Melanoma/Skin Cancer   

Questions discussed in this category



How would your treatment change for definitive vs post-surgical RT? Does approach differ depending on the anatomic (distal vs proximal and dorsal vs ...

What dose and fractionation do you utilize? Would your recommendations differ considering the site of disease is at the penile base/suprapubic region?

What topical therapies have you found most effective? Have you found laser therapy to be effective?

Do you favor one treatment over the other?  Do you find one treatment more effective than the other?

Have you utilized these gene-expression profiles in your practice? Is there sufficient data for this test to be used for clinical decisions?

Burnmeister data from 2012 showed a local control benefit for radiation therapy in selected patients, but that was without immunotherapy. Is adjuvant ...

Would you treat the primary site alone, include the hand and arm lymphatics to the epitrochlear nodes (one continious treatment volume from hand to el...

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

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

The SWOG 1801 trial showed improved event-free survival (EFS) in patients receiving neoadjuvant pembrolizumab followed by 15 cycles of adjuvant pembro...

Very-low-risk stage IIIA disease includes non-ulcerated lesions, primary ≤2 mm thickness, SLN metastasis <1 mm. Per NCCN the toxicity of adjuvan...

Definitive radiation therapy > 5 years ago. Positive margins, PNI of 0.1 mm. What volume would you cover? Dose/fractionation? 

The patient's current PET scan showed no systemic disease. Due to his age, there is a concern of whether the patient would tolerate dual immunotherapy...

Would you treat both at the same time? Does one need to be prioritized over the other? Does Xeloda have any efficacy against Merkel cell cancer? How...

Is there a potential role for concurrent radiation therapy? What if the tumor is BRAF mutated?

Which group of patients will benefit with observation versus adjuvant immunotherapy?

Especially in cases where the MIS portion is obvious but the dermal component may not be.

In patients with no apparent skin involvement but lymph-node showing basal cell carcinoma with extracapsular extension. Would this warrant radiation o...

What margins do you use for each cancer for photons vs electrons? If your margins differ between cBCC and cSCC, why?

Majority of patients on the seminal trial (Gross et al., PMID 36094839) had tumors isolated to head & neck, what was the rationale for this?

Do you base your decision on extent of residual disease?  Does the use of (neo)adjuvant immunotherapy have an impact on surgical site size or he...

If there are no pre-op photos, what would your fields look like and dose/fractionation?

CheckMate 511 trial showed reduced toxicity with flipped dosing of ipilimumab/ nivolumab (ipi 1 mg/kg and nivo 3 mg/kg instead of ipi 3 mg/kg and nivo...

How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...

What dose and margins would you use? The patient is s/p a liver transplant on immunosuppression. 

What level of PNI is considered "large nerve" in this disease?

This is an elderly patient with a BCC/SCC over the shin who is not eligible for Mohs due to concern for wound-healing issues. Orthovoltage/superficial...

50+ yo F. Mastectomy, chemo, and RT in 2016 for primary breast angiosarcoma, not RT induced. Had longstanding cyst on wrist, biopsied, and positive fo...

Pt with 1.3 cm Merkel cell (buttock) excised with negative margins. Two sentinel inguinal nodes sampled and one is IHC+. 

Does topical 5FU cause eruptive keratoacanthomas or have any other concerning side effects?

If the inguinal node was previously treated with SBRT 30Gy/5fx and immunotherapy >6 months, what treatment would you recommend?

If not, what tumor characteristics prompt you to collect debulking specimens for paraffin or frozen section staining? 

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice...

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

If the only indication were the parotid mets (primary site resected with no high risk features) would you treat the parotid and neck (assuming skin ca...

Would you offer RT if there was bone invasion? If there was poor wound healing causing a 6 months delay, would you still offer RT?

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

Is there any data to support it? What dose/fractionation would you consider?

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

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...

Would you treat the primary site only, include popliteal nodes, or include popliteal and inguinal nodes?

What radiation doses would you use for the scar and axillary nodal regions? Should supraclavicular and/or IMNs be covered? 

Would you use immunosuppression in patients several years after curative treatment for melanoma?

Would you choose re-treatment with electrons, photons, or brachytherapy?   What dose and fractionation scheme would you employ?

In a patient who would be otherwise fit for surgery +/- adjuvant RT, and the delay is caused by COVID-related OR staffing issues, what would be your a...

This question arises from a case of a patient with multifocal nodular melanoma with circumferential involvement of the perianal region.

With so many choices listed in NCCN guidelines ranging from 2-7 weeks, what considerations factor into your decision making? 

Is there any alteration in approach from the medical, surgical, or radiation oncology perspective that can mitigate the risk of forming keloids withou...

The index lesion was located inferior to the left knee and excised appropriately, with an additional in-transit metastasis in the left mid leg. The pa...

What is the role and sequence of surgery and/or RT? Which nodal levels would you include in your RT field(s)?

What are the surgical and radiation options? What dose and fractionation scheme is appropriate for fractionated SRS?

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 a patient with a history of a RLE melanoma s/p WLE and right ILND, how would you treat nodal recurrence? What are the surgical vs non-surgical opt...

Based on available results from the IMMUNED trial, which evaluated the role of adjuvant nivolumab/ipilimumab or nivolumab monotherapy vs placebo in re...

What approaches (surgical vs non-surgical) offer the best cosmesis for keratoacanthoma (low grade squamous cell carcinoma) ? 

Is there a role for radiation? Does your approach differ depending on site(s) of  disease, and/or if the patient has Basal-Cell Nevus (Gorlin) sy...

In treating skin cancers of the scalp,  are there any specific constraints you give to the skin itself to prevent alopecia?  How does changi...

In general, how would you approach such a case with regards to creation of your treatment volumes and dose-fractionation? 

Would you recommend radiation therapy or immunotherapy? If proceeding with radiation therapy, what dose-fractionation and technique would you utilize?

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

Would you treat with radiation (+/- surgery upfront, if resectable) or systemic therapy?

When do you electively treat the ipsilateral versus ipsi- and contralateral neck?

This particular case involves a patient with a frontal scalp low grade eccrine carcinoma status-post excision with positive margin complicated by...

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...

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 sarcomas or skin cancers with&...

*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...

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

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...

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

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...

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...

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?    

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?

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...

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...


Papers discussed in this category


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