 We'll turn it over to Sam Wittier, another U of U student who has been rotating with us this month. Thanks, Sam. Good morning, everyone. Thank you, Dr. Jardine. It's a pleasure to be here with you, to share the podium with my fellow colleague med students as well as Dr. Welsh. So we'll be presenting this morning on a case of coreroidal melanoma, we started with oncology, so we might as well finish up. This patient initially, so I met this patient in the plastics follow-up clinic, but he initially presented with Dr. Bernstein. His chief complaint was shadow and vision. He's a 19-year-old male who was referred for recent vision changes. He was seeing the day previous to him presenting here in the Colorado Emergency Department with these vision changes. Three days before we saw him, he had these upper peripheral visual field deficits that began with some blurry vision. He was not having any pain bilaterally. He was just mainly complaining of this pressure sensation along with these visual symptoms, and he had a fever that he had mentioned the week previous. Overall past medical history, relatively unremarkable if you, remote concussions, normal viral illnesses, but no ocular history, no family history that was remarkable, and no history of any dilated exams. His initial ocular exam was relatively not concerning except for this right superior visual field defect, and on slant lamp and fundus, pertinent findings, he did not have any scleral invasion at that point. No noticeable pigment changes, his angles were normal, and there was a large inferior pigmented mass with some surrounding subretinal fluid, a few drusen, no hemorrhage. A little bit of background on uveal melanoma, and I won't be laboring this because I know we've heard this very thoroughly today, it is of course the most common primary ocular malignancy incidence of about five per million, does have a predilection for caucasians in their fifth and sixth decade of life as we heard earlier. Relatively posterior uveal tumors, about 15% anterior, and then I think Dr. Walsh's rule of five is probably best used for the rate of metastasis, seems much more sophisticated, and then about 85% five-year survival rates. As far as signs go, it's worth mentioning that most of these are picked up just on routine exam, and they're not presenting with symptoms, especially given the age that they present, but you may see a subretinal-raised posterior pole lesion, and symptoms can be anywhere from asymptomatic up to nonspecific visual symptoms, even increased ocular pressure with more anterior lesions is, of course, the effect of that trabecular mesh work. Differential, given the fact that most of these are found on routine exams, can range of course from benign evi, vascular lesions all the way up to metastatic lesions, and of course vary depending on anterior versus posterior lesions. Following these patients, it typically involves some serial fundus photography to characterize them and monitor for growth, but a standard seems to be to say it'd be ultrasound. This low to medium internal echogenicity is this buzz phrase we look for on B ultrasound. FAA is less commonly used, but can be useful for characterizing low-risk lesions, and histology-wise, either status post-nucleation or less commonly, FNA. We may see that, you know, we've seen some epithelioid or spindle-shaped shells in these spindle-shaped cells, however, most of them are actually mixed. So this is back to the case. This is fundus photography. We can appreciate a pretty significant inferior mass here. We see some pigment changes on both of these here. These are both right eye, as well as some sub-retinal fluid. Here's a great montage, Glenn put together. We can appreciate, again, the size, some pallor there, and a note, this patient's macula was attached this time. This is optos, and here we can more appreciate that dome-shaped appearance that's typically associated with the poor prognosis, as well as some of those pigment changes on the patient's right. On B ultrasound, again, posterior lesion here, we can see that there's no scleral extension. It was initially characterized at about 14 by 14 millimeter diameter, and it was mentioned that there was spontaneous vascularity that was appreciated. A ultrasound, unfortunately, did reflect this medium reflective ecogenicity here that we can see just posterior to the retina. So generally speaking, stepping back away from the case, again, observation is reasonable in smaller lesions, and that was very articulated with Dr. Welsh's talk earlier, so I won't be late for that. But the overall goal is to prevent metathesis, that mantra of that Bible to preserve life first and foremost. Three areas of therapy currently, brachytherapy, radiation therapy, and enucleation, and that depends on, of course, the size of the lesion, the level of structural involvement, and, of course, visual impairment, and ultimately patient preference, and there's a plaque there and a plaque placement. So this patient's findings were consistent with a coroidal metastase, or coroidal melanoma without metastasis, and given his options, he chose to be referred to Will's Hospital in Philadelphia, and I did not choose this case prior to knowing the schedule today, so this is very interesting. But he saw Dr. Shields first and experienced the plaque radiotherapy in November, and he was staged at 3A. Per Dr. Shields' recs, appropriately, appropriate metastatic screening was overall unremarkable, and as mentioned, these lesions have a tendency to metastasize to the liver hematogenously. Thankfully, this patient did not have that metastasis, and his labs were normal. He came back to retina and saw Dr. Bernstein here in late December, and we pretty well knew the interval history, but his coroidal ophthalmologist referred him back for a non-healing spot in his eye. He was dilated when he presented, and we weren't able to assess his visual acuity. Still had that right superior field defect, and at that point seemed to be healing okay over that plaque and had, at that point, a large inferior serious retinal detachment that Dr. Bernstein made a decision to not surgically intervene at that time. His genetic analysis was relatively bleak. The findings that are consistent with the four prognosis of chromosome 3, as well as the increased expression of 8P, were consistent with his biopsy. He was deemed high risk, with over 50% recurrence expected, and recommended regimen of imaging follow-up for five years. In subsequent care at Wills, he was entered into a clinical trial and put on suit tent. He came with therapeutic tyrosine kinase inhibitor that was shown in a retrospective review of Wills from 2007 to 2013 to decrease recurrence risk by 10 to 20%, with a mortality hazard ratio of 0.53. So he was started on that, still on that. And after experiencing the expected chemo side effects, his eye became more painful. This is a young guy. He decided to undergo a nucleation, which was done successfully and that protein plant was placed. I saw him in plastics follow-up. His iris conformer was in place. He had great movement. He was not in any pain. He was happy, smiling, and really doing quite well. Going forward now, this patient is being treated at UC Health. They had a very small amount of biopsy left and they're building him a tumor-specific vaccine, so gene-directed therapy. He's patient number one in this trial. It's been used in breast and prostate and other experiments in animal models. And so he seems pretty excited about that. And in fact, there may be a special release on this patient if you pay attention. So his course is to be continued based off of that last slide. Overall takeaways, of course, most of these are picked up on routine exams except in this patient given that he doesn't meet the standard 56th generation of life presentation. First goal, preserve life, prevent metastasis, the three areas of treatment according to our standards of care right now. Sense of follow-up, even in unmetastatic diseases we saw in this patient. As we saw there at the end, novel therapies are on the horizon, which is part of the reason it shows this case. Those are my references. I just want to say thank you for letting me rotate through. Working with everyone has really been extraordinary, so I appreciate it.