How do you decide between initial radiotherapy vs systemic therapy in patients with metastatic melanoma and brain metastases?

An interesting question the answer to which is changing!

For discussion we will assume that the patient is not previously treated. Presence or absence of CNS symptoms is likely the most important way to dichotomize these patients. Other issues include number and size of the brain metastases, whether ...

I have seen excellent responses to BRAF inhibitors in BRAF+ patients. One patient with diffuse leptomeningeal disease had a memorable objective and subjective response within days.