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Knackstedt R, Smile T, Yu J, Gastman BR. Non-Operative Options for Loco-regional Melanoma. Clin Plast Surg 2021; 48:631-642. [PMID: 34503723 DOI: 10.1016/j.cps.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant melanoma is the 5th most common cancer and stage IV melanoma accounts for approximately 4% of new melanoma diagnoses in the United States. The prognosis for regionally advanced disease is poor, but there have been numerous recent advances in the medical management of melanoma in-transit metastases. The goal of this paper is to review currently accepted treatment options for in-transit metastases and introduce emerging therapies. Therapies to be discussed include limb perfusion and infusion, immunotherapy, checkpoint inhibitors, and radiation therapy.
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Affiliation(s)
- Rebecca Knackstedt
- Department of Plastic Surgery, Cleveland Clinic, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA
| | - Timothy Smile
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Jennifer Yu
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Center, 10201 Carnegie Avenue, Cleveland, OH 44195, USA
| | - Brian R Gastman
- Department of Plastic Surgery, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 2049 East 100th Street, Desk A60, Cleveland, OH 44195, USA.
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2
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Teras J, Carr MJ, Zager JS, Kroon HM. Molecular Aspects of the Isolated Limb Infusion Procedure. Biomedicines 2021; 9:biomedicines9020163. [PMID: 33562337 PMCID: PMC7915579 DOI: 10.3390/biomedicines9020163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 01/19/2023] Open
Abstract
For decades, isolated limb infusion (ILI) and hyperthermic isolated limb perfusion (HILP) have been used to treat melanoma in-transit metastases and unresectable sarcoma confined to the limb utilizing the effect of loco-regional high-dose chemotherapy to the isolated limb. Both procedures are able to provide high response rates in patients with numerous or bulky lesions in whom other loco-regional treatments are becoming ineffective. In comparison to systemic therapies, on the other hand, ILI and HILP have the advantage of not being associated with systemic side-effects. Although in principle ILI and HILP are similar procedures, ILI is technically simpler to perform and differs from HILP in that it takes advantage of the hypoxic and acidotic environment that develops in the isolated limb, potentiating anti-tumour activity of the cytotoxic agents melphalan +/− actinomycin-D. Due to its simplicity, ILI can be used in both preclinical and clinical studies to test new cytotoxic regimens and combinations with the aim to overcome tumour resistance. In the future, administration of cytotoxic agents by ILI, in combination with systemic treatments such as BRAF/MEK/KIT inhibitors, immunotherapy (CTLA-4 blockade), and/or programmed death (PD-1) pathway inhibitors, has the potential to improve responses further by inducing increased tumour cell death while limiting the ability of the tumour to suppress the immune response.
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Affiliation(s)
- Jüri Teras
- Department of Surgical Oncology, North Estonia Medical Centre Foundation, 13419 Tallinn, Estonia;
- Tallinn University of Technology, 12616 Tallinn, Estonia
| | - Michael J. Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| | - Hidde M. Kroon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
- Correspondence: ; Tel.: +61-8-7074-2163
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Hu J, Masoud SJ, Ravichandran S, Beasley GM, Mosca PJ. Retreatment with talimogene laherparepvec for advanced melanoma. Immunotherapy 2020; 12:1167-1172. [PMID: 32840157 DOI: 10.2217/imt-2020-0029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Talimogene laherparepvec (T-VEC) is a genetically modified oncolytic herpesvirus approved for the treatment of unresectable, locoregionally advanced and recurrent melanoma. There is little relevant literature in the context of retreatment with T-VEC. Materials & methods: We reviewed four patients aged 71-87 years old with stage IIIB-IV melanoma at treatment who were rechallenged with T-VEC after experiencing recurrence of locoregional disease or prior treatment-limiting toxicity. Results: Cessation of initial treatment was due to one of the following reasons: severe adverse event (one case), mixed response (one case) or complete response (two cases). Three males and one female underwent T-VEC retreatment with a mean of 5.5 injection cycles. Three patients experienced a complete response to retreatment, while one experienced disease progression. Conclusion: Intralesional T-VEC may be effective and well-tolerated in patients who have completed prior T-VEC therapy.
