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TumorDiagnostik & Therapie 2017; 38(03): 196-201
DOI: 10.1055/s-0043-101202
Thieme Onkologie aktuell
© Georg Thieme Verlag KG Stuttgart · New York

Hirnmetastasen beim malignen Melanom

Melanoma Brain Metastases
J. Brütting
1   Medizinische Fakultät Carl-Gustav-Carus, Technische Universität Dresden
,
R. Rauschenberg
2   Hauttumorzentrum am Universitätskrebszentrum Dresden (UCC), Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl-Gustav-Carus Dresden
,
E. G. C. Troost
3   Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl-Gustav-Carus, Technische Universität Dresden
4   OncoRay – Nationales Zentrum für Strahlenforschung in der Onkologie, Dresden
5   Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partnerstandort Dresden
6   Institut für Radioonkologie, Helmholtz-Zentrum Dresden-Rossendorf
7   Nationales Zentrum für Tumorerkrankungen (NCT), Partnerstandort Dresden
,
F. Meier
1   Medizinische Fakultät Carl-Gustav-Carus, Technische Universität Dresden
2   Hauttumorzentrum am Universitätskrebszentrum Dresden (UCC), Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl-Gustav-Carus Dresden
7   Nationales Zentrum für Tumorerkrankungen (NCT), Partnerstandort Dresden
,
M. Garzarolli
2   Hauttumorzentrum am Universitätskrebszentrum Dresden (UCC), Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl-Gustav-Carus Dresden
› Author Affiliations
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Publication History

Publication Date:
28 April 2017 (online)

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Zusammenfassung

Die Mehrheit der Melanom-Patienten mit Fernmetastasen ist auch von Hirnmetastasen betroffen, welche die häufigste Todesursache darstellen. Besteht der Verdacht auf Hirnmetastasierung, so sollten eine Staging-Diagnostik inklusive zerebraler Magnetresonanztomografie (cMRT) und eine neurologische Untersuchung erfolgen. Bei der Therapieplanung sind bekannte prognostische Faktoren wie die Anzahl und Symptomatik der Hirnmetastasen, der Serum-LDH- und S100-Wert, die extrazerebrale Metastasierung und der ECOG-Status zu berücksichtigen. Die Therapie sollte interdisziplinär besprochen werden und multimodal erfolgen. Bei Vorliegen einer einzelnen Hirnmetastase ist die Behandlung mittels neurochirurgischer Resektion oder stereotaktischer Radiatio etabliert. Für die Kontrolle der Hirnmetastasen war die Lokaltherapie bis vor kurzem die einzige Option. Durch die Neuzulassungen wirksamer Immun- (CTLA-4- und PD-1-Antikörper) und zielgerichteter Therapien (BRAF- und MEK-Inhibitoren) hat sich das Therapiespektrum jedoch entscheidend erweitert. Bei multiplen symptomatischen Hirnmetastasen wird die palliative Ganzhirnradiatio eingesetzt. Dabei konnte das Gesamtüberleben bislang nicht signifikant verlängert, jedoch die neurologische Symptomatik und Lebensqualität verbessert werden. Kortikosteroide und Antikonvulsiva sind bei erhöhtem Hirndruck und epileptischen Anfällen indiziert. Neue Therapieoptionen für das Melanom mit Hirnmetastasierung wie PD-1-Antikörper und Kombinationsstrategien von bspw. Ipilimumab und Nivolumab, BRAF-Inhibitoren und MEK-Inhibitoren oder stereotaktische Radiatio und Immun- bzw. zielgerichtete Therapie werden in laufenden klinischen Studien evaluiert.

Abstract

The majority of melanoma patients with metastatic disease stage IV is also affected by brain metastases, which are the main cause of death. If there is suspicion of brain metastases, staging diagnostics including cranial magnetic resonance imaging (cMRI) and a neurological examination are indicated. Prognostic factors, such as the number and symptoms of brain metastases, serum LDH and S100, existence of extracerebral metastases and ECOG status, should be considered in treatment planning. In addition, therapeutic interventions should be based on an interdisciplinary and multimodal approach. In case of a single brain metastasis, treatment by neurosurgical resection or stereotactic radiotherapy is standard of care. Until recently, the sole option for controlling brain metastases was local treatment. However, the spectrum of therapies has significantly expanded by approval of effective immune checkpoint (CTLA-4 and PD-1 antibody) and targeted therapies (BRAF and MEK inhibitors). In case of multiple symptomatic brain metastases, palliative whole-brain radiotherapy is used although there is no significant prolongation of overall survival (OS) but only some improvement of neurological symptoms and quality of life. Corticosteroids and anticonvulsants are indicated for increased intracranial pressure and epileptic seizures. New treatment options in melanoma with brain metastasis such as PD-1 antibodies and several combination strategies (e. g. ipilimumab plus nivolumab, BRAF inhibitors plus MEK inhibitors, or stereotactic radiotherapy plus immune or targeted therapy) will be evaluated in ongoing clinical trials.

 

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