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"Pediatric & Pregnancy Ocular Melanoma: Dr. Shields Reveals the Truth!" · The Eye Believe Podcast

• 0:00
  Hi you
• 0:00
  guys, and
• 0:00
  welcome
• 0:00
  back for
• 0:01
  another
• 0:01
  episode of
• 0:02
  the Eye
• 0:02
  Believe
• 0:02
  Podcast.
• 0:03
  I'm joined
• 0:04
  with doctor
• 0:04
  Carol
• 0:04
  Shields
• 0:05
  from Wills
• 0:05
  Eye
• 0:05
  Hospital,
• 0:06
  and today
• 0:06
  we're going
• 0:07
  to talk
• 0:07
  about
• 0:07
  pediatric
• 0:08
  ocular
• 0:08
  melanoma,
• 0:09
  as well
• 0:09
  as some of
• 0:10
  the myths
• 0:10
  and, myths
• 0:10
  busting
• 0:11
  around
• 0:11
  pregnancy
• 0:12
  and ocular
• 0:12
  melanoma.
• 0:12
  So Doctor
• 0:13
  Shields,
• 0:13
  thanks for
• 0:14
  joining us
• 0:14
  again. Yes.
• 0:15
  Thank you
• 0:15
  for
• 0:15
  having me.
• 0:16
  I was going
• 0:16
  to start
• 0:17
  with
• 0:17
  pediatric
• 0:18
  ocular
• 0:18
  melanoma
• 0:19
  if you want
• 0:19
  me to.
• 0:20
  Yeah,
• 0:20
  I think
• 0:20
  that
• 0:21
  sounds like
• 0:21
  an awesome
• 0:21
  place
• 0:22
  to start.
• 0:22
  Let's
• 0:22
  just cover
• 0:23
  some of the
• 0:23
  current
• 0:23
  research
• 0:24
  in
• 0:24
  pediatric
• 0:24
  ocular
• 0:25
  melanoma.
• 0:26
  So when we
• 0:26
  talk about
• 0:27
  ocular
• 0:27
  melanoma,
• 0:29
  we're
• 0:29
  talking
• 0:29
  about
• 0:29
  conjunctiva
• 0:30
  melanoma
• 0:31
  as well
• 0:32
  as Uveal
• 0:32
  melanoma.
• 0:33
  So I'm
• 0:33
  going to
• 0:33
  just start
• 0:33
  with
• 0:34
  conjunctiva
• 0:34
  melanoma.
• 0:36
  It's pretty
• 0:37
  rare
• 0:38
  to have
• 0:39
  conjunctiva
• 0:40
  melanoma
• 0:41
  in
• 0:41
  children.
• 0:41
  So when you
• 0:42
  see a child
• 0:43
  with a
• 0:43
  pigmented
• 0:44
  spot on
• 0:44
  the eye
• 0:45
  it's going
• 0:46
  to be
• 0:47
  nevus nevus
• 0:48
  nevus nevus
• 0:49
  and nevus.
• 0:50
  It's very
• 0:51
  rarely
• 0:52
  going to
• 0:52
  be
• 0:53
  melanoma.
• 0:54
  So don't
• 0:54
  worry.
• 0:55
  And most
• 0:56
  nevi occur
• 0:57
  right at
• 0:57
  the limbus.
• 0:58
  They tend
• 0:59
  to have
• 0:59
  their onset
• 1:00
  when the
• 1:00
  child's
• 1:01
  2, 3,
• 1:02
  4 or 5
• 1:03
  years old.
• 1:04
  They tend
• 1:04
  to get
• 1:04
  a little
• 1:04
  more
• 1:05
  pigmented
• 1:05
  as
• 1:06
  they head
• 1:06
  into
• 1:06
  puberty,
• 1:07
  and it's
• 1:08
  a good idea
• 1:08
  to
• 1:08
  have them
• 1:09
  resected
• 1:09
  just
• 1:10
  because
• 1:10
  nevus
• 1:11
  can
• 1:12
  transform
• 1:12
  into
• 1:13
  melanoma.
• 1:14
  So if you
• 1:15
  look at all
• 1:15
  pediatric
• 1:16
  conjunctival
• 1:17
  tumors,
• 1:18
  only 1%
• 1:19
  are
• 1:20
  melanoma.
• 1:20
  And that's
• 1:21
  in our
• 1:21
  practice.
• 1:22
  So imagine,
• 1:24
  you know,
• 1:24
  the real
• 1:25
  practice,
• 1:25
  the real
• 1:26
  world.
• 1:27
  It's way
• 1:27
  less
• 1:28
  than 1%.
• 1:29
  So
• 1:29
  I wouldn't
• 1:29
  worry
• 1:30
  about it.
• 1:30
  But it's
• 1:31
  a good idea
• 1:31
  to have a
• 1:32
  pigmented
• 1:32
  spot on the
• 1:33
  surface of
• 1:34
  the eye
• 1:34
  surgically
• 1:35
  removed
• 1:35
  just
• 1:35
  in case.
• 1:36
  Now
• 1:37
  I'll move
• 1:38
  on to
• 1:38
  Uveal
• 1:39
  melanoma.
• 1:40
  Hey again,
• 1:42
  it's
• 1:42
  totally
• 1:42
  rare to see
• 1:44
  Uveal
• 1:45
  melanoma
• 1:46
  in a kid.
• 1:47
  If you
• 1:47
  look at
• 1:47
  all uveal
• 1:48
  melanoma,
• 1:51
  only 1%
• 1:52
  occurs
• 1:53
  under the
• 1:53
  age of 20.
• 1:55
  And if you
• 1:56
  look at
• 1:56
  those
• 1:57
  children
• 1:58
  under
• 1:58
  the age
• 1:58
  of 20,
• 1:59
  they're
• 1:59
  mostly
• 2:00
  teenagers,
• 2:03
  and
• 2:06
  they tend
• 2:06
  to have
• 2:06
  approximately
• 2:08
  the same
• 2:08
  prognosis
• 2:09
  as older
• 2:10
  adults.
• 2:10
  But I
• 2:10
  do feel
• 2:12
  they have a
• 2:12
  little
• 2:12
  better
• 2:13
  prognosis.
• 2:15
  Why?
• 2:16
  Because
• 2:16
  when you do
• 2:17
  genetic
• 2:18
  testing
• 2:19
  of Uveal
• 2:19
  melanoma
• 2:20
  in
• 2:20
  children,
• 2:21
  you're
• 2:22
  more likely
• 2:22
  to get
• 2:23
  negative
• 2:24
  genetics.
• 2:25
  That means
• 2:26
  they're
• 2:26
  going to be
• 2:26
  A or B
• 2:27
  the Cancer
• 2:28
  Genome
• 2:28
  Atlas A
• 2:29
  or B,
• 2:29
  which means
• 2:31
  lower risk
• 2:31
  for
• 2:32
  mutation.
• 2:33
  We found that
• 2:34
  a long time
• 2:34
  ago,
• 2:35
  8, 10
• 2:36
  years ago,
• 2:36
  we
• 2:36
  published
• 2:37
  a report
• 2:38
  on 1,059
• 2:39
  eyes that
• 2:40
  we did
• 2:40
  genetic
• 2:41
  sampling,
• 2:41
  and
• 2:41
  we found
• 2:42
  increasing
• 2:43
  age
• 2:45
  correlates
• 2:46
  with worse
• 2:47
  genetic
• 2:48
  mutation.
