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Smith H, Hayes A. The role of regional chemotherapy in the management of extremity soft tissue malignancies. Eur J Surg Oncol 2016; 42:7-17. [DOI: 10.1016/j.ejso.2015.08.165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/06/2015] [Accepted: 08/15/2015] [Indexed: 10/23/2022] Open
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Testori A, Verhoef C, Kroon HM, Pennacchioli E, Faries MB, Eggermont AM, Thompson JF. Treatment of melanoma metastases in a limb by isolated limb perfusion and isolated limb infusion. J Surg Oncol 2011; 104:397-404. [DOI: 10.1002/jso.22028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Sanki A, Kroon HM, Kam PCA, Thompson JF. Isolated limb perfusion and isolated limb infusion for malignant lesions of the extremities. Curr Probl Surg 2011; 48:371-430. [PMID: 21549235 DOI: 10.1067/j.cpsurg.2011.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Amira Sanki
- Senior Registrar in Plastic and Reconstructive Surgery, Sydney, Australia
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Isolated limb perfusion for melanoma in-transit metastases: developments in recent years and the role of tumor necrosis factor alpha. Curr Opin Oncol 2011; 23:183-8. [PMID: 21150602 DOI: 10.1097/cco.0b013e3283424dbc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The treatment of in-transit metastasis of melanoma remains challenging and is essentially dictated by the biological behavior of melanoma. When lesions are large or numerous, isolated limb perfusion (ILP) is an attractive treatment modality. In this review an overview of literature on treatment options of melanoma in-transit metastases will be discussed. RECENT FINDINGS Most recent studies report on tumor necrosis factor (TNF) and melphalan based ILP (TM-ILP) series or mixed series of TM-ILP and melphalan only based ILP (M-ILP). After TM-ILP complete response rates of 70% (range 44-90%) have been reported, while for M-ILP this is lower with complete response rates of 54% (range 40-76%). The only randomized trial comparing TM-ILP and M-ILP revealed no clear benefit of TNF at 3 months, but improved outcome at 6 months and in patients with bulky disease. Reports on isolated limb infusion (ILI) with melphalan and actinimycin D indicate lower response rates, but similar local control rates as M-ILP at lower cost. SUMMARY ILP is an attractive treatment option in melanoma patients with multiple in-transit metastases. In our opinion TM-ILP is superior to M-ILP as it achieves higher response rates, especially in patients with bulky disease. When lesions are small and in the distal two-thirds of the leg only, ILI is a valuable alternative.
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Coleman A, Augustine CK, Beasley G, Sanders G, Tyler D. Optimizing regional infusion treatment strategies for melanoma of the extremities. Expert Rev Anticancer Ther 2010; 9:1599-609. [PMID: 19895244 DOI: 10.1586/era.09.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The incidence of malignant melanoma is increasing faster than any other cancer. In cases of recurrent melanoma confined to the extremities, hyperthermic isolated limb perfusion and isolated limb infusion provide a way to isolate the extremity and deliver a dose of chemotherapy several orders of magnitude higher than would be tolerated systemically. Although complete response rates of up to 80% for hyperthermic isolated limb perfusion and 44% for isolated limb infusion have been observed, there is still room for improvement and standardization in these two procedures in an attempt to optimize response while minimizing toxicity. Currently, new chemotherapy agents and small-molecule inhibitors are being investigated as a means of overcoming chemoresistance and improving response rates. In patients with advanced cutaneous disease confined to the extremities, evaluation of these new therapies can be very informative, as tissue acquisition at multiple treatment time points is easy owing to the superficial and multifocal nature of the disease. Through studying the biomolecular and genetic alterations in tumor tissue in response to these new therapies, genetically customized treatment regimens in which tumor resistance and sensitivity is predicted and treatment strategy is optimized before treatment begins may soon be available. Progress in regional therapy will prove not only beneficial for patients with disease confined to an extremity, but may also provide insight into developing novel treatment strategies for patients with systemic disease for whom current disease management options are poor.
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Affiliation(s)
- Andrew Coleman
- Duke University School of Medicine, Durham, NC 27710, USA.
