Radiotherapy Protocol for Malignant Melanoma

Primary Disease Radiotherapy Indications

The National Comprehensive Cancer Network recommends adjuvant radiotherapy for desmoplastic melanoma with narrow margins, locally recurrent disease, or extensive neurotropism 1
The European Society for Medical Oncology suggests adjuvant radiotherapy for inadequate resection margins of lentigo maligna melanoma when re-excision is not feasible, and for R1 resections of melanoma metastases when re-excision is not possible 2
The European Society for Medical Oncology also recommends considering adjuvant radiotherapy for head and neck melanomas where re-excision would be cosmetically disfiguring or functionally compromising 2, 3

The National Comprehensive Cancer Network recommends considering adjuvant nodal basin radiotherapy in selected patients following resection of clinically appreciable nodes if LDH is less than 1.5 times the upper limit of normal and one or more high-risk features are present, with a category 2B recommendation 1
The National Comprehensive Cancer Network suggests that adjuvant nodal basin radiotherapy should be considered for patients with involved lymph nodes greater than or equal to 4, or lymph nodes greater than 3 cm 1
The National Comprehensive Cancer Network also recommends considering adjuvant nodal basin radiotherapy for patients with recurrent disease 5
The standard hypofractionated protocol is 30 Gy in 5 fractions delivered over 2.5 weeks, which achieves a 5-year in-field locoregional control of 85-88% and reduces lymph node field recurrence compared to observation 1, 6

The National Comprehensive Cancer Network recommends using stereotactic radiosurgery and/or whole brain radiation therapy as adjuvant or primary treatment for brain metastases 1
The European Society for Medical Oncology suggests that palliative radiotherapy is indicated for symptomatic brain or localized bone metastases, and for other symptomatic or potentially symptomatic soft tissue and/or bone metastases 1, 2
The National Comprehensive Cancer Network recommends considering palliative radiotherapy for unresectable nodal, satellite, or in-transit disease 1

The National Comprehensive Cancer Network suggests holding BRAF and/or MEK inhibitors 3 days before and after fractionated radiotherapy, and 1 day before and after stereotactic radiosurgery or other high-dose-per-fraction regimens 1, 5
The National Comprehensive Cancer Network also recommends careful consideration of interactions between radiation and systemic therapies, such as BRAF inhibitors, interferon alfa-2b, and immune checkpoint inhibitors, due to the potential for increased toxicity 5

The European Society for Medical Oncology recommends isolated limb perfusion with melphalan and tumor necrosis factor as the preferred treatment for non-resectable transit metastases or inoperable primary tumors of the limbs without additional metastases, but notes that radiation therapy may be used as an alternative 2, 4