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Affiliation(s)
- Janice Hu
- School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Sabran J Masoud
- School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Surya Ravichandran
- School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - Georgia M Beasley
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Paul J Mosca
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Wright FC, Kellett S, Hong NJL, Sun AY, Hanna TP, Nessim C, Giacomantonio CA, Temple-Oberle CF, Song X, Petrella TM. Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline. Curr Oncol 2020; 27:e318-e325. [PMID: 32669939 PMCID: PMC7339852 DOI: 10.3747/co.27.6523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Objective The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma. Methods The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review. Recommendations "Minimal itm" is defined as lesions in a location with limited spread (generally 1-4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. "Moderate itm" is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. "Maximal itm" is defined as large-volume disease with multiple (>15-20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.■ In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered.■ In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette- Guérin or CO2 laser ablation outside of a research setting.■ In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference.■ In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.
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Affiliation(s)
- F C Wright
- Department of General Surgery, Sunnybrook Health Sciences Centre/Odette Regional Cancer Centre, Toronto, ON
| | - S Kellett
- Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), and Department of Oncology, McMaster University, Hamilton, ON
| | - N J Look Hong
- Department of General Surgery, Division of Surgical Oncology, Sunnybrook Health Sciences Centre, and Department of Surgery, University of Toronto, Toronto, ON
| | - A Y Sun
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, Toronto, ON
| | - T P Hanna
- Department of Oncology, Division of Radiation Oncology, Queen's University, Kingston, ON
| | - C Nessim
- Division of General Surgery, The Ottawa Hospital, and Department of Surgery, University of Ottawa, Ottawa, ON
| | - C A Giacomantonio
- Queen Elizabeth II Health Sciences Centre, Capital District Health, and Departments of Surgery and Pathology, Dalhousie University, Halifax, NS
| | - C F Temple-Oberle
- Departments of Oncology and Surgery, University of Calgary, Calgary, AB
| | - X Song
- Department of Internal Medicine, Division of Medical Oncology, University of Ottawa, and The Ottawa Hospital Cancer Centre, Ottawa, ON
| | - T M Petrella
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, and University of Toronto, Toronto, ON
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Broman KK, Zager JS. Intra-arterial perfusion-based therapies for regionally metastatic cutaneous and uveal melanoma. Melanoma Manag 2019; 6:MMT26. [PMID: 31807277 PMCID: PMC6891941 DOI: 10.2217/mmt-2019-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Locoregional disease remains a challenging problem in cutaneous melanoma and uveal melanoma. Arterial-based chemoperfusion strategies enable regional therapy delivery with minimal systemic toxicity. Herein we discuss intra-arterial therapies for in-transit cutaneous melanoma of the extremity including hyperthermic-isolated limb perfusion and isolated limb infusion. We also discuss open (isolated hepatic perfusion) and percutaneous hepatic perfusion techniques for isolated liver metastases from uveal melanoma. We review the current state of knowledge with respect to indications, procedural techniques, outcomes and expected toxicities for intra-arterial chemoperfusion for locoregional melanoma metastases.
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Affiliation(s)
- Kristy K Broman
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Abstract
In-transit melanoma is an uncommon pattern of recurrence, but presents unique management challenges and opportunities for treatment. The clinical presentation usually involves from 1 to more than 100 small subcutaneous or cutaneous nodules, ranging from submillimeter to multiple centimeters in diameter. Regional chemotherapy techniques are a mainstay of treatment of patients without systemic disease spread. Future applications of regional therapy are likely to involve combination therapy with cytotoxic agents and novel immune modulators. Regional therapy provides distinct opportunities for the treatment of unresectable disease, and offers a unique platform for investigation of novel therapeutics in early-stage clinical trials.
