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Linac based repeat srs dose

Neuronix

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1 progressive lesion of many treated melanoma mets. Previous dose 20Gy in 1 fx a year ago. 1.5 cm now with moderate vasogenic edema.

Thinking of fractionated approach. 6Gy x 5 or 9 Gy x 3. Any consensus?

No consensus. My first choice would be surgery to confirm growth of disease as opposed to RT necrosis. If you're convinced or resection is not feasible I would do 6 Gy x 5.
 
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evilbooyaa

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Wake forest has some toxicity data on re-treatment:


Plan for say 18x1, evaluating minimization of composite V40 with previous treatment, then after plan is completed, change prescription to 9x3 would be my go-to.
 

Lamount

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At a few places that I have worked, we had NSG use LITT in these circumstances... with the added benefit of obtaining a biopsy to determine necrosis vs. recurrence.
 
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BobbyHeenan

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This clinical case is becoming more common. I swear pre immunotherapy I never saw this. Everyone died a year later.


All I can say is get the bevacizumab ready. Works like a charm when you’re scratching your head on necrosis vs progression 3 months later.
 
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evilbooyaa

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This clinical case is becoming more common. I swear pre immunotherapy I never saw this. Everyone died a year later.


All I can say is get the bevacizumab ready. Works like a charm when you’re scratching your head on necrosis vs progression 3 months later.

Had one patient with steroid-refractory necrosis (like 8mg BID kept her symptoms in check but couldn't wean her off at all), who refused surgery (as she'd already had at least 2-3 resections) and finally convinced a med-onc to give the Avastin. The low-dose Avastin worked like a charm. Wish it wasn't so painful to convince med-onc/neuro-onc to give it.
 
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evilbooyaa

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I mean it's not 100% but probably closer to 20-30%, which is not nothing.

Sorry to clarify - I mean the risk of necrosis after you re-treat this. Melanoma brain mets not having 100% success rate to SRS is not unexpected.

If you're not convinced it's necrosis now, then reasonable IMO to re-treat.
 
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