Long Georgina V, Margolin Kim A
From the Melanoma Institute Australia, The University of Sydney, Sydney, Australia; University of Washington/Fred Hutchinson Cancer Research Center, Seattle, WA.
Am Soc Clin Oncol Educ Book. 2013:393-8. doi: 10.14694/EdBook_AM.2013.33.393.
Melanoma brain metastases are common, difficult to treat, and carry a poor prognosis. Until recently, systemic therapy was ineffective. Local therapy (including surgery, stereotactic radiotherapy, and whole brain radiotherapy) was considered the only option for a chance of disease control in the brain, and was highly dependent on the patient's performance status and age, number and size of brain metastases, and the presence of extracranial metastases. Since 2010, three drugs have demonstrated activity in progressing or "active" brain metastases including the anti-CTLA4 antibody ipilimumab (phase II study of 72 patients), and the BRAF inhibitors dabrafenib (phase II study of 172 patients, both previously treated and untreated brain metastases) and vemurafenib (a pilot study of 24 patients with heavily pretreated brain metastases). The challenge and unanswered question for clinicians is how to sequence all the available therapies, both local and systemic, to optimize the patient's quality of life and survival. This is an area of intense clinical research. The treatment of patients with melanoma brain metastases should be discussed by a multidisciplinary team of melanoma experts including a neurosurgeon, medical oncologist, and radiation oncologist. Important clinical features that help determine appropriate first line therapy include single compared with solitary brain metastasis, resectablity, BRAF mutation status of melanoma, rate of progression/performance status, and the presence of extracranial disease.
黑色素瘤脑转移很常见，难以治疗，预后较差。直到最近，全身治疗仍无效。局部治疗（包括手术、立体定向放射治疗和全脑放射治疗）被认为是控制脑部疾病的唯一选择，并且高度依赖于患者的身体状况、年龄、脑转移瘤的数量和大小以及颅外转移的存在情况。自2010年以来，三种药物已在进展性或“活动性”脑转移中显示出活性，包括抗CTLA4抗体伊匹木单抗（72例患者的II期研究），以及BRAF抑制剂达拉非尼（172例患者的II期研究，包括既往治疗和未治疗的脑转移瘤）和维莫非尼（24例接受过大量预处理的脑转移瘤患者的一项试点研究）。临床医生面临的挑战和未解决的问题是如何安排所有可用的局部和全身治疗的顺序，以优化患者的生活质量和生存率。这是一个临床研究活跃的领域。黑色素瘤脑转移患者的治疗应由包括神经外科医生、医学肿瘤学家和放射肿瘤学家在内的黑色素瘤专家多学科团队进行讨论。有助于确定合适一线治疗的重要临床特征包括单发与孤立性脑转移、可切除性、黑色素瘤的BRAF突变状态、进展速度/身体状况以及颅外疾病的存在情况。
