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Boby A, Dugan MM, Ghali H, Aflatooni S, DePalo DK, Fan W, Zager JS. Isolated Limb Infusion as First, Second, or Third or Later-Line Therapy for Metastatic In-Transit Melanoma. Cancer Control 2024; 31:10732748241297326. [PMID: 39500581 PMCID: PMC11539175 DOI: 10.1177/10732748241297326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 09/27/2024] [Accepted: 10/14/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND Ten percent of patients with melanoma develop in-transit metastases (ITM). Isolated limb infusion (ILI) is a well-established therapy for unresectable ITM on the extremities, but the ideal sequencing/line of therapy of ILI has not been defined. This study evaluates ILI as first-line, second-line, or third or later-line therapy. METHODS A retrospective review included all patients with unresectable ITM who underwent ILI from 2006-2023. RESULTS A total of 130 patients were identified, 61% female, median age of 71 (31-89) years. Median follow-up was 37.5 months. ILI was first-line therapy in 80% (n = 104), second-line in 15% (n = 19), and third or later-line in 5.4% (n = 7). Overall response rate (ORR) and complete response (CR) rates for ILI as any line of therapy were 74% and 41%, respectively. ORR for ILI as first, second, or third or later-line therapy were 78%, 63%, and 57%, respectively. CR rates for ILI as first, second, or third or later-line therapy were 42%, 37%, and 43%, respectively. There were no significant differences in ORR, progression-free survival (PFS), overall survival, or disease-free survival between therapy lines. Median PFS for ILI as first, second, or third or later-line therapy were 6.9, 5.4, and 18 months, respectively. CONCLUSION Patients responded well to ILI, whether or not they received previous therapies for unresectable ITM. First-line ILI appears to have a better ORR than later lines of ILI. Although sample size limited statistical significance, there was a 21% improvement in ORR when ILI was used as first-line vs third-line therapy, which is clinically meaningful. ILI is effective for unresectable melanoma ITM and can be used as salvage therapy.
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Affiliation(s)
- Aleena Boby
- University of South Florida Tampa, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michelle M. Dugan
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Helana Ghali
- University of South Florida Tampa, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Shaliz Aflatooni
- University of South Florida Tampa, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Danielle K. DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of General Surgery, University of Massachusetts Chan Medical School, Boston, MA, USA
| | - Wenyi Fan
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature. Cancers (Basel) 2021; 13:cancers13215485. [PMID: 34771649 PMCID: PMC8583108 DOI: 10.3390/cancers13215485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. METHODS PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000-2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. RESULTS Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. DISCUSSION ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. CONCLUSIONS ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies.
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Carr MJ, Sun J, Zager JS. Isolated limb infusion: Institutional protocol and implementation. J Surg Oncol 2020; 122:99-105. [PMID: 32162353 DOI: 10.1002/jso.25886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/25/2020] [Indexed: 01/20/2023]
Abstract
Patients with unresectable cutaneous and soft tissue malignancies confined to a limb have many treatment options. Isolated limb infusion (ILI) is one therapeutic option whereby the extremity is isolated and perfused with high-dose chemotherapy through a percutaneously placed catheter-based procedure. A detailed description of the ILI protocol at the Moffitt Cancer Center is given. We have shown that ILI is a safe and effective treatment strategy for malignancies confined to an extremity.
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Affiliation(s)
- Michael J Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - James Sun
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida
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Beasley GM, Zager JS, Thompson JF. The Landmark Series: Regional Therapy of Recurrent Cutaneous Melanoma. Ann Surg Oncol 2020; 27:35-42. [PMID: 31471842 DOI: 10.1245/s10434-019-07760-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Indexed: 01/20/2023]
Abstract
In-transit melanoma represents a distinct disease pattern in which melanoma recurs as dermal or subcutaneous nodules between the primary melanoma site and the draining regional lymph node basin. The disease pattern is often not amenable to complete surgical resection. Since the 1950s, regional therapies have been explored for the treatment of this disease entity, with the goal of maximizing delivery of the therapeutic agent to the tumor while minimizing systemic toxicity. We reviewed landmark studies describing and evaluating regional chemotherapy and intralesional therapies for patients with in-transit melanoma metastases.
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Affiliation(s)
- Georgia M Beasley
- Department of Surgery, Duke University, Durham, NC, USA.
- Duke University Medical Center, Durham, NC, USA.
