Management of brain metastases in melanoma
- Wolfram E Samlowski, MD
Wolfram E Samlowski, MD
- Comprehensive Cancer Centers of Nevada (Las Vegas)
- Clinical Professor
- University of Nevada (Reno)
- Kevin Oh, MD
Kevin Oh, MD
- Assistant Professor of Radiation Oncology
- Harvard Medical School
- Attending Radiation Oncologist
- Massachusetts General Hospital
- Julian K Wu, MD
Julian K Wu, MD
- Professor of Neurosurgery
- Tufts University School of Medicine
- Section Editors
- Michael B Atkins, MD
Michael B Atkins, MD
- Section Editor — Malignant Melanoma and Other Cutaneous Neoplasms; Cancer of the Kidney
- Deputy Director
- Georgetown Lombardi Comprehensive Cancer Center
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
Brain metastases are a frequent complication in patients with melanoma. In the past, brain metastases almost invariably contributed to the patients' death. However, major advances in neuroimaging, improved options for the neurosurgical and radiotherapeutic management of brain metastases, improved management of metastatic disease at systemic sites, and demonstrated activity of systemic treatments against central nervous system metastases have substantially improved the prognosis for many patients.
The management of patients with melanoma and brain metastases will be reviewed here. General aspects of the clinical manifestations, diagnosis, and management of cancer-related brain metastases are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of brain metastases" and "Overview of the treatment of brain metastases".)
EPIDEMIOLOGY AND CLINICAL PRESENTATION
Melanoma accounts for approximately 10 percent of all patients who develop brain metastases. In the United States, only lung and breast cancers are more frequent primary sites associated with brain metastases .
In the eighth edition of the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system for melanoma, brain metastases are separated from other sites of metastasis and form a separate M category, M1d (table 1).
Patients with melanoma limited to the skin and without lymph node involvement (stage I, II (table 2 and table 3)) have a low incidence of brain metastases , although younger patients with thick primaries may have an increased risk of late central nervous system (CNS) failure . In patients who presented with advanced regional melanoma (stage IIIB and C), a retrospective analysis of data from the large multi-institutional S0008 adjuvant trial observed a 15 percent incidence of subsequent brain metastases, which occurred predominantly in the first three years after surgery .
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- EPIDEMIOLOGY AND CLINICAL PRESENTATION
- RISK FACTORS
- APPROACH TO MANAGEMENT
- Multidisciplinary approach
- Asymptomatic small brain metastases
- Symptomatic or large brain metastases
- Leptomeningeal disease
- Symptom control
- Patient selection
- Management following surgery
- STEREOTACTIC RADIOSURGERY
- Radiation sensitization
- Role of WBRT after SRS
- SYSTEMIC THERAPY
- - Anti-PD-1 inhibitors
- - Ipilimumab
- - Nivolumab plus ipilimumab
- - Adoptive cell therapy
- Targeted agents
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS