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Pahwa R, Chhabra J, Kumar R, Narang R. Melphalan: Recent insights on synthetic, analytical and medicinal aspects. Eur J Med Chem 2022; 238:114494. [DOI: 10.1016/j.ejmech.2022.114494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/17/2022]
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Montalvo RN, Doerr V, Nguyen BL, Kelley RC, Smuder AJ. Consideration of Sex as a Biological Variable in the Development of Doxorubicin Myotoxicity and the Efficacy of Exercise as a Therapeutic Intervention. Antioxidants (Basel) 2021; 10:antiox10030343. [PMID: 33669040 PMCID: PMC7996538 DOI: 10.3390/antiox10030343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023] Open
Abstract
Doxorubicin (DOX) is an anthracycline antibiotic used to treat a wide variety of hematological and solid tumor cancers. While DOX is highly effective at reducing tumor burden, its clinical use is limited by the development of adverse effects to both cardiac and skeletal muscle. The detrimental effects of DOX to muscle tissue are associated with the increased incidence of heart failure, dyspnea, exercise intolerance, and reduced quality of life, which have been reported in both patients actively receiving chemotherapy and cancer survivors. A variety of factors elevate the probability of DOX-related morbidity in patients; however, the role of sex as a biological variable to calculate patient risk remains unclear. Uncertainty regarding sexual dimorphism in the presentation of DOX myotoxicity stems from inadequate study design to address this issue. Currently, the majority of clinical data on DOX myotoxicity come from studies where the ratio of males to females is unbalanced, one sex is omitted, and/or the patient cohort include a broad age range. Furthermore, lack of consensus on standard outcome measures, difficulties in long-term evaluation of patient outcomes, and other confounding factors (i.e., cancer type, drug combinations, adjuvant therapies, etc.) preclude a definitive answer as to whether differences exist in the incidence of DOX myotoxicity between sexes. This review summarizes the current clinical and preclinical literature relevant to sex differences in the incidence and severity of DOX myotoxicity, the proposed mechanisms for DOX sexual dimorphism, and the potential for exercise training to serve as an effective therapeutic countermeasure to preserve muscle strength and function in males and females.
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Eroğlu A, Ozcan H, Eryavuz Y, Kocağlu H, Demirci S, Aytac SK. Deep Venous Thrombosis of the Extremity Diagnosed by Color Doppler Ultrasonography after Isolated Limb Perfusion. TUMORI JOURNAL 2018; 87:187-90. [PMID: 11504375 DOI: 10.1177/030089160108700314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim Isolated limb perfusion (ILP) is used to treat locally advanced sarcoma and melanoma of the extremities. ILP is associated with a 1.7% to 10% incidence of deep venous thrombosis (DVT). The aim of the study was to examine the effect of ILP on the peripheral venous system and to evaluate the diagnostic accuracy of color Doppler ultrasonography (US). Methods A total of 26 patients with locally advanced sarcoma or melanoma of the extremities received a total of 38 ILP. The patients were evaluated preoperatively and postoperatively by color Doppler US as a noninvasive venous measurement. We used a color Doppler US system (SSA-270A, Toshiba) with a 7.5-MHz linear transducer for gray-scale imaging and a 5-MHz vascular transducer for color Doppler imaging. Results Seventeen patients underwent single ILP while the others were treated with multiple ILPs. Color Doppler US showed a reflux flow in three (7.9%) patients and DVT occurred subsequently in these patients. Conclusions Color Doppler US is a noninvasive and clinically useful diagnostic technique in the diagnosis of extremity DVT. We recommend anticoagulant therapy in patients with reflux on ultrasonographic examination.
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Affiliation(s)
- A Eroğlu
- Department of Surgical Oncology, Ankara University Medical School, Turkey.