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Surgery, University of South Florida Morsani School of Medicine, Tampa, FL, USA
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia
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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: 0.7] [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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Read T, Lonne M, Sparks DS, David M, Wagels M, Schaider H, Soyer HP, Smithers BM. A systematic review and meta‐analysis of locoregional treatments for in‐transit melanoma. J Surg Oncol 2019; 119:887-896. [DOI: 10.1002/jso.25400] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/13/2019] [Accepted: 01/19/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Tavis Read
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
- Griffith University, School of MedicineGold Coast Queensland Australia
| | - Michael Lonne
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - David S. Sparks
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - Michael David
- The University of Queensland, School of Health and Rehabilitation SciencesBrisbane Queensland Australia
- The University of Newcastle, School of Medicine and Public HealthNewcastle New South Wales Australia
| | - Michael Wagels
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
| | - Helmut Schaider
- The University of Queensland, Dermatology Research CentreBrisbane Queensland Australia
| | - H. Peter Soyer
- The University of Queensland, Dermatology Research CentreBrisbane Queensland Australia
| | - B. Mark Smithers
- Queensland Melanoma Project, Princess Alexandra HospitalBrisbane Queensland Australia
- The University of Queensland, Faculty of Medicine, Princess Alexandra HospitalBrisbane Queensland Australia
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Smith H, Wilkinson M, Smith M, Strauss D, Hayes A. The effect of age on outcomes after isolated limb perfusion for advanced extremity malignancies. Eur J Cancer 2018; 100:46-54. [DOI: 10.1016/j.ejca.2018.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022]
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Neuwirth MG, Song Y, Sinnamon AJ, Fraker DL, Zager JS, Karakousis GC. Isolated Limb Perfusion and Infusion for Extremity Soft Tissue Sarcoma: A Contemporary Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3803-3810. [PMID: 29022281 DOI: 10.1245/s10434-017-6109-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) and isolated limb infusion (ILI) have been variably used in recent years for the treatment of locally advanced or marginally resectable extremity soft tissue sarcomas (STSs). We performed a systematic review and meta-analysis of contemporary studies to further characterize treatment patterns and outcomes. METHODS PubMed was queried for articles published in or after the year 2000, in the English language, with > 10 patients, and with adequate outcome data following ILP/ILI. Descriptive aggregate statistics were performed. RESULTS Nineteen studies that met the inclusion criteria were identified, with a total of 1288 patients. Weighted mean patient age was 55.9 years and 52% were male. The majority underwent ILP (88%) versus 12% for ILI, and chemotherapeutic regimens used were as follows: (1) melphalan with tumor necrosis factor (TNF)-α (78%), (2) melphalan ± actinomycin (10%), and (3) other regimens (12%). Most common histologies treated were malignant fibrous histiocytoma (21%), liposarcoma (16%), synovial (11%) and leiomyosarcoma (7%). Aggregate overall response rate (ORR) post-procedure was 73.3%, with 25.8% demonstrating a complete response (CR). Similar unadjusted ORRs were noted in the melphalan treatment groups with and without TNFα (72.0 and 67.0%, respectively; p = 0.27). Grade III toxicity was observed in 15.4% of patients, and grade IV/V toxicity was observed in 6.0% of patients. Overall limb salvage rate was 73.8% and median time to local (in-field) progression ranged from 4 to 28 months (weighted median 22.1 months). CONCLUSION ILP and ILI for extremity STS can be safely performed with appreciable response rates and significant limb salvage rates. Further study is needed to identify optimal treatment regimens by histology.
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Affiliation(s)
- Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Madu MF, Deken MM, van der Hage JA, Jóźwiak K, Wouters MWJM, van Akkooi ACJ. Isolated Limb Perfusion for Melanoma is Safe and Effective in Elderly Patients. Ann Surg Oncol 2017; 24:1997-2005. [DOI: 10.1245/s10434-017-5803-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 11/18/2022]
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10
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Testori A, Ribero S, Bataille V. Diagnosis and treatment of in-transit melanoma metastases. Eur J Surg Oncol 2016; 43:544-560. [PMID: 27923593 DOI: 10.1016/j.ejso.2016.10.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023] Open
Abstract
In transit metastases (ITM) from extremity or trunk melanomas are subcutaneous or cutaneous lymphatic deposits of melanoma cells, distant from the primary site but not reaching the draining nodal basin. Superficial ITM metastases develop in 5-10% of melanoma patients and are thought to be caused by cells spreading along lymphatics; ITM appear biologically different from distant cutaneous metastases, these probably due to a haematogenous dissemination. The diagnosis is usually clinical and by patients, but patients need to be adequately educated in the recognition of this clinical situation. Ultrasound or more sophisticated instrumental devices may be required if the disease develops more deeply in the soft tissues. According to AJCC 2009 staging classification, ITM are included in stages IIIb and IIIc, which are considered local advanced disease with quite poor 5-year survival rates and outcomes of 24-54% at 5 years.2 Loco-regional recurrence is in fact an important risk factor for distant metastatic disease, either synchronous or metachronous. Therapy for this pattern of recurrence is less standardised then in most other clinical situations and options vary based on the volume and site of the disease. Definitive surgical resection remains the preferred therapeutic approach. However, when surgery cannot be performed with a reasonable cosmetic and functional outcome, other options must be utilized.3-6 Treatment options are classified as local, regional or systemic. The choice of therapy depends on the number of lesions, their anatomic location, whether or not these are dermal or subcutaneous, the size and the presence or absence of extra-regional disease.
