:16:47
  You know,
• 1:16:47
  if it's an issue of slot allocation,
• 1:16:49
  you know, it could be months
• 1:16:50
  until a slot becomes available.
• 1:16:52
  If slots are available, the time
• 1:16:54
  it takes to come in consent screen,
• 1:16:56
  and then start, you know,
• 1:16:57
  at minimum it's normally about 21, 28 days.
• 1:17:00
  so all of these things
• 1:17:02
  really need to be considered,
• 1:17:03
  you know, when you say, okay, clinical trial,
• 1:17:05
  you know,
• 1:17:05
  I will say that
• 1:17:07
  clinical trial availability
• 1:17:08
  in metastatic melanoma, ebbs and flows.
• 1:17:11
  you know,
• 1:17:11
  I think a year or two ago,
• 1:17:13
  there was
• 1:17:14
  so many trials,
• 1:17:15
  it was kind of like
• 1:17:16
  hard to pick and
• 1:17:17
  and lots of trials for all different
• 1:17:19
  patients every stage of the game.
• 1:17:20
  we're in a little bit of a lull right
• 1:17:22
  now, so,
• 1:17:23
  at least in the U.S, as of this week,
• 1:17:25
  I think there's only one liver directed trial.
• 1:17:28
  that's, actually here at Jefferson,
• 1:17:29
  and we are about to
• 1:17:30
  finish enrollment very soon.
• 1:17:32
  when it comes to targeted therapy
• 1:17:33
  trials, there's this trial called DYP
• 1:17:36
  688, which, is open, but slots have been
• 1:17:39
  hard to come by.
• 1:17:40
  Moffit actually has probably the most
• 1:17:42
  in the way of trials right now.
• 1:17:43
  with these three trials, one is a radiation
• 1:17:45
  trial and two are kind of looking at drugs.
• 1:17:48
  This is a drug that's used in breast cancer.
• 1:17:49
  And this is another drug that's,
• 1:17:51
  actually approving cutaneous melanoma
• 1:17:53
  combined with other things.
• 1:17:54
  this is probably the most, important trial
• 1:17:56
  right now for the Uveal melanoma community.
• 1:17:58
  This is the first line, Darrow Carrizo trial
• 1:18:00
  that that I mentioned already.
• 1:18:01
  and there's this other phase
• 1:18:02
  one study that's open at a few sites.
• 1:18:04
  and then for immunotherapy trials,
• 1:18:06
  there's a couple of trials.
• 1:18:07
  there's a, drug called
• 1:18:10
  plus pembro, there's a trial
• 1:18:12
  looking at something
• 1:18:13
  called tumor treating fields.
• 1:18:14
  and then there's this other trial
• 1:18:15
  of Smith Lab, which is immunotherapy,
• 1:18:17
  and then a kind of a, a, vascular inhibitor.
• 1:18:20
  also at Moffitt.
• 1:18:21
  so, you know,
• 1:18:22
  I would say kind of compared to,
• 1:18:24
  like I said, a couple years back,
• 1:18:25
  there's not a whole heck of a lot that's going
• 1:18:27
  on, at least trials that are open
• 1:18:28
  even at multiple sites.
• 1:18:30
  but more are, more are coming.
• 1:18:32
  So, the last bit of that kind of not pi,
• 1:18:36
  but the
• 1:18:36
  for the, for parameters
• 1:18:38
  and then the one in the middle of logistics.
• 1:18:40
  I just really want to highlight
• 1:18:41
  because I think
• 1:18:42
  sometimes, we forget
• 1:18:44
  that, you know, while HLA status is important,
• 1:18:46
  where the tumors are, is important
• 1:18:48
  and how quickly
• 1:18:49
  things are growing is important.
• 1:18:50
  you know, clinical trial availability,
• 1:18:51
  veterinary say that's important.
• 1:18:53
  what's really important is, is the patient,
• 1:18:55
  and you know,
• 1:18:56
  with, with the field kind of evolves
• 1:18:59
  and like I said, becoming more
• 1:19:00
  and more complex with standards
• 1:19:01
  care options with, kind of off
• 1:19:03
  label options,
• 1:19:04
  with clinical trial options,
• 1:19:05
  you really do need to weigh
• 1:19:06
  things like patient priorities,
• 1:19:08
  needs, wants, preferences,
• 1:19:10
  quality of life concerns.
• 1:19:12
  You know, is the patient still working?
