Metastatic Brain Cancer Treatment
It is important to know that metastatic brain tumors are often treatable, and can be well-controlled. Generally, the faster you start treatment, the better the chances of killing or controlling the disease.
The treatment options for brain metastases may include:
- Clinical trials
In many cases, surgery or radiation therapy can improve or entirely get rid of symptoms. Read more about brain tumor treatment.
Mechanisms Of Melanoma Brain Metastasis
Metastatic brain tumors are the most common intracranial neoplasm in adults . To better understand the formation of brain metastases, the Winkler lab used a mouse with a chronic cranial window to track the fate of fluorescently labeled melanoma cells during their colonization of the mouse brain. They characterized the steps of the late metastatic cascade as: cell arrest at vascular branch points, early extravasation, persistent close contact to microvessels, perivascular growth by vessel co-option, and angiogenesis . These steps provide a general framework in which to discuss the mechanisms underlying intracranial melanoma metastasis formation .
Steps and factors involved in melanoma metastasis to the brain.
Metastatic Melanoma In The Brain
Brain metastases can cause neurological problems such as seizures, dizziness, and vision and hearing problems. Although current therapies used to treat brain metastases may help to alleviate these symptoms, they can also compromise brain function. According to a 2010 study, only 5% of people with melanoma that has spread to the brain will live more than 5 years after a diagnosis of brain metastases.
With the availability of new immunotherapies over the past few years, though, the survival rate may be changing, Dr. Sharon said.
A handful of small studies provided initial evidence that, on their own or in combination, ipilimumab and nivolumab may shrink melanoma brain metastases. The new phase 2 trialsponsored by Bristol-Myers Squibb, the manufacturer of nivolumab and ipilimumabwas launched to provide stronger evidence.
More than 100 people with at least one metastatic melanoma tumor in the brain were enrolled in the trial. People with certain conditions or medical histories were excluded, such as those with cancer in part of the brain called the leptomeninges, with neurological symptoms from brain metastases, or who had been treated with steroids to alleviate swelling in the brain.
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Predictive Factors For Overall Survival
We analyzed the potential association between several factors and survival using univariate Cox regression of overall survival . Intriguingly, of factors in the primary tumor, increased levels of tumor-infiltrating lymphocytes showed a trend toward improved survival in patients with brain metastasis. Several clinical factors were found to be significantly associated with overall survival in patients with brain metastasis by univariate analysis . Factors associated with shorter overall survival included male sex, cerebellar involvement, higher number of metastatic brain tumors, concurrent presence of adrenal metastasis, or treatment with whole-brain radiation therapy. Factors associated with longer overall survival were treatment with craniotomy, stereotactic radiosurgery, or anti-PD-1 antibody therapy after initial diagnosis of brain metastasis.
Table 4 Univariate Cox regression analysis of association of various clinical factors with overall survival in melanoma patients with brain metastasis
Multivariate analysis of all eight factors revealed cerebellar involvement, craniotomy, and adrenal involvement as independently predictive of survival . There was trend toward significance for treatment with anti-PD-1 antibody .
Table 5 Multivariate Cox regression analysis of association of various clinical factors with overall survival in melanoma patients with brain metastasis
How Is Metastasis Detected
If your doctor suspects that your melanoma may have spread, there are several tools available to verify the diagnosis. These include a blood test for lactate dehydrogenase , which increases when melanoma metastasizes, and imaging studies, such as chest X-ray, computed tomography , magnetic resonance imaging , positron emission tomography and ultrasound.
The doctor may also need to take a sample of your lymph nodes, using a procedure called “sentinel lymph node mapping.” If confirmed, there are many treatments available, including chemotherapy, immunotherapy, radiation therapy and surgery.
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Treatment Of Metastatic Melanoma
Metastatic melanomas can be difficult to treat. The five-year survival rate for people diagnosed with melanoma that has spread to nearby lymph nodes is 66 percent, according to the American Cancer Society. When cancer has spread to distant parts of the body, there may also be other metastases too small to detect by scans. For people diagnosed with stage 4 melanoma, or melanoma that has spread to distant parts of the body, the five-year survival rate is 27 percent.
