Strom Tobin, Torres-Roca Javier F, Parekh Akash, Naghavi Arash O, Caudell Jimmy J, Oliver Daniel E, Messina Jane L, Khushalani Nikhil I, Zager Jonathan S, Sarnaik Amod, Mulé James J, Trotti Andy M, Eschrich Steven A, Sondak Vernon K, Harrison Louis B
Department of Radiation Oncology, Moffitt Cancer Center and Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
Department of Oncologic Sciences, University of South Florida Morsani College of Medicine
J Natl Compr Canc Netw. 2017 Apr;15(4):473-482. doi: 10.6004/jnccn.2017.0047.
Regional radiation therapy (RT) has been shown to reduce the risk of regional recurrence with node-positive cutaneous melanoma. However, risk factors for regional recurrence, especially in the era of sentinel lymph node biopsy (SLNB), are less clear. Our goals were to identify risk factors associated with regional recurrence and to determine whether a radiosensitivity index (RSI) gene expression signature (GES) could identify patients who experience a survival benefit with regional RT. A single-institution, Institutional Review Board-approved study was performed including 410 patients treated with either SLNB with or without completion lymph node dissection (LND; n=270) or therapeutic LND (n=91). Postoperative regional RT was delivered to the involved nodal basin in 83 cases (20.2%), to a median dose of 54 Gy (range, 30-60 Gy) in 27 fractions (range, 5-30). Primary outcomes were regional control and overall survival by RSI GES status. Median follow-up was 69 months (range, 13-180). Postoperative regional RT was associated with a reduced risk of regional recurrence among all patients on univariate (5-year estimate: 95.0% vs 83.3%; =.036) and multivariate analysis (hazard ratio[HR], 0.15; 95% CI, 0.05-0.43; <.001). Among higher-risk subgroups, regional RT was associated with a lower risk of regional recurrence among patients with clinically detected lymph nodes (n=175; 5-year regional control: 94.1% vs 69.5%; =.003) and extracapsular extension (ECE) present (n=138; 5-year regional control: 96.7% vs 62.2%; <.001). Among a subset of radiated patients with gene expression data available, a low RSI GES (radiosensitive) tumor status was associated with improved survival compared with a high RSI GES (5-year: 75% vs 0%; HR, 10.68; 95% CI, 1.24-92.14). Regional RT was associated with a reduced risk of regional recurrence among patients with ECE and clinically detected nodal disease. Gene expression data show promise for better predicting radiocurable patients in the future. In the era of increasingly effective systemic therapies, the value of improved regional control potentially takes on greater significance.
区域放射治疗（RT）已被证明可降低淋巴结阳性皮肤黑色素瘤的区域复发风险。然而，区域复发的危险因素，尤其是在前哨淋巴结活检（SLNB）时代，尚不清楚。我们的目标是确定与区域复发相关的危险因素，并确定放射敏感性指数（RSI）基因表达特征（GES）是否可以识别从区域RT中获得生存获益的患者。进行了一项单机构、经机构审查委员会批准的研究，纳入410例接受SLNB（伴或不伴根治性淋巴结清扫术[LND]；n = 270）或治疗性LND（n = 91）的患者。83例（20.2%）患者术后对受累淋巴结区域进行了RT，中位剂量为54 Gy（范围30 - 60 Gy），分27次给予（范围5 - 30次）。主要结局是根据RSI GES状态的区域控制和总生存情况。中位随访时间为69个月（范围13 - 180个月）。在单因素分析（5年估计：95.0%对83.3%；P = 0.036）和多因素分析（风险比[HR]，0.15；95%CI，0.05 - 0.43；P < 0.001）中，术后区域RT与所有患者区域复发风险降低相关。在高风险亚组中，区域RT与临床检测到淋巴结的患者（n = 175；5年区域控制：94.1%对69.5%；P = 0.003）和存在包膜外扩展（ECE）的患者（n = 138；5年区域控制：96.7%对62.2%；P < 0.001）区域复发风险较低相关。在有基因表达数据的部分接受放疗的患者中，与高RSI GES相比，低RSI GES（放射敏感）肿瘤状态与生存改善相关（5年：75%对0%；HR，10.68；95%CI，1.24 - 92.14）。区域RT与ECE和临床检测到淋巴结疾病患者的区域复发风险降低相关。基因表达数据有望在未来更好地预测可放疗患者。在全身治疗日益有效的时代，改善区域控制的价值可能具有更大的意义。