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Affiliation(s)
- A Testori
- Divisione di Chirurgia Dermatoncologica, Istituto Europeo di Oncologia, Milano, Italy.
| | - S Ribero
- Dermatologia, Dipartimentto di Scienze mediche, Università di Torino, Italy
| | - V Bataille
- West Herts NHS Trust, London, UK; Mount Vernon Cancer Centre, Northwood, UK
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Grünhagen DJ, Kroon HM, Verhoef C. Perfusion and infusion for melanoma in-transit metastases in the era of effective systemic therapy. Am Soc Clin Oncol Educ Book 2016:e528-34. [PMID: 25993219 DOI: 10.14694/edbook_am.2015.35.e528] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The management of melanoma in-transit metastases (IT-mets) is challenging. For many years, the absence of effective systemic therapy has prompted physicians to focus on regional therapies for melanoma confined to the limb. The introduction of isolated limb perfusion (ILP) and isolated limb infusion (ILI) has enabled effective delivery of cytotoxic drugs in an isolated circuit, so as to overcome systemic toxicity and maximize local response. Both techniques have evolved over years and both tumor necrosis factor (TNF)-alpha-based ILP and ILI have distinct indications. The development of new systemic treatment options for patients with melanoma in the past decade has shed a new light on melanoma therapy. The present manuscript focuses on the modern role of ILI and ILP in the treatment of patients with melanoma with in-transit metastases in the era of effective systemic therapy. The response and control rates of ILI/ILP are still superior to rates achieved with systemic agents. The extent of disease in patients with stage III disease, however, warrants effective systemic treatment to prolong survival. There is great potential in combining rapid response therapy such as ILI/ILP with systemic agents for sustainable response. Trial results are eagerly awaited.
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Affiliation(s)
| | - Hidde M Kroon
- From the Erasmus MC Cancer Institute, Rotterdam, Netherlands
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Abstract
Prior to the recent therapeutic advances, chemotherapy was the mainstay of treatment options for advanced-stage melanoma. A number of studies have investigated various chemotherapy combinations in order to expand on the clinical responses achieved with single-agent dacarbazine, but these have not demonstrated an improvement in overall survival. Similar objective responses were observed with the combination of carboplatin and paclitaxel as were seen with single-agent dacarbazine. The combination of chemotherapy and immunotherapy, known as biochemo-therapy, has shown high clinical responses; however, biochemo-therapy has not been shown to improve overall survival and resulted in increased toxicities. In contrast, palliation and long-term responses have been observed with localized treatment with isolated limb perfusion or infusion in limb-isolated disease. Although new, improved therapeutic options exist for first-line management of advanced-stage melanoma, chemotherapy may still be important in the palliative treatment of refractory, progressive, and relapsed melanoma. We review the various chemotherapy options available for use in the treatment and palliation of advanced-stage melanoma, discuss the important clinical trials supporting the treatment recommendations, and focus on the clinical circumstances in which treatment with chemotherapy is useful.
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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: 1.1] [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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Smith HG, Cartwright J, Wilkinson MJ, Strauss DC, Thomas JM, Hayes AJ. Isolated Limb Perfusion with Melphalan and Tumour Necrosis Factor α for In-Transit Melanoma and Soft Tissue Sarcoma. Ann Surg Oncol 2015; 22 Suppl 3:S356-61. [DOI: 10.1245/s10434-015-4856-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 11/18/2022]
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The Role of Regional Therapies for in-Transit Melanoma in the Era of Improved Systemic Options. Cancers (Basel) 2015; 7:1154-77. [PMID: 26140669 PMCID: PMC4586763 DOI: 10.3390/cancers7030830] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/17/2015] [Accepted: 06/24/2015] [Indexed: 12/21/2022] Open
Abstract
The incidence of melanoma has been increasing at a rapid rate, with 4%–11% of all melanoma recurrences presenting as in-transit disease. Treatments for in-transit melanoma of the extremity are varied and include surgical excision, lesional injection, regional techniques and systemic therapies. Excision to clear margins is preferred; however, in cases of widespread disease, this may not be practical. Historically, intralesional therapies were generally not curative and were often used for palliation or as adjuncts to other therapies, but recent advances in oncolytic viruses may change this paradigm. Radiation as a regional therapy can be quite locally toxic and is typically relegated to disease control and symptom relief in patients with limited treatment options. Regional therapies such as isolated limb perfusion and isolated limb infusion are older therapies, but offer the ability to treat bulky disease for curative intent with a high response rate. These techniques have their associated toxicities and can be technically challenging. Historically, systemic therapy with chemotherapies and biochemotherapies were relatively ineffective and highly toxic. With the advent of novel immunotherapeutic and targeted small molecule agents for the treatment of metastatic melanoma, the armamentarium against in-transit disease has expanded. Given the multitude of options, many different combinations and sequences of therapies can be offered to patients with in-transit extremity melanoma in the contemporary era. Reported response and survival rates of the varied treatments may offer valuable information regarding treatment decisions for patients with in-transit melanoma and provide rationale for these decisions.
