Yale School of Medicine, New Haven, Connecticut; present affiliation at Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts.
Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.
Int J Radiat Oncol Biol Phys. 2019 Dec 1;105(5):1113-1118. doi: 10.1016/j.ijrobp.2019.08.053. Epub 2019 Aug 31.
An increasing number of clinical trials are studying immunotherapy for the treatment of brain metastases. The role of local therapy in this setting has not been well described.
Twenty-three melanoma patients with brain metastases were treated with pembrolizumab in a prospective phase 2 trial, NCT02085070, and included in this secondary analysis. Patients had at least 1 untreated or progressive brain metastasis, 5 to 20 mm in size, without any associated neurologic symptoms. Local therapy (stereotactic radiosurgery, surgery, or laser interstitial thermal therapy) was used to treat concerning lesions immediately before trial enrollment and was also allowed on trial in patients whose brain metastases were progressing, but who were otherwise deriving benefit.
In total, 13 out of 23 patients (57%) received local therapy immediately before or during the trial-4 patients received local therapy before the trial owing to lesion size or location in sensitive areas; 6 during the trial because of tumor growth, hemorrhage, or radiation necrosis/cystic changes; and 3 both before and during the trial. Of the 10 patients who did not receive local therapy immediately before or during the trial, 8 patients (35%) did not later receive local therapy owing to rapid disease progression, and only 2 patients (9%) lived for 2 years without requiring any local therapy.
Local therapy continues to play an important role in the management of melanoma patients with brain metastases being treated with immunotherapy. These patients should be closely monitored via serial brain imaging, with a multidisciplinary team involved in clinical decision making to ensure each patient's neurologic safety.
越来越多的临床试验正在研究免疫疗法治疗脑转移。在这种情况下，局部治疗的作用尚未得到很好的描述。
23 名患有脑转移的黑色素瘤患者在一项前瞻性 2 期试验 NCT02085070 中接受了 pembrolizumab 治疗，并包括在这项二次分析中。患者至少有 1 个未经治疗或进展的脑转移，大小为 5 至 20 毫米，没有任何相关的神经症状。局部治疗（立体定向放射外科手术、手术或激光间质热疗）用于在试验入组前立即治疗有问题的病变，并且在脑转移进展但其他方面受益的患者中也允许在试验中使用。
总共有 23 名患者中的 13 名（57%）在试验前或试验期间接受了局部治疗-4 名患者因病变大小或位置在敏感区域而在试验前接受了局部治疗；6 名患者在试验期间因肿瘤生长、出血或放射性坏死/囊性改变而接受治疗；3 名患者在试验前和试验期间均接受了治疗。在试验前或试验期间未接受局部治疗的 10 名患者中，8 名（35%）由于疾病快速进展而未接受局部治疗，只有 2 名（9%）在 2 年内无需任何局部治疗。
局部治疗在接受免疫治疗的脑转移黑色素瘤患者的管理中仍然起着重要作用。这些患者应通过连续的脑部成像进行密切监测，多学科团队参与临床决策，以确保每位患者的神经安全。