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Beasley GM, Ross MI, Tyler DS. Future directions in regional treatment strategies for melanoma and sarcoma. Int J Hyperthermia 2009; 24:301-9. [DOI: 10.1080/02656730701827573] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Padussis JC, Steerman SN, Tyler DS, Mosca PJ. Pharmacokinetics & drug resistance of melphalan in regional chemotherapy: ILP versus ILI. Int J Hyperthermia 2008; 24:239-49. [PMID: 18393002 DOI: 10.1080/02656730701816410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Two forms of regional chemotherapy for the treatment of advanced melanoma or sarcoma of the extremity are isolated limb perfusion (ILP) and the more recently described isolated limb infusion (ILI). Melphalan is the most commonly employed agent in both ILP and ILI, although it is often used in conjunction with other cytotoxic and/or biologic therapies. While ILP and ILI are far more effective for the treatment of extremity disease than is systemic therapy, there is still significant room for improvement in outcomes, from the standpoint of both response rate and toxicity. An understanding of the pharmacokinetics of regional chemotherapy would allow for the prediction of tumor response and toxicity and therefore patient outcomes. In addition, elucidating the mechanisms of drug resistance would lead to opportunities to develop effective chemo-modulators that enhance the effectiveness of ILP and ILI. This paper reviews progress in these two key areas of active investigation.
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Affiliation(s)
- James C Padussis
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Sanki A, Kam PCA, Thompson JF. Long-term results of hyperthermic, isolated limb perfusion for melanoma: a reflection of tumor biology. Ann Surg 2007; 245:591-6. [PMID: 17414608 PMCID: PMC1877051 DOI: 10.1097/01.sla.0000251746.02764.fc] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the long-term duration of limb tumor complete remission (CR) and patient survival following therapeutic hyperthermic isolated limb perfusion (ILP) with cytotoxic drugs for melanoma. METHODS A retrospective case series of 124 ILPs performed in 111 patients. RESULTS There were 120 assessable ILPs. Patient staging (M.D. Anderson system) was stage II 11.7%, stage IIIA 44.2%, stage IIIAB 33.3%, and stage IV 10.8%. CR was initially attained after 83 ILPs (69.2%) and partial remission (PR) after 19 ILPs (15.8%). Limb CR was maintained in 28 (33.7%) of the 83 cases. Disease recurred in the perfused limb after an initial CR in the remaining 55 cases (median time to recurrence, 11 months); in 19 of these cases, the limb was disease-free at last follow-up after further locoregional treatment. A long-term CR was achieved, with or without further treatment, in 47 (56.6%) of the 83 cases in which an initial CR had occurred (mean follow-up, 97 months; median, 65 months). There was no significant difference in long-term local remission for stage IIIA and IIIAB patients. Five-year survival for those who had a partial or no response to ILP was 7%. Ten-year survival for those who had a long-term CR was 49%. CONCLUSIONS ILP, with or without further locoregional treatment, achieved long-term control of recurrent and metastatic limb disease in 56.6% of cases in which an initial CR was achieved. A complete response to ILP was a positive prognostic indicator for survival, probably reflecting more favorable tumor biology in this subset of patients.
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Affiliation(s)
- Amira Sanki
- Sydney Melanoma Unit, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Grünhagen DJ, de Wilt JHW, van Geel AN, Eggermont AMM. Isolated limb perfusion for melanoma patients—a review of its indications and the role of tumour necrosis factor-α. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2006; 32:371-80. [PMID: 16520016 DOI: 10.1016/j.ejso.2006.01.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 01/27/2006] [Indexed: 11/17/2022]
Abstract
AIMS The treatment of melanoma in-transit metastases (IT-mets) can vary widely and is dependant on the size and the number of the lesions. When multiple, large lesions exist, isolated limb perfusion (ILP) has established itself as an attractive treatment option with high response rates. METHODS Review on the various methods of treatment of melanoma in-transit metastases, with a focus on isolated limb perfusion. A Medline based literature search was performed for articles relating to this topic. Additional original papers were obtained from citations in those identified by the initial search. Indications and results are discussed and the extra value of tumour necrosis factor (TNF) is evaluated. RESULTS ILP with Melphalan results in complete response rates of 40-82% and showed to be 54% in a large retrospective meta-analysis. The addition of TNF can improve these completes response rates (59-85%) and although no data from randomized controlled trials are available, it seems of particular value in large, bulky lesions or in patients with recurrent disease after previous ILP. CONCLUSIONS TNF-based ILP has earned a permanent place in the treatment of patients with melanoma IT-mets. In patients with a high tumour burden, TNF-based ILP is the most efficacious procedure to obtain local control and achieve limb salvage.