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Berrocal A, Cabañas L, Espinosa E, Fernández-de-Misa R, Martín-Algarra S, Martínez-Cedres JC, Ríos-Buceta L, Rodríguez-Peralto JL. Melanoma: diagnosis, staging, and treatment. Consensus group recommendations. Adv Ther 2014; 31:945-60. [PMID: 25145549 DOI: 10.1007/s12325-014-0148-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Indexed: 10/24/2022]
Abstract
The incidence of malignant melanoma is increasing worldwide. In Spain, its incidence is increasing faster than any other cancer type, with a 5-year survival rate of about 85%. The impact and characteristics of malignant melanoma in the Spanish population can be ascertained from the national melanoma registry of the Academia Española de Dermatología y Venereología. This review presents consensus group recommendations for the diagnosis, staging and treatment of malignant melanoma in Spain. Incidence and mortality are discussed, as well as evaluation of various prevention and treatment strategies. Prognostic factors, such as BRAF and C-KIT mutations, which are expected to become routine staging procedures over the next few years, are outlined, especially in relation to treatment options. The use of recently approved targeted agents such as ipilimumab, a cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) inhibitor, and vemurafenib, a BRAF inhibitor, in metastatic disease are also discussed.
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Olofsson Bagge R, Mattsson J, Hafström L. Regional hyperthermic perfusion with melphalan after surgery for recurrent malignant melanoma of the extremities – Long-term follow-up of a randomised trial. Int J Hyperthermia 2014; 30:295-8. [DOI: 10.3109/02656736.2014.931601] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Rutkowski P, Zdzienicki M, Kozak K. Subcutaneous metastases from melanoma: a discussion of clinical experience. Melanoma Manag 2014; 1:31-40. [DOI: 10.2217/mmt.14.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The majority of locoregional relapses of cutaneous melanoma occur as subcutaneous local recurrences/in-transit metastases; subcutaneous metastases (SMs) are also common in distant metastases. SM therapy is challenging and depends on the number, site, depth, size, clinical behavior and presence of other metastases. Isolated, resectable SMs should be treated surgically. In multiple/unresectable lesions, several local modalities are used: carbon dioxide laser ablation, radiotherapy, cryotherapy, intralesional injections and electrochemotherapy. Hyperthermic isolated limb perfusion is the preferred method of treating multiple, bulky in-transit metastases in extremities, allowing for high response rates and long-lasting remission. Electrochemotherapy is a simple method for the fast ablation of SMs that are not feasible for hyperthermic isolated limb perfusion. Recent advances in systemic therapy of melanoma, including immunotherapy (anti-CTLA4/anti-PD-1) and targeted therapy (BRAF/MEK inhibitors), have significantly impacted on SM treatment. We present our own SM cases treated with different modalities. The future of SM therapy will rely on a combination of different local, locoregional and systemic modalities, and we can expect major improvements in long-term outcomes.
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Affiliation(s)
- Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma & Melanoma, Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland
| | - Marcin Zdzienicki
- Department of Soft Tissue/Bone Sarcoma & Melanoma, Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland
| | - Katarzyna Kozak
- Department of Soft Tissue/Bone Sarcoma & Melanoma, Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology, Roentgena 5, 02-781 Warsaw, Poland
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Abstract
OBJECTIVES To review the diagnosis, staging, and treatments (both standard and novel) for advanced melanoma and discuss the nursing role in the care of patients with melanoma. DATA SOURCES Published research and education articles, on-line journals, recent texts, and references from pertinent articles. CONCLUSION Most melanomas are diagnosed at early localized stages when surgery alone can be curative. For patients diagnosed with metastatic disease, treatment options have been limited and generally considered ineffective. Recent developments in tumor genetics and a greater understanding of the role of the immune system in cancer have translated to better treatments. IMPLICATIONS FOR NURSING PRACTICE Nurses play a key role in ensuring that patients with melanoma understand their diagnosis, treatment recommendations (including supportive care, palliative chemotherapy, immunotherapies), and participation in clinical trials.
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Affiliation(s)
- Krista M Rubin
- Center for Melanoma, Massachusetts General Hospital, Boston, MA, USA.