• 2:49
  So kids
• 2:49
  have better
• 2:50
  genetic
• 2:50
  mutation
• 2:51
  or less
• 2:52
  genetic
• 2:52
  mutation
• 2:53
  compared to
• 2:53
  older
• 2:54
  adults.
• 2:55
  So
• 2:55
  when we see
• 2:56
  melanoma in
• 2:57
  kids, yes,
• 2:59
  it happens.
• 3:01
  Usually
• 3:02
  they're
• 3:02
  over three
• 3:02
  millimeters
• 3:03
  in
• 3:03
  thickness.
• 3:04
  Occasionally
• 3:06
  they're
• 3:06
  mistaken
• 3:07
  as nevus or
• 3:09
  could this
• 3:09
  be
• 3:09
  retinoblastoma
• 3:10
  believe it
• 3:11
  or not.
• 3:12
  Or,
• 3:12
  could
• 3:13
  this be
• 3:13
  Coates
• 3:13
  disease
• 3:14
  or Von
• 3:15
  Hippel-Lindau
• 3:15
  disease?
• 3:15
  I mean
• 3:16
  there's
• 3:16
  all kinds
• 3:17
  of
• 3:17
  diagnoses
• 3:18
  that get
• 3:18
  sent to us,
• 3:19
  but
• 3:20
  you can
• 3:21
  make the
• 3:21
  diagnosis
• 3:22
  with
• 3:22
  a good ultrasound.
• 3:23
  And
• 3:24
  if you're
• 3:24
  not sure,
• 3:25
  maybe a
• 3:25
  good MRI,
• 3:26
  you'll see
• 3:27
  it
• 3:27
  enhances,
• 3:28
  and
• 3:28
  then you
• 3:28
  treat them
• 3:30
  usually
• 3:30
  with
• 3:30
  radiation
• 3:31
  if you
• 3:31
  can't you
• 3:32
  treat them
• 3:32
  with
• 3:33
  eye
• 3:33
  removal,
• 3:34
  but
• 3:35
  we always
• 3:35
  get genetic
• 3:36
  testing
• 3:37
  beforehand
• 3:38
  because
• 3:38
  we want
• 3:39
  to
• 3:39
  prognosticate
• 3:40
  for the
• 3:40
  patients.
• 3:41
  And, for
• 3:42
  example,
• 3:42
  today I saw
• 3:44
  like a
• 3:44
  12 year
• 3:45
  old girl
• 3:45
  who had
• 3:46
  a small
• 3:46
  ciliary
• 3:47
  body
• 3:47
  melanoma.
• 3:48
  We did
• 3:49
  genetic
• 3:49
  testing.
• 3:50
  It was the
• 3:50
  Cancer
• 3:51
  Genome
• 3:51
  Atlas
• 3:51
  Group A
• 3:52
  I was able
• 3:53
  to tell
• 3:53
  her, hey,
• 3:54
  that's low
• 3:55
  risk.
• 3:55
  You're
• 3:56
  likely to
• 3:56
  do fine
• 3:57
  long term.
• 3:58
  You're
• 3:58
  doing well.
• 4:00
  We'll keep
• 4:00
  a check
• 4:00
  on you
• 4:01
  once or
• 4:01
  twice
• 4:02
  a year.
• 4:03
  So keep
• 4:05
  in mind
• 4:05
  that
• 4:05
  melanoma
• 4:06
  of the uvea
• 4:07
  can occur
• 4:08
  in kids but
• 4:10
  generally
• 4:11
  and
• 4:11
  believe it
• 4:12
  when you
• 4:12
  see it
• 4:13
  and send
• 4:13
  them.
• 4:14
  If you're
• 4:14
  not sure,
• 4:15
  send them
• 4:16
  to an
• 4:16
  ocular
• 4:16
  oncologist
• 4:17
  to look
• 4:18
  and make
• 4:19
  a diagnosis.
• 4:20
  You never
• 4:20
  want to
• 4:21
  presume
• 4:21
  anything
• 4:22
  in a child.
• 4:23
  You don't
• 4:24
  want to
• 4:24
  presume
• 4:24
  retinoblastoma.
• 4:25
  You don't
• 4:26
  want to
• 4:26
  presume
• 4:26
  Coates
• 4:27
  disease.
• 4:27
  You want to
• 4:28
  be 100%
• 4:29
  sure.
• 4:30
  Is it
• 4:30
  melanoma or
• 4:31
  is it not
• 4:31
  melanoma?
• 4:34
  So
• 4:34
  are there
• 4:34
  any current
• 4:35
  specifically
• 4:36
  pediatric
• 4:36
  treatments
• 4:37
  that you're
• 4:37
  aware of
• 4:38
  that are
• 4:38
  just unique
• 4:38
  to the
• 4:39
  pediatric
• 4:39
  realm?
• 4:39
  and if not,
• 4:40
  then do
• 4:40
  you have
• 4:41
  hope that
• 4:42
  there
• 4:42
  would be
• 4:42
  some
• 4:42
  level of,
• 4:43
  For
• 4:43
  example,
• 4:44
  maybe the
• 4:44
  Bel-sar
• 4:45
  drug that
• 4:45
  you
• 4:45
  mentioned,
• 4:45
  something
• 4:46
  that
• 4:46
  could help
• 4:46
  to preserve
• 4:47
  vision
• 4:47
  because I'm
• 4:47
  sure for a
• 4:48
  younger
• 4:48
  child,
• 4:49
  preserving
• 4:49
  the vision
• 4:50
  as well
• 4:50
  as the life
• 4:51
  is also
• 4:51
  higher on
• 4:52
  the list
• 4:52
  because
• 4:52
  there's so
• 4:53
  much
• 4:53
  younger.
• 4:54
  Right?
• 4:54
  You know,
• 4:55
  today
• 4:55
  we had a
• 4:56
  five year
• 4:56
  old child
• 4:58
  who had
• 4:58
  a big
• 4:59
  ciliary
• 5:00
  body
• 5:00
  melanoma,
• 5:01
  but he had
• 5:01
  ocular
• 5:02
  melanocytosis.
• 5:04
  So that's
• 5:04
  what
• 5:04
  promoted
• 5:05
  his risk
• 5:06
  for
• 5:06
  melanoma
• 5:07
  at such a
• 5:08
  young age.
• 5:09
  He required
• 5:10
  eye
• 5:10
  enucleation,
• 5:12
  but
• 5:12
  one thing
• 5:12
  about kids,
• 5:14
  is
• 5:14
  kids just
• 5:15
  have a
• 5:15
  more robust
• 5:17
  system
• 5:18
  body.
• 5:19
  They
• 5:20
  respond to
• 5:20
  things
• 5:21
  more
• 5:21
  robustly.
• 5:22
  And
• 5:22
  the same
• 5:23
  thing is
• 5:23
  they
• 5:23
  respond
• 5:24
  to
• 5:25
  radiation
• 5:26
  more
• 5:26
  robustly.
• 5:27
  When you
• 5:27
  put
• 5:27
  a plaque on
• 5:28
  their eye,
• 5:29
  they're at
• 5:29
  risk to
• 5:30
  get worse
• 5:31
  radiation
• 5:32
  retinopathy.