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Affiliation(s)
- Paul J Speicher
- Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Claire H Meriwether
- Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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Testori A, Intelisano A, Verrecchia F, Menicanti C, Tosti G, Grassi E, Pari C, Pennacchioli E. Alternatives for the treatment of local advanced disease: electrochemotherapy, limb perfusion, limb infusion, intralesional IL2. What is the role? Dermatol Ther 2012; 25:443-51. [DOI: 10.1111/j.1529-8019.2012.01486.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alessandro Testori
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
| | - Antonio Intelisano
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
| | | | - Claudia Menicanti
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
| | - Giulio Tosti
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
| | - Elisa Grassi
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
| | - Chiara Pari
- Melanoma and Sarcoma Surgery; European Institute of Oncology; Milan; Italy
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Chai CY, Deneve JL, Beasley GM, Marzban SS, Chen YA, Rawal B, Grobmyer SR, Hochwald SN, Tyler DS, Zager JS. A multi-institutional experience of repeat regional chemotherapy for recurrent melanoma of extremities. Ann Surg Oncol 2011; 19:1637-43. [PMID: 22143576 DOI: 10.1245/s10434-011-2151-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hyperthermic isolated limb perfusion (HILP) or isolated limb infusion (ILI) are well-accepted regional chemotherapy techniques for in-transit melanoma of extremity. The role and efficacy of repeat regional chemotherapy for recurrence and which salvage procedure is better remains debatable. We aimed to compare toxicities and clinical outcomes by procedure types and the sequence. METHODS Data from 44 patients, who underwent repeat HILPs or ILIs from 3 institutions beginning 1997 to 2010, were retrospectively reviewed. Regional toxicity assessed by Wieberdink grade, systemic toxicity assessed by serum creatine phosphokinase level, length of hospital stay (LOS), response rates at 3 months after the procedure, and time to in-field progression (TTP) were analyzed. RESULTS Of 44 patients, 46% were men and 54% women with a median age of 66 (range 29-85) years at diagnosis. The median follow-up was 21.4 (range 4-153) months. Of 70 ILIs and 28 HILPs, the following groups were identified: group A, ILI → ILI (n = 25); group B, ILI → HILP (n = 10); group C, HILP → ILI (n = 12); and group D, HILP → HILP (n = 3). The comparison of Wieberdink grade, serum creatine phosphokinase level, LOS, and response rate between procedures (HILP vs. ILI), between sequence (initial vs. repeat), and among their interactions showed no statistically significant differences. TTP after initial procedure did not differ between HILP and ILI (P = 0.08), and no survival difference was seen (P = 0.65) when TTP after repeat procedure was compared. CONCLUSIONS Most patients tolerated repeat regional chemotherapy without increased toxicity or LOS. No statistical difference in clinical outcomes was noted when comparing repeat procedures, even though repeat HILPs showed higher complete response compared to repeat ILIs.
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Affiliation(s)
- Christy Y Chai
- Department of Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
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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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10
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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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11
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Huismans AM, Kroon HM, Kam PCA, Thompson JF. Does Increased Experience with Isolated Limb Infusion for Advanced Limb Melanoma Influence Outcome? A Comparison of Two Treatment Periods at a Single Institution. Ann Surg Oncol 2011; 18:1877-83. [DOI: 10.1245/s10434-011-1646-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Indexed: 11/18/2022]
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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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Abstract
