Melanoma and radiation video slides

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

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Melanoma and radiation video slides

  1. 1. Radiation for Malignant Melanoma Robert Miller MD www.aboutcancer.com
  2. 2. Treatment of Melanoma Treatment is generally surgery. Is there a role for radiation in this disease?
  3. 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. 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.
  5. 5. NCCN.com
  6. 6. NCCN.org
  7. 7. 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
  8. 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. 9. 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)
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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%
  15. 15. PostOp Lymph Node Field
  16. 16. PostOp Lymph Node Field
  17. 17. PostOp Lymph Node Field
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. Radiosurgery Right temporal lobe melanoma met before and 15 months after radiosurgery
  24. 24. 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.
  25. 25. 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.
  26. 26. Multiple Brain Mets… Whole Brain or Radiosurgery?
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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)
  32. 32. 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
  33. 33. Radiation for Malignant Melanoma Robert Miller MD www.aboutcancer.com

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