How do we manage brain metastases in the real world setting for patients with metastatic melanoma receiving immune checkpoint inhibition? Our experience within the North East of England.


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Abigail Gault, Nicola Cresti, Ruth Plummer

Abstract

Background

Immunotherapy in the form of checkpoint inhibition has revolutionised the care of patients with advanced melanoma. Failure to control disease within the brain is recognised to result in worse outcomes. We collected data for all patients with metastatic melanoma receiving immunotherapy at our centre in North East England over a period of five years from January 2013 to January 2018.

Method

One hundred and one consecutive patients with metastatic melanoma treated with checkpoint inhibitors (CPIs) alone or in combination, were identified via a retrospective search via our chemotherapy database.  Patients’ electronic medical records were reviewed to extract data with appropriate local data safeguarding in place.

Results

Thirty-five patients were identified with brain metastases, 20 of these were female and 15 male. Median age at diagnosis was 57 years (range 36 - 78 years). The majority of patients had cutaneous melanoma, though three had mucosal disease. Eighteen patients received combination CPI, 17 received single agent CPI. Twenty-five patients received immunotherapy as their first line systemic therapy, for nine patients this was their second line therapy and for one their third line therapy. Thirteen patients were known to have BRAF V600E mutation.

Location and number of brain metastases were heterogeneous within the group. Latency between diagnosis of the primary and development of brain metastases varied from 0 months – 17 years. Sixteen patients received whole brain radiotherapy, 7 patients did not receive any intracranial-directed therapy, and 12 episodes of SRS were delivered to 9 patients. Five patients underwent neurosurgical intervention, of which three also received SRS to the tumour bed. Eleven patients stopped therapy due to toxicity, and sixteen due to progressive disease. Twelve patients (34%) went on to receive subsequent systemic therapy. 

Conclusion

This data provides insight into our local practices surrounding management of brain metastases in a real world population. Our team aim for this data to help inform future practice at our centre.

Impact statement

Brain metastases are recognised to limit the control that systemic therapies can provide in metastatic melanoma, and this real-world study of the management of patients acts as a resource to prompt research questions.