• 1:19:14
  So, you know, if a patient still working,
• 1:19:17
  then a clinical trial
• 1:19:18
  and the patient needs to be working,
• 1:19:20
  then a clinical trial
• 1:19:20
  where they need to be at a different city
• 1:19:22
  three days a week is not feasible.
• 1:19:24
  you know, distance to getting that treatment.
• 1:19:26
  Other medical issues, insurance cost,
• 1:19:30
  you know, things that we really don't
• 1:19:31
  want to have in the equation.
• 1:19:33
  I mean, I
• 1:19:34
  and I hate to even ever have to make a decision
• 1:19:37
  based on those things,
• 1:19:38
  but sometimes it's just that
• 1:19:39
  it's just the reality of it,
• 1:19:41
  you know, family commitment.
• 1:19:43
  I put on their vacation, because,
• 1:19:44
  you know, I,
• 1:19:45
  I've had a couple of patients that, you know,
• 1:19:47
  we talked about a clinical trial.
• 1:19:48
  It's like, okay, we're going to start,
• 1:19:50
  you know, July 1st.
• 1:19:52
  and then you need to be back on day eight,
• 1:19:53
  which is the following week.
• 1:19:54
  And it's like,
• 1:19:55
  oh, actually, like, that's the one week
• 1:19:57
  my family goes on vacation and,
• 1:19:59
  and we don't ever want to get away in the way
• 1:20:01
  of, of patients being able
• 1:20:03
  to spend quality time with their family.
• 1:20:05
  So there's times literally
• 1:20:06
  where we will shift
• 1:20:07
  an entire clinical trial enrollment, or
• 1:20:10
  or postpone something or move
• 1:20:12
  something up,
• 1:20:12
  you know, to be in line with whether
• 1:20:13
  it's vacation or someone's
• 1:20:15
  graduation or things.
• 1:20:16
  So, you know, these are the logistics
• 1:20:17
  things that, you know, I know, for me, are part
• 1:20:20
  allowed, part
• 1:20:21
  of what the conversation is
• 1:20:22
  when we're
• 1:20:23
  when we're actually
• 1:20:23
  choosing treatments, in addition
• 1:20:25
  to all the science and all the other things.
• 1:20:26
  because I think it's really important.
• 1:20:27
  so I,
• 1:20:28
  I was asked to kind of just mention
• 1:20:30
  the comment about monitoring
• 1:20:31
  while on treatment.
• 1:20:32
  So you're on treatment, you know,
• 1:20:33
  how should you be followed.
• 1:20:35
  And it really varies
• 1:20:36
  depending on the treatment.
• 1:20:37
  clinical trials may scan as frequently
• 1:20:39
  as every up
• 1:20:40
  to six weeks, or up to 12 weeks.
• 1:20:42
  It may also change depending on
• 1:20:43
  how long on the trial.
• 1:20:44
  So there's some trials where
• 1:20:45
  if you're on for like a year,
• 1:20:47
  you may be scanned
• 1:20:48
  very frequently that first year,
• 1:20:49
  and then it actually extends,
• 1:20:50
  our practice
• 1:20:51
  kind of for metastatic patients on the whole,
• 1:20:53
  is it to scan it of about every eight weeks.
• 1:20:56
  And we do Cat scans, chest MRI, abdomen,
• 1:20:58
  Cat scan, pelvis to kind of get the bulk
• 1:21:00
  of where Uveal melanoma likes to go.
• 1:21:02
  but that can
• 1:21:02
  vary post radio embolization or PHP
• 1:21:05
  given there's different treatment intervals.
• 1:21:07
  It can vary.
• 1:21:08
  It's during immune checkpoint
• 1:21:09
  inhibition or induction.
• 1:21:11
  it can vary.
• 1:21:11
  If patients are on a
• 1:21:12
  treatment break that may shorten
• 1:21:13
  or lengthen the interval.
• 1:21:15
  sometimes we add other imaging modalities.
• 1:21:17
  So MRI of the brain, Pet scans, sometimes
• 1:21:20
  MRIs of different
• 1:21:22
  other parts of the body specifically like
• 1:21:24
  the spine or hips or things like that.
• 1:21:27
  and then I think
• 1:21:27
  one of the take homes
• 1:21:28
  is, is that, you know,
• 1:21:29
  if you're starting a new treatment,
• 1:21:31
  you really should have scans within a month
• 1:21:33
  of starting that new treatment,
• 1:21:34
  because it's really important
• 1:21:36
  to get the best baseline is
• 1:21:37
  things can change quickly.
