Melanoma/Skin   

Questions discussed in this category



Would you recommend adjuvant radiotherapy for a patient with positive margins for in situ disease with negative margins for invasive disease? If so, w...

Would there be any indication for postoperative RT if cervical lymph nodes are negative?

Assuming no other sites of disease on staging scans, surgery is not an option, and the patient is otherwise healthy with reasonable life expectancy. W...

I am considering every 6 week pembrolizumab dosing in patients >70 years old in whom I want to reduce clinic visits for, especially in the context ...

In this example, the patient had a resected melanoma with negative margins and the specimen was noted to have two nests of tumor cells in the deep der...

Given the location but no other high risk features would you offer RT?  If so, what dose and fields? 

In patients with cancers involving the lid requiring superficial x-ray treatment, I use an internal eye shield placed under the lid to protect the cor...

Specifically, for a melanoma of the axilla with proximity to the brachial plexus, how would you approach such a case to minimize chance of radiation-i...

A patient with stage 3 melanoma on adjuvant nivolumab needs radioactive iodine for papillary thyroid cancer.

What pathologic features are most important when evaluating the possible need for adjuvant therapy?

Patient is a  67yo with a pT1 (2.5mm) pN1a merkel cell of the chest, 1 mm deep, widely clear margins, SLN with 1.5mm met, 11 additional axillary ...

Is it possible to get a good measurement with TLDs? TLDs can overestimate the surface dose by 10 - 40%. Do you use a skin diode measurement on the fir...

Would you offer nodal dissection and/or additional adjuvant immunotherapy in addition to wide local excision?

Sometimes wound healing can delay adjuvant radiotherapy by several months. For aggressive histology, such as high grade sarcoma or skin cancers, is th...

*Negative margins, <1cm in size, no LVI, negative SLNB, not immunocompromised, no prior surgery (as well as a negative PET/CT scan).

Would your recommendation change with the following aggressive features: 8 cm, pericolic extension, positive radial margin, perineural invasion presen...

For instance, not chronic autoimmune diseases (eg RA, IBD) that may relapse/remit but events like Guillan Barre syndrome that is not likely to recur b...

Do you prescribe to 5mm/apex or use a margin? Do you add time for tumor growth or allow less than the prescription dose to the apex?

Especially in the setting of prior “standard” adjuvant dose and refusal of the patient to undergo more extensive surgery. Do you recommend...

Should concurrent chemotherapy be given? How would you modify the regimen in elderly/frail patients?

These patients are often not surgical candidates, but radiation complications may also be underappreciated.  Do you refer to vascular surgery pri...

Would you recommend axillary dissection, axillary dissection followed by adjuvant radiation, or axillary radiation alone? Does the number of positive ...

Is extrascleral extension or optic nerve invasion an indication?  I can find little in the literature or textbooks discussing this issue, likely ...

With increasing utility of immunotherapy across cancer types, patients with history of solid organ transplants may face need for cancer IO. How do you...

What are your dose constraints for treating axillary nodal basin in melanoma with the Ballo protocol 30Gy/5fx?

The FDA has approved the new dosing schedule of Nivolumab 480 mg every 4 weeks for multiple disease sites (melanoma, RCC, urothelial carcinoma, SCC of...

Should these patients have surgery if resectable? Should RT (SBRT) be directed at metastases during/concurrently with immunotherapy down the road?&nbs...

Would you recommend additional surgery for the violated neck? Or, would you proceed with adjuvant radiation therapy? If so, would you treat ipsilatera...

In this case, I have a patient with widely metastatic cutaneous melanoma (BRAF wild type, NRAS mutated) who is progressing through pembrolizumab and i...

Do you recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?

The trials for adjuvant nivo, ipi and BRAF targeted therapy excluded patients with high risk stage 2. If no clinical trials are available, would you o...

Patients with T3aN1a( stage IIIA per AJCC7) were excluded from nivolumab adjuvant trial. Would you consider nivolumab in these patients?

For example, in a patient status-post WLE with a close (2.5 mm) deep margin and negative neck node sampling, would clinical (but not pathologic) ...

Checkpoint inhibitors have demonstrated durable responses in clinical trials, which was never seen with cytotoxic chemotherapy in the past. What are t...

NCCN guidelines recommend both single agent Pembro and/or Ipi/Nivo as first line options. How would you choose between the two? In case of the latter,...

The FDA recently approved Braftovi (encorafenib) and Mektovi (binimetinib) in combination for unresectable or metastatic melanoma. When would they be ...

For example, would you consider this in a patient that would otherwise be eligible for adjuvant treatment (stage III or stage IV with oligometastatic ...

For example, for a squamous cell carcinoma of the forearm treated with Mohs surgery with negative margins, are there features that would lead you to e...

Per NCCN, only +/close margins and +PNI are given as indications for adjuvant RT. However, are the presence of other risks factors considered to guide...

Can you extrapolate the data on Durable Complete Response After Discontinuation of Pembrolizumab in Patients With Metastatic Melanoma to patients on a...

If the cyst was encapsulated and completely removed and SCC was found incidentally on final pathology, what are some factors that would influence your...

In this study, doses of 2mg/kg Q3wks, 10mg/kg Q3wks and 10mg/kg Q2wks were used. What did the majority of these patients in CR receive? 

NCCN lists only substantial perineural invasion.  What about other high-risk adverse features such as histologic subtype, multiple recurrences, d...

Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate?  Is there a decent equatio...

How do you treat these patients if they progress after immune checkpoint inhibitors?