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Affiliation(s)
- D J Grünhagen
- Department of Surgical Oncology, Erasmus University MC-Daniel den Hoed Cancer Center, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands
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Calvo E, Arcas R, Brugarolas A, Crespo A, Ten-Hagen T, Eggermont A. Perfusión de extremidad aislada en sarcomas de partes blandas irresecables: un nuevo estándar. Rev Esp Cir Ortop Traumatol (Engl Ed) 2004. [DOI: 10.1016/s1888-4415(04)76168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Noorda EM, Vrouenraets BC, Nieweg OE, Klaase JM, van der Zee J, Kroon BBR. Long-term results of a double perfusion schedule using high dose hyperthermia and melphalan sequentially in extensive melanoma of the lower limb. Melanoma Res 2003; 13:395-9. [PMID: 12883366 DOI: 10.1097/00008390-200308000-00009] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to assess the results of an isolated limb perfusion (ILP) schedule with high dose hyperthermia (42-43 degrees C) and melphalan, applied sequentially in patients with advanced melanoma of the limbs. Seventeen patients with extensive recurrent or bulky melanoma of a limb were treated with hyperthermic femoral ILP (42-43 degrees C) without drugs followed by normothermic (37-38 degrees C) ILP with melphalan. Eleven patients (65%) had a complete response. Three patients (27%) had limb recurrences after 5, 6 and 18 months, respectively. The 5 year limb recurrence-free interval for patients with a complete response was 63%. Limb toxicity was mild; pressure-related blistering and transient sensory disturbances occurred after the hyperthermic ILP, and 88% of the patients had a grade II reaction (mild erythema and oedema) after the second ILP. This sequential ILP schedule resulted in a high complete response rate and a low limb-recurrence rate in patients with extensive, recurrent melanoma of the limbs at the cost of only mild toxicity. This regimen could be an alternative to ILP with tumour necrosis factor-alpha and melphalan.
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Affiliation(s)
- Eva M Noorda
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Abstract
Isolated limb perfusion with melphalan is the treatment of choice for multiple (small) melanoma-in-transit metastases. The use of tumour necrosis factor alpha (TNFalpha) in isolated limb perfusion is successful for treatment of locally advanced limb soft-tissue sarcomas and other large tumours; this approach can avoid the need for amputation. TNFalpha was approved in Europe after a multicentre trial in patients with locally advanced soft-tissue sarcomas, deemed unresectable by an independent review committee; the response rate to isolated limb perfusion with TNFalpha plus melphalan was 76% and the limb was saved in 71% of patients. Moreover, the trial showed the efficacy of isolated limb perfusion of TNFalpha and melphalan against various other limb-threatening tumours such as skin cancers and drug-resistant bony sarcomas. Laboratory models of isolated limb perfusion have helped to elucidate mechanisms of action and to develop new treatment modalities. They have identified TNFalpha-mediated vasculotoxic effects on the tumour vasculature and have shown that addition of TNFalpha to the perfusate results in an increase of three to six times in uptake of melphalan or doxorubicin by tumours. New vasoactive drugs and new mechanisms of action are being discovered. Moreover, isolated limb perfusion is an effective modality for gene therapy mediated by an adenoviral vector. Various clinical phase I-II studies can be expected in the next few years.