• 1:21:38
  So you would say you were going
• 1:21:40
  to start a new treatment tomorrow being June,
• 1:21:43
  tomorrow's what June 22nd.
• 1:21:45
  And your last scan was April 4th.
• 1:21:47
  Well, it seems, you know,
• 1:21:48
  like a lot of work to get another scan.
• 1:21:50
  So it's just in April.
• 1:21:51
  What if there's been
• 1:21:51
  a lot of progression since April?
• 1:21:53
  I start on treatment tomorrow.
• 1:21:55
  You may next get your scan in two months.
• 1:21:57
  And if there's been progression
• 1:21:58
  since the scan in April,
• 1:22:00
  you have no idea
• 1:22:00
  if that happened between April
• 1:22:02
  and when you started treatment,
• 1:22:03
  or that the treatment's just not working.
• 1:22:05
  So very important.
• 1:22:06
  for us, we
• 1:22:07
  we were really kind of strict
• 1:22:08
  about that, of about having scans
• 1:22:10
  within within a month
• 1:22:11
  of starting the new
• 1:22:12
  treatment, and then changing
• 1:22:14
  treatment plans and progression.
• 1:22:15
  you know,
• 1:22:15
  I think this is a discussion
• 1:22:17
  best had, you know, with your,
• 1:22:18
  with a multi-discipline injury expert team,
• 1:22:20
  or at least with your oncologist
• 1:22:22
  who's communicating with,
• 1:22:23
  a multidisciplinary team,
• 1:22:25
  sometimes there's
• 1:22:26
  rationale for sequencing.
• 1:22:27
  So sometimes there is
• 1:22:28
  rationale for going from
• 1:22:30
  A to B versus A2D
• 1:22:32
  awareness of trial eligibility.
• 1:22:33
  So there's sometimes you need to be exposed
• 1:22:35
  to something in order to be eligible.
• 1:22:37
  on the opposite,
• 1:22:38
  sometimes if you are exposed to something
• 1:22:40
  then you're not eligible.
• 1:22:42
  and then liver control should, should try
• 1:22:44
  to be maintained through all of it
• 1:22:45
  because that, that unfortunately,
• 1:22:47
  as I've mentioned, is
• 1:22:47
  a thing that can sometimes, get
• 1:22:49
  out of hand and become, life threatening.
• 1:22:51
  So, kind of in conclusion, You know.
• 1:22:53
  The diagnosis.
• 1:22:54
  Well, the diagnosis of
• 1:22:55
  melanoma primary can be overwhelming.
• 1:22:57
  but certainly
• 1:22:58
  the diagnosis of metastatic
• 1:22:59
  melanoma can be overwhelming for,
• 1:23:01
  you know,
• 1:23:02
  I say 101,
• 1:23:03
  but I'm sure it's more like
• 1:23:04
  a gazillion reasons.
• 1:23:05
  And I think having connection
• 1:23:07
  to a knowledgeable medical oncology
• 1:23:09
  team from day one, can often expedite
• 1:23:11
  diagnosis and treatment.
• 1:23:12
  So just as Doctor Berry,
• 1:23:14
  you know, with saying, you know, there's a lot
• 1:23:15
  that can happen in that first week or two.
• 1:23:18
  and it's nice to already be connected.
• 1:23:20
  Biopsy should be attempted.
• 1:23:21
  If tumor suspected,
• 1:23:22
  HLA should have been done
• 1:23:24
  during surveillance or immediately
• 1:23:25
  once metastatic disease is expected.
• 1:23:27
  while
• 1:23:27
  there's a number of FDA approved therapies,
• 1:23:29
  access to these can still be a challenge.
• 1:23:31
  So whether it's
• 1:23:33
  specifically or
• 1:23:35
  specifically, these are not therapies
• 1:23:36
  that are being offered everywhere.
• 1:23:38
  so access can still be an issue.
• 1:23:40
  and having an understanding
• 1:23:41
  of the trial landscape
• 1:23:42
  can be helpful if, sequencing is needed.
• 1:23:44
  and like I said, to avoid things or
• 1:23:46
  get exposure to things.
• 1:23:47
  And then I really do
• 1:23:48
  think it's important to have a treatment plan
• 1:23:50
  that considers the logistics.
• 1:23:51
  So all the other stuff, to work with you
• 1:23:53
  to develop an approach, that is best for you
• 1:23:55
  and that is it.
• 1:23:56
  So as a patient, what can I focus on
• 1:23:59
  if I'm stuck in a waiting period,
• 1:24:01
  either between scans or treatments?
