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Patients with Brain Metastases from Melanoma: Treatment with Surgery and Radiotherapy
Introduction
Chemotherapy has been the mainstay of systemic treatment of malignancy but due to matters largely concerning the blood–brain-barrier and heterogeneity of the tumors it has been largely ineffective in the management of brain metastasis. Instead, surgery and radiation therapy has been the accepted first line treatment in the management of brain metastasis. Up until recently, melanoma was no exception but with the advent of targeted therapy, such as BRAF inhibitors and immune checkpoint inhibitors (CTLA/PD1 blocking antibodies), patients with melanoma brain metastasis have more effective options in disease management. Nonetheless, surgery and radiation therapy continues to play a major role in the care and management of patients with melanoma brain metastasis. Whole brain radiation in particular is associated with long-term cognitive sequelae leading to preferential use of stereotactic radiosurgery (SRS) for selected metastases. This is particularly relevant as patients are experiencing improved outcomes with the targeted and immunotherapies and hence, living long enough to experience the cognitive decline as can be seen in whole brain radiation. In this chapter, we discuss the history of surgical and radiation therapy in melanoma brain metastasis. We will also discuss new modalities such as laser interstitial tumor therapy (AutoLITT).
Epidemiology
Metastatic brain tumor is an unfortunate outcome of systemic malignancy with an incidence of greater than 200,000 cases per year in the United States; an incidence much greater than that of primary brain tumors ( ). Melanoma, in particular, is the third most common systemic malignancy to metastasize to the brain (5–10% of all metastatic brain tumors). Brain metastasis is linked with a particularly poor prognosis, with a reported average survival of less than 9 months ( ).
Melanoma brain metastasis is a frequent outcome of systemic melanoma. Approximately 50% of patients with stage IV melanoma develop brain metastasis prior to death with autopsy series demonstrating an even higher prevalence of up to 75% in melanoma patients ( ). Moreover, the prognosis of patients with melanoma brain metastasis remains dismal. The median overall survival (OS) from time of diagnosis is only 2 to 9 months ( ). With this high incidence and grim prognosis in mind, a systemic and multidisciplinary approach should be undertaken. Consideration for chemotherapy, surgery, and radiation in order to manage patients with melanoma and brain metastasis is paramount in improving patient survival and quality of life. Improvements in understanding the tumor biology as well as innovative surgical techniques will dictate the future of effective central nervous system (CNS) tumor control ( Fig. 13.1 ).
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