• 5:34
  So for
• 5:34
  kids,
• 5:35
  I think
• 5:35
  it's really
• 5:35
  important
• 5:36
  that we
• 5:37
  give them
• 5:37
  the
• 5:37
  prophylactic
• 5:38
  anti-VEGF
• 5:39
  Avastin,
• 5:40
  and that
• 5:41
  we put
• 5:41
  in a mini
• 5:42
  sector,
• 5:42
  PRP,
• 5:43
  to reduce
• 5:45
  their
• 5:45
  VEGF drive
• 5:46
  because
• 5:46
  their VEGF
• 5:47
  drive
• 5:47
  is going
• 5:48
  to be
• 5:48
  powerful,
• 5:49
  much more
• 5:50
  powerful
• 5:50
  than an
• 5:51
  80 year old
• 5:52
  VEGF drive.
• 5:53
  So
• 5:54
  we always
• 5:55
  watch
• 5:55
  these kids
• 5:56
  really
• 5:56
  closely
• 5:57
  and
• 5:57
  make sure
• 5:57
  we don't
• 5:58
  miss
• 5:59
  any
• 5:59
  treatments
• 6:00
  to reduce
• 6:02
  the vegf
• 6:02
  drive.
• 6:04
  Yes, I
• 6:04
  do think
• 6:05
  you
• 6:05
  mentioned
• 6:06
  Bel-sar
• 6:06
  down the
• 6:07
  road.
• 6:07
  Bel-sar
• 6:08
  would be
• 6:08
  one heck
• 6:09
  of a good
• 6:09
  treatment
• 6:10
  for small
• 6:11
  melanoma
• 6:12
  in a child.
• 6:13
  You know,
• 6:13
  if
• 6:13
  you have a
• 6:13
  small
• 6:14
  melanoma
• 6:14
  it has say
• 6:15
  three risk
• 6:16
  factors.
• 6:16
  You know
• 6:17
  the child
• 6:17
  is going
• 6:17
  to have
• 6:18
  a 34%
• 6:19
  chance
• 6:19
  for
• 6:20
  transformation
• 6:21
  into
• 6:21
  melanoma.
• 6:22
  with
• 6:22
  growth.
• 6:23
  yeah.
• 6:23
  We could treat
• 6:24
  that child
• 6:24
  with
• 6:25
  Bel-sar
• 6:25
  and
• 6:26
  hopefully
• 6:27
  protect
• 6:27
  the vision
• 6:28
  and
• 6:28
  hopefully,
• 6:29
  you know,
• 6:30
  cure the
• 6:30
  cancer
• 6:31
  and put it
• 6:31
  to sleep.
• 6:32
  But,
• 6:33
  you know,
• 6:33
  time
• 6:33
  will tell
• 6:34
  and we have
• 6:34
  to get
• 6:35
  Bel-sar
• 6:35
  FDA
• 6:36
  approved
• 6:36
  right now.
• 6:37
  We can't treat
• 6:38
  anyone
• 6:39
  under
• 6:39
  the age
• 6:39
  of 18
• 6:41
  with
• 6:41
  Bel-sar
• 6:41
  And I know
• 6:42
  that's
• 6:42
  definitely
• 6:42
  one of
• 6:42
  the things
• 6:43
  in the
• 6:43
  pediatric
• 6:43
  ocular
• 6:44
  melanoma
• 6:44
  community
• 6:45
  that,
• 6:45
  kind of rubs,
• 6:46
  because
• 6:46
  those
• 6:46
  parents
• 6:47
  are like,
• 6:47
  well,
• 6:47
  we want
• 6:47
  these
• 6:48
  clinical
• 6:48
  trials,
• 6:48
  whether
• 6:49
  it's for
• 6:49
  metastatic
• 6:49
  treatment
• 6:50
  for
• 6:50
  adjuvant
• 6:50
  treatment.
• 6:51
  We want
• 6:51
  these
• 6:52
  trials
• 6:52
  available
• 6:52
  for
• 6:52
  the kids
• 6:53
  because
• 6:53
  we want them
• 6:54
  to be
• 6:54
  okay, too.
• 6:55
  So
• 6:55
  I feel it's
• 6:56
  so
• 6:56
  reassuring
• 6:56
  to hear
• 6:56
  you talk
• 6:57
  a little
• 6:57
  bit more
• 6:57
  about the
• 6:58
  genomics
• 6:58
  of the tumor
• 6:59
  and how
• 7:00
  kids have
• 7:00
  a much
• 7:00
  better
• 7:01
  chance
• 7:01
  of having
• 7:01
  those
• 7:02
  better
• 7:02
  prognostication
• 7:03
  factors.
• 7:04
  So that was
• 7:04
  that was
• 7:05
  really helpful.
• 7:05
  is there
• 7:06
  anything else
• 7:06
  you want
• 7:06
  to say
• 7:06
  to
• 7:07
  pediatric?
• 7:07
  Yeah.
• 7:08
  So I mean,
• 7:09
  I can
• 7:10
  say a few
• 7:11
  words on,
• 7:12
  you know,
• 7:12
  retinoblastoma
• 7:13
  and how
• 7:14
  we have
• 7:15
  completely
• 7:17
  changed
• 7:17
  retinoblastoma
• 7:18
  in the
• 7:18
  past,
• 7:21
  since
• 7:21
  1994,
• 7:23
  using
• 7:23
  chemical
• 7:24
  therapy
• 7:24
  and I think
• 7:25
  we're on
• 7:26
  the cusp
• 7:27
  with uveal
• 7:28
  melanoma.
• 7:28
  I really think
• 7:30
  in the next
• 7:30
  few years
• 7:31
  things are
• 7:31
  going to
• 7:32
  shift,
• 7:33
  but
• 7:33
  right now,
• 7:34
  with
• 7:35
  retinoblastoma,
• 7:37
  we can cure
• 7:38
  the child.
• 7:39
  We can save
• 7:40
  the child's
• 7:41
  life.
• 7:41
  I mean,
• 7:41
  when I
• 7:42
  started,
• 7:43
  there was
• 7:43
  a 20%
• 7:45
  risk for
• 7:46
  metastatic
• 7:46
  disease
• 7:47
  with
• 7:47
  retinoblastoma.
• 7:48
  Now it's
• 7:50
  1% in
• 7:51
  our hands.
• 7:52
  It's less
• 7:52
  than 1%.
• 7:54
  Kids just
• 7:54
  don't die
• 7:55
  from
• 7:55
  this cancer,
• 7:56
  and we
• 7:57
  prevent
• 7:58
  the disease
• 7:59
  from
• 8:00
  transmitting
• 8:00
  to the
• 8:01
  next
• 8:01
  generation,
• 8:02
  isn’t
• 8:03
  that cool?
• 8:04
  That's
• 8:05
  so novel.
• 8:05
  That's
• 8:05
  so cool.
• 8:06
  Because
• 8:06
  retinoblastoma
• 8:08
  is, in
• 8:09
  one third
• 8:09
  of cases,
• 8:10
  a heritable
• 8:11
  disease.
• 8:12
  So now
• 8:12
  what we do
• 8:13
  is we do
• 8:14
  in vitro
• 8:15
  fertilization,
• 8:17
  and we only
• 8:17
  fertilize
• 8:18
  the female
• 8:19
  with
• 8:20
  fertilized
• 8:21
  eggs
• 8:22
  that do not
• 8:23
  carry
• 8:23
  the mutation.
• 8:24
  So the
• 8:25
  transmission
• 8:26
  stops
• 8:27
  with the
• 8:28
  next
• 8:28
  generation.
• 8:29
  That's
• 8:29
  incredible.
• 8:30
  I mean.
• 8:31
  I remember
• 8:31
  taking
• 8:32
  family
• 8:32
  trees,
• 8:33
  back
• 8:33
  in the 1980s
• 8:34
  when I was
• 8:35
  just
• 8:35
  starting,
• 8:36
  and, oh,
• 8:38
  Aunt Elsie
• 8:39
  died of
• 8:39
  retinoblastoma
• 8:40
  at age two.