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Eggermont AMM, van Geel AN, de Wilt JHW, ten Hagen TLM. The role of isolated limb perfusion for melanoma confined to the extremities. Surg Clin North Am 2003; 83:371-84, ix. [PMID: 12744614 DOI: 10.1016/s0039-6109(02)00095-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Isolated limb perfusion with Melphalan is the best treatment option to control symptomatic multiple small in-transit metastases. When lesions are bulky, Isolated Limb Perfusion (ILP) with Tumor Necrosis Factor (TNF) + Melphalan is superior as in soft tissue sarcoma. TNF changes the pathophysiology, greatly enhances the uptake of Melphalan and destructs selectively the vasculature of large tumors. To date, ILP is not indicated in an adjuvant setting.
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Affiliation(s)
- Alexander M M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center, Rotterdam-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Abstract
Melanoma is a significant health problem. Despite public education and free cancer screenings, the incidence and mortality of melanoma continues to rise; however, many currently diagnosed melanomas are thin lesions, suggesting that education and awareness is having an impact. In addition, there are still subsets of patients who need increased surveillance in order to increase their survival. Although large congenital nevi may be precursors of melanoma, small and medium congenital nevi have an insignificant risk for melanoma development. Large congenital nevi, which are axial in location, appear to be more likely to develop melanoma and are associated with melanocytosis and melanoma of the CNS, both of which portend a poor prognosis. Recently, the recommended margins of excision have become more conservative so that many of the surgical defects can be closed primarily. Lymphoscintigraphy and sentinel node biopsy have replaced elective node dissections, thus decreasing the morbidity associated with the surgical management of melanoma. Although controversy still exists as to whether or not sentinel lymph node biopsy alters a patient's prognosis, it has been shown to be a powerful prognostic indicator. Although most melanomas are managed by routine surgical excision, other modalities are sometimes employed. For example, cryosurgery or radiation therapy may be indicated in the frail, elderly individual with a large facial lentigo maligna. Mohs surgery is the treatment of choice for head and neck melanomas and those located in areas where maximum preservation of tissue is required and for desmoplastic and acral lentiginous melanomas. Much more work remains in the area of adjuvant therapy, chemotherapy, and immunotherapy. Dacarbazine remains the drug of choice in disseminated melanoma, but remissions are usually short lived. Interleukin and biochemotherapy has yielded good results but the percentage benefiting is small. Although high dose interferon increases disease-free and overall survival in some patients, it remains a controversial drug which is not easily tolerated. In the new staging system for melanoma, ulceration is second only to Breslow's thickness. In transit (satellite) lesions have also been included in this new system. The new system also recognizes that patients with only microscopic metastatic nodal disease fare better than patients with clinically enlarged metastatic nodes and that it is the number of nodes involved with metastases, not their size, that determines the patient's prognosis. Except for lesions <1mm thick, the Clark's level of invasion has been de-emphasized.
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Affiliation(s)
- Pearon G Lang
- Medical University of South Carolina, Charleston, South Carolina 29925, USA
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Zogakis TG, Bartlett DL, Libutti SK, Liewehr DJ, Steinberg SM, Fraker DL, Alexander HR. Factors affecting survival after complete response to isolated limb perfusion in patients with in-transit melanoma. Ann Surg Oncol 2001; 8:771-8. [PMID: 11776490 DOI: 10.1007/s10434-001-0771-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) results in complete response (CR) rates of 60% to 90% in patients with regionally advanced melanoma. Survival after a CR may be influenced by various factors, particularly out-of-field disease in iliac lymph nodes (ILN) identified during lower-extremity ILP. We examined clinical and pathological parameters, including ILN status and outcome, for patients with in-transit melanoma who had a CR to ILP. METHODS From May 1992 to July 1997, 50 patients (16 men and 34 women; median age, 57 years) with stage IIIA or IIIAB melanoma had a CR to a 90-minute hyperthermic iliac ILP with melphalan (10 mg/L limb volume, n = 20) or melphalan and tumor necrosis factor (4-6 mg+/-200 microg interferon; n = 30). Clinical and pathological parameters were analyzed by univariate and Cox proportional hazards models to determine which were associated with survival or in-field recurrence. RESULTS The median in-field recurrence-free survival in the cohort of 50 patients after a CR to ILP was 1.4 years, and the actuarial 5-year in-field recurrence-free