Melanoma Dose for Non Resectable Site of Disease.

[fiji128]

I hardly see melanomas anymore. What dose would folks use in this scenario:

80 yo woman. Left calf melanoma s/p Sx in 2015. Local/regional recurrence (including inguinal nodal) in 2016 s/p Sx. Has since been on Keytruda/Tafinlar/Mekinist. Now with local progression s/p Sx with positive margin in July 2023. Further local progression on PET with a 1.5 x 2.4 x 2.2 cm in calf lesion with a SUV 12. No further sites of PET avid disease. Not a candidate for further surgery.

Edit: I will also add that the PET avid area is essentially up to the skin so skin will also need dose coverage. PET image attached.

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[Palex80]

I hardly see melanomas anymore. What dose would folks use in the scenario.

80 yo woman. Left calf melanoma s/p Sx in 2015. Local/regional recurrence (including inguinal nodal) in 2016 s/p Sx. Has since been on Keytruda/Tafinlar/Mekinist. Now with local progression s/p Sx with positive margin in July 2023. Further local progression on PET with a 1.5 x 2.4 x 2.2 cm in calf lesion with a SUV 12. No further sites of PET avid disease. Not a candidate for further surgery.

Something equivalent to >60 Gy EQD2.
You could add superficial hyperthermia (is that a thing in the US?), if available.

 

[drowsy12]

40/5- 50/5, depending on your appetite.

 

[TheWallnerus]

40/5- 50/5, depending on your appetite.

I would not look forward to the skin effects from that dose in an older lady

I think I would just do 66/33 with 12 MeV electrons, a cm of bolus, and a good margin around the site, and prescribe to the 90% line.

 

[NotMattSpraker]

I would not look forward to the skin effects from that dose in an older lady

I think I would just do 66/33 with 12 MeV electrons, a cm of bolus, and a good margin around the site, and prescribe to the 90% line.

I like that.

If you wanted to hypofractionate 30/5 for melanoma is a tale as old as radiation time.

 

[MidwestRadOnc]

48/20, boost to 55.2/23

 

[RickyScott]

Something equivalent to >60 Gy EQD2.
You could add superficial hyperthermia (is that a thing in the US?), if available.

have used a heating pad for an hour as hyperthermia several times. (no, i didnt bill for it)

 

[drowsy12]

I would not look forward to the skin effects from that dose in an older lady

I think I would just do 66/33 with 12 MeV electrons, a cm of bolus, and a good margin around the site, and prescribe to the 90% line.

Would meet your skin constraint of choice. 30 if you want to be very conservative while still taking the rest to 40.

If it’s largely/only at skin then would favor something in 20 fractions.

 

[Palex80]

have used a heating pad for an hour as hyperthermia several times. (no, i didnt bill for it)

I considered using a Sous-vide for a Kaposi sarcoma of the foot.

My boss did not appreciate the idea.

 

[ramsesthenice]

Something equivalent to >60 Gy EQD2.
You could add superficial hyperthermia (is that a thing in the US?), if available.

I don't think it is. Duke and VCU were 2 of the last centers that I know were doing it (I am sure there are others, but not many) and I don't believe either still offer it.

 

[gmsquid]

6x6 to dmax with electrons to dmax is the classic mda definitive regimen, hopefully posterior calf

 

[NotMattSpraker]

I don't think it is. Duke and VCU were 2 of the last centers that I know were doing it (I am sure there are others, but not many) and I don't believe either still offer it.

Wash U is doing it, I think mainly for breast re-irradiation cases.

 

[Brim]

I considered using a Sous-vide for a Kaposi sarcoma of the foot.

View attachment 381112
My boss did not appreciate the idea.

I sous vide'd my own foot one time for a plantar wart.

(Success rate: 0/1)

 

[RickyScott]

I considered using a Sous-vide for a Kaposi sarcoma of the foot.

View attachment 381112
My boss did not appreciate the idea.

I considered using a Sous-vide for a Kaposi sarcoma of the foot.

View attachment 381112
My boss did not appreciate the idea.

8 years ago re-irradiated a surgeon with nasty squamous cell of scalp. He held the heating pad against his head with old perez/brady book 2-3 x week before treatment.

 

[TheWallnerus]

I considered using a Sous-vide for a Kaposi sarcoma of the foot.

View attachment 381112
My boss did not appreciate the idea.

Physics(thermodynamics)-wise, this would not work if you needed to go much below skin surface. Because a foot has a blood supply. For the same reason this plastic bag is fine in fire in the below video. Really need an electromagnetic method to heat something below the skin. Heating pads can work for skin, as long as you can treat through it, as could sous vide.

 

[Palex80]

Really need an electromagnetic method to heat something below the skin.

 

[Gfunk6]

Here is an advertorial I created with Accuray based on a patient I treated a couple of years ago with recurrent, inoperable melanoma.

YMMV.

 

[TheWallnerus]

Here is an advertorial I created with Accuray based on a patient I treated a couple of years ago with recurrent, inoperable melanoma.

YMMV.

View attachment 381179View attachment 381180

No bolus I’m guessing

 

[Gfunk6]

No bolus I’m guessing

As I recall we used wet gauze daily with a 0.5 cm bolus equivalent.

 

[communitydoc13]

Here is an advertorial I created with Accuray based on a patient I treated a couple of years ago with recurrent, inoperable melanoma.

YMMV.

View attachment 381179View attachment 381180

I'm so scared. Did the ulcer heal?

 

[A_DeMichele]

I would use photons and standard fractionation (66 Gy perhaps?). Distal extremity = may not heal like it would on the thigh

 

[Gfunk6]

I'm so scared. Did the ulcer heal?

Yes, the area where the melanoma formerly broke through healed although the overyling skin remained permanently hyper-pigmented. We measured the dose with surface TLDs and it was below the threshold for skin necrosis per TG-101. When you break up the dose between ~ 100 beams, the surface dose is frequently over-estiamted by the TPS.

 

[taserlaser]

Here is an advertorial I created with Accuray based on a patient I treated a couple of years ago with recurrent, inoperable melanoma.

YMMV.

View attachment 381179View attachment 381180

I like the idea of putting a fiducial in there on the leg. I find I get a fair amount of rotation even with best attempts with vac locs and aqua plast shells.

edit: will qualify as a fair amount as “some”. Not an issue for SBRT but more of a pain for longer volumes

 

[evilbooyaa]

40/5- 50/5, depending on your appetite.

This. For local recurrence without distant mets I would go ablative dosing. 50/5 to PTV with consideration of hotter GTV. Cover disease, counsel patient on late skin toxicity. Good news is that it's posterior calf as opposed to anterior.

 

[SneakyBooger]

I would not look forward to the skin effects from that dose in an older lady

I think I would just do 66/33 with 12 MeV electrons, a cm of bolus, and a good margin around the site, and prescribe to the 90% line.

Same. Except I would use IMRT and spare a strip of tissue.