Brain Metastases NSCLC — SCE Medical Oncology MCQ

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ModerateLung CancerBrain Metastases NSCLCSCE Medical Oncology

A 60-year-old man with NSCLC and asymptomatic brain metastases (4 small lesions, each <1 cm) is starting first-line pembrolizumab + chemotherapy. His brain metastases are untreated. What does current evidence suggest about ICI activity in untreated brain metastases?

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Correct answer: B — Checkpoint inhibitors have demonstrated intracranial activity in NSCLC brain metastases, particularly in PD-L1-high tumours; small asymptomatic brain metastases may be observed on ICI without immediate local therapy

Multiple trials (KEYNOTE-189, CheckMate 227, pooled analyses) have demonstrated intracranial activity of ICI in NSCLC, with intracranial response rates of approximately 30-40%. Small, asymptomatic brain metastases can be managed with systemic ICI-chemotherapy and close MRI surveillance, deferring SRS/WBRT unless there is CNS-specific progression. This approach avoids radiation neurotoxicity in patients whose brain metastases may respond to systemic therapy. SRS remains important for larger or progressive CNS lesions.

Reference: ESMO 2024 NSCLC and Brain Metastases Guidelines; Goldberg et al Lancet Oncol 2016; NICE NG122