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Hoekstra HJ, Veerman K, van Ginkel RJ. Isolated limb perfusion for in-transit melanoma metastases: Melphalan or TNF-melphalan perfusion? J Surg Oncol 2014; 109:338-47. [DOI: 10.1002/jso.23552] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 12/05/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Harald J. Hoekstra
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Kelly Veerman
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
| | - Robert J. van Ginkel
- Department of Surgical Oncology; University Medical Center Groningen, University of Groningen; Groningen The Netherlands
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Steinman J, Ariyan C, Rafferty B, Brady MS. Factors associated with response, survival, and limb salvage in patients undergoing isolated limb infusion. J Surg Oncol 2013; 109:405-9. [DOI: 10.1002/jso.23519] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/10/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Jonathan Steinman
- Department of Surgery; Gastric, Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center; New York New York
| | - Charlotte Ariyan
- Department of Surgery; Gastric, Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center; New York New York
| | - Brian Rafferty
- Department of Surgery; Gastric, Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center; New York New York
| | - Mary S. Brady
- Department of Surgery; Gastric, Mixed Tumor Service, Memorial Sloan-Kettering Cancer Center; New York New York
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22
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Lidsky ME, Speicher PJ, Jiang B, Tsutsui M, Tyler DS. Isolated limb infusion as a model to test new agents to treat metastatic melanoma. J Surg Oncol 2013; 109:357-65. [PMID: 24522940 DOI: 10.1002/jso.23502] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 10/24/2013] [Indexed: 02/06/2023]
Abstract
The limb model of in-transit disease can expand our understanding of treating melanoma because of the ease of obtaining tissue biopsies for correlative studies and the availability of preclinical animal models that allow validation of novel therapeutic strategies. This review will focus on regional therapy for in-transit melanoma as a platform to investigate novel therapeutic approaches to improve regional disease control, and help us develop insights to more rationally design systemic therapy trials.
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Affiliation(s)
- Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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23
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Wong J, Chen YA, Fisher KJ, Beasley GM, Tyler DS, Zager JS. Resection of residual disease after isolated limb infusion (ILI) is equivalent to a complete response after ILI-alone in advanced extremity melanoma. Ann Surg Oncol 2013; 21:650-5. [PMID: 24162840 DOI: 10.1245/s10434-013-3336-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a limb-preserving treatment for in-transit extremity melanoma. The benefit of resecting residual disease after ILI is unclear. METHODS A multi-institutional experience was analyzed comparing patients who underwent ILI plus resection of residual disease (ILI + RES) versus ILI-alone. RESULTS A total of 176 patients were included, 154 with ILI-alone and 22 with ILI + RES. There were no differences between the groups with respect to gender, age, extremity affected, or time from diagnosis to ILI. All surgical resections were performed as an outpatient procedure, separate from the ILI. Within the ILI + RES group, 15 (68%) had a partial response (PR), 2 (9%) stable disease (SD), and 5 (23%) progressive disease (PD). The ILI-alone group had 52 (34%) CR, 30 (19%) PR, 15 (10%) SD, and 46 (30%) PD. Eleven (7%) ILI-alone patients did not have 3-month response available for review. Evaluating overall survival (OS) from date of ILI, the ILI-alone group had a median OS of 30.9 months, whereas the ILI + RES group had not reached median OS, p = 0.304. Although the ILI + RES group had a slightly longer disease-free survival (DFS) compared to those with a CR after ILI-alone (12.4 vs. 9.6), this was not statistically significant, p = 0.978. Within the ILI + RES group, those with an initial PR after ILI had improved DFS versus those with SD or PD after ILI, p < 0.0001. CONCLUSIONS Resection of residual disease after ILI offers a DFS and OS similar to those who have a CR after ILI-alone. It may offer a treatment strategy that benefits patients undergoing ILI.
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Affiliation(s)
- Joyce Wong
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
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24
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Squires MH, Delman KA. Current Treatment of Locoregional Recurrence of Melanoma. Curr Oncol Rep 2013; 15:465-72. [DOI: 10.1007/s11912-013-0333-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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25
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Wong J, Chen YA, Fisher KJ, Zager JS. Isolated limb infusion in a series of over 100 infusions: a single-center experience. Ann Surg Oncol 2013; 20:1121-7. [PMID: 23456376 DOI: 10.1245/s10434-012-2782-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a therapeutic option for patients with recurrent, unresectable extremity malignancies. METHODS A prospectively collected single-institution database of patients undergoing ILI was analyzed for preoperative, intraoperative, and postoperative parameters and outcomes. RESULTS From May 2007 to January 2012, a total of 76 patients successfully underwent initial ILI, and 28 after either previous hyperthermic isolated limb perfusion or ILI. Seventy-nine patients (74 %) had melanoma, 24 (22 %) sarcoma, 3 (3 %) Merkel cell, and 1 (1 %) squamous cell carcinoma. There were 55 (72 %) initial and 22 (79 %) repeat lower extremity (LE) ILIs, and 21 (78 %) initial and 6 (22 %) repeat upper extremity (UE) ILIs. Serologic toxicity, measured by serum creatine kinase (CK), peaked higher and later in LE ILIs, median 620 versus 124 IU/L, and postoperative day 4 versus 2, respectively (P < 0.05). LE ILIs had a longer hospital length of stay (LOS), median 6 versus 5 days (P < 0.0001). A median grade II Wieberdink regional toxicity was observed. Three-month follow-up was available in 94 (90 %). A response (overall response rate, ORR) was seen in 72 % of ILIs performed for melanoma and 58 % for sarcoma. No difference in response was observed between UE versus LE or between initial versus repeat ILIs. Repeat UE ILIs, however, appeared to have an improved ORR than repeat LE ILIs, 83 versus 64 %. CONCLUSIONS ILI may be successfully performed for cutaneous and soft tissue malignancies. LE ILIs have higher CK levels and slightly longer LOS. Repeat ILIs are not associated with increased toxicity and similar ORR. UE ILIs may have better ORR.