Isolated limb perfusion is the preferred treatment option for locally advanced melanoma and sarcoma confined to a limb. This treatment results in high response rates with a satisfying duration of response in both tumours. A drawback of isolated limb perfusion, however, is the invasive and complex character of the procedure.Isolated limb infusion has been designed as a minimally invasive alternative to isolated limb perfusion. Treatment results of this simple technique, reported by various centres worldwide, show comparable response rates for melanoma and sarcoma. Therefore isolated limb infusion may replace isolated limb perfusion in the future as the preferred treatment option for these locally advanced limb tumours.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Melanoma Institute Australia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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Kroon HM, Lin DY, Kam PCA, Thompson JF. Efficacy of repeat isolated limb infusion with melphalan and actinomycin D for recurrent melanoma. Cancer 2009; 115:1932-40. [PMID: 19288571 DOI: 10.1002/cncr.24220] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND : Isolated limb infusion (ILI) is an effective and minimally invasive treatment option for delivering regional chemotherapy in patients with metastatic melanoma confined to a limb. Recurrent or progressive disease after an ILI, however, presents a challenge for further treatment. The value of repeat ILI in this situation has not been well documented. METHODS : Forty-eight patients were identified who had been treated with a repeat ILI. In all patients, a cytotoxic combination of melphalan and actinomycin D was used. RESULTS : The median time between the 2 procedures was 11 months. The complete response (CR) rate after repeat ILI was 23%, compared with 31% after the initial ILI (P = .36). The overall response was 83%, compared with 75% after the first procedure (P = .32). The median duration of response was 11 months (10 months for patients with CR; P = .80), and median survival was 38 months. In those patients achieving a CR, the median survival was 68 months (P = .003). Toxicity after repeat ILI was increased, with 20 patients experiencing Wieberdink grade III limb toxicity (considerable erythema and edema with blistering) and 5 patients experiencing grade IV toxicity (threatened or actual compartment syndrome), whereas after the initial ILI these toxicity grades occurred in 14 patients and 1 patient, respectively (P = .03). No patient experienced grade V toxicity (requiring amputation). CONCLUSIONS : Repeat ILI is an attractive treatment option to achieve limb salvage in patients with inoperable recurrent or progressive melanoma after a previous ILI. It can be associated with significant short-term regional toxicity, but is well tolerated by most patients, with satisfactory response rates. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Sydney Cancer Center, Royal Prince Alfred Hospital, Sydney, Australia
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15
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Safety and Efficacy of Isolated Limb Infusion With Cytotoxic Drugs in Elderly Patients With Advanced Locoregional Melanoma. Ann Surg 2009; 249:1008-13. [DOI: 10.1097/sla.0b013e3181a77ce5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kroon HM, Lin DY, Kam PCA, Thompson JF. Major amputation for irresectable extremity melanoma after failure of isolated limb infusion. Ann Surg Oncol 2009; 16:1543-7. [PMID: 19352777 DOI: 10.1245/s10434-009-0394-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 01/31/2009] [Accepted: 01/31/2009] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Isolated limb infusion (ILI) is an effective, minimally invasive treatment option that delivers high-dose regional chemotherapy to treat metastatic melanoma confined to a limb. In some patients, however, locoregional disease does not respond to the treatment or extensive recurrence occurs so that an amputation may become inevitable. In this study we analyzed indications for and results of amputation in these cases. METHODS 14 patients were identified in whom amputation of the affected limb had to be carried out after failure of ILI. RESULTS Following ILI, three patients had a complete response, seven had a partial response, two had stable disease and two patients had progressive disease. The median duration of response after ILI was 7 months (range 2-30). The median interval between ILI and amputation was 10 months. Amputation was performed in six of 20 patients who had been treated with an upper limb ILI, compared to eight amputations that were performed in 215 patients who had been treated with a lower limb ILI (P = .001). The indications for amputation were severe pain due to progression of tumor (n = 3), uncontrollable and troublesome tumor progression (n = 6) and bleeding from ulcerated lesions (n = 5). Five patients developed stump recurrence after amputation; these were treated by excision or radiation. Six of the eight patients who had a lower limb amputation became ambulant with the aid of prosthesis. Median survival after amputation was 13 months: three patients survived more than 5 years. CONCLUSIONS Amputation following upper extremity ILI is more common compared to lower extremity ILI. Amputation may provide effective long-term palliation in selected patients when there is extensive inoperable progressive or recurrent disease after ILI.
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Affiliation(s)
- Hidde M Kroon
- Sydney Cancer Centre, Royal Prince Alfred Hospital, NSW, Australia.