survival was 30%. By univariate analysis, there was a trend for improved outcome with female sex and stage IIIA (vs. IIIAB) at initial diagnosis was associated with improved survival after a CR to ILP (P = .056 and .012, respectively). Eleven (22%) of 50 patients had positive ILNs identified and resected at ILP. The probability of overall in-field recurrence was 70% after 4 years, and there was no difference between those with or without positive ILNs; median time to in-field recurrence was 13 and 19 months, respectively (P = .62). Similarly, overall survival was not influenced by positive ILN status (median [months]: +ILN, 69 vs. -ILN, 58; P = .68). Of note, Cox models identified that the risk of death was significantly greater in those with a history of prior systemic therapy (hazard ratio: 2.67 [95% confidence interval, 1.17-6.11]; P = .02) and those with an in-transit lesion size > or =1.4 cm2 (hazard ratio, 3.12 [95% confidence interval, 1.30-7.5]; P = .011). When these two variables were combined, there was a highly significant association with shortened survival (P = .002 by log-rank test). CONCLUSIONS These data indicate that for patients undergoing ILP and in whom positive ILNs are found and resected, ILP is justified. In addition, patients who have a CR after ILP and have a history of prior treatment or larger lesions should be considered for adjuvant systemic therapy.
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Affiliation(s)
- T G Zogakis
- Surgery Branch and the Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland 20892, USA
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Eggermont AM, ten Hagen TL. Isolated limb perfusion for extremity soft-tissue sarcomas, in-transit metastases, and other unresectable tumors: credits, debits, and future perspectives. Curr Oncol Rep 2001; 3:359-67. [PMID: 11389822 DOI: 10.1007/s11912-001-0090-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Isolated limb perfusion (ILP) with melphalan is effective against melanoma in-transit metastases but has failed in the treatment of limb-threatening extremity sarcomas. Tumor necrosis factor-alpha (TNF) has changed this situation completely. Now, ILP with TNF + melphalan is a very successful treatment to prevent amputation. In a multicenter European trial, ILP with TNF + melphalan resulted in a 76% response rate and a 71% limb salvage rate in patients with limb-threatening soft-tissue sarcomas, deemed unresectable by independent review committees, leading to approval of TNF in Europe. We have also reported on the success of this regimen against bulky melanomas, multifocal skin cancers, and drug-resistant bony sarcomas. High-dose TNF destructs tumor vasculature, and, most importantly, it enhances tumor-selective drug uptake (ie, melphalan and doxorubicin) by threefold to sixfold. Similar synergy is observed in well-vascularized liver metastases after isolated hepatic perfusion with TNF and melphalan. New (vasoactive) drugs and mechanisms of action and interaction with chemotherapy are in development. ILP is also a promising treatment modality for adenoviral vector-mediated gene therapy. Many clinical phase I/II evaluations in ILP are now underway.
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Affiliation(s)
- A M Eggermont
- Department of Surgical Oncology, University Hospital Rotterdam, Daniel den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA Rotterdam, The Netherlands. E-mail:
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Tominaga R, Nakano T, Shibata S, Siraishi K, Nagae S, Nakayama J, Yasui H. Systemic effects of hyperthermic isolated lower limb perfusion with carboplatin and interferon-beta. Artif Organs 2001; 25:36-41. [PMID: 11167557 DOI: 10.1046/j.1525-1594.2001.025001036.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The changes in systemic circulation during hyperthermic isolated lower limb perfusion with carboplatin and interferon-beta were investigated in 19 patients with malignant melanoma. The cardiac output (CO) increased significantly (p < 0.01) from 3.81 +/- 0.22 L/min before the procedure to 5.30 +/- 0.49 L/min 1 h after hyperthermic perfusion. The double product (mean arterial pressure x heart rate) also increased significantly (p < 0.01) from 5,145 +/- 372 mm Hg/min to 6,760 +/- 486 mm Hg/min. In some patients, it increased to more than twice the control value. These changes were accompanied by an increase in body temperature, presumably caused by the systemic leakage of both warmed blood and interferon-beta. Blood chemistry data demonstrated no significant changes in the liver or renal function. However, the serum CPK level increased markedly on the first postoperative day, and persisted for 1 week, thus suggesting that some muscle damage occurred during the procedure. There was no operative death or severe complications. From these data, we concluded that hyperthermic isolated limb perfusion with interferon-beta is a relatively safe therapeutic method for malignant melanoma of the extremities. However, care should be taken in patients with ischemic heart disease who may suffer a heart attack due to the rapid increase in cardiac work during the procedure.
