Management of in-transit melanoma of the extremity with isolated limb perfusion

A prospective feasibility trial exploring novel biomarkers for neurotoxicity after isolated limb perfusion

BACKGROUND

Isolated limb perfusion (ILP) is a regional cancer treatment in which high-dose chemotherapy is administered in an isolated extremity. The main side effect is regional toxicity, which occasionally leads to nerve damage. Measuring neuroaxonal biomarkers, might be a method predicting such complications. Therefore, the primary aim of the study is to investigate if neuronal biomarkers are measurable and alters in an isolated extremity during ILP. Secondly, if postoperative regional toxicity, alterations in sensitivity, and/or muscle strength are correlated to the biomarker levels.

METHODS

Eighteen scheduled ILP-patients were included in the study. Glial fibrillary acidic protein (GFAP), neurofilament light (NfL), and tau concentrations were measured in plasma sampled preoperatively, at the start and end of the ILP, on days 3 and 30, using ultrasensitive Single molecule array (Simoa) technology. The patients were assessed by a physiotherapist pre- and postoperatively.

RESULTS

At ILP end, significantly higher NfL and tau levels were measured in the extremity than in the corresponding systemic circulation (NfL; 17 vs 6 ng/L, p < .01, tau; 1.8 vs 0.6 ng/L, p < .01), and the extremity levels were significantly increased at ILP end (NfL; 66 ± 37%, p < .001, tau; 75 ± 45%, p = .001). On days 3 and 30, significantly increased NfL and GFAP levels were measured systemically (NfL day 3: 69 ± 30%, p < .001; day 30: 76 ± 26%, p < .001; GFAP day 3: 33 ± 22%, p < .002; day 30: 33 ± 23%, p ≤ .004). Finally, no significant correlations were found between regional toxicity or between postoperative muscle or sensitivity decrease and biomarker release.

CONCLUSION

During ILP, NfL and tau levels increased significantly. No obvious correlations were observed between biomarker release and regional toxicity or decreased muscle strength or sensitivity, although large-scale studies are warranted.

Non-invasive and invasive measurement of skeletal muscular oxygenation during isolated limb perfusion

BACKGROUND

Isolated limb perfusion (ILP) is a regional surgical treatment for localized metastatic disease. High doses of chemotherapeutic agents are administered within an extracorporeal circulated isolated extremity, treating the metastasis, while systemic toxicity is avoided. To our knowledge, indexed oxygen supply/demand relationship during ILP has not previously been described. Our aim was to measure and describe oxygen metabolism, specifically oxygen delivery, consumption, and extraction, in an isolated leg/arm during ILP. Also investigate whether invasive oxygenation measurement during ILP correlates and can be used interchangeable with the non-invasive method, near infrared spectroscopy (NIRS).

METHODS

Data from 40 patients scheduled for ILP were included. At six time points blood samples were drawn during the procedure. DO2, VO2, and O2ER were calculated according to standard formulas. NIRS and hemodynamics were recorded every 10 min.

RESULTS

For all observations, the mean of DO2 was 190±59 ml/min/m2, VO2 was 35±8 ml/min/m2, and O2ER was 21±8%. VO2 was significantly higher in legs compared to arms (38±8 vs. 29±7 ml/min/m2, p=0.02). Repeated measures showed a significant decrease in DO2 in legs (209±65 to 180±66 ml/min/m2, p=<0.01) and in arms (252±72 to 150±57 ml/min/m2, p=<0.01). Significant increase in O2ER in arms was also found (p=0.03). Significant correlation was detected between NIRS and venous extremity oxygen saturation (SveO2) (rrm=0.568, p=<. 001, 95% CI 0.397-0.701). When comparing SveO2 and NIRS using a Bland-Altman analysis, the mean difference (bias) was 8.26±13.03 (p=<. 001) and the limit of agreement was - 17.28-33.09, with an error of 32.5%.

CONCLUSION

DO2 above 170 ml/min/m2 during ILP kept O2ER below 30% for all observations. NIRS correlates significant to SveO2; however, the two methods do not agree sufficiently to work interchangeable. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT04460053 and NCT03073304.

Development of a leakage monitoring system in isolated limb perfusion with portable gamma camera

Isolated limb perfusion (ILP) is a method for treating unresectable lesions of limbs in patients with melanoma or sarcoma by using high doses of tumor necrosis factor alpha and melphalan. These high doses can result in high systemic toxicity if there is a drug leak from the isolated circulation of the limb to the systemic. This makes it imperative to monitor the leakage rate (F[%]) during the infusion, currently performed with radiotracers. The objective of this work was to develop a leakage monitoring protocol as accurate as possible to ensure safe ILP.