• 8:41
  Oh,
• 8:42
  Uncle
• 8:42
  Morton,
• 8:43
  he died
• 8:43
  at age
• 8:44
  five from
• 8:44
  retinoblastoma.
• 8:45
  Oh,
• 8:46
  and then
• 8:46
  my mom
• 8:46
  had it, and
• 8:47
  she
• 8:47
  survived,
• 8:48
  and she
• 8:48
  had me.
• 8:51
  That's
• 8:51
  going to
• 8:51
  all be
• 8:51
  done.
• 8:53
  Yeah.
• 8:53
  So we've
• 8:54
  we've done
• 8:55
  a lot
• 8:56
  with
• 8:56
  retinoblastoma.
• 8:57
  And
• 8:58
  you
• 8:58
  mentioned,
• 8:59
  oh, we need
• 9:00
  FDA
• 9:00
  approval.
• 9:01
  Well,
• 9:01
  we sort of
• 9:02
  don't
• 9:04
  have any
• 9:04
  FDA
• 9:05
  approval
• 9:05
  for any
• 9:06
  of
• 9:06
  the drugs
• 9:06
  we use
• 9:07
  in
• 9:07
  retinoblastoma
• 9:09
  care.
• 9:10
  We don't have
• 9:10
  any
• 9:10
  approval
• 9:11
  for the use
• 9:12
  of
• 9:12
  vincristine
• 9:12
  Etoposide,
• 9:13
  Carboplatin,
• 9:14
  Melphalan,
• 9:14
  Topotecan
• 9:16
  for
• 9:16
  retinoblastoma.
• 9:18
  We're
• 9:18
  using it
• 9:19
  all in
• 9:19
  kind of a
• 9:20
  sympathetic
• 9:20
  way,
• 9:21
  and
• 9:22
  we know it
• 9:22
  works,
• 9:23
  and we've
• 9:23
  done enough
• 9:24
  trials
• 9:24
  to
• 9:24
  show that
• 9:25
  it works
• 9:26
  but
• 9:26
  we don't
• 9:26
  have FDA
• 9:27
  approval.
• 9:27
  We're just
• 9:28
  using it
• 9:28
  because
• 9:29
  it's been
• 9:30
  shown
• 9:31
  thanks
• 9:31
  to Judy
• 9:32
  Kingston
• 9:33
  in London,
• 9:33
  who first
• 9:34
  did it,
• 9:35
  and thanks
• 9:35
  to Kaneko
• 9:36
  in Japan,
• 9:37
  who first
• 9:37
  did IAC.
• 9:39
  We learned
• 9:39
  those drugs
• 9:40
  work,
• 9:40
  we started
• 9:41
  using them,
• 9:41
  there's no
• 9:42
  FDA
• 9:42
  approval
• 9:43
  and kids
• 9:43
  have lived
• 9:45
  enormously,
• 9:47
  thanks to
• 9:48
  some great
• 9:49
  observers
• 9:50
  who contributed
• 9:51
  to
• 9:51
  the field.
• 9:51
  So I think
• 9:53
  even though
• 9:53
  Bel-sar
• 9:54
  might not
• 9:54
  be approved
• 9:55
  for use in,
• 9:56
  you know,
• 9:56
  under
• 9:56
  age 18,
• 9:58
  we could
• 9:58
  probably
• 9:58
  use it
• 9:59
  in a
• 9:59
  sympathetic
• 10:00
  way for
• 10:01
  young
• 10:01
  patients.
• 10:03
  So you
• 10:03
  mentioned
• 10:03
  a little
• 10:03
  bit of
• 10:04
  some of the
• 10:06
  changes
• 10:06
  in
• 10:06
  retinoblastoma
• 10:07
  helping
• 10:08
  to lead
• 10:08
  to this
• 10:08
  kind
• 10:09
  of cusp
• 10:09
  of research
• 10:09
  for the
• 10:10
  the way
• 10:10
  that you
• 10:11
  treat Uveal
• 10:11
  melanoma.
• 10:12
  do
• 10:12
  you want to
• 10:12
  touch
• 10:13
  on that
• 10:13
  a little
• 10:13
  bit?
• 10:15
  Yeah.
• 10:15
  So,
• 10:16
  you know,
• 10:16
  back in
• 10:16
  the day
• 10:17
  in 1994
• 10:18
  when Judy
• 10:19
  Kingston
• 10:19
  from,
• 10:20
  Saint
• 10:21
  Bartholomew's
• 10:22
  Hospital
• 10:22
  in London,
• 10:23
  England,
• 10:23
  made
• 10:25
  an
• 10:25
  observation,
• 10:26
  she said,
• 10:27
  oh, I treat
• 10:28
  neuroblastoma
• 10:29
  with VEC
• 10:30
  (Vincristine,
• 10:30
  Etoposide,
• 10:31
  Carboplatin),
• 10:32
  maybe I'll
• 10:33
  use that
• 10:33
  for
• 10:33
  retinoblastoma.
• 10:34
  She did,
• 10:35
  and
• 10:35
  she saw a
• 10:35
  dramatic
• 10:36
  response.
• 10:37
  So
• 10:37
  all of us
• 10:38
  in the U.S.
• 10:39
  heard
• 10:39
  about this,
• 10:40
  and all
• 10:41
  three of us
• 10:41
  in North
• 10:42
  America
• 10:42
  started
• 10:43
  using it.
• 10:44
  And
• 10:46
  it was
• 10:46
  scary
• 10:47
  because
• 10:47
  we would
• 10:48
  put these
• 10:48
  kids on
• 10:49
  systemic
• 10:50
  chemotherapy,
• 10:51
  never
• 10:51
  knowing
• 10:52
  what we
• 10:52
  were going
• 10:52
  to see
• 10:53
  in the
• 10:53
  operating
• 10:53
  room,
• 10:54
  a
• 10:55
  little bit
• 10:55
  worried
• 10:55
  that,
• 10:56
  you know,
• 10:56
  some kids
• 10:57
  might
• 10:57
  get worse.
• 10:59
  But
• 10:59
  on the contrary,
• 11:00
  almost
• 11:00
  everybody
• 11:01
  got better.
• 11:03
  And now
• 11:03
  we're
• 11:03
  saving more
• 11:05
  eyes than
• 11:05
  ever.
• 11:07
  You know,
• 11:07
  only 5%
• 11:08
  of kids now
• 11:09
  require
• 11:09
  enucleation,
• 11:11
  and only 1%
• 11:13
  develop
• 11:14
  metastatic
• 11:14
  disease.
• 11:15
  And the
• 11:16
  whole world
• 11:17
  of
• 11:17
  chemotherapy,
• 11:19
  whether we
• 11:19
  give it
• 11:19
  intravenous
• 11:21
  intra
• 11:22
  arterial
• 11:23
  to behind
• 11:23
  the eye
• 11:24
  or inject
• 11:25
  the vitreous
• 11:26
  or inject
• 11:27
  the aqueous,
• 11:30
  so
• 11:30
  many eyes
• 11:30
  are saved
• 11:31
  and kids
• 11:32
  march
• 11:33
  out of
• 11:33
  this
• 11:33
  hospital
• 11:34
  so happy
• 11:35
  and parents
• 11:36
  so proud
• 11:37
  that
• 11:38
  their child
• 11:39
  is doing
• 11:39
  well.
