Upfront targeted therapy for symptomatic melanoma brain metastases: paradigm changing?

The standard management of a single brain metastasis is usually maximal resection when feasible followed by radiotherapy. In case of multiple lesions, several options have to be considered depending on the natural behavior of the primary tumor, the localization of brain lesions, their functional impact and related symptoms. In case of life-threatening brain metastasis, debulking surgery is often proposed first, with the risk of major bleeding and postponing the initiation of other treatments. This approach is now challenged by the rapid tumor shrinkage that could be observed with novel targeted therapies. Here we report the case of a patient suffering from a melanoma with multiple brain metastasis, treated with BRAF and MEK double blockade, with impressive and rapid response.