Abstract
The first patient is a 76-year-old man who presented in June 2015 with aphasia and right hemiparesis. Imaging revealed a 3.5 × 3 × 1.3 cm left parietal mass. The patient underwent a craniotomy and pathology confirmed BRAF V600E mutant melanoma. He did not have a previous diagnosis of a primary melanoma. Subsequent PET imaging in August showed no evidence of systemic disease. Surveillance brain MRI in November showed several new nodular areas of enhancement along the dura and inter hemispheric falx, with CT of the body again not demonstrating other sites of disease. He was treated with whole brain radiation in December of 2015 (37.5 Gy, 15 fractions). In late January 2016 an MRI was done demonstrating mild progression of the anterior falcine dural metastatic disease. Given the progression was not significant and the patient was asymptomatic a watchful waiting approach was planned with a close follow-up MRI. Repeat MRI in March showed stable changes, thus surveillance continued.
Highlights
The development of Central Nervous System (CNS) disease, especially Leptomeningeal Disease (LMD), is a devastating complication in patients with metastatic melanoma
CNS disease, LMD, represents a significant challenge in the treatment of melanoma patients, due to limited treatment options, and due to significant morbidity and poor survival associated with this diagnosis
Recent studies have shown that immunotherapy can lead to responses in the brain, but LMD patients were excluded from these trials [5,6]
Summary
The development of Central Nervous System (CNS) disease, especially Leptomeningeal Disease (LMD), is a devastating complication in patients with metastatic melanoma. For LMD, life expectancy is typically measured in weeks, and current guidelines only recommend palliative radiotherapy or best supportive care [1]. For LMD, intrathecal immunotherapy with IL-2 has shown some promising results; this therapy is extremely toxic and should only be given to a select patient population [4]. While there are reports of CNS response to anti-PD1 treatment, little is known about the efficacy of anti-PD1 therapy in the treatment of LMD, though studies are currently ongoing (NCT02939300, NCT00338377) [5,6,7]. We report two cases of CNS melanoma patients, one with dural metastasis and a second with LMD, both achieving clinical benefit from treatment with anti-PD1 agents
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