Saturday, December 26, 2015

Yep! Immunotherapy can work in the brain...and pseudoprogression can be real!!

Melanoma brain metastasis pseudoprogression after pembrolizumab treatment. Cohen, Alomari, Vortmeyer, et al. Cancer Immunol Res. 2015 Dec 23

"The role of immunotherapy in treatment of brain metastases is unknown since most trials exclude patients with active brain lesions. As new immunomodulating agents gain approval for many malignancies, it is important to know if they have unique effects in the central nervous system (CNS). Here we present a case of a patient with progressing brain metastases treated with a single cycle of pembrolizumab, who presented with mental status changes 11 days thereafter. MRI of the brain showed enlargement of CNS lesions with intense central enhancement and diffuse perilesional edema. Histologic evaluation of a resected lesion revealed isolated clusters of tumor cells surrounded by reactive astrocytosis, scattered inflammatory cells and an abundance of microglial cells. Given the increasing use of immune checkpoint inhibitors in patients with brain metastases from melanoma and other diseases, recognition of pseudoprogression and management with immune suppression is essential."

Y'all know I've been yelling this for awhile:
1.  Yes, Virginia....immunotherapy works in the brain.  Anti-pd1 in melanoma: It works in the t-cells, brain, and everywhere else! 
2. It works even better combined with radiation.  Radiation for melanoma: better when combined with immunotherapy 
3.  No, we didn't allow folks with brain mets in treatments that could help soon enough!   
4.  Pseuodoprogression is real and it, along with other side effects, SHOULD be treated...even with prednisone (and other immune suppressing drugs) if needed when on immunotherapy!!!!!!  Those treatments do NOT impede response, but they can save your life and/or allow you to continue the therapy that will!!!  

Whew!  Ok.  Rant over.  I feel better.  Now...let's get lots of other folks feeling better.  We KNOW this stuff now!!  Let's USE what the ratties, who put their lives on the line, taught us for the good of ALL peeps dealing with melanoma in the brain and elsewhere. - c

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