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• W3093577492 abstract "Immunotherapy (IO) has dramatically improved survival of patients diagnosed with metastatic melanoma. Previous randomized data demonstrated a 5-10% risk of radiation necrosis (RN) following stereotactic radiosurgery (SRS) but there is a paucity of data regarding this risk with concurrent use of IO. Recent phase 2 trial data demonstrating potential efficacy of combination IOs in treating melanoma brain metastases (MBM) is leading to declining use of SRS for these patients. We evaluated outcomes and toxicities of patients who received SRS within a +/- 30-day window of IO administration (“concurrent SRS”). Between 2011 and 2019, 151 melanoma patients with brain metastases received concurrent SRS with IO (anti-CTLA4 monotherapy N = 43, anti-PD1 monotherapy N = 49, anti-CTLA4/anti-PD1 sequential therapy N = 21, and anti-CTLA4/anti-PD1 combination therapy N = 38). Patients receiving prior whole brain radiation (WBRT) were excluded from this analysis. Radiographic brain radionecrosis (RN) was evaluated by the initial reading radiologist and then verified by a neuroradiologist. Survival outcomes were estimated using the Kaplan-Meier (KM) method and time-dependent Cox regression analyses. Median follow up from the date of concurrent SRS was 31.6 months (reverse KM) while median overall survival (OS) was 15.4 months. OS did not differ based on type of IO received; median OS for patients receiving anti-CTLA4 monotherapy, anti-PD1 monotherapy, anti-CTLA4/anti-PD1 sequential, and anti-CTLA4/anti-PD1 combination therapy was 13.2, 22.7, 14.1, and 18.2 months, respectively (p = 0.22). Radiographic RN was identified in 14 patients (9.2%) occurring at a median of 6 months after SRS (range: 1-14.6). No differential rate of RN was identified based on type of IO received (p = 0.15), number of lesions treated (p = 0.41), total lesion volume (p = 0.21), prior or subsequent SRS (p = 0.17), or receipt of steroids after SRS (p = 0.80). Three patients with RN were observed without treatment, 5 received steroids alone, 3 received steroids followed by bevacizumab, 2 received laser interstitial thermal ablation, and 1 required craniotomy. Hemorrhage of treated and/or new untreated metastases was identified radiographically in 69 patients during follow up imaging with 10 requiring craniotomies (6%). Seventy-nine patients (52%) developed distant brain failure (DBF), which was associated with shorter OS (HR 1.6 95%CI 1.1-2.5; p = 0.03). DBF requiring salvage WBRT (36 patients, 24%) was also associated with shorter OS (HR 2.8, 95%CI 1.7-4.7; p<0.0001). Salvage surgery for symptomatic disease progression was performed in 7 patients (5%). Immunotherapy given concurrently with SRS does not increase the rate of RN compared to historical controls (conventionally 5-10%). The known benefit of local control of gross disease with SRS should not be withheld in favor of systemic therapy alone due to concerns regarding RN." @default.
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• W3093577492 date "2020-11-01" @default.
• W3093577492 modified "2023-10-17" @default.
• W3093577492 title "Concurrent Immunotherapy and Stereotactic Radiosurgery for Patients with Melanoma Brain Metastases is not Associated with Increased Risk of Brain Radionecrosis" @default.
• W3093577492 doi "https://doi.org/10.1016/j.ijrobp.2020.07.992" @default.
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