Metastatic Melanoma to the Brain: Surgery and Radiation Is Still the Standard of Care
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Skin Cancer (WH Sharfman, Section Editor)
Metastatic Melanoma to the Brain: Surgery and Radiation Is Still the Standard of Care Sarah Nicholas, BS 1, 4 Dimitrios Mathios, MD 2, 4 Christopher Jackson, BA 2, 4 Michael Lim, MD 2, 3,* Address 1 School of Medicine, University of Maryland, Baltimore, MD 21201, USA 2, * Department of Neurosurgery, The Johns Hopkins Hospital University School of Medicine, 600 N. Wolfe Street, Phipps 123, Baltimore, MD 21287, USA E-mail: [email protected] 3 Department of Oncology, The Johns Hopkins Hospital University School of Medicine, 600 N. Wolfe Street, Phipps 123, Baltimore, MD 21287, USA 4 1650 Orleans Street, Bunting Blaustein Cancer Research Building Room 424, Baltimore, MD 21231, USA E-mail: [email protected] E-mail: [email protected] E-mail: [email protected]
Published online: 17 March 2013 * Springer Science+Business Media New York 2013
Keywords Melanoma I Brain metastases I Immunotherapy I Stereotactic radiosurgery I Kinase inhibitors I Ipilimumab I Vemurafenib I Ant-PD1 I Craniotomy I Whole brain radiation therapy
Opinion statement Malignant melanoma with brain metastases remains a difficult disease to treat. Patients presenting with disease affecting the central nervous system (CNS) have a poor prognosis. Treatment depends on a number of factors, including the size and number of lesions, performance status, comorbidities, and presenting symptoms. Physicians and patients must weigh risks and benefits of treatments, with the main goal of palliating symptoms and decreasing the risk of neurological death. Opinions throughout the country vary, but first-line treatment for brain metastases is local therapy involving either craniotomy or stereotactic radiosurgery (SRS) using CyberKnife or Gamma Knife, with or without whole brain radiation therapy (WBRT). Clinical trials remain another option for patients, with chemotherapy reserved for patients who have exhausted other options. There has been a recent surge in knowledge regarding the pathophysiology and treatment of metastatic melanoma leading to recent FDA approval in 2011 of new drugs: ipilimumab, a novel immune therapy, and vemurafenib, which blocks the
Metastatic Melanoma to the Brain: Surgery and Radiation
Nicholas et al.
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MAP Kinase pathway. These drugs have the potential to treat patients with metastatic melanoma to the brain but are still undergoing clinical investigation. Despite these recent advances, the prognosis is poor, with few patients able to achieve durable and long-lasting response. Treatment for patients with brain metastases continues to lag behind treatment of other diseases, partly due to their exclusion from early clinical trials.
Introduction Melanoma is the third most common cause of brain metastases, only behind lung and breast cancer. Melanoma has a strong propensity to spread to the brain, and as many as 75 % of patients have brain metastases at autopsy [1]. Brain metastases cause death in 95 % of these patients [2, Class III]. Corticosteroids are used for symptomatic trea
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