• 1:24:03
  We're unable to have a definitive biopsy
• 1:24:05
  right away while navigating.
• 1:24:08
  Oh, This is this is a tricky one.
• 1:24:11
  you know, I, I say that the limbo,
• 1:24:14
  between scans.
• 1:24:15
  So maybe you haven't had a metastatic
• 1:24:17
  melanoma diagnosis yet, but you're high risk.
• 1:24:20
  So really, the the anxiety between
• 1:24:22
  scans is real,
• 1:24:23
  or there's been a scan
• 1:24:24
  that says, oh,
• 1:24:25
  there's a little
• 1:24:25
  something that we don't like,
• 1:24:26
  but it's too small to biopsy.
• 1:24:28
  We're going to have to get and,
• 1:24:29
  you know, another scan, or something like that.
• 1:24:31
  I mean, I think that's probably
• 1:24:33
  and I don't want to speak for patients
• 1:24:34
  for sure, but it's almost worse
• 1:24:37
  than kind of having the diagnosis
• 1:24:38
  and having a plan. Right.
• 1:24:39
  Everything's better when you have a plan.
• 1:24:41
  and that could just be a
• 1:24:42
  very uncomfortable place to be.
• 1:24:44
  and it's easy to say,
• 1:24:45
  well, just don't think about it.
• 1:24:46
  Just go about your life
• 1:24:47
  and just, like, do all your things.
• 1:24:49
  but that's obviously easier said than done.
• 1:24:51
  you know what
• 1:24:51
  I always tell my patients
• 1:24:53
  who certainly are in that kind of limbo zone
• 1:24:56
  is, listen, we're going to figure it out.
• 1:24:59
  You know, whether it ends up being
• 1:25:01
  something or ends up being nothing.
• 1:25:03
  We're going to figure it out.
• 1:25:04
  And, you know, I know that that.
• 1:25:06
  And for some patients getting data
• 1:25:08
  and knowledge is super helpful.
• 1:25:10
  So they go to the internet
• 1:25:11
  and they research as much as they can,
• 1:25:13
  which is fine.
• 1:25:14
  but I always try to give patients
• 1:25:16
  a comfort in knowing that's also my job.
• 1:25:18
  you know, our job, our collective job is,
• 1:25:20
  you know, specialists in the fields, you know,
• 1:25:22
  medical oncologists, you know, across
• 1:25:24
  the country and, and beyond is
• 1:25:26
  is to know what's going on, right?
• 1:25:28
  And to have a plan, you know, when a plan
• 1:25:31
  needs to be implemented. so I don't know.
• 1:25:33
  That's
• 1:25:33
  not really an exact answer to your question,
• 1:25:35
  but, It's kind of a nuanced question. It's.
• 1:25:37
  It's it's
• 1:25:37
  a tricky place to be,
• 1:25:38
  but you just have to kind of
• 1:25:40
  make sure you're in with the right people,
• 1:25:41
  and just kind of trust that, you know,
• 1:25:44
  they will make the right decisions with you,
• 1:25:47
  you know, certainly.
• 1:25:48
  there's a question about, mental health
• 1:25:49
  supports for patients who are navigating,
• 1:25:52
  diagnosis, treatment and care.
• 1:25:53
  I mean,
• 1:25:53
  I can't speak
• 1:25:54
  more highly about the, advocacy organization.
• 1:25:57
  So number of advocacy organizations
• 1:25:59
  I know A Cure in Site
• 1:26:00
  has, patient support groups.
• 1:26:02
  I know that's not necessarily
• 1:26:03
  kind of mental health support.
• 1:26:04
  but, every cancer center
• 1:26:06
  normally has, either social work
• 1:26:08
  or even kind of psycho oncology.
• 1:26:11
  that can help kind of navigate
• 1:26:12
  patients more individually.
• 1:26:14
  you know, through all of that,
• 1:26:15
  if your cancer
• 1:26:16
  center does not, you know,
• 1:26:17
  even so much as talking
• 1:26:18
  to your primary care doctor
• 1:26:20
  and getting a referral to,
• 1:26:21
  you know, a psychologist or a therapist,
• 1:26:24
  can can be beneficial.
• 1:26:30
  But, so I'll jump to this one.
• 1:26:34
  So what are the benefits of spot treatment
• 1:26:37
  versus a whole lobe treatment
• 1:26:38
  and liver directed therapy?