• 11:40
  So, today
• 11:41
  I saw
• 11:41
  a family
• 11:42
  from
• 11:43
  Wisconsin.
• 11:45
  I treated
• 11:45
  their
• 11:46
  young boy
• 11:46
  when he was
• 11:47
  four years
• 11:48
  old.
• 11:49
  He had advanced
• 11:50
  retinoblastoma.
• 11:51
  We gave him
• 11:52
  Intra-arterial
• 11:53
  chemotherapy,
• 11:54
  Intravitreal
• 11:55
  chemotherapy.
• 11:56
  He's now
• 11:57
  16 years
• 11:58
  old,
• 11:59
  driving
• 12:00
  a car.
• 12:01
  He has
• 12:02
  no
• 12:02
  recurrence
• 12:03
  and he's
• 12:04
  doing
• 12:04
  awesome,
• 12:05
  and he
• 12:05
  still has
• 12:06
  his eye
• 12:07
  and he's
• 12:08
  he's a
• 12:09
  very neat
• 12:10
  little
• 12:11
  guy.,
• 12:11
  young guy,
• 12:14
  thankful
• 12:15
  that he has
• 12:16
  his life
• 12:16
  and
• 12:17
  his eye,
• 12:17
  and he has
• 12:18
  some vision
• 12:18
  out of
• 12:18
  that eye.
• 12:20
  This
• 12:20
  is, you
• 12:21
  know,
• 12:21
  this is
• 12:22
  how the
• 12:23
  whole field
• 12:23
  of
• 12:24
  retinoblastoma
• 12:24
  has been
• 12:25
  flipped.
• 12:26
  And I
• 12:26
  do think
• 12:27
  we're going
• 12:28
  to see
• 12:28
  a similar
• 12:30
  maybe
• 12:30
  slower flip
• 12:32
  for
• 12:32
  melanoma
• 12:33
  because
• 12:33
  we don't
• 12:34
  get answers
• 12:35
  with
• 12:35
  melanoma
• 12:36
  as fast
• 12:36
  as we do
• 12:37
  with
• 12:37
  retinoblastoma.
• 12:38
  Retinoblastoma
• 12:39
  you get
• 12:39
  answers
• 12:40
  in a month.
• 12:41
  If
• 12:41
  a treatment
• 12:42
  is not
• 12:42
  going
• 12:43
  to work
• 12:43
  you're
• 12:43
  going
• 12:43
  to know
• 12:44
  in a month.
• 12:44
  Hence,
• 12:45
  we always
• 12:46
  see these
• 12:46
  kids back
• 12:47
  when we're
• 12:47
  doing a new
• 12:48
  treatment
• 12:48
  one month
• 12:49
  later.
• 12:50
  With
• 12:50
  melanoma,
• 12:51
  usually
• 12:51
  don't
• 12:51
  get answers
• 12:52
  like for
• 12:52
  four months
• 12:53
  or six
• 12:53
  months.
• 12:54
  So it's
• 12:54
  going to be
• 12:55
  a little
• 12:55
  bit slower
• 12:56
  to get
• 12:57
  some of the,
• 12:57
  you know,
• 12:58
  results
• 13:00
  We're
• 13:00
  poised
• 13:01
  to have
• 13:02
  a lot of
• 13:03
  new
• 13:03
  therapies,
• 13:04
  and
• 13:06
  we're
• 13:06
  poised
• 13:07
  to have
• 13:08
  kind of a
• 13:08
  game
• 13:09
  changer now
• 13:10
  with uveal
• 13:10
  melanoma
• 13:12
  and,
• 13:14
  you know,
• 13:14
  I think
• 13:15
  it's going
• 13:15
  to impact
• 13:16
  pediatrics
• 13:16
  as well as
• 13:18
  adult uveal
• 13:18
  melanoma.
• 13:20
  Thank you
• 13:20
  so much.
• 13:22
  Let's shift
• 13:23
  gears a
• 13:23
  little bit.
• 13:24
  This is
• 13:24
  maybe a
• 13:25
  hot topic
• 13:25
  for some of
• 13:26
  our younger
• 13:26
  ocular
• 13:27
  melanoma
• 13:27
  adults.
• 13:30
  patients
• 13:30
  in the community
• 13:31
  who worry
• 13:32
  about
• 13:32
  future
• 13:33
  pregnancy
• 13:33
  or worry
• 13:34
  about
• 13:34
  whether or
• 13:35
  not
• 13:35
  pregnancy
• 13:36
  has a
• 13:36
  risk for,
• 13:37
  you know,
• 13:37
  causing
• 13:38
  metastases
• 13:38
  or just
• 13:39
  any of
• 13:39
  those kinds
• 13:39
  of things,
• 13:40
  as well as
• 13:41
  the risks
• 13:42
  around
• 13:42
  being
• 13:42
  pregnant
• 13:43
  while
• 13:43
  you're
• 13:43
  being
• 13:43
  treated
• 13:44
  with ocular
• 13:44
  melanoma.
• 13:45
  So do
• 13:46
  you want to
• 13:46
  just talk
• 13:46
  a little bit
• 13:47
  about some
• 13:47
  of the
• 13:47
  myths
• 13:47
  versus the
• 13:48
  the facts
• 13:49
  around
• 13:50
  pregnancy
• 13:50
  and ocular
• 13:50
  melanoma?
• 13:51
  Let's
• 13:51
  just start
• 13:52
  with
• 13:52
  primary
• 13:52
  treatment
• 13:52
  first.
• 13:53
  Yeah.
• 13:56
  So uveal
• 13:57
  melanoma
• 13:58
  can
• 13:58
  definitely
• 13:58
  occur
• 13:59
  in younger
• 14:00
  patients,
• 14:02
  and it
• 14:02
  can occur
• 14:04
  during the
• 14:06
  years when
• 14:07
  pregnancy
• 14:08
  is possible
• 14:09
  and it can
• 14:10
  occur
• 14:10
  during
• 14:10
  pregnancy,
• 14:12
  but
• 14:12
  we don't
• 14:13
  think
• 14:13
  pregnancy
• 14:14
  has
• 14:15
  any impact
• 14:16
  on the
• 14:17
  development
• 14:17
  of uveal
• 14:18
  melanoma.
• 14:20
  Uveal
• 14:20
  melanoma
• 14:21
  most often
• 14:21
  occurs
• 14:22
  in fair
• 14:22
  skinned
• 14:23
  people.
• 14:24
  We
• 14:24
  call that
• 14:25
  Fitzpatrick
• 14:26
  skin type
• 14:26
  1 or 2
• 14:27
  like you
• 14:28
  and me,
• 14:29
  fair skin
• 14:29
  people and
• 14:32
  pregnancy
• 14:32
  does
• 14:33
  not lead
• 14:33
  to the
• 14:33
  development
• 14:34
  of uveal
• 14:34
  melanoma.
• 14:35
  That's
• 14:35
  a myth,
• 14:37
  and
• 14:37
  pregnancy
• 14:38
  does not
• 14:39
  portray
• 14:40
  or cause
• 14:41
  a higher
• 14:42
  risk for
• 14:42
  metastatic
• 14:43
  disease.
• 14:44
  That's
• 14:44
  a myth.
