How would you palliate a large, symptomatic vaginal melanoma recurrence with limited small pelvic lymph node metastases?

Palliation. Treat problems that are symptomatic. No expensive systemic work up. Pall RT to the pelvis if it’s symptomatic. 30 Gy/10 fractions, 25 Gy/5 fractions, or 20 Gy/2 fractions with a 1 week inter-fraction interval. Apologize for the lengthy response.

In the event of recurrence, pre-treatment workup should include a full body PET scan and MRI brain with and without contrast to look for a sanctuary site in the brain. It goes without saying that a clinical trial would be ideal for a patient like this. In the absence of a clinical trial, there are two aspects to providing care to this patient.

First - Ideally if the patient is not acutely symptomatic, then she is a great candidate for neoadjuvant immunotherapy. Recent trials (NADINA and SWOG-1801) show the EFS benefit in giving neoadjuvant immunotherapy. In patients who achieve a pathologic response, the survival outcomes are significantly better than those who do not respond. This approach will not only afford a better exposure of the neoa...

Vaginal melanoma is very difficult to resect without exenterative procedures. And I would not resect if bladder and/or rectal resection is needed. Would re-treat with IO (dual vs single agent is debated). We would also discuss hypofractionated RT to pelvis and with that give single agent pembro. We have published on this approach with promising results.

Could also consider a 48/20 regimen as per TROG with consideration of dose escalation to gross disease to 55-60 Gy/20 as feasible. I worry a touch about hypofractionating too much around sensitive vaginal, vulvar, and perianal tissues.

Expecting systemic therapy alone to control a 10 cm primary melanoma mass seems, to me, to be excessively optimistic. Putting a patient through indefinite ICI for locoregional disease, especially if the goal is just to palliate, seems excessive.

I think it would be reasonable to knock back the gross disease before starting/resuming systemic therapy. I personally like 6 Gy x 5 treated twice per week as per Dr. Ang's postoperative regimen, and would treat the main lesion and, if possible, any suspicious nodes, after which time I'd refer them for consideration of systemic treatment. And, of course, I'd have the patient presented at tumor board, etc., to make sure everyone was on board with the course of therapy before starting.

I understand the concern about morbidity from the large fraction size in this region, but vaginal SBRT boosts after 45-50.4 of chemorad to the pelvis has been studied in cervical cancer successfully, so I don't think it will be a severe morbidity risk as the pe...