• 1:26:39
  any data to support one over the other
• 1:26:41
  and how patient presents and a tumor burden.
• 1:26:43
  Kinetics, trend indicators.
• 1:26:44
  So, I don't know if that
• 1:26:45
  means spot treatment,
• 1:26:46
  meaning like ablation versus whole lobe.
• 1:26:48
  So liver directed therapy
• 1:26:49
  kind of in general,
• 1:26:50
  whether it's, you know, immuno
• 1:26:52
  embolization, chemo
• 1:26:53
  radio or PHP
• 1:26:54
  really treats the whole liver,
• 1:26:55
  at least in pairs or at the same time,
• 1:26:58
  whereas things like spot treatments
• 1:26:59
  would be ablation,
• 1:27:01
  you know, radiation or some of the other
• 1:27:02
  kind of local techniques.
• 1:27:03
  you know,
• 1:27:04
  I think the benefits of spot treatment
• 1:27:06
  are sometimes it can just be a one and done.
• 1:27:08
  you're giving
• 1:27:09
  a lot of treatment to that one area,
• 1:27:11
  but it obviously doesn't treat the whole liver.
• 1:27:13
  Whereas if there's multiple tumors,
• 1:27:15
  then spot treatments are not a good idea.
• 1:27:17
  And you want to treat the whole liver.
• 1:27:19
  There's also some thought
• 1:27:20
  that some liver directed therapy.
• 1:27:21
  So certainly even something like PHP
• 1:27:23
  where you're really
• 1:27:23
  saturating the entire liver,
• 1:27:25
  may also be killing cells that you can't see
• 1:27:27
  at radiographic
• 1:27:28
  there's no
• 1:27:28
  genetic indicators, though,
• 1:27:30
  that really have guided us in liver directed
• 1:27:33
  therapy world yet. all right.
• 1:27:34
  So moving on to, Leslie's question.
• 1:27:37
  I am negative with no mets
• 1:27:39
  What is involved in the trial?
• 1:27:41
  Is it an oral medication?
• 1:27:43
  or more complex than that?
• 1:27:44
  Where is it being conducted? So.
• 1:27:47
  It's kind of a long question.
• 1:27:49
  you know,
• 1:27:50
  I said hopefully
• 1:27:51
  you'll just never
• 1:27:52
  need any of this information, but,
• 1:27:53
  it it's being conducted at various sites,
• 1:27:56
  around the world, actually.
• 1:27:57
  So lots of sites in the US.
• 1:27:59
  it's like I said, it's a randomized trial.
• 1:28:00
  So kind of two
• 1:28:01
  thirds of patients get randomized to the
• 1:28:04
  which are pills that you take every day.
• 1:28:06
  and then the other
• 1:28:07
  patients are often, randomized to your voice
• 1:28:10
  which is an infusion.
• 1:28:11
  That's every three weeks at every four weeks.
• 1:28:13
  there are some kind of
• 1:28:14
  extra little testing
• 1:28:16
  that has to happen,
• 1:28:17
  with, doing, like, EKGs to monitor
• 1:28:19
  your heart and blood tests.
• 1:28:20
  but certainly anyone who's interested
• 1:28:22
  in that trial encourage you to,
• 1:28:23
  to speak with
• 1:28:24
  a physician who's, participating
• 1:28:26
  to see if you're eligible
• 1:28:27
  and what else goes into it.
• 1:28:28
  I'm wondering if. see it. Look on time.
• 1:28:30
  we've got about five minutes. Yeah.
• 1:28:32
  So what are the
• 1:28:32
  some of the local experts centers
• 1:28:34
  in the US with UVA melanoma
• 1:28:36
  medical oncology presence?
• 1:28:38
  I believe The Cure in Site
• 1:28:39
  has that resource, somewhere.
• 1:28:41
  It's a little tricky.
• 1:28:42
  The physician
• 1:28:43
  finder on our website, Doctor Berry referenced,
• 1:28:45
  I don't believe that we have a medical.
• 1:28:47
  You feel melanoma
• 1:28:48
  oncology like specifics? I think it
• 1:28:50
  mostly focuses on ocular oncology.
• 1:28:52
  So I guess I'm this is more of a question.
• 1:28:54
  This is actually for me, just like, you know,
• 1:28:56
  I know we know of Thomas Jefferson.
• 1:28:58
  you mentioned Moffitt
• 1:28:59
  Cancer Center,
• 1:29:00
  and so I'm going to assume
• 1:29:01
  those are two kind of regional locations.
