The relative effectiveness of radiation therapy, corticosteroids, and surgery in the management of melanoma metastatic to the central nervous system

The records of all patients who received radiotherapy for melanoma metastatic to brain (63 patients) and epidural space (9 patients) at the American Oncologic Hospital from January, 1971, through March, 1980, were reviewed. Patients were evaluated according to the type of therapy received (corticosteroids, radiotherapy, surgery) and whether their brain metastases were radiographically solitary (60%) or multiple (40%). Forty-nine patients with brain metastases received corticosteroid therapy for 2 to 7 days or more before radiotherapy. Seventy-three percent of these patients had documented responses to corticosteroids. This was substantially higher than the 42% overall response rate that could be attributed to radiotherapy. Fifty-two percent of the patients with solitary and 30% of those with multiple brain metastases responded to radiotherapy. The use of large doses (≥500 rad) per fraction produced a significantly higher response rate than did the use of low doses (≤400 rad) per fraction (P < .02), but only for those patients with solitary brain metastases. Fraction size had no effect on the duration of response or survival. Patients with irradiated solitary brain metastases had a longer duration of response and survival than did those with irradiated multiple brain metastases, but not significantly so. Patients undergoing surgical excision of a solitary brain metastasis and radiotherapy had significantly longer median durations of response (405 days versus 57 days; P = .0047) and survival (448 days versus 96 days; P = .0013) than did patients with solitary brain metastases who did not receive surgery. Re-irradiation was of benefit in relieving recurrent neurologic symptoms, but responses were short and survival was not prolonged. Patients with cord compression undergoing decompressive laminectomy had relief of neurologic symptoms, whereas those not paralyzed who received radiotherapy alone did not respond. Surgical excision with postoperative irradiation is recommended for the management of solitary brain metastases from melanoma. Surgical decompression is recommended for the management of epidural cord compression.