Malignant Melanoma
Malignant Melanoma
ROLE OF ADJUVANT RADIATION THERAPY
Elective lymph node dissection ELND, while effectively reducing regional recurrence rates, carries varying degrees of morbidity and does not offer any survival advantage in patients with thick primary tumors. On the other hand, therapeutic dissection of pathologically involved nodes is associated with a local recurrence rate of up to 50% in patients with head and neck melanomas.
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There is an apparent advantage in terms of local regional recurrence for adjuvant radiotherapy. The following is an update of the study with a median follow-up of 38 months. Through July, 1994, 224 patients (171 men and 52 women) were enrolled. Their ages ranged from 16 to 89 years (median: 55 years). Patients were organized into three groups. Group I consisted of 118 previously untreated patients who presented with primary lesions either greater than 1.5 mm thick or Clark level IV or V who had no palpable lymphadenopathy. Twenty-seven percent had lesions greater than 4.0 mm thick. After WLE, these patients received radiotherapy to the tumor bed and at least two echelons of the draining lymphatics of 30 Gy (Dmax ) delivered in five fractions with electron beams of appropriate energy. This group of patients had an overall 5-year actuarial rate of local regional control of 86% and a 5-year survival of 63%. It was interesting, that 71% of patients with primary lesions 1.6 to 4.0 mm thick were 5-year survivors after elective radiotherapy.
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Group II consisted of 39 patients with previously untreated disease who presented with clinically positive lymphadenopathy. These patients mostly received postoperative radiotherapy (30 Gy Dmax delivered in five fractions over 2.5 weeks); the remainder received preoperative treatment (2 Gy Dmax delivered in four fractions over 2 weeks). These patients achieved a 5-year local regional control rate of 92% and 5-year survival of 41%, with survival being inversely proportional to the number of pathologically involved lymph nodes.
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Group III consisted of 67 patients who presented with recurrent regional and/or local disease, but without evidence of distant metastases. These patients were treated in the same manner as group II patients. Their 5-year local regional control rate was 88% and survival 45%. With the addition of adjuvant radiotherapy, the local-regional control rate of group II and III patients was not affected by the number of positive nodes or extracapsular extension.
These results demonstrate that adjuvant radiotherapy, either alone in clinically node-negative patients or as a surgical adjuvant in pathologically node-positive patients, can achieve local regional control in excess of 85%. This is substantially better than rates previously reported with surgery alone in comparable patients. The radiotherapy schedule used was not associated with any significant morbidity. In total, 3 of the 224 patients treated to date have sustained mild to moderate sequelae. There has been no severe complications. Although these data are impressive, proof of a therapeutic benefit from adjuvant radiotherapy can be obtained only from a prospective randomized trial. Such a trial, based on this pilot study, has been activated by the Radiation Therapy Oncology Group (RTOG).