The role of radiation therapy in the treatment of patients with malignant melanoma

1. Radiation for
Malignant Melanoma
Robert Miller MD
www.aboutcancer.com

2. Treatment of Melanoma
Treatment is generally surgery. Is there a
role for radiation in this disease?

3. Does Melanoma Respond to
Radiation?
RTOGTrial 83-05 compared to dose regimens for
measurable melanoma, Response Rate as Noted:
Complete Partial
8Gy X 4 24% 36%
2.5Gy X 20 23% 34%
Overall 59% response to radiation and no
difference by dose
Int J Radiat Oncol Biol Phys. 1991 Mar;20(3):429-32

4. A randomized study comparing two high-dose per fraction
radiation schedules in recurrent or metastatic malignant
melanoma.
Compared 3Gy X 9 or 5Gy X 8 and no difference
Response Rate
complete and persistent 69%
partial response 29%
total response rate 97%
Int J Radiat Oncol Biol Phys.1985 Oct;11(10):1837-9.

6. NCCN.com

7. NCCN.org

8. Treatment Guidelines
• Early stages: wide local excision
• More advanced: wide local excision
plus sentinel node biopsy, then based
on the pathology consider research
trial, observation or interferon
• Metastatic: clinical trial, possible
radiation and systemic therapy

9. Treatment Guidelines
• Early stages: wide local excision
• More advanced: wide local excision
plus sentinel node biopsy, then based
on the pathology consider research
trial, observation or interferon
• Metastatic: clinical trial, possible
radiation and systemic therapy

10. Role for Radiation in Melanoma
Primary Disease
Consider adjuvant treatment (PostOp) in
selected patients with desmoplastic melanoma
with narrow margins, locally recurrent disease
or extensive neurotropism (invading into the
nerves or around them)

11. Radiation Alone for Melanoma
Old data for lentigo maligna showed control with radiation in
92%, the control for nodular or mucosal melanoma is lower
Adjuvant RT may be considered in the following settings
●Following resection of melanomas with desmoplastic or
neurotropic features
●Thick melanomas (>4 mm) particularly if ulcerated or
associated with satellitosis
●Melanomas arising from the head and neck particularly those
involving mucosal sites
●Inability to achieve negative resection margins

12. Treatment Guidelines
• Early stages: wide local excision
• More advanced: wide local excision
plus sentinel node biopsy, then based
on the pathology consider research
trial, observation or interferon
• Metastatic: clinical trial, possible
radiation and systemic therapy

13. Role for Radiation in Melanoma
Regional Disease
Consider adjuvant treatment (PostOp) if:
Lymph node basin radiation will reduce the risk of local recurrence but has no
impact on relapse-free survival

14. Value of PostOp Radiation for
high risk Lymph Node Patients
Category Radiation No Radiation
Relapse/5y 10.2% 40.6%
Side Effects / lymphedema
20% 13%
Cancer. 2009 Dec 15;115(24):5836-44

15. Value of PostOp Radiation for
high risk Lymph Node Patients
Lancet Oncol. 2012 Jun;13(6):589-97
Randomized trail of postOp radiation in
high risk patients after lymphadenectomy
Radiation No Radiation
Local Relapse 18% 32%

16. PostOp Lymph Node Field

17. PostOp Lymph Node Field

18. PostOp Lymph Node Field

19. Treatment Guidelines
• Early stages: wide local excision
• More advanced: wide local excision
plus sentinel node biopsy, then based
on the pathology consider research
trial, observation or interferon
• Metastatic: clinical trial, possible
radiation and systemic therapy

20. Role for Radiation in Melanoma
Brain Metastases: radiosurgery and/or
whole brain radiation either as adjuvant
(postOp) or primary treatment
Treat other symptomatic or potentially
symptomatic soft tissue and/or bone
metastases

21. The role of radiation therapy
following resection of single brain
metastasis from melanoma
Relapse in the Brain after Treatment
Surgery Only: 85%
Surgery and
PostOp Radiation: 24%
Neurology January 1990 vol. 40 no. 1 158

22. Benefits of Palliative Radiation
for Metastatic Melanoma
Significant Symptom Relief: CNS (39%) non-
CNS (68-84%)
Objective Response: 49 – 97% and complete
response 17-69%
Study: Response Rate: CNS (54%) and Nodes
(77%, with 44% complete response)

23. Radiosurgery for
Brain Metastasis
 Local control Rates of 73 to 94%
 Risk of radiation necrosis of 5 to 10%
Better than whole brain if single lesion and good performance patient in the
RTOG 95-08 Trial

24. Radiosurgery
Right temporal lobe melanoma met
before and 15 months after radiosurgery

25. Radiosurgery Brain
Survival after whole brain radiation is
generally 3.6 to 4.1 months
In series using radiosurgery the median
survival was 11.1 months and 48%/1y
and 18%/ 2y
Multimodality treatment of melanoma brain metastases
incorporating stereotactic radiosurgery (SRS). Cancer. 2007 May
1;109(9):1855-62.

26. RS Melanoma Brain Mets at UCSF
Median survival was 35 weeks (8 months) ,
solitary (35w) and multiple (33w)
Local control at 6 months (89%) and at 12
months (77%)
Cancer J Sci Am. 1998 Mar-Apr;4(2):103-9.

27. Multiple Brain Mets… Whole
Brain or Radiosurgery?

28. RTOG Class for People with
Brain Metastases
 I (KPS =70, age < 65y, mets to brain
only)
 II KPS = 70
 III KPS < 70
Karnofsky Score (KPS) 70 = Cares for self; unable to carry on
normal activity or do active work
KPS 60 = Requires occasional assistance, but is able to care
for most personal needs

29. Survival byTreatment (WB whole brain, S surgery,
RS radiosurgery) and Performance Score (RTOG)
RTOG WB S RS
I 7.1 mos 14.8 mos 16.1 mos
II 4.2 mos 9.9 mos 10.3 mos
III 2.3 mos 6.0 mos 8.9 mos

30. Radiosurgery Brain
Radiosurgery for melanoma brain metastases in
the ipilimumab era and the possibility of longer
survival.
RS RS + Ipilim.
mean survival 4.9 mos 21.3 months
survival/2 years 19.7% 47.2%
J Neurosurg. 2012 Aug;117(2):227-33

31. Role for Radiation in Melanoma
Brain Metastases: radiosurgery and/or
whole brain radiation either as adjuvant
(postOp) or primary treatment
Treat other symptomatic or potentially
symptomatic soft tissue and/or bone
metastases

32. Benefits of Palliative Radiation
for Metastatic Melanoma
Significant Symptom Relief: CNS (39%)
non-CNS (68-84%)
Objective Response: 49 – 97% and complete
response 17-69%
Study: Response Rate: CNS (54%)
Nodes (77%, with 44% complete response)

33. Response Rates
Mayo Clinic Study, 114 non-CNS lesions
Complete response: 9%
Partial response: 75%
No Change: 11%
Worsening: 5%
Cancer. 2007 Oct 15;110(8):1791-5

34. Radiation for
Malignant Melanoma
Robert Miller MD
www.aboutcancer.com