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Affiliation(s)
- R Tominaga
- Department of Cardiovascular Surgery , Kyushu University Faculty of Medicine, Fukuoka, Japan
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Abstract
BACKGROUND Local recurrence of melanoma is associated with a grave prognosis. However, the characteristics and the mode of disease progression for patients with local recurrence have not been adequately addressed in the literature. METHODS A retrospective analysis of patients treated at a single institution revealed a subset of patients (n = 648) with local recurrence of melanoma as a first event. Patient characteristics, histologic determinants, and disease free interval were variables used to identify prognostic factors. RESULTS In this group of patients, male gender (P = 0. 0163), increasing age (P = 0.0001), head and neck primaries (P = 0. 0001), thicker Breslow depths (P = 0.0022), deeper Clark levels (P = 0.0010), and ulceration of the primary tumor (P = 0.0348) suggested a shorter time until local recurrence. Breslow depth (P = 0.0004), Clark level (P = 0.0043), and ulceration (P = 0.0001) still factored into the survival prognosis after recurrence. Truncal primaries (P = 0.0005) and shorter disease free intervals (P = 0.0098) were also associated with poorer outcomes after recurrence. Of the 648 patients, 124 showed no progression, 196 developed another local recurrence, 178 developed in-transit/lymph node metastases, and 150 had systemic recurrences. Survival was only 33.6% for patients with further metastases, compared with 77.4% for patients with no progression of disease after a median follow-up of 38.9 months. CONCLUSIONS There was a 48.5% mortality rate at 5 years of follow-up after local recurrence. Long term survival (> 10 years) was estimated to be 34.9%. The patterns of failure after local recurrence suggest that patients may benefit from aggressive locoregional therapy.
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Affiliation(s)
- X D Dong
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Vrouenraets BC, Hart GA, Eggermont AM, Klaase JM, van Geel BN, Nieweg OE, Kroon BB. Relation between limb toxicity and treatment outcomes after isolated limb perfusion for recurrent melanoma. J Am Coll Surg 1999; 188:522-30. [PMID: 10235581 DOI: 10.1016/s1072-7515(99)00018-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The optimal toxic reaction of the normal tissues in perfused limbs after isolated limb perfusion (ILP) is unknown. Theoretically, more severe limb toxicity could reflect a concomitant increased toxic effect to the tumor and improved outcomes. We determined whether there is a relation between limb toxicity and treatment outcomes after ILP for recurrent limb melanoma. STUDY DESIGN Among 252 patients with recurrent melanoma of the limbs, treatment outcomes in 192 patients (76%) with no or mild acute limb toxicity were compared with those in 60 (24%) with more severe reactions. Multivariate analysis was used to identify prognostic factors for complete response, limb recurrence-free interval, and survival. RESULTS Among 112 patients with measurable disease, 65 patients (58%) had a complete response and 27 (42%) experienced a relapse in the perfused limb. For complete response, uninvolved regional lymph nodes (p = 0.0025) and ILP using tumor necrosis factor-alpha (p = 0.0076) appeared to be favorable prognostic factors in multivariate analysis. There was no evidence of a relation between limb toxicity and complete response either in univariate (p = 0.16) or multivariate analysis (p = 0.46). For limb recurrent-free interval, only the number of lesions was a significant prognostic factor (p = 0.047); limb toxicity was not (p = 0.095). In 140 patients with recurrent melanoma excised before or at the moment of ILP, independent prognostic factors for survival were gender, the number of positive nodes, and stage of disease. There was no relation between limb toxicity and survival in either univariate (p = 0.53) or multivariate analysis (p = 0.94). Forty-eight (34%) of the 140 patients had a relapse in the perfused limb. No prognostic factors for limb recurrent-free interval could be identified; limb toxicity was not related to relapse time in univariate or multivariate analyses (p = 0.16 and p = 0.14, respectively). CONCLUSIONS More severe acute limb toxicity is not associated with improved outcomes. One should aim at grade II toxicity (slight erythema or edema, compatible with complete recovery) at the most to increase the therapeutic ratio of ILP.
