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Chandrasekhar S, Perez M, Niaz Z, Ekram J, Lal N, Koly S, Cao B, Zager JS, Alomar M. Troponin Elevation in Patients Undergoing Percutaneous Hepatic Perfusion for Metastatic Uveal Melanoma. Cancer Control 2024; 31:10732748241246898. [PMID: 38605434 PMCID: PMC11010739 DOI: 10.1177/10732748241246898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/08/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Percutaneous Hepatic Perfusion (PHP) is a liver directed regional therapy recently FDA approved for metastatic uveal melanoma to the liver involving percutaneous isolation of liver, saturation of the entire liver with high-dose chemotherapy and filtration extracorporeally though in line filters and veno-venous bypass. The procedure is associated with hemodynamic shifts requiring hemodynamic support and blood product resuscitation due to coagulopathy. OBJECTIVE To assess the cardiac safety and subsequent clinically significant sequalae of this therapy. METHODS Consecutive PHP procedures done at our center between 2010-2022 were assessed retrospectively. Cardiac risk factors, post procedural cardiac enzymes, electrocardiograms, and transthoracic echocardiograms along with 90-day cardiac outcomes were reviewed. All data were reviewed by cardio-oncologists at our institution. RESULTS Of 37 patients reviewed, mean age was 63 years and 57% were women. 132 procedures were performed with an average of 3.57 procedures per patient. 68.6% of patients had elevated troponin during at least 1 procedure. No patients were found to have acute coronary syndrome, heart failure, unstable arrhythmias, or cardiac death. No patients had notable echocardiographic changes. 10.8% of patients with positive troponin had asymptomatic transient electrocardiographic changes not meeting criteria for myocardial infarction. One patient had non-sustained ventricular tachycardiac intra-operatively which did not recur subsequently. Three patients died from non-cardiac causes within 90-days. There was no oncology treatment interruption, even in those with troponin elevation. In multivariable analysis, a history of hyperlipidemia was a predictor of postoperative troponin elevation. (P = .042). CONCLUSION Percutaneous Hepatic Perfusion is safe and associated with a transient, asymptomatic troponin elevation peri-operatively without major adverse cardiac events at 90 days. The observed troponin elevation is likely secondary to coronary demand-supply mismatch related to procedural hemodynamic shifts, hypotension, and anemia.
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Affiliation(s)
- Sanjay Chandrasekhar
- Division of Cardiovascular Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Matthew Perez
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Zurain Niaz
- Division of Cardiovascular Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jahanzaib Ekram
- Division of Cardiovascular Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Neelam Lal
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sarah Koly
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Biwei Cao
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Mohammed Alomar
- Division of Cardiovascular Sciences, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Department of Cardio-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Perez MC, Depalo DK, Zager JS. A safety review of recently approved and late-stage trial treatments for metastatic melanoma: systemic and regional therapies. Expert Opin Drug Saf 2023; 22:789-797. [PMID: 37551723 DOI: 10.1080/14740338.2023.2245333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/30/2023] [Accepted: 08/03/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Advanced melanoma accounts for the majority of skin cancer-associated deaths. Over the past 15 years, there has been a dramatic change in the treatment options and prognosis for patients with advanced melanoma secondary to the development of novel systemic immunotherapies (IO) and targeted therapies. In addition to these novel systemic therapies, regional therapies (intralesional and perfusional) also continue to play a major role in the management of these patients. AREAS COVERED In this article, we review recent updates in the management of advanced melanoma via Medline (PubMed) and Google Scholar, including recently published trials in the metastatic, adjuvant, and neoadjuvant settings. We also review recently published trials for regional therapies and discuss future directions in the management of patients with advanced melanoma. EXPERT OPINION A significant portion of patients with advanced melanoma will develop recurrent or progressive disease following treatment with IO or targeted therapy. Therefore, identifying not only the appropriate therapeutic agent but also the sequence and duration of treatment is pivotal for these patients.
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Affiliation(s)
- Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
| | - Danielle K Depalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
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Sajan A, Fordyce S, Sideris A, Liou C, Toor Z, Filtes J, Krishnasamy V, Ahmad N, Reis S, Brejt S, Baig A, Khan S, Caplan M, Sperling D, Weintraub J. Minimally Invasive Treatment Options for Hepatic Uveal Melanoma Metastases. Diagnostics (Basel) 2023; 13:diagnostics13111836. [PMID: 37296688 DOI: 10.3390/diagnostics13111836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/01/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023] Open
Abstract
Uveal melanoma is one of the most common primary intraocular malignancies that accounts for about 85% of all ocular melanomas. The pathophysiology of uveal melanoma is distinct from cutaneous melanoma and has separate tumor profiles. The management of uveal melanoma is largely dependent on the presence of metastases, which confers a poor prognosis with a one-year survival reaching only 15%. Although a better understanding of tumor biology has led to the development of novel pharmacologic agents, there is increasing demand for minimally invasive management of hepatic uveal melanoma metastases. Multiple studies have already summarized the systemic therapeutic options available for metastatic uveal melanoma. This review covers the current research for the most prevalent locoregional treatment options for metastatic uveal melanoma including percutaneous hepatic perfusion, immunoembolization, chemoembolization, thermal ablation, and radioembolization.
