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Please advise on radiotherapy dosage.
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Please advise on radiotherapy dosage.

› Forums › Cutaneous Melanoma Community › Please advise on radiotherapy dosage.

  • Post
    • September 11, 2019 at 12:38 am
    Affected
    Participant
      Hi Everyone,

      My husband is to begin radiotherapy (IMRT) soon to his neck and lower jaw, but I am very worried about the dosage. According to the radiotherapy oncologist, he wants to give him 2 Gy daily, 5 times a week, for 6 weeks. Based on this information, he would be getting 60 Gys in total to the same area . Does this sound right? I’ve been searching previous posts to try to gauge whether this is standard, but compared to the previous posts I have found which mention radiotherapy dosages, 60 Gys is way too high. I know I should do more research myself, but have been hit by another whammy as we have not been able to schedule the brain MRI which the medical oncologist ordered due to the insurance company saying it is not covered. The oncologist says it is, so we believe it is just the insurance company being difficult.

      To recap on my husband’s resected tumor via parotidectomy and CLND:
      Nodular type, Clarke level of V, Breslow thickness of 17mm, ulceration present, no regression identified, lymphovascular invasion not identified, perineural invasion not identified, mitotic rate of 19 per 10 HPF, micro satellite lesions not identified, closest margin of 14mm (invasive), deep margin of 2.5mm (invasive), 2 involved lymph nodes out of 43 retrieved (one of which is involved due to direct extension), Level II-IV lymph nodes from separate right neck dissection are negative for metastatic melanoma, pathological stage: pT4b N1

      Any sharing of radiotherapy experience would be so greatly appreciated.

      Thank you once again for all your support, and take very good care of yourselves.

      Affected

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    • Replies
        • September 11, 2019 at 12:53 am
        doragsda
        Participant
          I can’t speak directly to radiotherapy, but my wife received gamma knife treatment to two brain mets. Each tumor received a max dose of 40Gy over a period of about an hour and a half. In that context, receiving 60Gy over a 6 week regimen doesn’t seem out of bounds to me.

          I was a Radiation Safety Officer at a university for 25 years, but we didn’t have a medical school so we weren’t dosing people. When they told me that her dose was going to be 40Gy I almost fainted – that’s about 10 times the lethal dose to the whole body, but since it was focused on such a small area, it is not dangerous to the person other than doing the intended damage in the target zone. Hopefully someone will have information more specific to your situation.

            • September 11, 2019 at 11:14 am
            Affected
            Participant
              Dear Doragsda,

              Thank you for sharing your wife’s dosage. As you yourself have mentioned, compared to your wife’s dosage, my husband’s doesn’t seem out of bounds. I find any new information I get about melanoma treatment very empowering even if it doesn’t seem that pertinent to my husband’s situation at the moment because, as I am learning day by day that melanoma is so unpredictable, and given my husband’s medical oncologist’s insistence on getting a brain MRI for my husband as soon as possible, we may be dealing with gamma knife treatment ourselves in the very near future.

              Again, thanks very much for sharing. I will keep you and you and your wife in my prayers.
              Affected

            • September 11, 2019 at 2:01 am
            BillB
            Participant
              I had a nodular melanoma, 7 mm , ulcerated and subsequent parotidectomy. 4 of 35 lymph nodes impacted on CLND. I find it hard to believe a 17 mm deep nodular melanoma didn’t have neuro/vascular invasion but you are lucky. I had neuro/vascular invasion at 7 mm. I received 48 Gy over 20 weekdays. Didn’t stop the melanoma from moving to my lung. I would look to start immunotherapy ASAP, in conjunction with the radiation.
              The inside of my mouth and throat were burned by the radiation. I was prescribed a dexamethasone oral rinse which helped immensely. If you have additional questions please contact me.
              Good luck,
              Bill
                • September 11, 2019 at 10:57 am
                Affected
                Participant
                  Hi Bill,
                  Thank you so so so much. The medical oncologist actually does want to begin with Nivo, but at the moment, we are waiting for the insurance company to approve the brain MRI he asked for. As I type, (we live in Ireland) my husband is at the dentist having his teeth cleaned because we are going to the hospital tomorrow to have him measured for the mask he is to wear for the IMRT radiotherapy which we are told will probably cause damage to his mouth and teeth. His doctor worked at Sloane Kettering, so having read your profile I’m feeling some relieve that my husband’s dosage is okay. Thank you for writing such a detailed profile. I will write one as well for my husband’s melanoma as I am finally coming out of my numb state and realizing that we are not alone and there is hope.
                  Were your 20 weekdays of therapy consecutive? In the case of my husband, that is what is being proposed: 30 consecutive weekdays of 2 Gys.
                  Was your radiotherapy dosage the standard given at MSKCC? or was it a bespoke dosage based on your specific pathology? My worry is that if your dosage was the standard used at MSKCC for cases after a parotidectomy and CLND, my doctor may be giving my husband a dosage that was also the standard at MSKCC, BUT an OUTDATED standard given that he worked there quite a few years ago, and has just not been able to update this old standard because of being located across the Atlantic.
                  Given that your melanoma pathology is so similar to my husband’s, and that you are part of this forum still after almost 3 years of being diagnosed has really given me hope. Please please keep fighting the melanoma. I will keep you in my prayers daily.

