adjuvant protocol for HAN melanoma?

[Kroll2013]

Dear colleagues,
What protocol of adjuvant radiation therapy do you use for HAN (parotid) melanoma with positive ipsilateral positive nodes that was completely resected with extended LND?
do you use 30/5 or 48/20 for example?

ty

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[radoncgrad2019]

In the current era?


IO.

 

[Palex80]

There is not evidence for RT in the era of modern melanoma adjuvant therapy.

 

[temujim]

Dear colleagues,
What protocol of adjuvant radiation therapy do you use for HAN (parotid) melanoma with positive ipsilateral positive nodes that was completely resected with extended LND?
do you use 30/5 or 48/20 for example?

ty

Still would treat even in the era of IO. 48/20.

 

[gmsquid]

I use both 48/20 and 30/5. Prefer the former but use the latter in very old patients or people with difficult transportation. Very keen on the heat of my plans with the latter.

 

[gmsquid]

There is not evidence for RT in the era of modern melanoma adjuvant therapy.

There is not evidence that RT is not beneficial here either. It’s an open question. With better systemic therapy does local therapy matter more or less? Particularly in a disease where systemic failure previously may have obviated the need for local therapy. I’ve seen quite a few locoregional failures in this disease with adjuvant immuno absent RT. It’s still considered a standard of care.

 

[deleted1002574]

If they would have fit on the TROG study, they should be considered for adjuvant RT.

That being said, the authors basically said that even though RT reduces recurrences (36%->21%), patients should probably go on an adjuvant systemic clinical trial.

Now, that we got some nice magic juice, local control will become more important (I assume) and future trials may show a benefit.

In addition, after the first time you have to treat a gnarly melanoma recurrence, you’ll reconsider omitting radiation. 30/5, given twice a week, is quite gentle. I’d presume 48/20 is going to lead to more fibrosis / late effects.

 

[Palex80]

If they would have fit on the TROG study, they should be considered for adjuvant RT.

Why? Was the TROG trial positive for its primary endpoint?

Many of us have been trained to treat pN+ melanoma with adjuvant RT which was based on retrospective studies and a general „its–malanoma–we–need–to–do–something“ approach at a time when nothing worked in melanoma. Yet we should also grasp the fact that the TROG trial showed no improvement in relevant endpoints through RT (other than in–field recurrence) and that modern systemic therapy has made huge advances.

 

[medgator]

Yet we should also grasp the fact that the TROG trial showed no improvement in relevant endpoints through RT (other than in–field recurrence) and that modern systemic therapy has made huge advances.

Is there a detriment to combining them? IO plays well with xrt in most sites.

Moreover, an head and neck recurrence is not a great situation to deal with

 

[Palex80]

Is there a detriment to combining them? IO plays well with xrt in most sites.

No, of course not. At least none that we are aware of.
But there is no data pointing out an improvement of the outcomes. The trials on IO as adjuvant treatment for melanoma did not include RT.

Moreover, an head and neck recurrence is not a great situation to deal with

The same can be said for mucositis, fibrosis, xerostomia...

 

[scarbrtj]

Back in the day, 30/5 seemed like a MOAB; it's probably more hand grenade. Despite understanding radiobiology mathematically, no one easily accepted that 30/5 to the H&N should have less late/acute effects than most other commonly used H&N fractionations (70/35 for SCC e.g.; even 48/20 should have more acute effects). XRT of 30/5 should be very low risk if given conformally and won't preclude other therapies. The rad onc seeing a stage III melanoma patient is a very rare occurrence in this "era of modern melanoma adjuvant therapy." In "the wild," a rad onc gets referred a patient like this because the referring doc (almost always med onc) feels like XRT will make a therapeutic impact. Although in general this is an iffy rationale to proceed with treatment... it's one of those special situations IMHO where you say to the med onc, "Who am I to argue?"

 

[radoncgrad2019]

Yeah I am honestly pretty surprised you got a referral so if you do get one, may as well treat, because someone thought the local risk factors were high enough.

what were those factors? how many nodes and was there ECE?

IO works just about as well locally as it does distantly in the big adjuvant trials, but certainly people can still have local failures. it remains an open question on which patients have a high enough LRF risk that it's worth treating. I am not worried about the IO/RT toxicity interaction.

If it was just 'node-positive' with nothing fishy going on in terms of risk factors, you may just have a med onc colleague who isn't really that up to date?

 

[seper]

For those of you who combine hypoFx RT to head and neck melanoma with Opdivo or Keytruda, have you seen any unusual toxicities? I feel a bit leery doing it but it's just a gut feeling.

 

[medgator]

For those of you who combine hypoFx RT to head and neck melanoma with Opdivo or Keytruda, have you seen any unusual toxicities? I feel a bit leery doing it but it's just a gut feeling.

I've done 50/20 to an isolated high scv nodal met from nsclc while pt continued opdivo without a problem. He's NED currently out about a year or so from xrt, still on immunotherapy

 

[gmsquid]

For those of you who combine hypoFx RT to head and neck melanoma with Opdivo or Keytruda, have you seen any unusual toxicities? I feel a bit leery doing it but it's just a gut feeling.

I do it quite frequently and have not seen any.

