Complications associated with immunotherapy for brain metastases

PURPOSE OF REVIEW

Median survival after the diagnosis of brain metastases has historically been on the order of months. With the recent development of immune checkpoint inhibitors, intracranial activity and durable responses have been observed in brain metastases on multiple phase 2 clinical trials, which have primarily been conducted in patients with melanoma. Immune-related adverse events related to checkpoint inhibitor therapy of brain metastasis can present unique challenges for the clinician and underscore the need for a multidisciplinary team in the care of these patients. The goal of this review is to address the current knowledge, limitations of understanding, and future directions in research regarding immune therapy trials and neurologic toxicities based on retrospective, prospective, and case studies.

RECENT FINDINGS

Immune therapy has the potential to exacerbate symptomatic edema and increase the risk of radiation necrosis in previously irradiated lesions. Neurologic toxicities will likely increase in prevalence as more patients with brain metastatic disease are eligible for immune therapy.

SUMMARY

An improved understanding and heightened awareness of the unique neurologic toxicities that impact this patient group is vital for mitigating treatment-related morbidity and mortality.

Les métastases cérébrales de cancer du rein, un défi clinique

BRAIN METASTASES IN RENAL CELL CARCINOMA, AN UNMET NEED

Brain metastases from renal cell carcinomas are associated with dismal prognosis and might be present in up to 10 % of metastatic patients. Biologically, the blood brain barrier might be disrupted in brain metastases and thus do not exclusively account for treatment resistance. Brain metastases often acquire additional molecular alterations that might provide aggressive features. They are also associated with high lymphocytic infiltration and expression of immune checkpoints PD-1/PD-L1. In clinical routine, scores based on metastatic volume and patients' performance status might help better predict survival. The cornerstone of brain metastases treatment is stereotactic radiation therapy if patients are eligible, while systemic treatments such as antiangiogenics and immune checkpoint inhibitors only provide limited disease control. Early identification of patients with brain metastases from renal cell carcinomas and promotion of dedicated clinical trials will be important to try and improve current clinical management.