• 14:45
  The
• 14:46
  one thing
• 14:46
  that's
• 14:46
  a truth
• 14:48
  A patient
• 14:48
  who's
• 14:48
  pregnant
• 14:49
  tends
• 14:50
  to retain
• 14:51
  more
• 14:51
  bodily fluids,
• 14:53
  and
• 14:54
  when they
• 14:54
  have a
• 14:55
  melanoma in
• 14:55
  the eye,
• 14:56
  they tend
• 14:56
  to have
• 14:56
  more fluid
• 14:57
  with the
• 14:58
  melanoma
• 14:58
  in the eye,
• 15:00
  that's
• 15:00
  okay.
• 15:01
  The fluid
• 15:01
  goes away
• 15:02
  with
• 15:02
  treatment,
• 15:03
  no big
• 15:03
  deal.
• 15:04
  But,
• 15:04
  they're not
• 15:05
  going
• 15:05
  to get
• 15:06
  any higher
• 15:06
  risk of
• 15:07
  metastatic
• 15:08
  disease
• 15:09
  than a
• 15:09
  non-pregnant
• 15:10
  person.
• 15:10
  Now
• 15:10
  how do we know
• 15:11
  this.?
• 15:11
  Well we did
• 15:12
  a study
• 15:12
  on this
• 15:13
  many years
• 15:14
  ago,
• 15:15
  I think
• 15:15
  it was
• 15:16
  again
• 15:16
  in
• 15:17
  the 1990s.
• 15:18
  We looked
• 15:19
  at I think,
• 15:19
  it was 16
• 15:21
  pregnant
• 15:21
  patients
• 15:22
  and
• 15:23
  compared
• 15:23
  them to
• 15:25
  non-pregnant
• 15:26
  patients
• 15:27
  in the
• 15:27
  same age
• 15:28
  group
• 15:29
  and
• 15:29
  we found
• 15:29
  that they
• 15:30
  had the
• 15:30
  same
• 15:31
  incidence
• 15:32
  of
• 15:32
  metastatic
• 15:32
  disease.
• 15:33
  Then,
• 15:34
  Dan Albert,
• 15:35
  when
• 15:35
  he was
• 15:35
  up at
• 15:37
  Mass Eye
• 15:37
  and Ear,
• 15:38
  he looked
• 15:39
  at pregnant
• 15:41
  patients
• 15:42
  who had
• 15:42
  juvenile
• 15:42
  melanoma,
• 15:43
  who were
• 15:43
  pregnant
• 15:44
  and came
• 15:45
  to
• 15:46
  enucleation.
• 15:46
  He looked
• 15:47
  at surface
• 15:48
  markers on
• 15:49
  the
• 15:49
  melanoma.
• 15:50
  Do
• 15:50
  they have
• 15:50
  estrogen
• 15:51
  or
• 15:51
  progesterone,
• 15:55
  receptors
• 15:56
  that maybe
• 15:58
  the
• 15:58
  progesterone
• 15:59
  going up
• 15:59
  in
• 15:59
  pregnancy
• 16:00
  led to the
• 16:01
  development
• 16:01
  of melanoma
• 16:02
  and he said
• 16:03
  no
• 16:03
  receptors.
• 16:04
  So
• 16:05
  they don't
• 16:05
  have
• 16:06
  normal
• 16:07
  receptors
• 16:08
  that are
• 16:09
  found in
• 16:09
  pregnant
• 16:10
  women okay.
• 16:11
  So
• 16:12
  we really
• 16:13
  don't
• 16:15
  think
• 16:15
  pregnancy
• 16:16
  has any
• 16:16
  impact
• 16:17
  on the
• 16:17
  development
• 16:17
  or
• 16:20
  the risk
• 16:20
  for
• 16:20
  metastasis
• 16:21
  of
• 16:21
  melanoma.
• 16:22
  However,
• 16:23
  if
• 16:23
  a pregnant
• 16:24
  patient
• 16:25
  has a
• 16:25
  melanoma,
• 16:26
  we try not
• 16:27
  to
• 16:28
  irradiate
• 16:28
  during the
• 16:28
  first
• 16:29
  trimester
• 16:30
  because
• 16:33
  we
• 16:33
  don't
• 16:33
  want to
• 16:34
  expose
• 16:34
  the fetus
• 16:35
  to any
• 16:35
  radiation.
• 16:36
  If we have to
• 16:37
  irradiate,
• 16:38
  we will have
• 16:41
  the mother
• 16:42
  wear lead
• 16:44
  the entire time
• 16:46
  she has
• 16:46
  radiation
• 16:47
  on.
• 16:47
  So we
• 16:48
  give her
• 16:49
  our lead
• 16:49
  vest and
• 16:50
  a lead
• 16:51
  skirt
• 16:52
  so that way
• 16:53
  the radiation
• 16:54
  to her
• 16:55
  eye can't
• 16:56
  penetrate
• 16:56
  the lead
• 16:57
  vest,
• 16:57
  so it's not
• 16:58
  going
• 16:58
  to get
• 16:59
  to the fetus,
• 17:01
  and we
• 17:01
  do
• 17:01
  everything,
• 17:02
  all of
• 17:02
  our surgery
• 17:03
  under local
• 17:04
  anesthesia.
• 17:04
  No general
• 17:05
  anesthesia.
• 17:07
  Even if
• 17:07
  she's in
• 17:08
  second
• 17:08
  trimester
• 17:09
  and even
• 17:10
  sometimes
• 17:10
  in third
• 17:11
  trimester,
• 17:12
  we still do
• 17:13
  the lead
• 17:13
  vest on
• 17:15
  the mother,
• 17:16
  just for
• 17:17
  peace
• 17:18
  of mind,
• 17:19
  you know?
• 17:20
  so when we
• 17:22
  come in
• 17:23
  with our
• 17:23
  Geiger
• 17:23
  counter
• 17:24
  to check
• 17:25
  for
• 17:25
  radiation
• 17:26
  in a patient
• 17:27
  with
• 17:27
  melanoma,
• 17:28
  if
• 17:28
  we're this
• 17:29
  far away,
• 17:30
  we usually
• 17:31
  can't
• 17:31
  detect it
• 17:32
  in arm
• 17:33
  length
• 17:34
  but
• 17:34
  as soon as
• 17:34
  you get
• 17:35
  a little
• 17:35
  bit closer,
• 17:37
  like a fist
• 17:37
  length
• 17:38
  away,
• 17:39
  you can detect
• 17:39
  it.
• 17:40
  So imagine
• 17:41
  you're only
• 17:42
  going
• 17:42
  to detect
• 17:43
  a
• 17:44
  little bit
• 17:44
  of
• 17:44
  radiation
• 17:45
  in this
• 17:46
  aura,
• 17:46
  about
• 17:47
  the size
• 17:47
  of the
• 17:47
  head,
• 17:48
  and
• 17:49
  the
• 17:49
  radiation
• 17:50
  does not
• 17:50
  cause
• 17:51
  any damage
• 17:51
  to the
• 17:52
  opposite
• 17:52
  eye, to
• 17:53
  the brain,
• 17:53
  to
• 17:53
  the mouth,
• 17:54
  to the
• 17:54
  sinuses.
• 17:55
  So it's
• 17:56
  so minor
• 17:57
  that it's
• 17:58
  not going
• 17:58
  to cause
• 17:59
  any risk
• 18:00
  to
• 18:00
  the fetus,
• 18:01
  but we
• 18:01
  still, just
• 18:02
  for peace
• 18:03
  of mind,
• 18:04
  put a lead
• 18:05
  vest
• 18:06
  and a
• 18:06
  lead skirt
• 18:07
  on the mom,
• 18:08
  and
• 18:08
  in the past,
• 18:09
  and we
• 18:09
  sometimes
• 18:10
  still
• 18:10
  do this
• 18:11
  instead
• 18:11
  of having
• 18:12
  the mom
• 18:12
  wear it
• 18:14
  heavy on
• 18:14
  her abdomen
• 18:15
  that's
• 18:15
  already
• 18:16
  big.
