Cerebral Metastasis from Melanoma1

Abstract

Fif ty-seuen patients suffering from melanotic cerebral metastares are reviewed. The nature and course of the primary lesion, the clinical history of the cerebral metastases and the results of treatment are discussed. Radiotherapy, chemotherapy, surgery and immunotherapy formed the basis o f treatment. CEREBRAL metastasis from melanoma carries an extremely poor prognosis. Beresford (1969) reported a mean survival of 78 days from the onset of symptoms of cerebral metastasis in 37 patients managed conservatively. Of patients coming to autopsy 80% had multiple or diffuse cerebral metastases. In the series of Satran and McDonald (1968) of 34 similar patients there was a 50% mortality within two months of the onset of symptoms, irrespective of treatment. At autopsy 33 patients (97%) had multiple cerebra1 metastases. Gottlieb et a& (1972) reported a mean survival of 52 days from the onset of symptoms in 25 patients who did not respond to treatment for cerebral melanoma. The present article is a survey of 57 cases of cerebral metastasis from melanoma seen in the Melanoma Clinic (now at Sydney Hospital) between 1952 and 1975.The aim of this investigation has been: (i) to characterize the primary lesions and possible differences between them and primary melanomas in general ; (ii) to describe the course of metastatic disease and determine its relevance to subsequent cerebral metastasis ; ( 3 ) to determine the natural history of cerebral metastasis, including its diagnosis and subse-' Presented at the 48th annual general scientific meeting of the Royal Australasian College of Surgeons, Queenstown, 1975. . quent course; and (iv) to determine the effects of treatment of cerebral metastasis, and in particular to compare the results following several different treatment regimes. PATIENTS AND METHODS (i)Patients.-There were 57 patients in the whole series. These were divided into two major groups, Group A, 26 patients who were treated symptomatically; and Group B, 31 patients who received specific treatment for ,their cerebral metastases. Group B was subdivided into Groups BI, B2 and B2a for the purposes of assessment of individual treatment regimes (see Table 3 ) .All data relating to the series were collected from systematic records kept by the Melanoma Unit and confirmed when necessary by reference to hospital records. The data were recorded on a standard pro-forma sheet for each patient. (ii) Primary Zesions.-The characteristics of the primary lesions are summarized in Table I . (iii) Metastases.-Both Groups A and Bwere analysed separately and together to determine the site, character and duration of the lesions before the appearance and subsequent behaviour of metastases other than cerebral. Metastatic disease was considered to be any spread beyond the primary site, and included local recurrences, regional nodal and distant metastases. An analysis of two subgroups within Group B was undertaken to determine whether slowly progressive disease favoured increased survival with cerebral metastasis and

Primary cutaneous malignant melanoma metastatic to the iris.

“…The rapid deterioration in the patient's clinical condition after the appearance of the first metastasis is consistent with the known behaviour of intracranial malignant melanoma metastases (Pennington and Milton, 1975).…”

“…Metastasis of malignant melanoma from the skin to the central nervous system exclusively is rare (Pennington and Milton, 1975). Intracranial metastases from the skin would suggest spread via the internal carotid system, which explains also the intraocular involvement.…”

Melanoma of the Central Nervous System

“…However, there has been no cause for optimism with the use of cytotoxic drugs in the later Queensland cases. The use of Thiotepa, imidizo carboxamide, endoxan, BCNU, and CCNU has been reported by others (Pennington and Milton, 1975;Gottlieb et alii, 1972). In a series of 47 patients that Einhorn et alii (1974) treated with cytotoxic preparations, there was a mean survival of 2.75 months.…”

“…However, Young reported (Wigg, 1976) that of all patients with cerebral metastatic tumours, two-thirds could expect t o benefit symptomatically. Mean survivals of up to six months from the onset of cerebral symptoms have been reported by Pennington and Milton (1975) and Beresford (1 969); these were small series of cases, and most patients were covered with corticosteroids. Savitz and Anderson (1 974) conclude that "radiation therapy has been essentially ineffective in almost all cases".…”

“…Papers referring t o the treatment of cerebral melanoma often speak of mean improvements t o life expectancy of three t o six months (Beresford, 1969;Pennington and Milton, 1975), and one might be excused for thinking that this was really a significant breakthrough for the patient. More often, the patient is hospitalized, becomes invalid, and the quality of life is poor.…”