Review Article

Management of Melanoma Brain Metastases in the Era of Targeted Therapy

Table 1

Potential management strategies for melanoma patients with brain metastases.

Brain metastasesLargest lesionSymptomatic*Suggested CNS treatmentSystemic metastasesSystemic therapy§

1<3 cmyes or nosurgeryGK or SRSnonot suggested
1>4 cmyes or nosurgerynonot suggested
2–5<4 cmyes or noGK or SRSnono
2–5<4 cmyes or noGK or SRSyesyes
>5<4 cmyes or noWBRT¥nono
>5<4 cmyes or noWBRT¥yesyes

*Palliative glucocorticosteroid administration should be considered to decrease symptomatic edema, if present.
Resectability may depend on location related to critical brain structures.
GK and SRS are probably equivalent to surgical resection for lesion control if <2 cm.
§The majority of these patients do not progress with systemic disease and there is little evidence that early systemic treatment improves either the risk of systemic relapse or helps control CNS metastases.
Patients should have CNS lesions treated and controlled first, potentially effective agents include immunotherapy (ipilimumab, possibly IL-2) and targeted therapy (B-RAF inhibitor, etc.), if the appropriate activating mutation is present in tumors.
¥Stereotactic boost to dominant lesions > 1 cm after WBRT may increase local lesion control and survival in patients with early CNS control and controlled systemic disease based on randomized trials.