From the Guidelines
Whole brain radiotherapy (WBRT) is not recommended as a first-line treatment for multiple melanoma brain metastases due to its limited efficacy and significant neurocognitive side effects. According to the most recent and highest quality study 1, WBRT has been shown to have a median survival of only 3-6 months when used as initial treatment for patients with multiple brain metastases, with 10%-15% of patients alive at 1 year. In contrast, stereotactic radiosurgery (SRS) and systemic therapies such as immune checkpoint inhibitors (pembrolizumab, nivolumab, ipilimumab) or BRAF/MEK inhibitors (dabrafenib/trametinib for BRAF-mutated melanoma) have been shown to be more effective approaches for treating multiple melanoma brain metastases 1.
Some key points to consider when evaluating the efficacy of WBRT for multiple melanoma brain metastases include:
- The limited efficacy of WBRT in providing long-term disease control, with a median survival of only 3-4 months 1
- The significant neurocognitive side effects associated with WBRT, including memory loss and cognitive decline 1
- The availability of more effective alternative treatments, such as SRS and systemic therapies 1
- The importance of considering the patient's overall performance status, age, and extent of brain disease when deciding on a treatment approach 1
In terms of specific treatment recommendations, SRS is preferred for patients with limited lesions, while systemic therapies such as immune checkpoint inhibitors or BRAF/MEK inhibitors are recommended for patients with multiple brain metastases 1. When WBRT is necessary due to extensive brain disease, hippocampal-sparing techniques and memantine (10mg daily, titrated up from 5mg) can help reduce cognitive side effects 1. Overall, the goal of treatment should be to prioritize the patient's quality of life and minimize morbidity and mortality.
From the Research
Efficacy of Whole Brain Radiotherapy for Metastasis in Patients with Multiple Melanoma
- The efficacy of whole brain radiotherapy (WBRT) for metastasis in patients with multiple melanoma is a topic of ongoing research and debate 2, 3, 4, 5, 6.
- According to a study published in 2021, WBRT may provide palliative benefits in patients with multiple brain metastases 2.
- Another study published in 2020 found that WBRT provides no clinical benefit in oligometastatic melanoma brain metastases, and that combined immunotherapy is a preferred treatment option for asymptomatic brain metastases 3.
- A retrospective study published in 2006 found that WBRT with 20 Gy/5 fractions or 30 Gy/10 fractions, followed by temozolomide-based chemotherapy, resulted in a median survival time of 4 months, with no significant difference between the two treatment schedules 4.
- A 2025 overview of the role of radiotherapy in the management of melanoma brain metastases noted that WBRT is an integral part of treating melanoma brain metastases, but that the use of immunotherapy and targeted therapy has significantly changed the outcome in patients with melanoma metastases 5.
- A randomised phase III trial published in 2011 compared WBRT to observation following local treatment of intracranial melanoma metastases with surgery and/or stereotactic radiosurgery, and found that WBRT may prolong intracranial control and reduce neurological events, but may also impair neurocognitive function 6.
Key Findings
- WBRT may provide palliative benefits in patients with multiple brain metastases 2.
- Combined immunotherapy is a preferred treatment option for asymptomatic brain metastases 3.
- WBRT provides no clinical benefit in oligometastatic melanoma brain metastases 3.
- The use of immunotherapy and targeted therapy has significantly changed the outcome in patients with melanoma metastases 5.
- WBRT may prolong intracranial control and reduce neurological events, but may also impair neurocognitive function 6.