• 18:17
  We put that,
• 18:19
  you know,
• 18:19
  in
• 18:19
  a hospital
• 18:20
  how
• 18:20
  you have,
• 18:21
  like,
• 18:21
  the dinner
• 18:22
  tray, that
• 18:23
  little
• 18:23
  moving
• 18:23
  dinner
• 18:24
  tray.
• 18:25
  We put that
• 18:25
  over
• 18:26
  the mother
• 18:27
  and
• 18:27
  we just lay
• 18:28
  the lead on
• 18:28
  top of that
• 18:29
  so
• 18:30
  that it's
• 18:30
  not on her
• 18:31
  abdomen,
• 18:32
  it's on
• 18:32
  the dinner
• 18:33
  tray, so
• 18:34
  it can't
• 18:35
  go through
• 18:35
  that.
• 18:37
  But a lot
• 18:37
  of it
• 18:37
  is myth,
• 18:39
  and
• 18:41
  not fact.
• 18:43
  This year
• 18:43
  at the
• 18:44
  Academy,
• 18:44
  though,
• 18:44
  I am giving
• 18:45
  a talk on
• 18:47
  ocular
• 18:47
  oncology
• 18:48
  and
• 18:48
  pregnancy.
• 18:50
  And
• 18:51
  you know
• 18:51
  what I'm
• 18:51
  talking
• 18:51
  about
• 18:53
  basically
• 18:54
  two things.
• 18:56
  Yeah,
• 18:56
  I'll talk
• 18:56
  about
• 18:57
  melanoma,
• 18:57
  but
• 18:57
  I'll say
• 18:58
  it's mostly
• 18:58
  myth.
• 18:59
  But with
• 19:00
  choroidal
• 19:01
  hemangioma,
• 19:02
  a pregnant
• 19:03
  woman gets
• 19:05
  lots of
• 19:05
  fluid, so
• 19:07
  choroidal
• 19:07
  hemangioma
• 19:08
  can get
• 19:09
  worse
• 19:09
  during
• 19:09
  pregnancy.
• 19:11
  So,
• 19:12
  if you have
• 19:12
  a choroidal
• 19:13
  hemangioma,
• 19:13
  it might
• 19:14
  become more
• 19:14
  leaky
• 19:15
  during
• 19:16
  pregnancy
• 19:17
  and
• 19:17
  what do we
• 19:18
  do?
• 19:19
  We usually
• 19:19
  wait for
• 19:20
  the patient
• 19:21
  to become
• 19:22
  unpregnant
• 19:23
  because
• 19:24
  the fluid
• 19:24
  tends to go
• 19:25
  away.
• 19:26
  I'll never
• 19:27
  forget
• 19:29
  20
• 19:29
  years ago
• 19:30
  I had a Hispanic
• 19:32
  lady
• 19:32
  who had a
• 19:33
  choroidal
• 19:33
  hemangioma.
• 19:34
  She had
• 19:35
  total
• 19:35
  retinal
• 19:36
  detachment
• 19:37
  and we
• 19:37
  said, let's
• 19:38
  sit tight
• 19:39
  till she
• 19:39
  delivers
• 19:40
  the baby.
• 19:40
  She delivered
• 19:41
  the baby.
• 19:42
  All her
• 19:42
  fluid
• 19:42
  went away
• 19:45
  because all
• 19:45
  that
• 19:45
  fluid that
• 19:46
  you retain
• 19:47
  goes away.
• 19:48
  So it's
• 19:49
  good
• 19:49
  to wait
• 19:49
  on that.
• 19:49
  The same
• 19:50
  with
• 19:50
  meningioma.
• 19:51
  That's the
• 19:52
  second
• 19:52
  tumor.
• 19:53
  Meningioma
• 19:54
  is
• 19:54
  if they're
• 19:54
  in
• 19:54
  the brain
• 19:55
  or around
• 19:56
  the nerve
• 19:56
  of the eye.
• 19:57
  They can
• 19:58
  get worse
• 19:58
  with water
• 20:00
  retention
• 20:00
  during
• 20:00
  pregnancy,
• 20:01
  but then
• 20:02
  that goes away
• 20:03
  once they
• 20:03
  deliver
• 20:04
  the baby.
• 20:06
  I think
• 20:06
  as far
• 20:06
  as
• 20:06
  pregnancy
• 20:07
  and uveal
• 20:07
  melanoma
• 20:08
  goes,
• 20:08
  I think
• 20:08
  hearing you
• 20:09
  talk about
• 20:09
  some of
• 20:09
  those
• 20:10
  studies
• 20:10
  that you
• 20:10
  shared
• 20:11
  around,
• 20:12
  just
• 20:12
  showing
• 20:12
  that we
• 20:13
  don't see
• 20:13
  any of
• 20:14
  those risk
• 20:14
  factors
• 20:15
  for
• 20:15
  progesterone
• 20:15
  or
• 20:16
  estrogen,
• 20:16
  showing
• 20:17
  that
• 20:17
  pregnancy
• 20:18
  would
• 20:18
  exacerbate,
• 20:18
  say,
• 20:19
  metastatic
• 20:19
  growth
• 20:20
  or the
• 20:20
  primary
• 20:20
  tumor
• 20:21
  growth.
• 20:21
  That's
• 20:22
  hugely
• 20:22
  reassuring
• 20:23
  and I'm
• 20:23
  sure
• 20:23
  that the
• 20:23
  people
• 20:24
  listening,
• 20:24
  we can share
• 20:25
  that with
• 20:25
  our friends
• 20:25
  just to
• 20:26
  make sure
• 20:26
  that they
• 20:26
  know,
• 20:27
  there's,
• 20:27
  there's so
• 20:28
  many ways
• 20:28
  and so
• 20:29
  many things
• 20:29
  that
• 20:29
  especially
• 20:30
  when we're
• 20:30
  a younger
• 20:30
  patient
• 20:31
  that ocular
• 20:31
  melanoma,
• 20:32
  uveal
• 20:32
  melanoma
• 20:33
  can just
• 20:33
  feel very
• 20:34
  scary
• 20:34
  and
• 20:34
  uncertain.
• 20:35
  Right,
• 20:35
  and bottom
• 20:37
  line,
• 20:37
  early
• 20:38
  detection
• 20:39
  makes a
• 20:39
  difference.
• 20:41
  Really
• 20:41
  important!
• 20:42
  So you
• 20:43
  mentioned
• 20:43
  not
• 20:43
  treating
• 20:44
  in the
• 20:44
  first trimester.
• 20:45
  So if you
• 20:45
  find
• 20:46
  something
• 20:46
  that is
• 20:46
  early like
• 20:47
  a small
• 20:48
  nevus,
• 20:49
  let's just
• 20:49
  hypothetically
• 20:50
  speak here.
• 20:50
  would
• 20:51
  you still
• 20:51
  want
• 20:52
  to wait
• 20:52
  for
• 20:53
  a couple
• 20:53
  of months?
• 20:53
  Do you have
• 20:54
  that kind
• 20:54
  of window
• 20:54
  of time
• 20:55
  to work
• 20:55
  with,
• 20:55
  with the
• 20:55
  first
• 20:56
  trimester
• 20:56
  versus
• 20:57
  the second
• 20:57
  in a
• 20:57
  pregnancy?
