melanoma
MELANOMA
Treatment Guideline Chart
Melanoma is a skin neoplasm that originates from malignant transformation of melanocytes.
It commonly occurs in the extremities of women and on trunk or head and neck in men.
Metastases are via lymphatic and hematogenous routes.

Melanoma Treatment

Radiotherapy

  • Used as definitive therapy in patients with unresectable stage III melanoma with clinical satellite or in-transit disease, or in patients ineligible for surgery
  • Management option for patients with lentigo maligna who are not in favor of surgical therapy
  • May be considered in primary disease desmoplastic melanoma with narrow margins, comorbidities or extensive neurotropism and in regional disease as adjuvant therapy in patients with lentigo maligna melanoma whose surgical margins were inadequate, in patients with microscopic tumor remnants, or bulky disease post-surgery and as palliative therapy for unresectable satellite, nodal or in-transit melanoma
  • Recommended regimens for definitive radiotherapy:
    • Primary disease: 64-70 Gy in 32-35 fractions for 6 to 7 weeks; 50-57.5 Gy in 20-23 fractions for 4 to 5 weeks; 35 Gy in 5 fractions for 1 week for fields <3 cm in diameter; 32 Gy in 4 fractions once/week
    • Regional disease: 24-27 Gy in 3 fractions for 1to 1.5 weeks; 32 Gy in 4 fractions, 40 Gy in 8 fractions or 50 Gy in 20 fractions for 4 weeks; 30 Gy in 5 or 10 fractions for 2 weeks; 20 Gy in 5 fractions for 1 week; 8 Gy in 1 fraction for 1 day
    • Distant metastases: Depends on the technique, tumor size and whether as primary or adjuvant therapy
  • Preferred radiotherapy techniques to be used for brain metastases, both as primary and adjuvant therapy, include stereotactic radiosurgery (SRS), fractionated stereotactic radiation therapy (SRT) and image-guided radiation therapy (IGRT) is recommended for better accuracy in the delivery
    • Large lesions should be treated with fractionated SRS to decrease the risk of radionecrosis
    • Whole brain radiation therapy (WBRT) as primary treatment may be considered in patients with numerous brain lesions and with symptoms due to intracranial pressure
    • Adjuvant WBRT may be used in cases of suspected leptomeningeal spread or when SRT and SRS are not technically feasible
  • For extracranial metastases, stereotactic body radiation therapy (SBRT) may be considered
  • Adjuvant radiation therapy
    • Should be considered in patients with desmoplastic neurotropic melanoma especially those with extensive neurotropism or are at high risk for local recurrence, especially if margins are suboptimal to improve local control
    • May be considered to prevent or control nodal relapse in select patients with clinically positive nodes and patient's at risk
    • May be used after surgery in patients with brain metastases
    • May be an option for selected patients with unresectable symptomatic regional recurrences without alternative options
  • Adjuvant nodal basin radiotherapy for stage III with clinically positive nodes and unresectable stage IV melanoma with brain metastases may be delivered via intensity-modulated or image-guided techniques
  • Recommended regimens for adjuvant radiotherapy:
    • Primary disease: 60-66 Gy in 30-33 fractions in 6 to 7 weeks; 48 Gy in 20 fractions for 4 weeks; 30 Gy in 5 fractions for 2 weeks
    • Regional disease: 50-66 Gy in 25-33 fractions for 5 to 7 weeks; 48 Gy in 20 fractions for 4 weeks; 30 Gy in 5 fractions for 2 weeks
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