MATERIAL AND METHOD

We built a phantom with 3compartments (body, limb and precordial area) and a high sensitivity collimator fitted to a portable gammacamera. We simulate ILP with scheduled leaks every 10minutes from 1% to 9% (theorical F[%]). We mesured F(%) using 2equation: one is the proposed in the literature and another corrected by decay of the radioisotope. We test the optimal radiopharmaceutical doses to minimize the detector dead time error and compare F(%) mesured by both equations regarding the theoretical F(%). The leakage monitoring protocol was used in 17 ILP of 16 patients and an analysis of the recorded data was performed.

RESULTS

We found significant differences between F(%) mesured using the first equation and theoretical F(%), obtaining results very adjusted to the theorical after applying the decay correction.

CONCLUSIONS

The decay correction of the radioisotope is a simple manner to carry out the procedure more safely, reducing the error in the calculation of F(%).

Evaluation of Intra-Lesional Interleukin 2 for the Treatment of In-Transit Melanoma Disease: L'évaluation de l'interleukine-2 intralésionnelle pour traiter les mélanomes en transit

Background

Intra-lesional interleukin 2 (IL-2) therapy trials for the treatment of in-transit melanoma using different treatment protocols have been published reporting varied results. This study assesses the results of IL-2 therapy in our institution and to evaluate the reproducibility of our response rates when using the same treatment protocol as another Canadian centre.

Methods

A retrospective review was undertaken of patients with in-transit melanoma who were treated with intralesional IL-2 in a single institution from 2010 to 2016. Responses were evaluated using RECIST criteria. Demographic data, tumour characteristics, follow-up data, in-transit-free interval, and survival data were collected and analysed.

Results

Forty-nine patients were identified. Overall tumour response rate was 72%, including complete response in 23 patients (47%) and partial response in 12 patients (24%). Stable disease was observed in 4% of patients and progressive disease in 25%. The main side effects were minor discomfort with injections and auto-limited flu-like symptoms. The presence of tumour-infiltrating lymphocytes may be a predictor of better response.

Conclusion

This study confirms prior experience with intra-lesional IL-2, demonstrating it to be an effective, safe, and well-tolerated therapy for in-transit melanoma. Tumour-infiltrating lymphocytes as a predictor of better response warrant further study.

Management of Locoregionally Advanced Melanoma

Melanoma has a unique propensity for locoregional metastasis secondary to intralymphatic transit not seen in other cutaneous or soft tissue malignancies. Novel intralesional therapies using oncolytic immunotherapy exhibit increasing response rates with observed bystander effect. Intralesional modalities in combination with systemic immunotherapy are the subject of ongoing clinical trials. Regional therapy is used in isolated limb locoregional metastasis whereby chemotherapy is delivered to an isolated limb avoiding systemic side effects. Multimodal treatment strategy is imperative in the treatment of locoregionally advanced melanoma. One must be versed on these quickly evolving therapeutic options.

Locoregional therapies in melanoma

In-transit disease is defined as any dermal or subcutaneous metastases that arise between the primary melanoma but not beyond the draining regional nodal basin. Patients who develop in-transit disease are at further risk to develop additional locoregional and distant disease. Treatment must be individualized and take into consideration the extent of disease, tumor characteristics, and patient characteristics including age, comorbidities, previous therapies, and site of recurrence. Surgery, regional perfusions and intralesional injections all play a role in management options. These patients should be discussed and managed by a multidisciplinary team whenever possible.

Intra-lesional interleukin-2 for the treatment of in-transit melanoma

PURPOSE

To investigate the role of intra-lesional interleukin-2 (IL-2) injection for treatment of in-transit melanoma metastases.

METHODS

Consecutive patients with in-transit metastases were treated with intra-lesional IL-2 injections. Two independent observers evaluated response to treatment using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria. A blinded pathologist confirmed clinical response with post-treatment biopsies.

RESULTS

Thirty-nine patients were included. Patients received biweekly IL-2 injections. At each treatment session, a mean of 2.08 ml (5 µ/ml) of IL-2 were distributed amongst a mean of 12 (range 1-57) in-transit lesions. Patients were followed for an average of 30.4 months (range 2.2-66.6 months). The overall patient response rate was 82%. A complete response was obtained in 20 patients (51%), a partial response in 12 (31%), and no response in seven (18%). Of the 629 in-transit metastases, 479 (76%) completely resolved. Complete responders had a significant in transit-free (P = 0.0005) and an overall (P = 0.012) survival advantage compared with partial responders.