 How does your fractionation choice change if the lesion is abutting the pleura?

Would your recommendation change at all depending on time to relapse or original stage of melanoma?

If staged so due to satellite lesion and negative nodes? How do you decide between adjuvant PD-1 inhibitor or BRAF/MEK inhibition in BRAF-mutated pati...

Assuming SRS to the resection cavity is advised, would you recommend early immunotherapy to improve outcomes/enhance a possible abscopal eff...

These patients have been largely excluded from these trials.  What if the infection is well controlled?

When elective nodal radiation is recommended, which nodes would you treat (i.e. facial, pre-auricular, peri-parotid, levels I-III, etc.)?

Would you ever considering re-starting immunotherapy before completing the taper? According to the new guildelines on managing immunotherapy related ...

Is the use of immunotherapy being considered, and if so, is the data extrapolated from treatment of mNSCLC and head and neck SCC?

Patient underwent a shave biopsy of a 6x5x2mm preauricular lesion that showed moderatley differentiated sebaceous carcinoma with deep and lateral marg...

How would your management change in an elderly patient with no surgery verus superficial parotidectomy or total parotidectomy? 

Per the NCCN guidelines, in this specific scenario, adjuvant radiation therapy to the locoregional lymph nodes after lymph node dissection is not indi...

In a clinical N0 patient with high risk (large, deeply invasive, poorly differentiated, +PNI, etc) cutaneous SCC of the head and neck, who do you...

Unlike in post-operative cases, you lack detailed pathologic information in this scenario. Do you base your decision on location, size, and/or patholo...

What dose/fractionation would yield the lowest risk of graft failure? Does your treatment management change based of location, ex the ear vs back?

For example, would you recommend treatment of the cervical and posterior occipital lymphatics for a 4 cm lesion deeply invading the posterior ridge of...

Is there data for switching from nivolumab/ipilimumab to pembrolizumab if a patient develops significant pneumonitis but also had a significant radiog...

How do you decide between plaque brachytherapy and external beam approaches? What dose do you use for plaque brachytherapy? For external beam, what do...

What dose-fractionation schedule and treatment volumes would you utilize for adjuvant radiation therapy status-post total parotidectomy with negative ...

Can immune check point inhibitor be restarted if grade 4 hyperglycemia (with acidosis and insulin drip requirement) has resolved?

Is there a minimum amount of nodes you would like to be removed before you omit radiation to the neck? Do you consider other factors when deciding whe...

In a patient who already received 13 courses of radiation (with complete response), is there any other effective treatment?

Specifically, the cheek? If so, which nodes should be treated and to what dose?    

Should definitive radiotherapy be used as a standard approach? If so, what are the dose and technique considerations in treating these complicated tum...

If a patient has undergone wide local excision with residual disease, but negative margins, is it safe to observe? If adjuvant treatment is indicated,...

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage.  Is t...

Would you treat large/total scalp fields to definitive skin cancer doses? If the patient has a more limited KPS, would you treat sequentially in order...

Would your recommendations change if it was a partial vs complete radiographic response?

How long would you typically wait between date of surgery and initiation of radiation therapy? What factors influence this decision?

What immunosuppressive agents are used and in what order?  Does your approach differ depending on the organ involved, e.g. colitis vs. pneumoniti...

If so, how large of a margin would you place on the primary lesion and would you incorporate any adjacent lymph node levels?

Does the risk of severe inflammation of the liver lead you to choose other therapies in in this population?  What about in patients with mild liv...

Does the site of progression or response matter?  What if there is progression in the lungs but response in lymphadenopathy, for example?  

If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?

For example, if you had an octogenarian with a previously resected squamous cell carcinoma of the skin who presented with metastases to the parotid an...

Do you give a treatment break? Is so, how long should RT be held? Are there skin management techniques to use?

Following Mohs surgery and in the absence of other high risk features, do you offer RT for any PNI?  A single nerve < 0.1 mm? A single ne...

Would you be comfortable with 55Gy in 20 fractions around the optic nerves and brainstem, or would you treat with a more protracted fractionation? Do ...

Would re-irradiation be an appropriate option? What dose/field would you incorporate? If treating with standard fractionation, would you take the enti...

If the patient is a poor surgical candidate and is a symptomatic, can he or she live with this?

I have seen some patients who may undergo large complex closures (sometimes as a separate procedure) for smaller lesions with resulting scars that sig...

Is there any consensus regarding the optimal RT dose, fractionation, and timing to the best abscopal response? What is the optimal metastatic site to ...

Decrease the dose? Treatment break? Steroids?

For example, if a 5 x 5 cm squamaous cell carcinoma with deep invasion has been resected via Mohs with negative margins, will your PTV include the ent...

Is modern surgical/reconstruction treatment superior to radiation therapy? If contact brachytherapy or superficial (orthovoltage) therapy isnt possib...

Is the surrounding erythema as part of the GTV so that the margin is placed around the erythema rather than around the gross lesion only?

Assume all other options have been exhausted or are not feasible (e.g. systemic treatments, medically inoperable, etc.). Is there a BED or EQD2 that y...

With novel therapies quickly evolving, it's becoming more difficult to discern the proper sequence of therapies and the point at which a clinical tria...

What is the preferred dose, fractionation, and role of concurrent chemo? 

Do you hypofractionate or add any concurrent systemic therapy? What specific dose-fractionation regimens do you recommend?

Even though data from TROG 02.01 showed 52% decrease in LR, I've heard some argue that toxicity is increased and that "it damages the blood vessels an...


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