Melanoma Nodes

Question 1

Work up

Answer 1

“SLN bx for depth >1-4 mm (optional for 0.8-1 mm). No benefit with dissection in negative SLNB. Always perform dissection for gross nodes

CT/PET for Stage III and above (e.g. SLN+) or for specific signs and symptoms

Indications:
For clinical trial eligibility, note that nodes had to be palpable. However, some will treat non palpable disease
ECE or
≥1 parotid node or size ≥3cm
≥2 cervical nodes or size ≥4cm
≥3 involved nodes or size ≥4 cm"

Question 2

Treatment

Answer 2

“48 Gy/20 fx (TROG)
30 Gy/5 fx (MDACC)

Caution using <2.5 Gy per fraction: major clinical trials used at least 2.5 Gy per fraction. However there is no difference between 2.5 and 8 Gy per fraction, so 2 Gy might possibly be acceptable. “

Question 3

Fields

Answer 3

“Consider inclusion up to primary site and intransit lymphatics (i.e. don’t leave gap in field between primary and nodes, treat entire portion), nodal levels, flap, nerve if PNI

Axilla: classic field includes axilla plus SCV. Some omit supraclavicle
Neck: level II down to supraclavicle
Inguinal: inguinal plus ipsilateral pelvic nodes

Axilla and inguinal fields are classically treated AP/PA however in the axilla this will treat a large amount of lung. Neck fields are classically treated with electrons, though on dosimetry in reality this usually leads to poor coverage. IMRT may lead to better coverage and less toxicity. Include primary site and intransit lymphatics with IMRT.”

Question 4

Chemo

Answer 4

“Nivolumab,

or D+T combo in BRAF mutated”

Question 5

Dosimetry

Answer 5

“MDACC 5 fx regimen:
Cord and brain max < 24 Gy (however with use of modern dosimetry planning, one may see this was likely actually rarely achieved)

TROG: brain and cord <40 Gy
bowel, brachial plexus, mandible, larynx <45 Gy
Femoral neck, bowel V1000 cc <35 Gy”