CONCLUSIONS

The treatment of in-transit metastatic melanoma with intra-lesional IL-2 resulted in a 76% percent clearance of lesions. Complete response is associated with superior in transit-free and overall survival when compared with partial response.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

Treatment of cutaneous melanoma: current approaches and future prospects

Melanoma is the most aggressive and deadly type of skin cancer. Surgical resection with or without lymph node sampling is the standard of care for primary cutaneous melanoma. Adjuvant therapy decisions may be informed by careful consideration of prognostic factors. High-dose adjuvant interferon alpha-2b increases disease-free survival and may modestly improve overall survival. Less toxic alternatives for adjuvant therapy are currently under study. External beam radiation therapy is an option for nodal beds where the risk of local recurrence is very high. In-transit melanoma metastases may be treated locally with surgery, immunotherapy, radiation, or heated limb perfusion. For metastatic melanoma, the options include chemotherapy or immunotherapy; targeted anti-BRAF and anti-KIT therapy is under active investigation. Standard chemotherapy yields objective tumor responses in approximately 10%-20% of patients, and sustained remissions are uncommon. Immunotherapy with high-dose interleukin-2 yields objective tumor responses in a minority of patients; however, some of these responses may be durable. Identification of activating mutations of BRAF, NRAS, c-KIT, and GNAQ in distinct clinical subtypes of melanoma suggest that these are molecularly distinct. Emerging data from clinical trials suggest that substantial improvements in the standard of care for melanoma may be possible.

TIMP-1-GPI in combination with hyperthermic treatment of melanoma increases sensitivity to FAS-mediated apoptosis

Resistance to apoptosis is a prominent feature of malignant melanoma. Hyperthermic therapy can be an effective adjuvant treatment for some tumors including melanoma. We developed a fusion protein based on the tissue inhibitor of matrix metalloproteinase-1 linked to a glycosylphosphatidylinositol anchor (TIMP-1-GPI). The TIMP-1-GPI-fusion protein shows unique properties. Exogenous administration of TIMP-1-GPI can result in transient morphological changes to treated cells including modulation of proliferation and decreased resistance to apoptosis. The effect of TIMP-1-GPI on the biology of melanoma in the context of a defined hyperthermic dose was evaluated in vitro. Clonogenic assays were used to measure cell survival. Gelatinase zymography determined secretion of MMP-2 and MMP-9. Monoclonal antibody against FAS/CD95 was applied to induce apoptosis. The expression of pro- and anti-apoptotic proteins and the secretion of immunoregulatory cytokines were then evaluated using Western blot and ELISA. TIMP-1-GPI combined with a sub-lethal hyperthermic treatment (41.8 degrees C for 2 h) suppressed tumor cell growth capacity as measured by clonogenic assay. The co-treatment also significantly suppressed tumor cell proliferation, enhanced FAS receptor surface expression increased tumor cell susceptibility to FAS-mediated killing. The increased sensitivity to FAS-induced apoptosis was linked to alterations in the apoptotic mediators Bcl-2, Bax, Bcl-XL and Apaf-1. The agent works in concert with sub-lethal hyperthermic treatment to render melanoma cells sensitive to FAS killing. The targeted delivery of TIMP-1-GPI to tumor environments in the context of regional hyperthermic therapy could be optimized through the use of thermosensitive liposomes.

Molecular mechanisms of apoptosis activation by heat shock in multidrug-resistant Chinese hamster cells

Multidrug resistance (MDR) is a major obstacle to the success of chemotherapy in cancer treatment and is associated with overexpression of P-glycoprotein. MDR cells, aside from resistance to chemotherapy, might also inhibit apoptosis at various levels in the death signaling pathways. Currently, hyperthermia is used in cancer treatment to sensitize tumor cells to radiation and/or chemotherapy. This study investigated the induction of death receptor and mitochondria-mediated signaling pathways of apoptosis by hyperthermia (41-43 degrees C) in MDR CHRC5 cells compared to drug-sensitive AuxB1 Chinese hamster ovary cells. In the receptor-mediated pathway, CHRC5 cells exhibited higher levels of c-FLIP and lower caspase 8 and caspase 10 activation in response to hyperthermia. In the mitochondria-mediated pathway of heat-induced apoptosis, CHRC5 cells showed higher mitochondrial levels of Bax and tBid, more pronounced mitochondrial membrane depolarization, and increased Apaf-1. Similar levels of caspase 3 activation and cleavage of caspase substrates occurred, showing that overall, CHRC5 cells are not resistant to hyperthermia-induced apoptosis compared to AuxB1 cells. This study reveals for the first time the molecular mechanisms of hyperthermia-induced apoptosis in MDR cells overexpressing P-glycoprotein. CHRC5 and AuxB1 cells showed similar clonogenic survival responses to heat, which implies that hyperthermia could be a promising strategy for eradicating MDR tumor cells in the clinic.

