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Management of brain metastases in melanoma

INTRODUCTION

Melanoma is the third most common cancer causing brain metastases in the United States, after cancers of the lung and breast [1], which appears to reflect the relative propensity of melanoma to metastasize to the central nervous system (CNS) [2]. Brain metastases are responsible for 20 to 54 percent of deaths in patients with melanoma [3], and among those with documented brain metastases, these lesions contribute to death in up to 95 percent of cases [4].

As with other primary tumors, patients with melanoma metastatic to brain typically present with symptoms of increased intracranial pressure (eg, headache), focal neurologic deficits, and/or seizures. Brain metastases from melanoma may have a particularly high propensity for spontaneous hemorrhage.

The risk factors, prognosis, and management of brain metastases will be reviewed here. The general clinical manifestations and diagnosis of brain metastases are discussed separately. (See "Overview of the clinical manifestations, diagnosis, and management of patients with brain metastases".)

RISK FACTORS

Although all patients with melanoma are at risk for metastasis to the brain, certain characteristics that are associated with increased risk of systemic metastases also correlate with the subsequent development of brain metastasis. These factors include [4,5]:

  • Male gender
  • Melanomas arising on mucosal surfaces or the skin of the trunk, head, or neck
  • Wide, thick, deeply invasive, or ulcerated primary lesions
  • Acral lentiginous or nodular lesions on histologic examination
  • Involvement of more than three regional lymph nodes, either at diagnosis or relapse [6]
  • Visceral metastasis at the time of diagnosis, especially if the visceral metastasis is disseminated to more than one organ
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