Chapters Transcript Video Radiation Therapy for Melanoma Including Lentigo Maligna Back to Symposium Dr. Prabhakar Tripuraneni discusses the role and efficacy of radiation for treating melanoma. And our last speaker to take us to the break and we will be taking our full break is dr trepany me of the radiation oncology section at Scripps Clinic provoke a are you here? I'm here? All right, let's take it away and tell us about radiation therapy for melanoma. Good afternoon. As dr mary mentioned earlier, it's always a hard act to follow dR us. And I want to thank dr Baruch, Conductor Greenway friend way to make it into this conference. And also it's a great pleasure for me to work with Dr Greenway. And the most group of doctors are a conductor kelly and most of dermatologist. Normal group very closely. More than half my practice actually skin cancer. One of the enjoyable Mondays in the years are most fellows actually rotate with me for several Mondays. These are very sharp dermatologist that are going to be most sergeants. They keep me on my toes about radiation therapy. In scan cancer management. And they do their best to keep me on my toes. And I do my best actor to convert them from most surgeons when they joined the program into cutting his oncologist because these are the last line of defense for the multidisciplinary treatment of the skin cancers including the llamas. And I think most of them. But then they got the year of the program. They turned into cutaneous oncology and think broadly in the broad strokes of how to manage these patients with the falcon who wanted to my talk radiation type of for Malema include England family. Now I don't have any disclosures Artificial radiation actually was first invented in 1895. The very next year. In 1896. A faster patient was straight through the radiation therapy. Yeah. 1st tax where mrs Langdon you can see the wedding ring. First known patient treat in Chicago for a business silk are some of the most in 1986. And we do have about close to 30 year follow up skin. Most of you must have seen your patients in the follow up clinic soon. Even though skin comes the small council, let's say about half sentiment damage or radiation oncologists end up treating with field about almost 2.5 or three centimeter size. And also the skin reaction is much bigger. This is the reason so called the penumbra. When we are treating the skin cancer like this here you have to treat a much bigger beam because actually by the time it goes into the depth rating, they're the kind of field narrows and also there is lots of fuzzy edges of the radiation. Be able that goes out farther. Almost up there, one centimeter 1.5 centimeter that is not adequate those to treat the cancer. Also from this total diagram, you can see when we treat with electrons, you know, use a field of free by this into metro The skin reaction goes up to almost four x 4 cm. But the actual radiation therapy that you're giving me a high doses in the center 1 to 1.5 centimeters. Only mm hmm. At the end of the day radiation. The radiation and all the differences. Basically how superficial are how deep you are going to treat? What is the volume? Are you going to treat a limit? The volume are going to take the margins on a white field. You can use many kind of access grants rates that are very superficial frequently after a millimeter to depth. And we typically use about 25 to particular voltage. You can treat up 200 kilovolt tax rate street up there but maybe 3-4 mm depth. The complete with electrons anywhere from a few millimeters to a few centimeters. And you can use mega voltage X rays occasionally. And they do go to a much deeper depth. But actually we have fancy technically news such as a marty and we can use programs I use mostly electrons. Yeah. And also McNulty's expression, uh we don't have killed all these machines. So I really don't use that machine. And I think it's important actually that you're proficient in using water. You have in your place. The typical fracture national radiation therapy is 200 to 300 centigrade. Typically used anywhere between 12 to 35 fractions More recently in the past two decades we have been using more of a hyper fraction nation anywhere between 300 to 600 degree. About 60 15 fractions more recently in the past maybe 5 to 10 years. And we started using stereotyped radiosurgery in stereotyped brain stereotype, radiosurgery and stereotyped IQ body. To the therapy, I will show you some of the examples. These are particularly useful in treating algoma started disease of the malignant melanoma, especially in the brain melts lang mats are solid little government are born yet we do usability of radiation therapy and I think gamma knife cyberknife came up with the fancy names and those machines became very popular. But the both the stereotype tickly day surgery and stereotyping body. Ready therapy that gamma knife from cyber map does is an equal level with the linear accelerators that most of the people who use it this time. What the major advances and radiation therapy over the past decade is a complete rejection of the radiation producing apparatus Essentially when I started my training about 22 years ago in it expects were there but they were kind of crude, almost like a Food model T car and fast forward about 40 years right in their emissions are completely computerized and we can do lots of fancy things very quickly. The second thing that happened that is not so much applicable in the skin cancer, but when they are treating any deep seated thomas, immediate guidance, we want to see where we are treating in the past. We used to put a few tattoos on the skin and kind of blindly treat the patient. We do know that actually putting a tattoo on the skin has no bearing on what goes on in the lung or what goes on in the prostate, right in there. So we do a lot more sophisticated techniques. We can take express look at the bones. We can actually do a cat scan while the patient is on the table and look at what you're creating and make the proper adjustments just before the radiation therapy. And more recently there are multiple uh marguerite treatment machines that actually is continuously acquiring the images four frames per second while treating and modifying the beams depending upon the organ motion. Very advanced technique. Also, the other advantages, almost all patients with different content are being treated with concrete immunotherapy are concurrent chemotherapy and these are the good examples of brain cancer, having a cancer, lung cancer and G8 et cetera. The role of radiation therapy in both clinical malignant, also in malignant melanoma is relatively small but relatively important role. It used to mainly prevented local reconstructive surgery, especially if somebody has a high chance of local residents, decrease the regional differences. Any palpitation of transit metastases alienation of bone symptoms, which is a very important component in the management brain. Mets bone itself. Fishnets and local variation of what non surgical candidates like that patient Actually. We had the discussion in the morning in the case discussion. The first patient, even though decline, she would have been a good candidate to receive radiation therapy. Okay, radiations have been used mainly for local control, regional control and the management of distant metastatic disease to improve the quality of life. Local control of clinical malignant melanoma, Lama radiation type is a reasonable alternative for primary treatment. Local controls you can expect about 90%. It's typically probably we treat maybe about a half a dozen patients a year. Often it is used in the ideal setting for references and also like that patient this morning. Any closer positive margins That prospect to study from British general dermatology. 150 patients, All of them treated with 30 kilovolt is x rays. Does is quite varied from 40 to 54,000,000,007 to nine factions, 7%. Local reckons it's seven years, marginal failures. Most of patients that failed actually failed when the margin was less than 10 millimeters. So recommendation was actually used white margins for this melanoma in searches that actually we used to just know that actually even relation is relatively small as you do most. What do you find margins keep going on Under study from Sweden had blog largest cities to single largest cities. 593 patients treat over the past 20 years plus 73 of the 593 approximately 12% did not clear with the radiation therapy, 21% of those patients that did not clear with radiation therapy did not have adequate skin reaction. That means actually patient did not have any of those abbreviations will be delivered to them for a variety of reasons. And also there are several patients that actually had multiple skin falls and the dose of radiation therapy the energy of radiation therapy was not picked appropriately and the depth was inadequate and most of the patients actually failed either because the inadequate depth are insufficient margins Under 2012. The 73 patients actually for you showed that patients had a typical melanocytes in that next structures saying that these are aggressive Malawian structures handlebars conclusions. Ara quit those to reach the skin reaction adequate field size. They recommend anywhere between giving 5-20 million margin adequate depth when I'm using electrons, I don't have to be able to do it because I have the tool that I can pick and choose any debt they want. And after I tend to overestimate and treat more than 3 to 4 millimeter margin than what I think I need to treat in melanoma. In searches I typically try to give at least 10 millimeter margin if not more. Yeah, largest threes of systematic review. President by Hendrik SAT Down. Uh this is published recently in 2020 and you have the citation there. They reviewed about 14 different studies and a total of 1200 plus patients created with radiation therapy. And initially as most of radiation oncologist they concluded that they started the paper saying that the trap the gold standard for million lines such as the surgical excision. However, there are many patients that are treated with radiation therapy for a variety of reasons. When they looked at these 14 studies, the local reconstructs range never with 0% to 31% and were comparable to multiple surgical city system. Again, it boils down to the patient selection and also experience and expertise of the radiation oncologist. Just like the most. Such. Again, the doses were quite variable. Cosmetic results were reported as good to excellent by the majority of patients. In conclusion the available low level evidence. The reason I chose that were low level. There is no randomized studies. There's no prospect of studies. These are all retrospective studies. That reason why I picked up a choice of borders. The low