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Affiliation(s)
- B C Vrouenraets
- Department of Surgery, The Netherlands Cancer Institute (Antoni van Leeuwenhoek Ziekenhuis), Amsterdam
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Abstract
Cutaneous melanoma represents the main cause of death among skin cancers. Early diagnosis gives, for the time being, the only possibility for high rate of curative treatment. Diagnosis is based on pathological findings, and at primary tumor stage. Breslow thickness of the lesion is the best prognostic index. At local stage of the disease, treatment is precisely codified by international recommendations and consensus conferences. Follow-up after surgical treatment is also well codified. Treatment of lymph node invasion or metastatic disease is, on the other hand, less codified. Despite recent advances, especially in immunotherapy, treatment of advanced stages of melanoma remains difficult.
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Affiliation(s)
- L Thomas
- Unité de dermatologie, Hôtel-Dieu, université Claude-Bernard-Lyon, France
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Würl P, Eichfeld U, Pauer HD, Gläser A, Rose U, Dralle H. Technique and results of regional hyperthermic cytostatic arm perfusion for malignant melanoma. Surg Today 1997; 27:719-25. [PMID: 9306586 DOI: 10.1007/bf02384984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Isolated hyperthermic cytostatic limb perfusion has been established as an efficient procedure for the treatment of malignant melanoma of the limbs. However, perfusions of the upper extremities are generally carried out much less frequently than would be expected given the distribution pattern of malignant melanoma and sarcoma. Thus, isolated descriptions of treatment results for perfusion of the upper extremities are not available. Between 1991 and 1994, arm perfusions using melphalan 1.0 mg/kg body weight were given to 14 patients with malignant melanoma, using the standardized method of perfusion described herein. Within an average observation period of 34.9 months (range, 12-65 months), 11 (78.7%) of the 14 patients who had M.D. Anderson stage II-IV melanoma remained free of local recurrence. In fact, 10 (71.6%) of the patients were still alive at the end of the observation period. None of the 14 patients showed any systemic adverse effects, although 1 patient developed a lymphedema 32 months after perfusion and 2 patients showed a postoperative temporary neurologic deficit. These results demonstrate that isolated perfusion of the upper limb with heat and melphalan under standardized conditions remains the treatment of choice for melanoma of the arm, as for melanoma of the leg, without a higher rate of complications.
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Affiliation(s)
- P Würl
- Department of General Surgery, Martin-Luther-University Halle, Germany
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Karakousis CP, Kontzoglou K, Driscoll DL. Tourniquet infusion chemotherapy for extremity in-transit lesions in malignant melanoma. Ann Surg Oncol 1997; 4:506-10. [PMID: 9309342 DOI: 10.1007/bf02303677] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Perfusion remains the standard of regional chemotherapy for extremity in-transit lesions from melanoma. However, there is an interest in other forms of intraarterial chemotherapy due to the simplicity and feasibility of repeat administration of the latter. METHODS Review of 51 patients with extremity in-transit lesions from melanoma treated with the tourniquet infusion (TI) method on the basis of a prospective protocol. Drugs used were either Adriamycin (group A) or Dacarbazine (DTIC) + cisDDP (group B). The median number of courses was two. Lesions were resected at the same time as TI (n = 27) or after a month or more of observation in the absence of complete regression. RESULTS There was no significant difference in response rates between groups A and B. The overall objective response rate in 24 evaluable patients was 75%, being complete in seven (29%), partial (> 50%) in 11 (46%), minor (< 50%) in three (12.5%), and progression of disease in three (12.5%). At a mean follow-up time of 40 months, no recurrence was observed in the treated extremity in 18 patients (35%), but further recurrences were noted in 31 patients (61%). The 5-year survival rate was 30%. CONCLUSION TI provides an objective response rate of 75% for in-transit lesions, but after TI and resection of in-transit lesions as needed, the recurrence rate in the treated extremity is high (61%). Further work is needed with higher drug doses, local hyperthermia, or the administration of suitable doses of new regimens that are more successful with perfusion.