                  Best wishes, Affected

                  • September 11, 2019 at 5:18 pm
                  BillB
                  Participant
                    Hi, yes my radiation treatments were 20 consecutive weekdays. sorry, didn’t inquire about dosage at the time I trusted the radiation oncologist at MSK knew what he was doing. With your husbands tumor being so much deeper than mine it makes sense to me for additional radiation to cover the depth but I really don’t know. They can make mouth guards to protect the teeth. So far I haven’t had any problems with my teeth since the radiation. Remember, this dose of radiation is meant to kill and residual melanoma and prevent recurrence in the original area. In my case it had already travelled to my lung. In my case the side affects began after treatment #10, burned mouth and throat along with being tired. Evan after they complete the radiation treatments, the radiation continues to work for another 2 weeks. Recovery will begin after that. Look into the dexamethasone rinse, it was a lifesaver for me. Because it is a steroid it did make me a little ornery. Hope this helps, contact if you want more details.
                  • September 11, 2019 at 5:57 pm
                  Edwin
                  Participant
                    I received 50 Gy radiation to a melanoma tumor under my left jaw in 2018. I received 10 Gy radiation on 5 days: May 22, May 24, May 29, May 31 and June 4. This treatment gave me fatigue for a day or two. I have had no long term problems from this radiation.
                      • September 11, 2019 at 9:18 pm
                      swalters1038
                      Participant
                        I had similar treatment as Edwin. I had some throat issues for a week after treatment but no long term side effects. My oncologist was pretty clear that the treatment was solely for the prevention of localized re-occurence and would have zero impact on long term survivability. He let me know that a second surgery in the head neck area is highly unlikely.
                      • September 12, 2019 at 1:26 am
                      Ellie_82
                      Participant
                        Hi Affected, here us what the current National Comprehensive Cancer Network (NCCN) guidelines say about radiation therapy for loco regional melanoma. Based on these guidelines, your doc is spot on with the dose.

                        Regional Disease
                        • Adjuvant Therapy for High-Risk Resected Regional Disease
                        Adjuvant nodal basin RT is associated with reduced lymph node field recurrence in patients at high risk for regional recurrence, but is
                        not associated with improved relapse-free survival (RFS) or overall survival (OS).7,12,13 The benefit of radiation therapy must be weighed
                        against potential toxicities, such as lymphedema (limb) or oropharyngeal complications. The impact of these potential toxicities should be
                        considered in the context of newer adjuvant systemic options.
                        Risk factors for regional recurrence include gross and/or histologic extracapsular extension of melanoma in clinically (macroscopic)
                        involved node(s), ≥1 parotid node, ≥2 cervical or axillary nodes, ≥3 inguinofemoral nodes, ≥3 cm cervical or axillary node, and/or ≥4 cm
                        inguinofemoral node.12,14,15
                        Dosing Regimens: Optimal regional nodal doses are not well established, but potential regimens include:a,16
                        ◊ 50–66 Gy in 25–33 fractions over 5–7 weeks17,18
                        ◊ 48 Gy in 20 fractions over 4 weeks12
                        ◊ 30 Gy in 5 fractions over 2 weeks (twice per week or every other day)11

                        • September 12, 2019 at 3:37 pm
                        jbronicki
                        Participant
                          Hi Affected,

                          I’m an Irish girl living in Houston (my mother was an O’Brien) but I’m not the one with Melanoma to date. I just wanted to respond since my husband had a similar presentation. His nodular melanoma was 22 mm with mitotic rate of 8. His was on upper back, left shoulder area. His was unique in that it didn’t have skin component and no sign of regression so they were sure if this was primary or distant metastasis to the skin from an unknown primary. There was no vascular, perineural invasion identified and no ulceration or regression either and had 3 sentinel lymph nodes identified which did not show any melanoma. He underwent surgery at MD Anderson on 2/17/2014. At that time Opdivo and Keytruda hadn’t yet been FDA approved (I think it was September of 2014 for Keytruda and December of 2014 for Opdivo) so wasn’t available outside of a clinical trial and definitely wasn’t available yet for adjuvant. The treatments were pretty tough that he was offered. He chose not to have any treatment other than surgery and has been scanned for the past five year. We will get his yearly scan in November 2019. I’m glad your husband is getting treatment, both radiation and soon with Nivo. Our resident research/data expert Celeste has shared the research showing that radiation along with immunotherapy can be powerful combination. From what others have posted, the dosing seems acceptable. It must be scary though anytime you see numbers about what is going to be zapped into the body 🙂 Just wanted to share a similar pathology and we are five and half years out so far. No guarantees but if he progresses, I know we have options that were not available at the time. Many hugs

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