• 20:58
  patient.
• 20:59
  Yes.
• 20:59
  We have so
• 21:00
  much better
• 21:02
  treatment
• 21:02
  options.
• 21:03
  We have
• 21:03
  so much
• 21:04
  more
• 21:04
  freedom
• 21:04
  for
• 21:05
  treatment
• 21:05
  second
• 21:06
  and third
• 21:07
  trimester.
• 21:09
  First
• 21:09
  trimester,
• 21:09
  we really
• 21:10
  want to be
• 21:11
  super
• 21:12
  careful
• 21:12
  with the
• 21:12
  fetus
• 21:13
  because,
• 21:15
  you know,
• 21:17
  cells
• 21:17
  are
• 21:18
  dividing
• 21:18
  into the
• 21:18
  liver,
• 21:19
  into the eye,
• 21:20
  into
• 21:20
  different
• 21:21
  organ
• 21:22
  structures
• 21:22
  and we
• 21:22
  don't
• 21:22
  want to
• 21:23
  disturb
• 21:23
  any of that.
• 21:24
  So if
• 21:25
  we saw
• 21:25
  a choroidal
• 21:26
  nevus
• 21:26
  that was
• 21:26
  a bit
• 21:27
  suspicious
• 21:28
  in the
• 21:28
  first trimester,
• 21:29
  we would
• 21:29
  probably
• 21:30
  bring
• 21:30
  the mother
• 21:30
  back
• 21:31
  in, say
• 21:31
  2 to 3
• 21:32
  months,
• 21:33
  hopefully
• 21:34
  get them
• 21:34
  into the
• 21:34
  second
• 21:35
  trimester,
• 21:35
  and then
• 21:36
  if we
• 21:36
  needed to
• 21:37
  do
• 21:37
  treatment,
• 21:37
  whether
• 21:38
  it be
• 21:40
  low dose
• 21:41
  radiotherapy
• 21:42
  or standard
• 21:42
  dose
• 21:43
  radiotherapy
• 21:44
  versus
• 21:45
  maybe
• 21:45
  transpupillary
• 21:46
  thermotherapy,
• 21:47
  we would
• 21:47
  do it,
• 21:48
  okay?
• 21:50
  so much
• 21:51
  more
• 21:51
  freedom
• 21:52
  in the
• 21:52
  second
• 21:52
  trimester
• 21:54
  and
• 21:54
  of course
• 21:54
  a
• 21:54
  difference,
• 21:55
  much more
• 21:55
  freedom.
• 21:56
  By the time
• 21:56
  you get in
• 21:57
  the third
• 21:57
  trimester,
• 21:58
  most of the
• 21:58
  organ
• 21:58
  systems
• 21:59
  are already
• 21:59
  developed.
• 22:00
  It's
• 22:00
  mostly just
• 22:01
  growth of
• 22:02
  the organ
• 22:03
  systems
• 22:03
  at that
• 22:03
  point.
• 22:05
  This
• 22:05
  has been
• 22:06
  so, so
• 22:06
  neat to
• 22:07
  listen to.
• 22:07
  So Dr.
• 22:08
  Shields,
• 22:08
  I'm
• 22:08
  so thankful
• 22:09
  to you,
• 22:09
  so thankful
• 22:10
  for your
• 22:10
  expertise
• 22:11
  and we here
• 22:12
  at A Cure
• 22:12
  In Sight,
• 22:13
  and through
• 22:13
  the Eye
• 22:13
  Believe
• 22:13
  Podcast
• 22:14
  listening
• 22:14
  community,
• 22:15
  are so
• 22:15
  grateful
• 22:15
  for
• 22:16
  everything
• 22:16
  that
• 22:16
  you've shared
• 22:17
  and
• 22:17
  just the
• 22:17
  continued
• 22:18
  efforts
• 22:19
  that you
• 22:19
  and your
• 22:19
  team make
• 22:20
  in
• 22:20
  research,
• 22:20
  in
• 22:21
  training,
• 22:21
  the next
• 22:21
  generation
• 22:22
  of ocular
• 22:22
  oncologists.
• 22:24
  that you do
• 22:24
  a lot of
• 22:25
  medical
• 22:25
  teaching
• 22:25
  with your
• 22:26
  fellows
• 22:26
  and your
• 22:26
  students,
• 22:27
  so we are
• 22:28
  so thankful
• 22:28
  for
• 22:28
  everything
• 22:29
  that you do
• 22:29
  for the
• 22:29
  ocular
• 22:30
  melanoma
• 22:30
  community
• 22:31
  every
• 22:32
  single day.
• 22:33
  Well, thank
• 22:35
  you and
• 22:36
  our
• 22:36
  whole team
• 22:37
  feels
• 22:37
  honored.
• 22:38
  I couldn't
• 22:38
  do this
• 22:38
  without all
• 22:39
  the
• 22:40
  technicians
• 22:40
  and the
• 22:41
  front
• 22:41
  desk,
• 22:42
  back desk
• 22:43
  counselors,
• 22:44
  you
• 22:44
  name it.
• 22:45
  We all work
• 22:45
  together
• 22:46
  as a team.
• 22:47
  You know,
• 22:47
  it's not
• 22:48
  just one
• 22:48
  person
• 22:49
  taking care
• 22:49
  of
• 22:49
  the patient.
• 22:50
  It is
• 22:50
  really an
• 22:51
  entire team
• 22:52
  and for us,
• 22:53
  it's
• 22:54
  a great honor
• 22:55
  and we will
• 22:56
  continue
• 22:57
  to strive
• 22:57
  to do
• 22:58
  our best.
• 23:00
  Well,
• 23:00
  for those
• 23:01
  of you
• 23:01
  listening,
• 23:01
  please
• 23:01
  make sure
• 23:02
  to share
• 23:02
  this
• 23:02
  episode
• 23:03
  with any of
• 23:03
  your
• 23:03
  friends
• 23:04
  and
• 23:04
  anyone else
• 23:04
  in the
• 23:04
  ocular
• 23:05
  melanoma
• 23:05
  community
• 23:06
  and we
• 23:07
  are so
• 23:07
  delighted
• 23:08
  to have Dr.
• 23:08
  Shields
• 23:09
  here.
• 23:09
  We hope
• 23:09
  we'll
• 23:09
  get to have
• 23:09
  you back
• 23:10
  at a future
• 23:10
  date,
• 23:10
  maybe
• 23:11
  to talk
• 23:11
  about
• 23:11
  something
• 23:12
  new or
• 23:12
  something
• 23:13
  a little
• 23:13
  more
• 23:13
  specific.
• 23:14
  Maybe
• 23:14
  we could
• 23:14
  talk about
• 23:15
  Bel-sar,
• 23:15
  or we could
• 23:15
  talk about
• 23:16
  Daro,
• 23:16
  a little
• 23:17
  bit more
• 23:17
  in depth
• 23:18
  but
• 23:18
  it's
• 23:18
  been such
• 23:18
  a pleasure,
• 23:19
  and we
• 23:19
  look
• 23:19
  forward to
• 23:20
  having
• 23:20
  you back
• 23:20
  next time.
• 23:22
  Great!
• 23:22
  Thank you,
• 23:22
  Danet!
• 23:22
  Tonight,
• 23:23
  this was
• 23:23
  really a,
• 23:24
  a fun
• 23:25
  conversation.
• 23:26
  I really
• 23:26
  appreciate
• 23:27
  it.
• 23:27
  Thanks to
• 23:28
  all of.