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Affiliation(s)
- C P Karakousis
- State University of New York, Millard Fillmore Hospital, Buffalo 14209, USA
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Taber SW, Polk HC. Mortality, major amputation rates, and leukopenia after isolated limb perfusion with phenylalanine mustard for the treatment of melanoma. Ann Surg Oncol 1997; 4:440-5. [PMID: 9259973 DOI: 10.1007/bf02305559] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a treatment for cutaneous melanoma performed by several centers worldwide. The final data analysis of the World Health Organization and European Organization for Research and Treatment of Cancer in the use of ILP as adjuvant treatment for cutaneous melanoma is pending. ILP is effective to treat recurrent cutaneous melanoma. We determined the published rates of morbidity and mortality of ILP and put that component of the procedure into contemporary perspective. METHODS A MEDLINE search was conducted of the English-language literature from 1980 to 1995 for all publications reporting perfusion with phenylalanine mustard alone or combined with other agents. Patients treated by staged perfusion or fractional doses of chemotherapy were excluded. All published series were analyzed for the rate of mortality, number of major amputations, and presence of leukopenia. RESULTS The 30-day mortality rate for > 2,000 patients was 0.6%. Death often resulted from cardiopulmonary complications or overwhelming sepsis from leukopenia. Leukopenia occurred in 0.7% of patients reviewed, caused by leakage of chemotherapeutic agents into the systemic circulation. Major amputations occurred in 0.8% of patients, and most were of the lower extremity. CONCLUSIONS The definition of efficacy of ILP in the treatment of extremity melanomas remains to be clearly defined. However, based on this review of worldwide publications, the risk of death, amputation, and leukopenia is low.
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Affiliation(s)
- S W Taber
- Department of Surgery, University of Louisville School of Medicine, Kentucky 40292, USA
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Vrouenraets BC, Nieweg OE, Kroon BB. Thirty-five years of isolated limb perfusion for melanoma: indications and results. Br J Surg 1996; 83:1319-28. [PMID: 8944445 DOI: 10.1002/bjs.1800831004] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Isolated limb perfusion (ILP) for limb melanoma remains controversial despite its frequent use for over 35 years. To determine whether it has proven benefits, reported results have been reviewed. The value of adjuvant ILP cannot be determined from the multitude of retrospective studies on this subject. Preliminary results of the large European Organization for Research and Treatment of Cancer-World Health Organization-North American Perfusion Group trial suggest that patients with melanomas of 1.5-3.0 mm in thickness who do not undergo elective lymph node dissection may have a locoregional control benefit from ILP. However, as long as a definite survival advantage for ILP has not been demonstrated, such treatment does not seem justified for these patients. The value of prophylactic ILP after resection of recurrent limb melanoma is also scientifically unproven. The potential prevention of further limb recurrence for only a limited period of time, as demonstrated in a rather small Swedish trial, probably does not justify routine use of ILP in these patients; a large international trial will be needed to assess whether ILP provides a survival advantage. For those with locally inoperable limb melanoma, ILP appears to be the treatment of choice since it results in complete disappearance of all macroscopic disease in a substantial proportion of patients, removing the need for amputation and providing palliation of symptoms. However, high limb recurrence rates and short duration of response need improvement. Results of alternative treatments should be compared prospectively with those of ILP in this clinical situation.
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Affiliation(s)
- B C Vrouenraets
- Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
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