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Affiliation(s)
- Joyce Wong
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, USA
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26
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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: 0.7] [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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27
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Ashton KS. Nursing care of patients undergoing isolated limb procedures for recurrent melanoma of the extremity. J Perianesth Nurs 2012; 27:94-109. [PMID: 22443922 DOI: 10.1016/j.jopan.2012.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Revised: 11/15/2011] [Accepted: 01/12/2012] [Indexed: 11/17/2022]
Abstract
Isolated limb perfusion and isolated limb infusion are surgical interventions that provide high-dose regional chemotherapy to patients experiencing a recurrence of melanoma in an extremity. Nurses may be unfamiliar with these treatment options, as they are not available in all hospitals; however, the number of people diagnosed with melanoma is increasing. It is important for nurses to understand these surgical procedures to provide safe high-quality care before and after the surgery. Currently, there are several gaps in our knowledge about patients' experiences or nurse-sensitive outcomes. There are abundant opportunities for nurses to improve the care of patients who undergo surgical interventions to manage melanoma in the extremity.
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Affiliation(s)
- Kathleen S Ashton
- School of Nursing, The University of North Carolina at Greensboro, Greensboro, NC, USA.
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28
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Abstract
Circulating tumor cells (CTCs), enumerated by the Food and Drugs Administration-cleared CellSearch(®) system, are an independent prognostic factor of progression-free survival (PFS) and overall survival (OS) in metastatic breast cancer (MBC) patients. Several published papers demonstrated the poor prognosis for MBC patients who presented basal CTC count ≥5 in 7.5 mL of blood. Therefore, the enumeration of CTCs during treatment for MBC provides a tool with the ability to predict progression of disease earlier than standard timing of anatomical assessment using conventional radiological tests. Randomized clinical trials are ongoing to demonstrate whether CTCs detected by CellSearch(®) may help to guide treatments in MBC patients and improve prognosis. Moreover, the ability to perform molecular characterization of CTCs might identify a new druggable target in MBC patients. For example, the RT-PCR-based approach AdnaTest BreastCancerSelect(™) showed a high discordance rate in receptor expression between the primary tumors and CTCs. Theoretically, the phenotypic analysis of CTCs can represent a "liquid" biopsy of breast tumor that is able to identify a new potential target against the metastatic disease.
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Affiliation(s)
- Antonio Giordano
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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29
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Deroose JP, Eggermont AMM, van Geel AN, de Wilt JHW, Burger JWA, Verhoef C. 20 years experience of TNF-based isolated limb perfusion for in-transit melanoma metastases: TNF dose matters. Ann Surg Oncol 2011; 19:627-35. [PMID: 21879272 PMCID: PMC3264869 DOI: 10.1245/s10434-011-2030-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Indexed: 12/11/2022]
Abstract
Background Approximately 5–8% of melanoma patients will develop in-transit metastases (IT-mets). Tumor necrosis factor-α (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is an attractive treatment modality in melanoma patients with multiple IT-mets. This study reports on a 20 years experience and outlines the evolution and major changes since the introduction of TNF in ILP. Methods A total of 167 TM-ILPs were performed in 148 patients, between 1991 and 2009. TM-ILPs were performed at high doses of TNF (3–4 mg) from 1991 to 2004 (n = 99) and at low doses of TNF (1–2 mg) from 2004 to 2009 (n = 68) under mild hyperthermic conditions (38°C–39.5°C.). Melphalan doses were unchanged at 10–13 mg/l (leg and arm, respectively). Characteristics for the 167 ILPs were: 81 stage IIIB, 65 stage IIIC, and 21 stage IV disease. Results The overall response rate was 89% (n = 148). (Complete response [CR] = 61%; partial response [PR] = 28%). CR rates correlated with stage (P = .001) and with high-dose vs. low-dose TNF (70% vs. 49%; P < .006). High-dose TNF prolonged local control (median 16 months vs. 11 months; P = .076). Survival was not influenced by TNF dose. CR after ILP and number of lesions also correlated with local progression-free interval. Overall survival did correlate with stage of disease (P < .001), size of the lesions (P = .001), and a CR (P < .001). Conclusions This 2-decade single-center experience demonstrates that TM-ILP is a safe and effective treatment modality for melanoma patients with multiple IT-mets. Higher dose of TNF was associated with significantly higher CR rates and prolonged local control without an effect on overall survival.
