Metastatic Melanoma Brain Metastases

Source: OncLive, August 2019

Jeffrey S. Weber, MD, PhD: The other sort of important issue that’s come up over the last couple of years is 1 that’s dear to the heart of almost all of us here, and that is how do you manage brain metastases. And it used to be, the urban legend is that as soon as you had brain metastases, that meant you had a 3-month, 4-month median survival and you were going to die. It didn’t matter what treatment you had. But to some people’s surprise, that is not the case. Jason, tell us about current management. For example, the idea in the old days was that you’d give whole-brain radiation, and then you’d follow-up with subsequent therapy. But I gather most of us—including, I’m sure, you—were pretty cynical about the utility of whole brain. Has that been put to rest yet?

Jason J. Luke, MD, FACP: In medicine we never try to say never, but I would actually have to say yes. I think we have gotten to a point in the field that everyone here and everyone you speak with would say, “Please just do not do whole-brain radiation on patients with metastatic melanoma.” And the details of that are really that we now have these systemic agents that can be quite effective. Whole-brain radiation really had never been…to have efficacy in melanoma specifically. And we’re aware from previous studies now that BRAF inhibitors can induce responses, albeit it with potentially attenuated PFS [progression-free survival]. But it’s the immunotherapies that are really changing the game in that setting.

And so combination immunotherapy, shown by the Australian group, as well as a group led by Dr Tawbi, really should be the standard of care at this point—ipilimumab and nivolumab in patients who can get immunotherapy, but again, not all patients with brain metastases are good candidates for that, but I really think that is the standard of care. We need to try to get patients to immunotherapy as fast as we can. Because the initial results are 50% disease control in the brain, and there’s really no other therapy that has the potential to do that. And going back to what you said, 3-month PFS, and now we’re talking about people who are out years with brain metastases who are doing just fine. I just think we can’t emphasize that enough. Doing whole-brain radiation first messes up the potential to do that, to get that immunotherapy, and we really need to try to make sure people aren’t doing that anymore.