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Kroon HM, Moncrieff M, Kam PCA, Thompson JF. Factors Predictive of Acute Regional Toxicity After Isolated Limb Infusion with Melphalan and Actinomycin D in Melanoma Patients. Ann Surg Oncol 2009; 16:1184-92. [DOI: 10.1245/s10434-009-0323-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 12/02/2008] [Accepted: 12/03/2008] [Indexed: 11/18/2022]
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Kroon HM, Lin DY, Kam PCA, Thompson JF. Isolated Limb Infusion as Palliative Treatment for Advanced Limb Disease in Patients with AJCC Stage IV Melanoma. Ann Surg Oncol 2009; 16:1193-201. [DOI: 10.1245/s10434-009-0326-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 11/18/2022]
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McMahon N, Cheng TY, Beasley GM, Spasojevic I, Petros W, Augustine CK, Zipfel P, Padussis JC, Sanders G, Tyler DS. Optimizing melphalan pharmacokinetics in regional melanoma therapy: does correcting for ideal body weight alter regional response or toxicity? Ann Surg Oncol 2009; 16:953-61. [PMID: 19184236 DOI: 10.1245/s10434-008-0288-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 12/01/2008] [Accepted: 12/02/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aims to determine what effect correcting melphalan dosing for ideal body weight (IBW) has on toxicity and response in isolated limb infusion (ILI) in patients with advanced extremity melanoma. METHODS This was an open observational study examining whether correcting the melphalan dose for IBW will influence response and toxicity in patients undergoing ILI for advanced extremity melanoma in 41 patients undergoing 42 procedures (13 without correction for IBW; and 29 with correction for IBW). Melphalan pharmacokinetics, limb toxicity, serologic toxicity, and response at 3 months were compared. RESULTS The corrected group had a lower estimated limb volume (V (esti)) to melphalan volume at steady state (V (ss)) (P < .0001) ratio as well as lower incidence of grade > or =3 regional toxicity, serologic toxicity, and compartment syndrome (P = .0249, P = .027, P = .02). There was a positive correlation of V (esti)/V (ss) to toxicity (P = .0127, r = .382). No significant difference in response (P = .3609) between the groups was found, although there was a trend of association between V (esti)/V (ss) and response (P = .051, r = .3383). CONCLUSIONS Correcting for IBW in ILI lowers toxicity without significantly altering response rates.
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Affiliation(s)
- N McMahon
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Kam PC, Thompson JF. Pharmacokinetics of Regional Therapy: Isolated Limb Infusion and Other Low Flow Techniques for Extremity Melanoma. Surg Oncol Clin N Am 2008; 17:795-804, ix. [DOI: 10.1016/j.soc.2008.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Mcloughlin JM, Zager JS, Sondak VK, Berk LB. Treatment Options for Limited or Symptomatic Metastatic Melanoma. Cancer Control 2008; 15:239-47. [DOI: 10.1177/107327480801500307] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Vernon K. Sondak
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Immunology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Lawrence B. Berk
- Radiation Oncology Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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22
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Möller MG, Lewis JM, Dessureault S, Zager JS. Toxicities associated with hyperthermic isolated limb perfusion and isolated limb infusion in the treatment of melanoma and sarcoma. Int J Hyperthermia 2008; 24:275-89. [PMID: 18393005 DOI: 10.1080/02656730701805520] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) may play a significant role in the treatment of patients with recurrent or in transit extremity melanoma or sarcoma that is unresectable. These procedures may be indicated when patients are otherwise faced with the possibility of a debilitating amputation. Not entirely benign treatment modalities, HILP and ILI can be associated with regional and systemic toxicities. We conducted a literature search of published studies using HILP and ILI for the treatment of extremity sarcomas and melanomas, and associated toxicities was performed. The regional toxicities of HILP and ILI are similar. The most common toxicities reported are mild to moderate. However, when severe regional toxicity occurs, albeit infrequently (<5%), fasciotomies or even amputation may be necessary. Some studies have showed a relationship between acute regional toxicities and long term regional morbidity. Systemic toxicity appears to be more frequent when TNF-alpha is used in combination with other drugs during HILP, however the use of TNF-alpha in the United States is limited to trials. Although regional toxicities are similar, systemic toxicity of ILI is minimal compared to HILP. ILI is easier to repeat, technically less complex, and may be more acceptable in infirmed patients. Long term morbidity and outcomes for ILI are still being evaluated. Both of these techniques may be suitable options in patients with unresectable advanced or recurrent, or in transit extremity melanoma or sarcoma.
