Advanced Stage of Eye Cancer: Prognosis, Expansion, Signs, and Further Details
In the world of eye cancer, the most common staging system used for various types, including uveal melanoma, is the TNM system. This system describes the size and extent of the primary tumor, whether the cancer has spread to nearby lymph nodes, and whether it has metastasized to distant parts of the body.
When cancer reaches stage 4, it typically involves liver metastasis. At this stage, the cancer can be any size, and it may or may not have spread to nearby lymph nodes, or there may be metastasis to distant areas.
Common treatment options for stage 4 eye cancer (uveal melanoma with metastasis) include radiation therapy, chemotherapy, surgery, immunotherapy, targeted therapies, and palliative care. Given the high rate of liver metastases in stage 4 eye cancer, liver-directed treatments are a significant focus.
Radiation therapy is used primarily for local control, but for metastatic uveal melanoma, especially in the liver, specific approaches such as transarterial radioembolization (TARE) with yttrium-90 beads are employed to target liver tumors directly while sparing healthy tissue. External beam radiation may also be applied for some local lesions.
Chemotherapy, when systemic, has limited efficacy in uveal melanoma. Instead, liver-directed chemotherapy via embolization techniques such as transarterial chemoembolization (TACE) or regional-isolation perfusion (e.g., isolated hepatic perfusion [IHP] or percutaneous hepatic perfusion [PHP]) allows high-dose chemotherapy (often melphalan) to be delivered directly to liver metastases. PHP, marketed as HEPZATO KIT, is a less invasive and repeatable option approved for metastatic uveal melanoma with liver involvement.
Surgery is rarely curative in metastatic stage 4 disease but may be used to remove isolated metastases in select patients or for liver metastases when feasible. Surgical removal of primary eye tumors typically occurs earlier in the disease prior to metastasis.
Immunotherapy with checkpoint inhibitors, effective in cutaneous melanoma, has shown poor response rates (~18%) in uveal melanoma. A newer promising immunotherapy is the bi-specific T-cell engager tebentafusp, approved for metastatic uveal melanoma in patients with the right HLA subtype; it has improved overall survival despite a modest 9% response rate. Emerging cell therapies, such as IMA203 PRAME cell therapy, are under investigation showing encouraging results in metastatic cases.
Targeted therapies have limited established roles currently since uveal melanoma has distinct molecular characteristics compared to skin melanoma, making many common systemic targeted agents less effective. Research continues into this area.
Palliative care focuses on managing symptoms and maintaining quality of life, especially since metastatic uveal melanoma is often aggressive and difficult to cure. This includes pain control, treating complications, and supporting daily function.
Symptoms of stage 4 eye cancer include eye pain, visible lump or mass in the eye, redness or swelling of the eye, blurred or distorted vision, loss of vision, eye fluid and discharge, light sensitivity, changes in the size or shape of the pupil, pressure in the eye or face, bulging of the eye, headaches, weakness, fatigue, and weight loss.
The outlook for stage 4 eye cancer depends on several factors, including the type of eye cancer, its location, and how much it has spread. Factors that can affect the outlook include the location of the cancer, whether it has spread outside the eye, tumor size, cell type, mitotic count, chromosome changes, genetic changes, tumor tissue classification, age, and a person's immune system function.
The 5-year survival rate for the last stage of eye melanoma is 16%. In the last stage, the cancer has spread beyond the eye to regional lymph nodes and distant areas, including the bone, liver, and lungs.
In summary, liver-directed therapies (embolization, perfusion, radioembolization) combined with newer immunotherapies like tebentafusp represent the forefront of treatment for stage 4 metastatic uveal melanoma, while systemic chemotherapy and traditional immunotherapy have limited effectiveness. Surgery and radiation may be used for local control or symptom relief, and palliative care is important throughout.
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