• 1:29:03
  But if we could, you know, pinpoint
• 1:29:05
  maybe an area where you know, of,
• 1:29:06
  you've
• 1:29:07
  met our medical oncologist
• 1:29:08
  in the Midwest, and then I know
• 1:29:10
  my doctor out here in the West.
• 1:29:11
  that way we could kind of
• 1:29:12
  just show people on the map.
• 1:29:13
  Yeah, I mean, I always
• 1:29:15
  I appreciate this question.
• 1:29:16
  I just also don't ever
• 1:29:17
  want to leave, any anyone out.
• 1:29:19
  because I think there's some hard there's,
• 1:29:21
  you know, a lot of centers
• 1:29:22
  and I definitely no want to leave
• 1:29:23
  anyone centers out.
• 1:29:24
  but, you know, you know,
• 1:29:26
  you could probably think of almost any major
• 1:29:28
  academic center right now, in the US,
• 1:29:30
  you know, you know,
• 1:29:31
  there's obviously the sites in Boston,
• 1:29:34
  sites in New York, here in Philly,
• 1:29:36
  you know, Baltimore, Atlanta.
• 1:29:40
  I'm just
• 1:29:41
  I'm just literally going down, down the map,
• 1:29:43
  in, in North Carolina and Charlotte.
• 1:29:46
  And this is also I'm also really bad at
• 1:29:47
  geography, so, do not, do not penalize me.
• 1:29:50
  a couple of sites down in Florida,
• 1:29:52
  Texas, you know, Colorado, Ohio.
• 1:29:57
  Arizona, obviously California, Oregon.
• 1:30:00
  I mean, there's
• 1:30:00
  definitely some states in the Midwest,
• 1:30:02
  you know, like,
• 1:30:03
  no, there's not really an expert site
• 1:30:05
  in North Dakota or South Dakota.
• 1:30:07
  you know, and those patients often
• 1:30:08
  have to have to travel.
• 1:30:10
  but, you know,
• 1:30:10
  I think
• 1:30:11
  this is where going to, some of the patient
• 1:30:15
  support groups, you know,
• 1:30:16
  and you could probably geographically hear
• 1:30:18
  about kind of,
• 1:30:19
  you know, who's, who's open or actually
• 1:30:21
  just going on to ClinicalTrials.gov.
• 1:30:23
  Honestly, if you were to look
• 1:30:24
  to see
• 1:30:24
  which sites are offering
• 1:30:26
  the drug, a sort of trial,
• 1:30:27
  that's probably a site that is,
• 1:30:29
  you know, you know, because, there
• 1:30:30
  some places, you know,
• 1:30:31
  think of like University of Iowa, turns out,
• 1:30:33
  you know, they see quite
• 1:30:34
  a bit of UVA melanoma and have this trial.
• 1:30:36
  So again, I don't want to leave any sites out.
• 1:30:38
  because I think
• 1:30:39
  there are a lot of sites
• 1:30:40
  that that, see, a decent amount of melanoma and
• 1:30:43
  have a lot of options for patients.
• 1:30:44
  Yeah.
• 1:30:44
  And I think, like you said,
• 1:30:45
  it's it's ever changing, ever growing.
• 1:30:47
  I think it's just important
• 1:30:48
  that patients recognize,
• 1:30:50
  hopefully, that there is something on the map
• 1:30:53
  that they can locate,
• 1:30:54
  and it doesn't necessarily
• 1:30:55
  have to necessitate them traveling
• 1:30:56
  from east coast to West Coast.
• 1:30:58
  Maybe something in between.
• 1:30:59
  Yeah, yeah. okay. Wonderful.
• 1:31:01
  Well, do you want to pick one
• 1:31:02
  more question and then I can send you
• 1:31:03
  the rest of these via email.
• 1:31:04
  Yes. Let's see here.
• 1:31:06
  There's a liver transplant question.
• 1:31:08
  Do you want to cover that one?
• 1:31:09
  It's an interesting. Question.
• 1:31:10
  It's an easy a softball.
• 1:31:12
  so, no, so liver transplant
• 1:31:14
  is not an option, for metastatic melanoma.
• 1:31:16
  a lot of patients ask that
• 1:31:18
  because if you were to Google liver cancer,
• 1:31:21
  liver transplants, an option,
• 1:31:22
  because in that case,
• 1:31:23
  primary liver cancer, right.
• 1:31:24
  The cancer starts in the liver.
