Intracarotid cisplatin as therapy for melanoma metastatic to brain: ipsilateral response and contralateral progression

In Patients With Melanoma Brain Metastases, Is Combination Immune Checkpoint Inhibition a Safe and Effective First-Line Treatment? A Critically Appraised Topic

BACKGROUND

Combined PD-1/PD-L1 and CTLA-4 immune checkpoint inhibition for the has been shown to produce superior results in the treatment of malignant melanoma when compared to monotherapy. However, patients with intracranial disease were excluded from these studies given their poor prognosis.

OBJECTIVE

The objective of this study was to critically assess current evidence supporting the co-administration of PD-1/PD-L1 and CTLA-4 inhibitors in the treatment of melanoma brain metastases.

METHODS

The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-oncology.

RESULTS

A recent, open-label, non-comparative randomized phase II trial was selected for critical appraisal. This trial evaluated the efficacy and safety of nivolumab alone or in combination with ipilimumab in 79 adult patients with untreated, asymptomatic melanoma brain metastases. The rates of the primary outcome (intracranial response at ≥12 wk) in the primary endpoint cohort were 46% for cohort A (combination therapy) and 20% for cohort B (nivolumab monotherapy). No treatment related deaths were observed in the study. Grade 4 adverse events occurred in 9% of patients in cohort A and none in cohort B.

CONCLUSIONS

Co-administration of ipilimumab and nivolumab as first-line therapy is effective in the treatment of asymptomatic melanoma brain metastases, with an acceptable safety profile.

Surgical management of distant melanoma metastases

Disseminated melanoma remains a tumour that is poorly responsive to chemotherapy and radiotherapy. However, this review demonstrates that surgical removal of visceral metastases such as at the, lung or digestive sites, as well as the brain, yields consistent median survivals, often longer than 12 months, and long-term survivors. Such surgery is followed by little complication cost and low perioperative mortality. Our experience tends to confirm that complete debulking offers longer survivors as compared to partial. Also, one site of metastases, whatever its anatomical location, when operated on, gives a better chance for survival than when there are multiple sites.

Systemic therapy in disseminated melanoma

There is no standard treatment for advanced melanoma. As long as metastases are satellites or in-transit metastases localized in a leg or arm, the prospects for curative treatment by isolation perfusion are good. But as soon as metastases have spread via the circulation, curative treatment with cytotoxic agents becomes virtually impossible. When the tumor burden is not too extensive, however, palliative treatment can be of clinical value. Some combinations of cytotoxic agents or combinations of biologic response modifiers have been shown to induce worthwhile remissions. Toxicity remains a problem, however. The advantages of the newer immunological approaches, especially with interleukin-2 (IL-2) and T-cell lymphocytes, is that treatment for a short period may result in good remissions at an early stage. Much clinical research is still needed to improve these costly approaches.