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Affiliation(s)
- Jan P Deroose
- Department of Surgical Oncology, ErasmusMC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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30
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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: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Hamilton E, Clay TM, Blackwell KL. New Perspectives on Zoledronic Acid in Breast Cancer: Potential Augmentation of Anticancer Immune Response. Cancer Invest 2011; 29:533-41. [DOI: 10.3109/07357907.2011.605413] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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32
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Deroose JP, Grünhagen DJ, Van Geel AN, De Wilt JHW, Eggermont AMM, Verhoef C. Long-term outcome of isolated limb perfusion with tumour necrosis factor-α for patients with melanoma in-transit metastases. Br J Surg 2011; 98:1573-80. [DOI: 10.1002/bjs.7621] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2011] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The use of tumour necrosis factor (TNF) α in isolated limb perfusion (ILP) for in-transit melanoma metastasis is not uniformly accepted. This article reports the long-term results of adding TNF-α to standard melphalan-based ILP (TM-ILP) for treatment of melanoma in-transit metastases.
Methods
Data for patients treated between 1991 and 2005 were retrieved from a prospectively maintained database. Hyperthermic ILP was performed with 1–4 mg TNF-α. With a median potential follow-up of 13 years, response rates, time to local progression and disease-specific survival were analysed in relation to standard baseline factors.
Results
Some 118 TM-ILPs were analysed in 105 patients, 54 for stage IIIA, 50 for stage IIIAB and 14 for stage IV disease. The overall response rate was 93·2 per cent; the response was complete in 67·8 per cent and partial in 25·4 per cent. The response rate was significantly influenced by stage of disease (IIIA versus IIIAB; P = 0·006). The complete response was maintained until the end of follow-up in 35 patients (33·3 per cent), and local control was achieved with one additional intervention in 12 others (11·4 per cent). Local progression occurred after 66 ILPs (55·9 per cent). Number of in-transit metastases (P = 0·008) and complete response after ILP (P < 0·001) were strong prognostic factors for time to local progression. The 5-year disease-specific survival rate was 27·3 per cent; survival was positively influenced by age, stage of disease, previous ILP and complete response after ILP.
Conclusion
ILP with TNF-α may obtain long-term local control in selected patients with in-transit metastases from melanoma.
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Affiliation(s)
- J P Deroose
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - D J Grünhagen
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - A N Van Geel
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - J H W De Wilt
- Division of Surgical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - A M M Eggermont
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
- Institut de Cancérologie Gustave Roussy, Villejuif-Paris, France
| | - C Verhoef
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Leong SPL, Gershenwald JE, Soong SJ, Schadendorf D, Tarhini AA, Agarwala S, Hauschild A, Soon CWM, Daud A, Kashani-Sabet M. Cutaneous melanoma: a model to study cancer metastasis. J Surg Oncol 2011; 103:538-49. [PMID: 21480247 DOI: 10.1002/jso.21816] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nodal status in melanoma is a critically important prognostic factor for patient outcome. The survival rate drops to <10% when melanoma has spread beyond the regional lymph nodes and includes visceral involvement. In general, the process of melanoma metastasis is progressive in that dissemination of melanoma from the primary site to the regional lymph nodes occurs prior to systemic disease. The goal of this review article is to describe melanoma as a clinical model to study cancer metastasis. A future challenge is to develop a molecular taxonomy to subgroup melanoma patients at various stages of tumor progression for more accurate targeted treatment.
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Affiliation(s)
- Stanley P L Leong
- Center for Melanoma Research and Treatment and Department of Surgery, California Pacific Medical Center and Research Institute, San Francisco, California 94115, USA.
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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: 1.9] [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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35
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Current world literature. Curr Opin Oncol 2011; 23:227-34. [PMID: 21307677 DOI: 10.1097/cco.0b013e328344b687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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Bisphosphonates in the adjuvant treatment of breast cancer: rationale and clinical data. ACTA ACUST UNITED AC 2011. [DOI: 10.4155/cli.10.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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37
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Abstract
For in-transit melanoma confined to the extremities, regional chemotherapy in the form of hyperthermic isolated limb perfusion and isolated limb infusion are effective treatment modalities carrying superior response rates to current standard systemic therapy. Despite high response rates, most patients will eventually recur, supporting the role for novel research aimed at improving durable responses and minimizing toxicity. Although the standard cytotoxic agent for regional chemotherapy is melphalan, alternative agents such as temozolomide are currently being tested, with promising preliminary results. Current strategies for improving chemosensitivity to regional chemotherapy are aimed at overcoming classic resistance mechanisms such as drug metabolism and DNA repair, increasing drug delivery, inhibiting tumor-specific angiogenesis, and decreasing the apoptotic threshold of melanoma cells. Concurrent with development and testing of these agents, genomic profiling and biomolecular analysis of acquired tumor tissue may define patterns of tumor resistance and sensitivity from which personalized treatment may be tailored to optimize efficacy. In this article rational strategies for treatment of in-transit melanoma are outlined, with special emphasis on current translational and clinical research efforts.