• 1:31:26
  whereas in
• 1:31:27
  youthful melanoma, the cancer travels
• 1:31:29
  from the eye to the liver.
• 1:31:31
  So it's basically assumed
• 1:31:32
  that cells are circulating.
• 1:31:33
  So just by transplanting
• 1:31:35
  the liver, you're
• 1:31:35
  not really going to eradicate
• 1:31:37
  cells that are floating around.
• 1:31:38
  And then you have to go
• 1:31:39
  on immune suppression, which is also not good.
• 1:31:41
  And, you know,
• 1:31:42
  the cells in theory
• 1:31:42
  can just kind of hone their way
• 1:31:44
  on their way back to, to their liver.
• 1:31:46
  So yeah, we do not we do not you can't that
• 1:31:48
  that's not an indication.
• 1:31:49
  in the US, for, for a liver transplant.
• 1:31:52
  All right.
• 1:31:52
  I think that covers it.
• 1:31:53
  Unless you see one that you're dying
• 1:31:55
  to answer right now.
• 1:31:56
  yeah, I think that's.
• 1:31:56
  I think that's pretty good.
• 1:31:57
  I can answer the other ones outside.
• 1:31:59
  Awesome.
• 1:31:59
  Well,
• 1:32:00
  I will go ahead and get those answers from you
• 1:32:02
  sometime in the next week or so, but please.
• 1:32:03
  Thank you.
• 1:32:04
  well, thank you so much for
• 1:32:05
  being here,
• 1:32:06
  for your time, for your expertise.
• 1:32:08
  Thank you to our audience for being here.
• 1:32:10
  And I will go ahead
• 1:32:11
  and, dismiss you all off
• 1:32:12
  so you can get to
• 1:32:13
  the rest of your Friday afternoon.
• 1:32:15
  Thank you. All right. See everybody. Bye.
• 1:32:17
  All right, well,
• 1:32:18
  if you guys are still here, hang out
• 1:32:19
  for just
• 1:32:20
  so I can give you some housekeeping
• 1:32:21
  announcements and we will wrap it up.
• 1:32:23
  So, just by way
• 1:32:25
  of your information, if you didn't know this,
• 1:32:27
  if you didn't come across the registration
• 1:32:29
  link for this webinar
• 1:32:30
  in a way that you had hoped,
• 1:32:32
  please register at our website.
• 1:32:34
  You can go to a
• 1:32:34
  site.org, and at the top area of the website,
• 1:32:37
  there's a little button that you can push that
• 1:32:39
  allows you to register for our newsletter.
• 1:32:41
  Our newsletter goes out every Friday.
• 1:32:42
  our sorry every final Friday
• 1:32:44
  of every single month.
• 1:32:45
  And then we also will push out
• 1:32:47
  just news releases, press releases.
• 1:32:49
  So this is one of the best ways
• 1:32:51
  that you can stay in the know
• 1:32:52
  on what is going on in the Uveal
• 1:32:54
  melanoma space right now, this month.
• 1:32:57
  What's the new data?
• 1:32:58
  What kinds of things
• 1:32:58
  should you be aware of with your doctor?
• 1:33:00
  so please make sure to subscribe
• 1:33:01
  to the newsletter, head to the website
• 1:33:03
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• 1:33:04
  and you can just find that little subscribe
• 1:33:06
  to the newsletter at the top area of the page.
• 1:33:08
  Our website is also a wealth of information.
• 1:33:11
  Doctor
• 1:33:11
  Berry mentioned the clinical trial finder,
• 1:33:13
  are the physician finder.
• 1:33:15
  Doctor Orloff
• 1:33:15
  mentioned the clinical trial finder.
• 1:33:17
  There are so many resources,
• 1:33:18
  and if you have feedback for us
• 1:33:20
  and would like to send us
• 1:33:21
  that, please send us an email
• 1:33:22
  at contact at Karen site.org.
• 1:33:24
  finally, if you're here, you're listening.
• 1:33:26
  You're watching here live on the webinar.
• 1:33:28
  Thank you again for being here.
• 1:33:29
  Go tell a friend to register
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• 1:33:41
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  Whenever we release a new episode,
• 1:33:49
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• 1:33:50
  from something like this webinar, by way
• 1:33:52
  of just final quick announcements,
• 1:33:54
  we have major events
• 1:33:56
  coming up in the next few months.
• 1:33:57
  Our first event to be
• 1:33:58
  aware of is our patient meeting.
• 1:34:00
  That is the, I believe, patient meeting, the
• 1:34:02
  I believe survivorship seminar.