For stage 3 and 4 melanomas, the following treatments may be used:
Multiple therapies can be used at any given time, and your care plan is a dynamic process. You and your care team should discuss all the options and decide on a treatment plan. Each treatment has different side effects, and its important to feel fully informed of all the associated risks. Other medications and options may help manage the symptoms of your cancer treatment, so you can live the highest quality of life possible throughout the course of your treatment and disease.
Expert Review And References
- Nater A, Vincent F, Fehlings MG. Spinal column tumors. Bernstein M and Berger MS . Neuro-oncology: The Essentials. 3rd ed. New York: Thieme 2015: 40: 474-492.
- National Cancer Institute. Adult Central Nervous System Tumors Treatment for Health Professionals . 2016: .
- Patel AJ, Lang F, Sawaya R. Metastatic brain tumors. Bernstein M and Berger MS . Neuro-oncology: The Essentials. 3rd ed. New York: Thieme 2015: 38: 451-461.
- US National Library of Medicine. MedlinePlus Medical Encyclopedia: Metastatic Brain Tumor. 2014: .
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Metastatic Brain Tumor Surgery
Surgery provides fast relief of mass effect pressure inside the skull resulting from a growing metastatic tumor and swelling of the brain. Some patients may find improvement of symptoms as early as within hours of surgery if mass effect is what is causing your symptoms.
The goal of surgery is to minimize the amount of space the tumor takes up by debulking, which means removing as much of the tumor as possible while maintaining neurological function.
In general, doctors recommend surgery for metastatic brain cancer when:
- There is a clear link between the symptoms and the tumors location.
- The primary cancer is treatable and under control.
- The tumor can be safely removed.
The most common type of surgery to remove metastatic brain tumors is called a craniotomy, which can be performed through a variety of approaches, including the keyhole craniotomy.
What Makes Yale Medicine’s Approach To Treating Metastatic Brain Tumors Unique
Yale Medicine is leading the way nationally in the use of the newer chemotherapy agents, including immunotherapy and targeted therapies.
For example, Yale Medicine offers a unique clinical trial evaluating the use of immunotherapy alone, and deferring radiation, to treat brain metastases. Data showing preliminary success was recently published in Lancet Oncology.
Yale Medicine is the only multidisciplinary consortium providing comprehensive brain cancer care in southern New England. This gives patients access to the full range of treatment options, from medical therapy to cutting-edge radiosurgery.
At Yale Medicine, treatment is not suggested based on the technology we own, but rather is personalized to the patient’s needs and evidence-based, acquired through national research and experience. Discussion of challenging cases, both from within our Yale Cancer Centeras well as referred to Yale Medicine from other centers around the state, occurs at a weekly tumor board. Recommendations from the Tumor Board are then communicated back to the involved physicians to ensure seamless coordination of care.
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Who Is At Risk
More than 60% of all Stage IV melanoma patients will develop brain metastases at some point, but certain factors increase the risk :
- The primary tumor was on the head, neck, trunk, or abdomen
- The primary tumor was ulcerated, deep, or invasive
- The LDH is elevated at diagnosis of unresectable Stage III or Stage IV
- The presence of NRAS or BRAF mutation
- The melanoma has spread to the internal organs
What Is Recovery Like
Even if they come in with neurological problems due to their brain metastases, many patients today make full recoveries – especially if their metastases are caught early.
“It’s nice to be able to offer relief and say that, in fact, the cancer in the brain is really not the determinant of a patient’s survival,” says Dr. Chiang.
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More Than Doubled Median Survival
Clinical trials of checkpoint blockade immunotherapies in advanced melanoma have shown some promising early results in recent years.
However, the authors note that many of these trials have excluded or included disproportionately fewer cases in which melanoma has spread to the brain. The main reason has been about impact on other treatments and whether the drug can actually cross from the bloodstream into the brain.
This had resulted in a lack of information about whether these new immunotherapies might also benefit melanoma patients with brain metastases.