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Affiliation(s)
- Mecker G Möller
- H Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa. FL 33612, USA
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23
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Gimbel MI, Delman KA, Zager JS. Therapy for Unresectable Recurrent and In-Transit Extremity Melanoma. Cancer Control 2008; 15:225-32. [DOI: 10.1177/107327480801500305] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mark I. Gimbel
- Surgical Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Keith A. Delman
- Department of Surgery at Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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24
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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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25
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Abstract
The biological behavior of melanoma is unpredictable. Three to five per cent of melanoma patients will develop in-transit lesions and the median time to recurrence ranges between 13-16 months. At the time of recurrence the risk of occult nodal metastasis, with clinically negative regional lymph nodes, is as high as 50%. The risk of in-transit lesions depends on the tumor biology and not on the surgical approach to the regional lymph nodes. The high incidence of in-transit lesions at the lower limb may be caused by the gravity and delayed lymphatic drainage. The treatment of limited disease is local excision, laser ablation, cryosurgery, while multiple in-transit lesions or bulky disease located in a limb can be successfully treated with regional chemotherapy, a therapeutic isolated limb perfusion or infusion with melphalan or a combination of melphalan and tumor necrosis factor (TNF) alpha. If local regional treatment or systemic dacarbazine based systemic treatment fails, novel systemic treatment strategies with vaccines, antibodies and gene therapy are currently investigated.
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Affiliation(s)
- H J Hoekstra
- Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
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26
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Kroon HM, Moncrieff M, Kam PCA, Thompson JF. Outcomes following isolated limb infusion for melanoma. A 14-year experience. Ann Surg Oncol 2008; 15:3003-13. [PMID: 18509706 DOI: 10.1245/s10434-008-9954-6] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 03/25/2008] [Accepted: 04/16/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique for delivering regional chemotherapy in patients with advanced and metastatic melanoma confined to a limb. It is essentially a low-flow isolated limb perfusion (ILP) performed via percutaneous catheters without oxygenation. METHODS From our prospective database 185 patients with advanced metastatic melanoma of the limb treated with a single ILI between 1993 and 2007 were identified. In all patients a cytotoxic drug combination of melphalan and actinomycin-D was used. Drug circulation time was 20-30 min under mild hyperthermic conditions (38-39 degrees C). RESULTS The majority of patients (62%) were female. Their average age was 74 years (range 29-93 years). Most patients had MD Anderson stage III disease (134/185). The overall response rate was 84% [complete response (CR) rate 38%, partial response rate 46%]. Median response duration was 13 months (22 months for patients with CR; P = 0.01). Median follow-up was 20 months and median survival was 38 months. In those patients with a CR, the median survival was 53 months (P = 0.005). CR rate and survival time decreased with increasing stage of disease. On multivariate analysis significant factors for a favorable outcome were achievement of CR, stage of disease, thickness of primary melanoma, the CO(2 )level in the isolated circuit, and a Wieberdink limb toxicity score of III (considerable erythema and edema). CONCLUSION The response rates and duration of response after ILI are comparable to those achieved by conventional ILP. ILI is a minimally invasive alternative to the much more complex and morbid conventional ILP technique for patients with advanced metastatic melanoma confined to a limb.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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27
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Thompson JF, Kam PCA. Current status of isolated limb infusion with mild hyperthermia for melanoma. Int J Hyperthermia 2008; 24:219-25. [DOI: 10.1080/02656730701827565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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28
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Abstract
Isolated limb infusion involves administrating cytotoxic drugs in a patient with malignant melanoma confined to one limb, and which is not surgically resectable. It provides palliation in cases where cutaneous disease is extensive.
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Affiliation(s)
- Z Al-Hilli
- Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Ireland
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29
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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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30
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Thompson JF, Kam PCA. Isolated limb infusion for melanoma: A simple but effective alternative to isolated limb perfusion. J Surg Oncol 2004; 88:1-3. [PMID: 15384062 DOI: 10.1002/jso.20112] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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