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Melanoma Brain Metastases — SCE Medical Oncology MCQ

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HardMelanoma & SkinMelanoma Brain MetastasesSCE Medical Oncology

A 60-year-old woman with metastatic melanoma on nivolumab + ipilimumab develops new-onset seizures. MRI brain shows multiple new enhancing lesions consistent with brain metastases. She had no brain metastases at baseline. ECOG PS 1 after seizure control. What is the most appropriate treatment approach?

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Correct answer: E — Continue nivolumab + ipilimumab and add stereotactic radiosurgery to the brain lesions

For melanoma patients developing brain metastases on combination ICI, the approach is to continue immunotherapy (which has demonstrated intracranial activity in CheckMate 204 and ABC trials) and add local CNS-directed therapy (SRS for limited metastases). Combination nivolumab + ipilimumab has shown intracranial response rates of approximately 46-57% in treatment-naive brain metastases. Whole-brain radiotherapy is avoided due to neurocognitive toxicity unless numerous lesions preclude SRS.

Reference: ESMO 2024 Melanoma and Brain Metastases Guidelines; CheckMate 204 Tawbi et al NEJM 2018; ABC trial Long et al Lancet Oncol 2018