In this retrospective single institutional study, we found Stage III melanoma patients treated with LND and adjuvant RT whose tumor exhibited a BRAF mutation had significantly worse LRC compared to patients with BRAF negative (wild-type) tumors. We found no differences in the other clinical outcomes evaluated, including DMFS, DFS, and OS.
Adjuvant RT may be considered in patients who have clinically positive nodes and meet certain criteria for high-risk for local recurrence. The benefit of RT must be weighed against potential toxicities. These high-risk criteria are based on the phase III ANZMTG 01.02/TROG 02.01 trial that randomized patients to adjuvant RT or observation after LND with the following: LDH < 1.5 times the upper limit of normal, as well as ≥ 1 parotid, ≥ 2 cervical or axillary, or ≥ 3 groin positive nodes, a maximum nodal diameter of ≥ 3 cm in the neck, ≥ 4 cm in the axilla or groin, or nodal extracapsular extension.12 After a median follow-up of 73 months, this phase III trial showed improved regional lymph node control in the adjuvant RT arm compared to the observation group.3 Twenty one percent of patients had nodal relapses in the adjuvant RT group compared to 36% in the observation group (HR 0.52 [95% CI 0.31–0.88]; p = 0.023). However, there was no significant differences in relapse-free survival or OS between the two groups. Additionally, adjuvant RT was associated with long-term toxic effects such as pain and fibrosis of the skin and subcutaneous tissues. Further, there was a significant increase in lower limb volumes after adjuvant radiotherapy (difference of 7.3% [95% CI 1.5–13.1]; p = 0.014).12
Similar results to this phase III trial have also been found in multiple retrospective studies, demonstrating an improvement in local control with adjuvant RT, but not long-term survival.13–16 One retrospective study that looked at 615 patients (509 who received adjuvant RT and 106 who did not), did show that receiving adjuvant RT was significantly associated with improved DFS on multivariate analysis.17 However, in a study comparing patients from the National Cancer Database (NCDB) who received adjuvant RT after LND versus those who did not, the authors did not find adjuvant RT to be significantly associated with OS on multivariate analysis.16 The lack of a clear survival benefit from adjuvant RT, compounded with its additional toxicities and costs, has limited its use in many centers. However, the use of adjuvant RT is still to consider radiotherapy in selected high-risk patients in the latest NCCN guidelines.18 The results of this study further identify a subgroup of high risk patients where perhaps adjuvant RT could be omitted.
Over the past couple decades, there has been a dramatic change in systemic therapies for melanoma. This change has been underscored by a better understanding of the disease’s genetic and immunologic underpinnings. One of the major advancements in our understanding is the role that the mitogen-activated protein kinase (MAPK) signal transduction pathway plays in the pathogenesis of melanoma. The primary activating mutation implicated in this pathway is in the BRAF gene.4,19 BRAF mutations are found in about 40–60% of melanomas, with about 80% occurring as a V600E mutation, 5–30% as V600K mutations, and the rest other rare mutations.20–22 BRAF mutation has been associated as a poor prognostic factor in other cancer types, for example in papillary thyroid cancer.23 BRAF mutation was associated with worse OS in the Medical Research Council Fluorouracil, Oxaliplatin and Irinotecan: Use and Sequencing (MRC FOCUS) rectal trial, with a hazard ratio [HR] of 1.40 (95% CI, 1.20 to 1.65; p < .0001).24 In melanoma, a French institutional cohort of Stage III melanoma patients of which 40% had confirmed BRAF + mutational status showed BRAF mutant patients had significantly worse overall survival and distant metastasis-free survival. However, there was no data on the use of adjuvant RT available in this report.25
There is emerging pre-clinical and clinical evidence that BRAF or upstream KRAS mutations in cancer cells results in heightened radiation resistance. Pre-clinical studies revealed that KRAS inhibition through silencing with siRNAs or pharmaceutical inhibition of farnesylation of KRAS led to radiosensitization of tumor cells.26,27 In clinical studies, patients with Stage I non-small cell lung cancer (NSCLC) or liver metastasis treated with ablative radiation (i.e stereotactic body radiation therapy, SBRT) whose tumors were KRAS mutant had worse local control compared to patients with KRAS wild-type tumors.28,29 Furthermore, a pre-clinical study recently showed that BRAF V600E + thyroid cancer cell lines displayed higher resistance to radiation, and forced expression of a BRAF V600E mutation into wild-type BRAF thyroid cancer cells resulted in increased radiation resistance in vitro.11 In this study, targeted inhibition of oncogenic BRAF with vemurafenib potently radiosensitized BRAF mutant thyroid cancer cells in vitro and in vivo.
Our study has some limitations such as the inherent biases in all retrospective studies. Although we found a difference in local and regional recurrences in the BRAFmut patients, this did not impact other clinical outcomes such as DFS or OS. Another limitation was due to the treatment era of most of the study patients, current immunotherapy and molecular targeted agents were not standardly used in all patients. The use of adjuvant RT in stage III melanoma is somewhat controversial in the immunotherapy era. The RFS in the EORTC 1325 and EORTC 18071 trials were significantly improved, but LRR was still 12–15%.10,30 We argue that a more selective delivery of adjuvant RT should be considered in patients based on the results of this study.