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Affiliation(s)
- Abin Sajan
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Samuel Fordyce
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Andrew Sideris
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Connie Liou
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Zeeshan Toor
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - John Filtes
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Venkatesh Krishnasamy
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Noor Ahmad
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Stephen Reis
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Sidney Brejt
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Asad Baig
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Shaheer Khan
- Department of Medicine, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Michael Caplan
- Department of Medicine, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - David Sperling
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
| | - Joshua Weintraub
- Department of Radiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA
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Vogel A, Ochsenreither S, Zager JS, Wacker F, Saborowski A. Chemosaturation for primary and secondary liver malignancies: A comprehensive update of current evidence. Cancer Treat Rev 2023; 113:102501. [PMID: 36587472 DOI: 10.1016/j.ctrv.2022.102501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/25/2022]
Abstract
Regional therapies for primary and secondary liver tumors have garnered interest in recent years and several types of treatment approaches have been pursued to control disease, palliate symptoms, and extend survival. Chemosaturation is an innovative way to deliver high-dose chemotherapy to the liver via the hepatic artery. Within the last decade, "isolated hepatic perfusion" (IHP) has evolved from an open surgical approach to a minimally invasive procedure, now termed "chemosaturation" (CS) with "percutaneous hepatic perfusion (PHP)". The most conclusive data on CS-PHP is currently available for patients with hepatic metastases from uveal melanoma (UM) - a rare but devastating disease with a poor long-term survival rate. A global phase-3 study and several cohort studies have provided compelling evidence that CS-PHP is an effective salvage treatment for liver-dominant metastatic UM in institutions with appropriate expertise. In this review we provide an overview on the technique, available clinical data, including safety and efficacy, and potential indications for CS-PHP.
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Affiliation(s)
- Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Sebastian Ochsenreither
- Department of Hematology, Oncology and Tumor Immunology, Charité Campus Benjamin Franklin, Berlin, Germany; Charité Comprehensive Cancer Center, Berlin, Germany
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, United States; Department of Oncological Sciences, University of South Florida, Morsani School of Medicine, Tampa, FL, United States
| | - Frank Wacker
- Department of Radiology, Hannover Medical School, Hannover, Germany
| | - Anna Saborowski
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Schank TE, Hassel JC. Tebentafusp for the treatment of metastatic uveal melanoma. Future Oncol 2022; 18:1303-1311. [PMID: 35172589 DOI: 10.2217/fon-2021-1260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Uveal melanoma is a rare disease; nevertheless, it is the most common primary intraocular malignancy among adults. Approximately half of affected patients will suffer from metastatic disease, mostly to the liver. No standard-of-care treatment exists for these patients. Median progression-free survival and overall survival for all types of treatment, including checkpoint inhibitors, have remained poor. However, the most recent phase III study results for tebentafusp, a member of a new-in-class molecule, are raising hopes for stage IV uveal melanoma patients. In this review, we examine the current literature, focusing on the most recent trial results for this new reagent. We evaluate the latest clinical results for tebentafusp and aim to shed light on its immunological strategy.
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Affiliation(s)
- Timo E Schank
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, 69120, Germany.,National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, 69120, Germany
| | - Jessica C Hassel
- Department of Dermatology, University Hospital Heidelberg, Heidelberg, 69120, Germany.,National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, 69120, Germany
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Rantala ES, Hernberg MM, Piperno-Neumann S, Grossniklaus HE, Kivelä TT. Metastatic uveal melanoma: The final frontier. Prog Retin Eye Res 2022; 90:101041. [PMID: 34999237 DOI: 10.1016/j.preteyeres.2022.101041] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
Treatment of primary intraocular uveal melanoma has developed considerably, its driver genes are largely unraveled, and the ways to assess its risk for metastases are very precise, being based on an international staging system and genetic data. Unfortunately, the risk of distant metastases, which emerge in approximately one half of all patients, is unaltered. Metastases are the leading single cause of death after uveal melanoma is diagnosed, yet no consensus exists regarding surveillance, staging, and treatment of disseminated disease, and survival has not improved until recently. The final frontier in conquering uveal melanoma lies in solving these issues to cure metastatic disease. Most studies on metastatic uveal melanoma are small, uncontrolled, retrospective, and do not report staging. Meta-analyses confirm a median overall survival of 10-13 months, and a cure rate that approaches nil, although survival exceeding 5 years is possible, estimated 2% either with first-line treatment or with best supportive care. Hepatic ultrasonography and magnetic resonance imaging as surveillance methods have a sensitivity of 95-100% and 83-100%, respectively, to detect metastases without radiation hazard according to prevailing evidence, but computed tomography is necessary for staging. No blood-based tests additional to liver function tests are generally accepted. Three validated staging systems predict, each in defined situations, overall survival after metastasis. Their essential components include measures of tumor burden, liver function, and performance status or metastasis free interval. Age and gender may additionally influence survival. Exceptional mutational events in metastases may make them susceptible to checkpoint inhibitors. In a large meta-analysis, surgical treatment was associated with 6 months longer median overall survival as compared to conventional chemotherapy and, recently, tebentafusp as first-line treatment at the first interim analysis of a randomized phase III trial likewise provided a 6 months longer median overall survival compared to investigator's choice, mostly pembrolizumab; these treatments currently apply to selected patients. Promoting dormancy of micrometastases, harmonizing surveillance protocols, promoting staging, identifying predictive factors, initiating controlled clinical trials, and standardizing reporting will be critical steppingstones in reaching the final frontier of curing metastatic uveal melanoma.