• 1:34:04
  It's going to be hosted here in my hometown
• 1:34:06
  in the Scottsdale, Arizona area
• 1:34:07
  by Doctor Justin Moser with the Honor
• 1:34:09
  Health Research Institute here.
• 1:34:11
  And we are thrilled
• 1:34:12
  to be here in Scottsdale.
• 1:34:13
  We hope you will make the trek.
• 1:34:14
  It is in October.
• 1:34:15
  And as an Arizona
• 1:34:17
  living in the sun, only I can tell you,
• 1:34:20
  October is when it gets much more pleasant.
• 1:34:22
  So we're going to be there mid-October.
• 1:34:23
  You can find the details, on our website.
• 1:34:26
  You can also, just reach out directly
• 1:34:27
  if you have questions
• 1:34:28
  or find our social media posts
• 1:34:30
  regarding registration for I believe
• 1:34:32
  if you're not already
• 1:34:33
  aware of our five KS, our five KS happen
• 1:34:36
  all around the country
• 1:34:37
  and I believe we have a few
• 1:34:38
  coming up the remainder of the summer.
• 1:34:40
  We've got, one coming up in Palo Alto in July.
• 1:34:43
  We've got a Seattle five K
• 1:34:44
  coming up, later in August.
• 1:34:46
  We have other dates happening.
• 1:34:47
  And if you had to
• 1:34:49
  looking for a cure.org, you can find out
• 1:34:51
  if there is a location near you.
• 1:34:53
  we would really encourage
• 1:34:54
  you patients to be there.
• 1:34:56
  Caregivers,
• 1:34:56
  pharmaceutical companies,
• 1:34:58
  representatives, encourage your doctors,
• 1:34:59
  your community to be there in present,
• 1:35:01
  in person,
• 1:35:02
  but also to fundraise for us
• 1:35:04
  because we cannot put on these events
• 1:35:06
  without fundraising efforts.
• 1:35:07
  we have to be our own
• 1:35:08
  advocates in ocular melanoma,
• 1:35:10
  and that can be
• 1:35:11
  really hard and really draining.
• 1:35:12
  And so just finding the ways
• 1:35:14
  that we can rely on community
• 1:35:15
  support can be huge.
• 1:35:16
  we appreciate all of you
• 1:35:17
  who have made the trek out to the five KS.
• 1:35:19
  this year
• 1:35:19
  we have some special five K metals
• 1:35:22
  that are going out, for just survivors
• 1:35:24
  for ocular melanoma patients specifically.
• 1:35:26
  So we haven't gotten that special medal.
• 1:35:28
  Please make sure to make your way
• 1:35:29
  to A5K in person.
• 1:35:30
  And those are, given out
• 1:35:31
  to patients during the events.
• 1:35:33
  And, lastly,
• 1:35:34
  if you guys have just a quick minute
• 1:35:36
  sometime this month or at a future point
• 1:35:38
  in the year, really, you could do it
• 1:35:40
  whenever you choose
• 1:35:41
  anniversaries, your birthday,
• 1:35:42
  any other kind of time in the day,
• 1:35:44
  if you're
• 1:35:44
  on social media in any capacity
• 1:35:46
  and you're willing to make or learn
• 1:35:48
  how to make
• 1:35:48
  a social media fundraiser for us,
• 1:35:50
  then we would love it
• 1:35:51
  if you would help us
• 1:35:52
  fundraise for a cure in sight
• 1:35:54
  so that we can continue funding things
• 1:35:55
  like these webinars, patient programs,
• 1:35:57
  patient financial aid,
• 1:35:59
  and of course, funding
• 1:35:59
  critical research for ocular melanoma.
• 1:36:01
  We can't do this alone.
• 1:36:03
  we need your guys's help.
• 1:36:04
  We need our patients and our caregivers.
• 1:36:06
  We need the community
• 1:36:07
  coming together.
• 1:36:07
  So thank you for listening
• 1:36:09
  to my Ted talk.
• 1:36:10
  Thank you
• 1:36:10
  for being present
• 1:36:11
  for the webinar today
• 1:36:12
  with Doctor Berry and doctor or last,
• 1:36:14
  and we will see you guys next time.
• 1:36:16
  And just stay tuned for the recording
• 1:36:18
  of this episode, from the webinar series
• 1:36:21
  to come in the next month or so.
• 1:36:23
  So thank you again for being here
• 1:36:24
  and have a great weekend, everybody.