Treatment Options for Limited or Symptomatic Metastatic Melanoma

Background

Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis.

Methods

The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma.

Results

A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival.

Conclusions

A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.

Therapy for Unresectable Recurrent and In-Transit Extremity Melanoma

Background

Unresectable recurrent and in-transit extremity melanoma presents a dilemma for the treating physician. While the disease is confined to the involved limb, the survival mimics that of multiple nodal metastases, with a 10-year survival rate of approximately 40%. This represents late-stage disease for which curative treatment options are limited.

Methods

To review the current treatment strategies for stage IIIB (N2c) in-transit and recurrent melanoma focusing on the options for unresectable disease, MEDLINE was searched for studies of known and experimental treatments for in-transit and recurrent extremity melanoma. Further results were obtained after review of the initial citations.

Results

For unresectable recurrences and in-transit metastases, therapies are limited to palliative (radiation), local (intratumoral injection, laser ablation and electroporation), regional (isolated limb perfusion/infusion), and systemic (chemotherapy) when local or regional techniques are not feasible.

Conclusions

In this patient population, intratumoral techniques have a limited role with current treatment regimens, but with the development of new drugs, these techniques may have more utility. If not contraindicated, regional techniques provide the greatest control and have minimal operative morbidity. Until new regimens are available, systemic therapy continues to be associated with considerable toxicity and only marginal response rates.

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Cytoreductive Surgery for Melanoma

Cytoreductive surgery represents a therapeutic attempt to improve patient outcomes by reducing overall tumor burden to render postsurgical therapy effective or at least increase its effectiveness. The intent of cytoreduction differs from palliative or curative-intent surgery for oligometastatic melanoma. Both palliative surgery and attempted curative resection have important roles to play in the management of patients with melanoma that has spread beyond the regional nodes or recurred "in transit" between the primary and the regional nodal basin. To date, however, no evidence shows that cytoreductive surgery offers any meaningful benefit to patients with metastatic melanoma, and, outside of a clinical trial, there is no role for cytoreductive surgery in melanoma. To date, adjuvant vaccine therapy after complete resection of metastatic melanoma has not proved to be efficacious in clinical trials, so there is little reason to believe that the use of currently available immunotherapy strategies will be enhanced after incomplete tumor resections.

Surgical Therapy of Cutaneous Melanoma

For most solid tumors therapy has evolved from surgery alone to a multidisciplinary approach. Malignant melanoma remains an exception, with surgery maintaining the principal role not only for treatment of the primary lesion but also staging and the management of advanced disease. The surgical management of melanoma has evolved over the years, resulting in a substantial decrease in the morbidity associated with treatment without a compromise in outcome. This article will review the changes that have occurred leading to the current surgical approach to melanoma, the evidence behind these recommendations, and new questions that need to be addressed.

FDG PET/CT Demonstrates the Effectiveness of Isolated Limb Infusion for Malignant Melanoma

A 43-year-old woman presented with a nodular melanoma treated with wide excision, split skin graft, and sentinel node biopsy. At 2-year follow up, she was noted to have clinical recurrence at the excision site. FDG PET/CT demonstrated in-transit metastasis in her left thigh in addition to disease at the site of the sentinel node biopsy. Isolated limb infusion was performed with melphalan and dactinomycin. PET/CT at 5 weeks demonstrated resolution of the in-transit metastasis and the disease at the excision site. This report of PET/CT demonstrates the effectiveness of chemotherapy for malignant melanoma delivered by isolated limb infusion.

Chirurgie des sarcomes des tissus mous des membres chez l'adulte : historique et avancées thérapeutiques

In the seventies, limb-sparing surgery and radiation therapy appeared capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremities. No survival benefit could be demonstrated in the patients selected for amputation. Microscopically positive surgical margins are related to a greater risk of local recurrence, whereas overall survival is compromised by high grade and large tumor size. Presurgery multidisciplinary discussion, management in reference center and management within cancer network independently predict conformity to the clinical practice guidelines. Reoperation should be a planned part of definitive management whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. Soft tissue flap reconstruction facilitates therapy for patients with locally advanced tumors so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Vascular reconstruction is a feasible option in case of involvement of major vessels. Isolated limb perfusion (ILP) with TNF and chemotherapy is an efficient limb-sparing neoadjuvant therapy for locally advanced limb soft tissue sarcomas. Efficacy and safety of low-dose TNFalpha could greatly facilitate ILP procedures in the near future.

Melanoma

The surgical management of melanoma continues to evolve. A large body of information serves as a foundation for the oncologic principles, surgical excisions, and reconstructive methodologies that are currently in use. This article serves as a guide for the physician considering surgical management of the melanoma patient.