 

[deleted1002574]

No, of course not. At least none that we are aware of.
But there is no data pointing out an improvement of the outcomes. The trials on IO as adjuvant treatment for melanoma did not include RT.


The same can be said for mucositis, fibrosis, xerostomia...

You’re saying that with certainty. Must be difference in European paradigm. We at least have the discussion for high risk patients. Agree data is not strong. But, local recurrence is reduce by almost half. There is value in that.

 

[evilbooyaa]

We generally would reserve for specific risk factors concerning for locoregional recurrence such as positive margins or ECE. Would not blanket recommend RT for all stage III melanoma, even for head and neck, as IT is more important.

Would have discussion with med-onc about whether to do it sequentially (IT before RT would be my preference) or RT concurrently with IT.

I personaly favor 48/20 for big areas or just standard 60/30. 30/5 I would use more for smaller more localized areas. I'm still nervous about long-term toxicity of 30/5 to an entire face/neck in an era where patients are living much longer.

 

[Palex80]

You’re saying that with certainty. Must be difference in European paradigm. We at least have the discussion for high risk patients. Agree data is not strong. But, local recurrence is reduce by almost half. There is value in that.

ESMO guidelines (published 30.03.2019):


A prospective randomised trial has demonstrated that adjuvant irradiation after LN dissection reduces the risk for relapse in the irradiation field by approximately 50%, but has no impact on recurrence-free survival (RFS) and overall survival (OS) [46]. Since local control is rarely the therapeutic objective in melanoma, adjuvant RT can no longer routinely be recommended in the adjuvant setting [III, B]. It could still be discussed in specific cases where local control is critical like in Head & Neck melanoma.



"Discussed".

 

[OTN]

I do 60 Gy in 2 Gy fractions in patients with high nodal burden, no evidence of mets. I’m not impressed by the hypofx data, and the MDA paper author famously testified AGAINST a guy who did it and caused brachial plexopathy. Good toxicity in the short and long term with 60 in 30 as we know from scca. LRR but no OS benefit. I treat when LRR would cause problems/be tough to resect/etc.

 

[deleted1002574]

ESMO guidelines (published 30.03.2019):


A prospective randomised trial has demonstrated that adjuvant irradiation after LN dissection reduces the risk for relapse in the irradiation field by approximately 50%, but has no impact on recurrence-free survival (RFS) and overall survival (OS) [46]. Since local control is rarely the therapeutic objective in melanoma, adjuvant RT can no longer routinely be recommended in the adjuvant setting [III, B]. It could still be discussed in specific cases where local control is critical like in Head & Neck melanoma.



"Discussed".

Sounds like it's definitely different across pond. Very reasonable not to. Very reasonable to have a discussion.
Interesting about the MDACC doc testifying against that regimen. Might be right - not ideal in neck.

 

[gmsquid]

I do 60 Gy in 2 Gy fractions in patients with high nodal burden, no evidence of mets. I’m not impressed by the hypofx data, and the MDA paper author famously testified AGAINST a guy who did it and caused brachial plexopathy. Good toxicity in the short and long term with 60 in 30 as we know from scca. LRR but no OS benefit. I treat when LRR would cause problems/be tough to resect/etc.

I would be curious how he testified and How the patient was treated. The original MDA paper prescribed to a max dose of 30 Gy in 5 fx. So it’s different than prescribing to cover a ptv with that dose. It’s a situation where you may want to let the plexus only get 25-30 Gy max using IMRT. Though the lung SBRT lit allows higher to a point dose. Even the 48 in 20 regimen doesn’t allow 48 to the plexus per the original paper.

 

[deleted1002574]

I would be curious how he testified and How the patient was treated. The original MDA paper prescribed to a max dose of 30 Gy in 5 fx. So it’s different than prescribing to cover a ptv with that dose. It’s a situation where you may want to let the plexus only get 25-30 Gy max using IMRT. Though the lung SBRT lit allows higher to a point dose. Even the 48 in 20 regimen doesn’t allow 48 to the plexus per the original paper.

Right. MDACC coverage goal is not to PTV. It's written very specifically. They may have testified: "you didn't do it the way we said to do it"
EDIT: they cover with 27 Gy, limit max point dose to 31 Gy (brain/optics to 24 Gy)

 

[seper]

60 Gy/30 BED3 is higher than 30 Gy/5, presuming 10% hotspot in each plan

 

[bix]

If I get an axillary or H&N stage III referral that fits the TROG 02.01 criteria, I will discuss local control benefit and state no overall or PFS benefit and let patient decide. If local recurrence factors higher (ie 8 cm node with ECE) then lean more towards RT. I do 30/5 and have not had any issues with concurrent immunotherapy.

The stage III melanoma’s usually referred to me tend to be the ones that have already had nodal recurrence in the same basin on adjuvant immunotherapy and no distant disease or who had a large nodal burden (5-6 positive nodes, > 6 cm + ECE).

 

[medgator]

The stage III melanoma’s usually referred to me tend to be the ones that have already had nodal recurrence in the same basin on adjuvant immunotherapy and no distant disease or who had a large nodal burden (5-6 positive nodes, > 6 cm + ECE).

Ditto. I usually get nodal recurrences post op too prevent further recurrence

 

[gmsquid]

Ditto. I usually get nodal recurrences post op to prevent further recurrence

Me too. And it’s surprising how many of these we get.