Adjuvant Axilla-Radiotherapy for Malignant Melanoma

[Palex80]

Here is a good publication on this issue:
Matthew T. Ballo, Eric A. Strom, Gunar K. Zagars, Agop Y. Bedikian, Victor G. Prieto, Paul F. Mansfield, Jeffrey E. Lee, Jeffrey E. Gershenwald and Merrick I. Ross
Adjuvant irradiation for axillary metastases from malignant melanoma
International Journal of Radiation Oncology*Biology*Physics
Volume 52, Issue 4, 15 March 2002, Pages 964-972


Now, onto practice:
I had a patient presented to me today. He developed axillary metastases 2 years after resection of a malignant melanoma (Clark-Level III) on his back. Surgery was 3 weeks ago with 17/18 positive axillary lymph nodes, all 3 axillary levels resected, R0-status with partial extracapsular invasion. Pre-operative FDG-PET-scan was only positive in the axilla.

He recovered well from surgery, has a bit of lymphoedema and required puncture of a seroma. He is receiving Interferon therapy at the moment.

1. When would you suggest irradiation of the axilla on an adjuvant basis for R0-resected axillary lymph node metastases of malignant melanoma?
2. Would you irradiate this particular patient?

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[radonc]

per ch 39, pg 974, gunderson & tepper, the md anderson treatment regimen for axillary disease is as follows: patients with axillary disease would receive RT if there is any one of the following: ece, >/= 3cm disease, >/= 4 nodes positive, or recurrent disease. this would be to reduce the risk of loco-regional recurrence. however, adjuvant systemic therapy is a good option as well...no head to head comparisons of adjuvant rt vs systemic therapy.

lymphedema as a contra-indication to RT is not a valid argument given that many women are treated with RT after ALND and have <10% rates of lymphedema. also, adjuvant IFN is toxic and not very well tolerated...and is very expensive.

i would discuss the risks & benefits of each therapy (RT, IFN, no treatment) and make a decision based on having a complete record including my H&P before offering an opinion.

 

[PimpMyRad]

This one is a no-brainer. Pt is at very high risk of developing recurrence in the axilla despite the axillary dissection, and there is no evidence that anything other than axillary RT will reduce this risk. I would wait until his scar is healed and the seroma has resolved maximally, and then treat him per the MDAH regimen. Yes, pt may develop lymphedema as a result of axillary dissection and RT, but an axillary recurrence will also cause this and many other problems. This pt will likely eventually die due to systemic disease, but preventing regional relapse would still be clinically meaningful IMHO.

 

[Brim]

I wouldn't say it's a no brainer.

You have to balance the patient's risk of axillary recurrence (which is high) versus an equally high (or higher) risk of dying of metastatic disease.

Many would argue that it's pointless to give RT to improve local/regional control when most patients are going to develop distant mets regardless of treatment within a matter of months (median time to distant mets = 6 months in the Ballo paper).

Damned if you do; damned if you don't.

The risk of lymphedema isn't insignificant. Grade 2 edema occurred in 20% of pts; much higher than we see in breast cancer.

With that being said, an axillary recurrence can be quite morbid, and it's best to be prevented if possible. A number of these patients are potentially cured, so long-term locoregional control becomes important.

I would offer treatment for such patients, using the indications as outlined in this Ballo paper (as well as the more general guidelines in the Ballo article in Oncology 2004).

With the lack of good randomized evidence, we have to rely on good retrospective data, and the Ballo paper is probably the best we have.

 

[PimpMyRad]

In other words, it's a no brainer.

EVERYTHING we do in rad onc is a balance between risk and benefit; if the risk is greater than the benefit, don't treat. If the benefit exceeds the risk, treat. You can talk about it until you're blue in the face, but at the end of the consult you have to make a recommendation based on your assessment of the individual situation. Sure, you can present all sides of the issue and then ask the pt to decide, but I've found that most of my pts want to know what I think they should do. And in a situation like this I would present the pros and cons, but would not hesitate to recommend treatment for the reasons we have both pointed out.

This pt may well be damned whether he does or doesn't get the healing rays, but that shouldn't stop us from offering tx that could be reasonably expected to help. And I'll guarantee you this: it will do more good, cause far less toxicity, and cost thousands of dollars less than whatever the medical oncologist has to offer.

 

[Palex80]

I am happy to see that I was not the only one coping with the same problems, when having to decide what to recommend this patient.

Both the risk of regional and systemic progression are high in this patient.

The question is how do we adress those two risks and what side effects do we consider are reasonable for this patient.

Interferon is a good medication for this case. It can have several side effects (our patient here is having no problems with it) and is pretty easy to apply at home. It may prevent systemic progression for a short time. The oncologist who is seeing the patient decided not to try DTIC or Temozolomid, because the patient did not have any measurable lesion at this time. I find that a good argument and would agree to giving chemotherapy only in case of systemic progression, when one can measure its effectiveness.

A bit of more information on the operation, which I forgot to mention:
It was quite extensive, involving Level 3 as well (which is not always standard in axillary dissection for breast cancer) and pretty radical. That may lead to more lymphoedema in the process.
Please bear in mind that there is no survival benefit shown for axillary RT in breast cancer patients that have underwent R0-axillary dissection. So whether or not one irradiates the axilla in dissected patients is institute policy. There is no hard evidence backing it up.
The risk of lymphoedema in patients with breast cancer, axillary dissection and axilla RT can be up to 20% in some cases.

What will kill this patient?
Systemic progression.
Do we have any evidence that if regional recurrence occur this would lead to a faster systemic progression?
Nope. He had 17/18 lymph nodes full of tumor, whether or not he suffers a regional recurrence is irrelevant when it comes to his overall survival. He already had micrometastatic disease.

So what did we do?

We discussed all these issues with the patient, informed him of both possibilities, talked about the (probably) equally high risks of systemic and regional progression and then we talked about the side effects.
In the end I gave out a veray careful recommendation that we can irradiate his axilla if he wishes that, because that would not be "wrong" by the book and the evidence that we so far have. I also stressed out the fact that I have serious doubts if that is purposeful in his situation.
That was enough for him and he said, he doesn't want to have radiation therapy.

I do not find it right that we have to give out a strict recommendation when we do not have enough evidence.
I also find it highly debateable whether or not M.D. Anderson should give out guidelines and algorithms on when to irradiate or not solely based on retrospective data.

I also don't understand the point mentioned by the latest poster when it comes to systemic therapy.
This patient will receive systemic therapy no matter if we do or don't irradiate him. Simply because of the risk of systemic progression.
If he does indeed suffer a recurrence regionally, then we would discuss the issue with the surgeons and decide whether or not to operate or irradiate the axilla. I do not think however that this would interfere with his systemic treatment.