MELANOMA: A Closer Look-- Arising from Eye or Brain

Melanoma in the Back of the Eye (Uveal Melanoma) 

It is a rare type of cancer that starts in the melanocytes, the cells that produce pigment in the eye’s uveal tract (iris, ciliary body, or choroid). The choroid, at the back of the eye, is the most frequent spot for this cancer. It’s the leading primary eye cancer in adults, affecting roughly 5–7 people per million each year. 

Here at Nashville Dermatology Physicians, both Dr. Jeffrey Berti and Dr. Toula Berti believe it is important to learn all one can about their skin, the risk factors and what can be done to treat various conditions, including melanoma. Knowing melanoma can arise in our eye explains why your dermatologist will tell you to have your eyes examined by an ophthalmologist.

Some potential links:

• Sunlight exposure: Unlike skin melanoma, the link to UV light is weak for uveal melanoma.
• Genetics: Mutations in genes like GNAQ or GNA11 often drive this cancer. A BAP1 mutation can make it more likely to spread.
• Who’s at risk: It’s more common in people with fair skin, light eyes (think blue or green), and those around age 60.
• Other factors: A condition called ocular melanocytosis, where the eye has extra pigmentation, can raise the risk.

Symptoms:

• Early on, it’s often silent, especially in the choroid.
• You might notice blurry vision, floaters, or blind spots.
• Pain or red eyes are uncommon but can happen if the cancer progresses.
• Sometimes, it’s caught by chance during a routine eye checkup.

How It’s Diagnosed:

• Eye exam: A doctor uses a dilated eye exam to spot the tumor.
• Ultrasound: This shows the tumor’s size and position in the eye.
• Angiography: A dye test highlights blood vessels in the tumor.
• Biopsy: Rarely done, but it can confirm the diagnosis or reveal genetic clues.
• Scans: MRI or CT checks if the cancer has spread, often to the liver.

Treatment Options:

• Watch and wait: Small, symptom-free tumors might just be monitored.
• Radiation: Techniques like plaque brachytherapy (tiny radioactive seeds placed near the tumor) or proton beam therapy can target the cancer while often saving vision.
• Surgery: If the tumor’s large or vision can’t be preserved, the eye might need to be removed (enucleation).
• Laser: Smaller tumors may respond to a heat-based laser treatment called transpupillary thermotherapy.
• Advanced therapies: If the cancer spreads, drugs like pembrolizumab (immunotherapy) are used, though they’re less effective than in skin melanoma.

Melanoma in the Brain

Brain melanoma is usually metastatic, meaning it spreads from a primary melanoma (often in the skin) to the brain. Primary melanoma starting in the brain itself is incredibly rare, typically forming in the meninges (the brain’s protective layers). Up to half of advanced skin melanoma cases spread to the brain.What Causes It:

• Source: Most brain melanomas come from skin melanoma, though eye or mucosal melanomas can also spread there.
• Genetics: BRAF mutations are common in skin melanoma and drive many brain cases; NRAS mutations also play a role.
• Risk factors: Late-stage melanoma, lots of sun exposure, fair skin, or a family history of melanoma increase the chances. Notable!

Symptoms:

• Headaches, seizures, or trouble thinking clearly (like memory lapses or confusion).
• Weakness, numbness, or paralysis in parts of the body.
• Vision or speech problems, depending on where the tumor is.
• Nausea or vomiting from increased pressure in the skull.

How It’s Diagnosed:

• Scans: MRI or CT with contrast dye lights up brain tumors.
• Biopsy: If there’s no known primary melanoma, a biopsy confirms the diagnosis.
• Genetic tests: Checking for BRAF mutations helps guide treatment.
• Full-body scans: PET/CT looks for other cancer spread, like to the lungs or liver.

Treatment Options:

• Surgery: If there’s one accessible tumor, it might be removed to ease symptoms.
• Radiation: Focused beams (like Gamma Knife) target small tumors, or whole-brain radiation handles multiple spots.
• Immunotherapy: Drugs like nivolumab or ipilimumab work for some melanomas without BRAF mutations.
• Targeted drugs: For BRAF-mutant melanomas, drugs like dabrafenib (with trametinib) can help.
• Supportive care: Steroids (like dexamethasone) reduce brain swelling, and anti-seizure meds control symptoms.

Here at Nashville Dermatology Physicians, Dr. Jeffrey Berti and Dr. Toula Berti have been practicing for over 20 years and are experienced examining skin for cancer and discussing the unusual sites for Melanoma, as the informed patient is one who will hopefully be proactive, detect early changes and present to our office earlier. 

To schedule a skin cancer screening: 615-212-2517 or Request an appointment on website