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Affiliation(s)
- Ryan S. Turley
- Duke University, Department of Surgery, DUMC 3443, Durham, NC 27710,
| | | | - Douglas S. Tyler
- Professor of Surgery, Duke University, Department of Surgery, DUMC 3118, Durham, NC 27710,
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38
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Hadji P. Managing bone health with zoledronic acid: a review of randomized clinical study results. Climacteric 2010; 14:321-32. [DOI: 10.3109/13697137.2010.529966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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39
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:293-304. [DOI: 10.1097/spc.0b013e328340e983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Algazi AP, Soon CW, Daud AI. Treatment of cutaneous melanoma: current approaches and future prospects. Cancer Manag Res 2010. [PMID: 21188111 DOI: 10.2147/cmar.s6073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Alain P Algazi
- Department of Medicine, Division of Hematology and Oncology
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41
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Algazi AP, Soon CW, Daud AI. Treatment of cutaneous melanoma: current approaches and future prospects. Cancer Manag Res 2010; 2:197-211. [PMID: 21188111 PMCID: PMC3004577 DOI: 10.2147/cmr.s6073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Alain P Algazi
- Department of Medicine, Division of Hematology and Oncology
| | - Christopher W Soon
- Department of Dermatology, University of California, San Francisco San Francisco, CA, USA
| | - Adil I Daud
- Department of Medicine, Division of Hematology and Oncology
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42
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Rossi CR, Pasquali S, Mocellin S, Vecchiato A, Campana LG, Pilati P, Zanon A, Nitti D. Long-term results of melphalan-based isolated limb perfusion with or without low-dose TNF for in-transit melanoma metastases. Ann Surg Oncol 2010; 17:3000-7. [PMID: 20429035 DOI: 10.1245/s10434-010-1104-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aims of the study were: (1) to determine toxicity, response rate, local-regional control, and survival in the entire population of the perfused patients; (2) to compare toxicity, response, and survival among patients who underwent melphalan-based perfusion with or without low-dose tumor necrosis factor (TNF); and (3) to identify factors that predict a complete response and survival. MATERIALS AND METHODS A total of 53 patients with extensive in-transit metastases (47%) underwent perfusion with melphalan, and 59 (53%) also received low-dose TNF. RESULTS No difference was observed between the 2 drug regimens for what concerns local toxicity (P = 1.0). The tumor complete response rate was higher in patients treated with TNF (60.3% versus 41.5%, P = .036), in particular in the case of locally advanced tumors (66.7% versus 30%, P = .049). The presence of lymph node metastases had a negative influence on the tumor response rate (P = .003). Median time to local progression and survival were 19.6 and 34.5 months, respectively. Long-term complete response was achieved in 68% of the patients with initial CR (39 of 57 patients). The tumor response after perfusion was the only prognostic factor for local control and survival (P < .0001 and P = .002, respectively). CONCLUSIONS In the case of locally advanced disease, the addition of low-dose TNF to melphalan-based isolated limb perfusion appears safe and particularly useful. The presence of lymph node metastases is associated with decreased response rates. A sustained complete response was obtained in about one-third of the patients.
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Affiliation(s)
- Carlo Riccardo Rossi
- Department of Oncological and Surgical Sciences, University of Padova, Padova, Italy
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Moreno-Ramirez D, de la Cruz-Merino L, Ferrandiz L, Villegas-Portero R, Nieto-Garcia A. Isolated limb perfusion for malignant melanoma: systematic review on effectiveness and safety. Oncologist 2010; 15:416-27. [PMID: 20348274 DOI: 10.1634/theoncologist.2009-0325] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) involves the administration of chemotherapy drugs directly into a limb involved by locoregional metastases. Unresectable locally advanced melanoma of the limbs represents one of the clinical settings in which ILP has demonstrated benefits. METHODS A systematic review of the literature on ILP for patients with unresectable locally advanced melanoma of the limbs was conducted. MEDLINE, EMBASE, and Cochrane database searches were conducted to identify studies fulfilling the following inclusion criteria: hyper- or normothermic ILP with melphalan with or without tumor necrosis factor (TNF) or other drugs providing valid data on clinical response, survival, or toxicity. To allocate levels of evidence and grades of recommendation the Scottish Intercollegiate Guidelines Network system was used. RESULTS Twenty-two studies including 2,018 ILPs were selected with a clear predominance of observational studies (90.90%) against experimental studies (9.10%). The median complete response rate to ILP was of 58.20%, with a median overall response rate of 90.35%. ILP with melphalan yielded a median complete response rate of 46.50%, against a 68.90% median complete response rate for melphalan plus TNF ILP. The median 5-year overall-survival rate was 36.50%, with a median overall survival interval of 36.70 months. The Wieberdink IV and V regional toxicity rates were 2.00% and 0.65%, respectively. CONCLUSIONS ILP is effective in achieving clinical responses in patients with unresectable locally advanced melanoma of the limbs. The disease-free and overall survival rates provided by ILP are acceptable. ILP is safe, with a low incidence of severe regional and systemic toxicity.
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Affiliation(s)
- David Moreno-Ramirez
- Melanoma Unit, Dermatology Department, Hospital Universitario Virgen Macarena, Seville, Spain.
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