level evidence suggest that radiation therapy may be safe and effective treatment for malignant or malignant melanoma. The data from the prospect of trials such as the Phase three radical trial admitted to confirm that these promising findings are comparable to radiation therapy. This is the only randomized trial that I know of actual that is being compared between radiation therapy for the human for melanoma in situ I guess are these are pretty active in this space. Especially skin cancers, malignant melanoma cells. And they also have multiple 12th. Actually in the actual radiation therapy for regional reference in malignant melanoma cells. They're actually comparing this melanoma inside to patients with uh radiation that we want to make more than 260 patients. And I think they start enrolling patients. And this is truly supposed to complete the enrollment by 2021. I have not seen any updated. Are any interim data. If anybody have. Have you please feel free to share with us Fracture nation. They recommend is the standard fractions in their communities to greater fraction to go to Joseph anywhere between 54 to 60 grade. I typically is a 2.5 ready to go to the 50th regular so that patients are done for in half x. And occasionally if the area surface area that I'm treating is too large, especially more than 20 to 30 square centimeters. I kind of go to to greater fraction to go to 60 to 62 66th grade. Occasionally in all the patients you can use hyper fracture nation Sometimes it may take up to 24 months actually for the pigmentation to completely disappear. So when you treat Malawian such with radiation therapy, you don't have to jump the gun within three months. Inaccuracy patient has failing. I have seen patients up to the skin reaction grabbed the member. My pigmentation gradually fades Even at the end of 24 months. Actually you can see a failing to share our discoloration but usually not that visible. Typically we like to kind of reassess in the six months to see what happens. And the papers published that actual report that victims can happen as early as three months. In fact not clearing the LLama and as late as 108 months. So that means actually we need to follow these patients in summary radiotherapy for Lincecum Alexandra malignant melanoma seems to provide excellent local control with good cosmetic results. Typically in the 90% local control with the very good custom crystals in more than 80 to 90% of patients and consider a preferable nonsurgical treatment modality. Radiotherapy should be discussed in a multi discipline meeting as a treatment option, particularly in elderly patients with relations in the head and neck region who have contraindications are risk factors for surgery. Postoperative radiation to be useful in patients with positive margins and our references. I think we're going to switch the case and we went to malignant melanoma, malignant melanoma. Agilent radiation therapy two months with high risk factors for local reckons Breslow depth of more than four millimeters. Seth analysis After not used as a management of system takes precedence right in there. Anybody who can breastfeed after more than four. Actually they have a high risk of actually regional restaurants and high risk of a distant metastatic disease. And so they kind of basically gone to uh systemic therapies rather than proceeding with local radiation therapy. Radiation therapy is quite useful in particular myeloma such as that's more plastic Malema. And also patients with paranormal innovation. There are much higher local failures. Almost up to 40 these patients. These specific class of patients actually don't have a significant distant metastatic disease. And I think in this class of patients actually adamant radiation therapy would be very useful to improve the local regional control. So I recommend post operative radiation therapy and select class of malignant melanoma. Patients with desmond plastic mama. Any patients with the significant pretty nor generation close margins of less than one cm and dictums evil melanoma doctor manner has covered quite nicely in his talk earlier melanoma in situ if you pictures to show quickly right in their patient actually the myeloma inside you. He didn't want to be treated with surgery and I treated with radiation therapy in the central one. You can actually the field I used right in there and that the actual we put a small lead shielding the no salt actually we don't treat the septal membrane at the other side of the nose patient to follow up for three years. You can barely see anything has been done. You can still see if you look closely there's a tiny little brush Had a post biopsy I think somewhere between 4-6 months and that was negative and patient is quite happy. I don't know whether you noticed or not. He lose a little bit of the mustache right here affiliation is very good rating there. A large out certain malignant melanoma and a year three months after radiation therapy and the combined umbrellas mob large neck lymph node that was causing symptoms. Same thing. It almost completely disappeared. The same patients actually in the city with a large tumor bulk right here. Post radiation therapy, post treatment would significantly resolved. Mhm. Local treatments are usually done with electrons four times with advanced techniques. Typically we try to use a rapid fracture nation schedule for these patients because