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Affiliation(s)
- Elina S Rantala
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
| | - Micaela M Hernberg
- Comprehensive Cancer Center, Department of Oncology, Helsinki University Hospital and University of Helsinki, Paciuksenkatu 3, PL 180, FI-00029, HUS, Helsinki, Finland.
| | | | - Hans E Grossniklaus
- Section of Ocular Oncology, Emory Eye Center, 1365 Clifton Road B, Atlanta, GA, 30322, USA.
| | - Tero T Kivelä
- Ocular Oncology Service, Department of Ophthalmology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4 C, PL 220, FI-00029, HUS, Helsinki, Finland.
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Dewald CLA, Warnke MM, Brüning R, Schneider MA, Wohlmuth P, Hinrichs JB, Saborowski A, Vogel A, Wacker FK. Percutaneous Hepatic Perfusion (PHP) with Melphalan in Liver-Dominant Metastatic Uveal Melanoma: The German Experience. Cancers (Basel) 2021; 14:cancers14010118. [PMID: 35008282 PMCID: PMC8749811 DOI: 10.3390/cancers14010118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 12/14/2022] Open
Abstract
Percutaneous hepatic perfusion (PHP) delivers high-dose melphalan to the liver while minimizing systemic toxicity via filtration of the venous hepatic blood. This two-center study aimed to examine the safety, response to therapy, and survival of patients with hepatic-dominant metastatic uveal melanoma (UM) treated with PHP. A total of 66 patients with liver-dominant metastasized uveal melanoma, treated with 145 PHP between April 2014 and May 2020, were retrospectively analyzed with regard to adverse events (AEs; CTCAE v5.0), response (overall response rate (ORR)), and disease control rate (DCR) according to RECIST1.1, as well as progression-free and overall survival (PFS and OS). With an ORR of 59% and a DCR of 93.4%, the response was encouraging. After initial PHP, median hepatic PFS was 12.4 (confidence interval (CI) 4–18.4) months and median OS was 18.4 (CI 7–24.6) months. Hematologic toxicity was the most frequent AE (grade 3 or 4 thrombocytopenia after 24.8% of the procedures); less frequent was grade 3 or 4 hepatic toxicity (increased aspartate transaminase (AST) and alanine transaminase (ALT) after 7.6% and 6.9% of the interventions, respectively). Cardiovascular events included four cases of ischemic stroke (2.8%) and one patient with central pulmonary embolism (0.7%). In conclusion, PHP is a safe and effective salvage treatment for liver-dominant metastatic uveal melanoma. Serious AEs—though rare—demand careful patient selection.
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Affiliation(s)
- Cornelia L. A. Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, 30623 Hannover, Germany; (J.B.H.); (F.K.W.)
- Correspondence: ; Tel.: +49-511-532-3421
| | - Mia-Maria Warnke
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, 21033 Hamburg, Germany; (M.-M.W.); (R.B.); (M.A.S.)
| | - Roland Brüning
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, 21033 Hamburg, Germany; (M.-M.W.); (R.B.); (M.A.S.)
| | - Martin A. Schneider
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, 21033 Hamburg, Germany; (M.-M.W.); (R.B.); (M.A.S.)
| | - Peter Wohlmuth
- Biostatistics, ProResearch, Asklepios Hospital St. Georg, 20099 Hamburg, Germany;
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, 30623 Hannover, Germany; (J.B.H.); (F.K.W.)
| | - Anna Saborowski
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30623 Hannover, Germany; (A.S.); (A.V.)
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30623 Hannover, Germany; (A.S.); (A.V.)
| | - Frank K. Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, 30623 Hannover, Germany; (J.B.H.); (F.K.W.)
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