ESMO-IO 2019 – Considering immunotherapy for treating brain metastases?

  • Carolina Rojido
  • Univadis
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  • Immunotherapy has an increasing role for the treatment of brain metastases (BMs).
  • The role of whole brain radiotherapy (WBRT) may be decreasing.

Why this matters

  • BMs are often treated with surgery and RT. As systemic treatments such as immunotherapy become options too, many elements must be considered.

For patients taking dexamethasone, adding WBRT has produced a small difference in quality-adjusted life years (QALYs), no difference in survival and quality of life, and little additional clinically significant benefit.

Factors that favour RT are:

  • Adequate performance status.
  • Single or solitary metastases.
  • No or stable (more than 3 months) extracranial tumour manifestations.
    • In favour of stereotactic radiotherapy (SRT), there are lesions that  not surgically accessible, and a high surgical risk.

Factors that favour surgery are:

  • Neuroradiologically uncertain lesions.
  • Unknown primary tumour.
  • Presentation of the tumour (large cystic or necrotic lesion, mass effect).
  • Need for molecular profiling.

Immunotherapy or other systemic treatments should be chosen based on the primary tumour, its molecular characteristics, and prior treatments. Other factors are:

  • No or mild neurological deficits.
  • Multiple small BMs.
  • Extra-CNS progression.
  • Radioresistant tumour.

In conclusion, personalised treatment should be based on:

  • Cancer type and its molecular characteristics.
  • Neurological and general status; use of supportive treatments.
  • BMs’ imaging presentation.
  • Extra-central nervous system disease status.
  • Therapeutic options available.

In terms of response assessment to stereotactic radiosurgery or immunotherapy there are:

  • Clinical challenges (neurological deterioration related to concomitant complications/toxicities and steroids).
  • Imaging challenges (haemorrhages, pseudo progression, and radio necrosis).