therefore multiple other things going on at the same time Because the elements are actually pretty resistant and they're not easy to treat with if suddenly cannot be done. You can do primary radiation therapy. Typically local control is no more than 50%. Typically with surgery, local witnesses could be anywhere between 30 to 80% and most of the mucosa llamas. After maximum surgery, we almost always after post operative radiation therapy with the net local control. In the 15 to 30% range, distant metastases. As I said, the militant melanoma is actually notorious for distant metastatic disease. Patients have bone pain, Arlington and pain. We typically tend to give it a single fraction are one week fraction are cubic fractions of 392 paper fraction times 10 spine single fraction of 1673 R five fractions of stereotyping body. Red therapy depending upon how big a volume you're creating and how close you are to the spinal cord. Somebody with symptomatic bony metastases patient got computers and that's in contractions with just a plain three D. Can formal technique, spine brain metastases actually common problem Patients with good Karnowski performance status. This limited mitosis anywhere between 1-2 initially and right at this point, up to 10 metastases. We can treat with a single fraction of radiation therapy. This is where stereotype threat subject comes in very handy. You can actually see my consistent tom right there and I think three months after complete response, We are very good at this actually the control rates are actually 90-95% and hardly any complications. Things patients if somebody has multiple asians are a large volume mitosis, we tend to fraction it up to five fractions that's called steri attractive body or therapy. A large relation you can see almost completely disappear in between these two. You can actually tell patients had a shunt placed. We use whole brain radiation therapy for patients with the poor Karnowski perform status and multiple metastases. We use aqua plus casting mobilization to keep them. Most of patients actually get radiation therapy from the head and neck area for skin cancer is also we use cast to kind of keep them in the same position without moving. While we are giving radiation therapy. We have lots of fancy tools in radiation therapy. We can bring in the pet scans and mris and cat scans and fuse with what we're about to treat and do the real management how to define the tor and also we have pretty good tools actually we can you can see a patient with their multiple brain model system actually fused with the camera in the pet scan and you can actually slice and place anywhere you want and look at what you're about to treat and how to treat them. It's almost turning into a video game these days. Right in there. Obviously there's lots of cognitive component but its tools are very easy these days to use once you get to know them, somebody that got ripped a word follow different mitosis in a matter of less than half hour, 20 years ago, nobody could have imagined. I could I could treat disagreement houses in the brain. Okay, radiation therapy in the llama primary disease agent. Radiation therapy in selected patients with deep dismal, plastic myeloma, extensive neuro trumpism. Our local aircrew disease regional disease. Agilent radiations have been select patients with clinically and one positive especially with external extension and mental influence positive, but most patients actually the states who don't even bother offering them because they're going to add joint immunotherapy metastatic disease. Radiation therapy is a great tool in the living uh pain or any symptoms from the metastatic disease and improve the quality of life. And we have many different ways. Actually we can create these patients immunotherapy melanoma is actually just starting to come in as dr ross has mentioned. I think my colleague dr Catherine bullets are going to talk about it. To me the way it looks just the beginning with so much more potential in so many uh thomas. Radiation therapy historically has been known to have a couple effects, especially in a lymphomas. When somebody has an informal, when we treat one personal informa, all the other informers also start going away. A few cases have been reported malignant melanomas. Also, I think probably this distant objects related to activation of the thomas specific effect our T cells through generation of inside the vaccine. Wow. And I think new area of research that developing is immunotherapy in radiation therapy. Radiation therapy, a joint immunotherapy to enhance the proportion of responses and extend the duration of response under lots of unanswered questions at this point in time between the immunotherapy radiation therapy, the role of radiation therapy in malignant melanoma is a small but important role in preventing local concern. After suddenly decrease the reason references valuation of in transit metastases especially population of symptoms from the born brain and safety mitosis and local population for non surgical candidates. 30. Park, Broken Hill, probably the most beautiful place in 30 points cat in the hat in front of ted Gasol Pavilion of scripts clinic with that I thank you very much Published August 16, 2021 Created by Related Presenters Prabhakar Tripuraneni, MD Director, Radiation Oncology Scripps Clinic Dr. Prabhakar Tripuraneni, radiation oncologist. View full profile
