Radiation Therapy for Cutaneous Melanoma
Introduction
In 2002, the Collaboration for Cancer Outcomes Research and Evaluation of Australia estimated that over the course of their disease approximately 23% of patients diagnosed with cutaneous melanoma (CM) would be appropriately treated with radiation therapy (RT) based on the best available evidence. Using population registry data, these investigators found that RT was part of the treatment of 13% of patients in New South Wales, Australia, and 1% to 6% of patients in the United States.1 Others have noted the infrequent and dwindling use of RT for CM over time.2, 3 Awareness of the evidence supporting the use of RT for the treatment of CM is vital to delivering the optimal care of patients with this potentially lethal disease.
Several general aspects of RT for melanoma are not addressed in this review. The myth that melanoma is not responsive to RT has been adequately described and dispelled elsewhere.3, 4, 5 The curative and organ-preserving potential of RT for uveal melanoma has been demonstrated by the Collaborative Ocular Melanoma Study6 and is beyond the scope of this review. Likewise, the role of RT in the management of mucosal melanoma is beyond the scope of this article. Herein, data providing the highest levels of evidence supporting the use of RT for CM are presented and discussed, acknowledging a significant dearth of high-level evidence in many situations.
Section snippets
Radiation therapy for the primary tumor
Although the effective use of RT as definitive local therapy for primary CM has been described,7, 8, 9, 10 the therapeutic modality of choice for resectable CM in the medically operable patient is surgery. At present, pathologic staging by surgery provides the most valuable prognostic information available for early-stage CM. However, there are situations in which surgery might preclude acceptable functional or cosmetic outcomes to some patients.
Radiation therapy for regional lymph nodes
Regional RT has been studied extensively in retrospective series and has been well summarized by Guadagnolo and Zagars.28 The topic is controversial, as evidenced by the inability to accrue patients to an intergroup trial of adjuvant RT initiated by the RTOG and ECOG (9302), or in another trial activated by ECOG alone (3697). However, 2 prospective, randomized controlled trials have been performed, and form the highest level of evidence available on this topic.
The first trial was conducted at
Radiation therapy for distant metastases
RT is most commonly used for palliative purposes in patients with metastatic melanoma.1 There is a wide variety of situations in which RT may be helpful. However, many of the research studies investigating the efficacy and toxicity of palliative RT have not focused specifically on metastatic melanoma. In many situations, extrapolating findings from other metastatic cancers is necessary. In this section, attention is paid to studies specifically studying the role of palliative RT in metastatic
Advanced techniques in radiation therapy for treatment of metastases
Advanced techniques in RT have allowed for the delivery of a single or a few high doses to several sites of metastatic melanoma. Gerszten and colleagues52 reported on the experience at the University of Pittsburgh, and found that 96% of patients reported long-term improvement in spine pain, with mean improvement of 7 points on a 10-point pain scale. Treatment with doses of 17.5 to 25 Gy was found to be safe, with no clinical or radiographic evidence of radiation-associated neurologic toxicity.
Summary
RT has a role in the management of patients with CM. As new data emerge on the relative efficacy and toxicity of RT, a change in practice patterns may be observed. Further carefully planned studies of RT in CM are necessary to optimize the outcomes of patients with this potentially lethal disease.
References (55)
- et al.
How gender, age, and geography influence the utilization of radiation therapy in the management of malignant melanoma
Int J Radiat Oncol Biol Phys
(2006) - et al.
Radiotherapy in England in 2007: modelled demand and audited activity
Clin Oncol (R Coll Radiol)
(2009) - et al.
Radiotherapy for malignant melanoma: a re-appraisal
Cancer Treat Rev
(1981) - et al.
Dispelling the myths surrounding radiotherapy for treatment of cutaneous melanoma
Lancet Oncol
(2006) - et al.
Ann Dermatol Venereol
(2006) - et al.
Fractionated radiotherapy of lentigo maligna and lentigo maligna melanoma in 64 patients
J Am Acad Dermatol
(2000) - et al.
Revised UK guidelines for the management of cutaneous melanoma 2010
J Plast Reconstr Aesthet Surg
(2010) - et al.
Adjuvant radiation therapy for high-risk nodal metastases from cutaneous melanoma
Lancet Oncol
(2009) - et al.
A prospective phase II study of adjuvant postoperative radiation therapy following nodal surgery in malignant melanoma-Trans Tasman Radiation Oncology Group (TROG) Study 96.06
Radiother Oncol
(2006) A review of the clinical evidence for intensity-modulated radiotherapy
Clin Oncol (R Coll Radiol)
(2010)
Postoperative radiotherapy for cutaneous melanoma of the head and neck region
Int J Radiat Oncol Biol Phys
Radiosurgery versus surgery, both with adjuvant whole brain radiotherapy, for solitary brain metastases: a randomised controlled trial
Clin Oncol (R Coll Radiol)
Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomised controlled trial
Lancet Oncol
Radiotherapy for metastatic carcinomas of the kidney or melanomas: an analysis using palliative end points
Int J Radiat Oncol Biol Phys
Palliative radiotherapy for recurrent and metastatic malignant melanoma: prognostic factors for tumor response and long-term outcome: a 20-year experience
Int J Radiat Oncol Biol Phys
Fraction size in external beam radiation therapy in the treatment of melanoma
Int J Radiat Oncol Biol Phys
A randomized study comparing two high-dose per fraction radiation schedules in recurrent or metastatic malignant melanoma
Int J Radiat Oncol Biol Phys
Randomised trial of hyperthermia as adjuvant to radiotherapy for recurrent or metastatic malignant melanoma. European Society for Hyperthermic Oncology
Lancet
Estimation of an optimal radiotherapy utilization rate for melanoma: a review of the evidence
Cancer
Collaborative Ocular Melanoma Study randomized trial of I-125 brachytherapy
Clin Trials
Melanoma of the nose
Br J Surg
Radiation therapy of primary and metastatic melanoma
Ann N Y Acad Sci
Radiotherapy of acral lentiginous melanoma of the foot
J La State Med Soc
Provisional results of treatment of the mélanose précancéreuse circonscrite Dubreuilh by Bucky-rays
Dermatologica
A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using Grenz or soft X-rays
Br J Dermatol
Treatment of melanotic freckle with x-rays
Arch Dermatol
Lentigo maligna of the head and neck. Results of treatment by radiotherapy
Arch Dermatol
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2015, Journal of the American Academy of DermatologyCitation Excerpt :Grenz rays and fractionated radiotherapy have varying degrees of success.97,98 Recurrence rates range from 0% to 20%, and side effects include radiation dermatitis, telangiectasias, hypo- or hyperpigmentation, erythema, and the development of other neoplasms, such as basal and squamous cell carcinoma.98-102 Radiation therapy is not considered a first-line treatment but may be appropriate depending on other factors, such as lesion size, anatomic site, and patient comorbidity.
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2014, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Radiation therapy has long played a role in the management of all types and stages of melanoma. In cutaneous melanoma, radiation therapy may be an alternative to surgery for in situ disease; radiation therapy may be a valuable adjuvant after surgery for high-risk early stage or locally advanced disease (7). In uveal melanoma, brachytherapy and external beam radiation therapy have both been used and provide high rates of local tumor control with preservation of vision (8, 9).
The authors have no relevant conflicts of interest.