For their investigation, the researchers analyzed data on 2,753 melanoma patients in the National Cancer Database who were diagnosed with melanoma brain metastases in hospitals around the U.S. during 20102015.
They discovered that the median survival for those who were treated with checkpoint blockade immunotherapies was 12.4 months, which is more than double the 5.2 months median survival for those who did not receive the treatment.
This means that 28.1 percent of the people who received checkpoint blockade immunotherapy were alive 4 years later, compared with just 11.1 percent of those who did not.
The benefit was even more dramatic for people whose melanoma had spread only to the brain and not also to other parts of the body, such as the liver or the lungs.
Immunotherapy For Metastatic Brain Tumors
Cancer immunotherapy is a fast-growing field of research that seeks to develop drugs, vaccines and other therapies that trigger the immune systems natural abilities to fight cancer. Many immunotherapy drugs for metastatic brain tumors act as checkpoint inhibitors. Normally, tumor cells can evade attack by activating certain proteins that disarm your immune system. Checkpoint inhibitors prevent tumor cells from exploiting this process.
Immunotherapy drugs to treat metastatic brain tumors include:
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Chemical Fixation For Electron Microscopy
MUG-Mel1, C8, and D5 were grown on an Aclar film , fixed in 2.5% glutaraldehyde and 2% paraformaldehyde in 0.1M phosphate buffer, pH 7.4, for 2h, postfixed in 2% osmium tetroxide for 2h at room temperature, dehydrated in graded series of ethanol and embedded in TAAB epoxy resin. Ultrathin sections were cut with a UC 7 Ultramicrotome and stained with lead citrate for 5min and with uranyl acetate for 15min. Images were taken using a Tecnai G2 20 transmission electron microscope with a Gatan ultrascan 1000 charge coupled device camera . Acceleration voltage was 120 kV.
Mutation Analysis Using Ampliseq
Genomic DNA of primary tumor, MUG Mel1 and clones was isolated on a Maxwell, MDxResearch System . Highly multiplexed PCR was used to generate amplicon libraries covering the coding region of 50 genes commonly implicated in cancer . All analyses were performed in duplicates. Libraries were prepared using the Ion AmpliSeq Library Kit 2.0 and sequencing was performed on an Ion Proton Sequencer . Emulsion PCR and sequencing runs were performed with the appropriate kits using Ion PI chips. Sequencing length was set to 520 flows and yielded reads ranging from 70 to 150bp, consistent with the expected amplicon size range. Initial data analysis was performed using the Ion Torrent Suite Software version 4.1 Plug-ins .
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What You Need To Know
- Metastatic brain cancer is caused by cancer cells spreading to the brain from a different part of the body.
- The most common types of cancer that can spread to the brain are cancers of the lung, breast, skin , colon, kidney and thyroid gland.
- Metastatic brain tumors are five times more common than primary brain tumors .
- Metastatic brain tumors can grow rapidly, crowding or destroying nearby brain tissue. Sometimes a patient may have multiple metastatic tumors in different areas of the brain.
How Are Metastatic Brain Tumors Diagnosed
Metastatic brain and spine tumors are not usually diagnosed until symptoms appear. Here are some ways doctors may diagnose a metastatic brain tumor:
- Physical exam: After gathering information about your symptoms and personal and family health history, the doctor proceeds with a physical exam and vision and reflex tests.
- Magnetic resonance imaging
- Diffusion tensor imaging is a type of MRI that visualizes how water molecules pass through parts of the brain. It reveals microscopic differences of tissue structure, including very early infiltration of cancer cells.
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No New Safety Concerns
Brain metastases can hinder brain function by destroying healthy brain cells and by causing swelling in the brain. Because immunotherapies can cause inflammation, there were concerns that these treatments might trigger brain swelling and more neurological issues, Dr. Tawbi explained.
However, only seven participants had a serious neurological side effect, such as swelling or bleeding in the brain. In total, 55% of participants had a serious adverse event related to the treatment, most commonly an immune response in the liver . One participant died from inflammation of the heart muscles , which was related to the treatment.
