Surgical management of melanoma brain metastases in patients treated with immunotherapy

Abstract

Object Despite the increasing use of immunotherapy in the treatment of metastatic melanoma, the effects of this therapy on the management of patients with associated brain metastases are not completely defined. The authors undertook this study to determine the effectiveness of resection and the effects of immunotherapy on brain metastasis management. Methods The authors analyzed data pertaining to consecutive patients with metastatic melanoma treated with immunotherapy within 3 months of discovery of brain metastases that were surgically resected. Results Forty-one patients (median age 44.4 years, range 19.2–63.1 years) underwent resection of 53 brain metastases (median number of metastases 1, range 1–4). The median metastasis volume was 2.5 cm3. Fifteen patients underwent whole-brain radiation therapy (WBRT) and 26 patients did not. Duration of survival from brain metastasis diagnosis was not significantly different between patients who received WBRT (mean 24.9 months) and those who did not (mean 23.3 months) (p > 0.05). Local and distant brain recurrence rates were not statistically different between the WBRT (7.1% and 28.6%, respectively) and non-WBRT (7.7% and 41.0%) groups for the duration of follow-up (p > 0.05). An objective systemic response to immunotherapy was associated with increased duration of survival (p < 0.05). Conclusions Resection of melanoma brain metastases in patients treated with immunotherapy provides excellent local control with low morbidity. An objective response to systemic immunotherapy is associated with a prolonged survival in patients who have undergone resection of melanoma brain metastases. Moreover, adjuvant WBRT in melanoma immunotherapy patients with limited metastatic disease to the brain does not appear to provide a significant survival benefit.

Asymptomatic brain metastases in patients with cutaneous metastatic malignant melanoma

“…For patients with brain metastases, many retrospective analyses have confirmed that selected patients with few brain metastases have a better prognosis using local treatment interventions. Treatment strategies for selected melanoma patients with good performance status and with limited number of brain metastases include surgical resection or stereotactic radio surgery [21,22] as well as a combination of local therapy and immunotherapy [1]. Various treatment combinations have also been used in the treatment of our patients with asymptomatic brain metastases, with the longest survival in a group that was suitable for local treatment combined with immunotherapy.…”

“…Melanoma represents only up to 5% of all skin cancers [1], but is clearly clinically the most aggressive type of skin cancer.…”

Challenges in the Delivery of Therapies to Melanoma Brain Metastases

“…The therapeutic interventions employed for the treatment of MBM include surgery, radiation and a combination of these with systemic therapies, both immunotherapy and chemotherapy (Lonser et al 2011; Salvati et al 2012; Rochet et al 2012). Surgical resection is a preferred treatment option when feasible.…”

“…Surgical resection is a preferred treatment option when feasible. In patients having solitary MBM in operable locations with a diameter of lesions over 3 cm, surgical resection is appropriate as it appears to prolong survival (Lonser et al 2011; Salvati et al 2012; Kolar et al 2013). For smaller lesions with size less than 2 cm, or when the lesions are surgically inaccessible, stereotactic radiosurgery (SRS) is employed as an alternative.…”

Detection of candidate melanoma blood biomarkers by RNA-Sequencing

“…Melanoma begins from a local transformation of melanocytes from healthy individuals, and metastasizes to multiple organs, most commonly to, the liver, lung and brain via regional drainage to lymph node metastasis or directly through the hematogenous route (Miller and Mihm, 2006). Rapid metastasis results in poor prognosis, which was explained by the fact that 60%~70% of melanoma patients have phenomena of brain metastasis (Denkins et al, 2004) and on average a half of patients were dead even with aggressive multi-modality therapy (Lonser et al, 2011). Till now, molecular mechanism in melanoma and the high lethality have not been well studied.…”