The role of radiotherapy in recurrent and metastatic malignant melanoma: a clinical radiobiological study.

A review of the literature and our data has been completed to analyze the clinical radiobiology of malignant melanoma. Six hundred eighteen radiotherapy-treated malignant melanoma lesions were analyzed with regard to radiobiological parameters such as total dose, dose per fraction, treatment time, tumor volume, and various fractionation models. Forty-eight per cent of the treated tumors achieved complete response, which was persistent in 87% after 5 years. Neither total dose, treatment time, nor various modifications of the NSD concept showed any well-defined correlation with response. There was, however, a significant relationship between dose per fraction and response, and a high dose per fraction yielded a significantly better response (59% CR for doses greater than 4 Gy versus 33% CR for doses per fraction less than or equal to 4 Gy). The lack of treatment time influence allowed analysis of the data according to the linear-quadratic model, resulting in an alpha/beta ratio of 2.5 Gy. Using this ratio, an iso-effect for different fractionation schedules could be estimated by the extrapolated total-dose (ETD). The ratio was further improved when corrected for the tumor volume. Thus, an iso-effect formula for malignant melanoma could be calculated as: ETDvol (Gy) = D X [d + 2.5)/2.5) X M-.33, where D and d are total dose and dose per fraction in Gy, respectively, and M is the mean tumor diameter in cm. Based on a logit analysis, a complete response level of 50% appeared at an ETDvol value of 83 Gy. The formula is currently the best way to determine an optimal radiation schedule for an effective radiation treatment of malignant melanoma. The tumor response was further improved in 134 additional cases receiving adjuvant hyperthermia. Here, a thermal enhancement ratio (TER) of 2.0 was observed. In a group of 131 patients with only local or regional disease, a 5 year survival rate of 49% was observed in 77 patients with persistent local tumor control, but only 3% survived among the 54 patients in whom local therapy failed. It is therefore, highly important to the probability of survival in recurrent melanoma that proper local treatment be performed.