The safety profile in this population was consistent with that reported in studies involving patients without brain metastases, noted Drs. Turajlic and Larkin.
It appears theres no increased safety risk in patients with melanoma brain metastases, said Dr. Sharon. I think that was the most interesting finding.
Chemotherapy For Metastatic Brain Tumors
Because traditional chemotherapy cannot cross the blood-brain barrier, newer treatments called targeted therapy are used as the primary type of chemotherapy for treating metastatic brain tumors.
These drugs identify and attack cancer cells with minimal harm to normal cells while preventing the growth and spread of cancer cells. Targeted therapy can be administered after surgery or in conjunction with radiation therapy to destroy remaining cancer cells.
Targeted therapies used to treat metastatic brain tumors include:
- Trastuzumab for breast cancer that has spread to the brain
- Erlotinib for the most common type of lung cancer that has spread to the brain
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How Melanoma Can Spread From Your Skin To Your Brain
When former U.S. President Jimmy Carter announced that not only did he have melanoma, but that it had spread to his liver and brain, many people probably had the same thoughts: Isnt melanoma skin cancer? And how do you get it on your brain?
People think, ‘Oh, it’s melanoma that’s just skin cancer you cut it out and you don’t have to worry about it,’ says Dr. Tim Turnham, executive director of the Melanoma Research Foundation in Washington, D.C.
That thought has two implications: it isolates patients often people diagnosed with melanoma feel people don’t understand that theyre dealing with a life threatening illness because they think it’s ‘Cancer Lite’ but more significantly, it means that people don’t understand the risks and don’t take appropriate steps to alleviate those risks.
One of those risks is that melanoma can metastasize to other, more vulnerable, parts of the body.
How Melanoma Spreads
Melanoma is particularly nefarious form of skin cancer. According to The Skin Cancer Foundation, though it accounts for less than two per cent of all skin cancer diagnosis, melanoma is responsible for the vast majority of skin cancer deaths. This is because it is the skin cancer most likely to metastasize to other organs.
Melanoma is also one of the cancers that tends to metastasize to the brain. While no one quite knows for sure why that is, Turnham believes it has to do with receptors in the cancer cells.
How Do You Know You Have Melanoma?
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Diagnosis Of Metastatic Melanoma
Your care team may use several tests to diagnose metastatic melanoma.
If theres evidence of a primary tumor, a biopsy may be taken. For this, a small section of suspected cancerous skin is removed with a razor, scalpel or small punch tool. The removed tissue is examined under a microscope to determine whether its melanoma.
Additional tests are needed to determine whether the cancer is metastatic melanoma, or if theres no visible primary tumor. To test for metastatic melanoma, or melanoma that has spread to lymph nodes or distant parts of the body, your care team may perform the following tests.
- Lymph node mapping and sentinel lymph node biopsy : Your doctor may perform a physical exam of your lymph nodes and check for swelling or physical masses. If no tumors are found , an SLNB may be done. For an SLNB, a radioactive dye is injected to locate the primary tumor. Then, the doctor will remove the lymph nodes that the dye traveled to and check them for melanoma.
- Computed tomography scan, positron emission tomography scan, magnetic resonance imaging scan or ultrasound exam: Each of these scans is a noninvasive way to look inside your body and check for tumors.
- Blood chemistry studies: Cancer may cause elevated or abnormal levels of certain substances in your blood. A laboratory test can identify if your blood chemistry shows signs of a cancerous tumor.
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Animal Models Of Melanoma Brain Metastasis
There is a strong need to develop experimental models that accurately mimic the human disease both at the molecular and cellular levels such that more effective therapeutic strategies to prevent, delay, and treat melanoma brain metastases can be developed. Melanoma brain metastases have been successfully generated following transplantation of melanoma cells into immunodeficient mice . Studies that introduce melanoma cells subcutaneously have the advantage of being able to recreate and analyze the full range of metastatic events necessary for the development of brain metastases from the primary tumor . However, these models often have a long latency and require excision of the primary tumor followed by serial passage of the tumor cells in vivo to derive cell lines that reproducibly generate brain metastases.