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Kroon HM, Coventry BJ, Giles MH, Henderson MA, Speakman D, Wall M, Barbour A, Serpell J, Paddle P, Smithers BM, Thompson JF. Safety and Efficacy of Isolated Limb Infusion Chemotherapy for Advanced Locoregional Melanoma in Elderly Patients: An Australian Multicenter Study. Ann Surg Oncol 2017; 24:3245-3251. [PMID: 28799064 DOI: 10.1245/s10434-017-6046-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) offers a minimally invasive treatment option for locally advanced extremity melanoma. OBJECTIVE The aim of the current study was to evaluate the safety and efficacy of ILI in elderly patients in an Australian multicenter setting. METHODS The results of 316 first ILI procedures, performed between 1992 and 2008 in five Australian institutions, were identified and analyzed, with the main focus on elderly patients (≥75 years of age). All institutions used the same protocol: melphalan was circulated in the isolated limb for 20-30 min (±actinomycin D), and toxicity, responses, and survival were recorded. RESULTS Characteristics of patients aged ≥75 years (n = 148) were similar to those aged <75 years (n = 168), except that older patients had more melanoma deposits (median 4 vs. 5; p = 0.035) and lower limb volumes (5.4 vs. 6.5 L; p = 0.001). Median drug circulation times were lower in the older group (21 vs. 24 min; p = 0.04), and older patients experienced less limb toxicity (grade III/IV in 22 and 37% of patients, respectively; p = 0.003). A complete response (CR) was seen in 27% of patients aged ≥75 years and in 38% of patients aged <75 years (p = 0.06), while overall response rates were 72 and 77%, respectively (p = 0.30). No difference in survival was seen (p = 0.69). CONCLUSIONS The ILI technique proved safe and effective in elderly patients. When present, toxicity was localized, and lower compared with younger patients, possibly due to shorter drug circulation times. CR rates were higher in younger patients, although not significantly, while overall response and survival were equal. Optimization of perioperative factors in elderly patients may allow response rates to be raised further, while maintaining low toxicity.
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Affiliation(s)
- Hidde M Kroon
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia. .,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
| | - Brendon J Coventry
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Mitchell H Giles
- Department of Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Michael A Henderson
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - David Speakman
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Mark Wall
- Division of Surgical Oncology, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Barbour
- Queensland Melanoma Project, Discipline of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan Serpell
- Discipline of Surgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Paul Paddle
- Discipline of Surgery, The Alfred Hospital, Melbourne, VIC, Australia
| | - Bernard M Smithers
- Queensland Melanoma Project, Discipline of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, QLD, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.,Discipline of Surgery, The University of Sydney, Sydney, NSW, Australia.,Department of Surgical Oncology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Stamatiou D, Ioannou CV, Kontopodis N, Michelakis D, Perisinakis K, Lasithiotakis K, Zoras O. Hyperthermic isolated limb perfusion. The switch from Steinmann pins to Omni-tract assisted isolation. J Surg Res 2017; 213:147-157. [PMID: 28601307 DOI: 10.1016/j.jss.2017.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/21/2017] [Accepted: 02/17/2017] [Indexed: 12/27/2022]
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Jakob J, Hohenberger P. Role of isolated limb perfusion with recombinant human tumor necrosis factor α and melphalan in locally advanced extremity soft tissue sarcoma. Cancer 2016; 122:2624-32. [DOI: 10.1002/cncr.29991] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 02/17/2016] [Accepted: 02/22/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Jens Jakob
- Division of Surgical Oncology, Department of Surgery, University Medical Center and Medical Faculty Mannheim; University of Heidelberg; Mannheim Germany
| | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, University Medical Center and Medical Faculty Mannheim; University of Heidelberg; Mannheim Germany
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Nichols TC, Whitford MH, Arruda VR, Stedman HH, Kay MA, High KA. Translational data from adeno-associated virus-mediated gene therapy of hemophilia B in dogs. HUM GENE THER CL DEV 2015; 26:5-14. [PMID: 25675273 DOI: 10.1089/humc.2014.153] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Preclinical testing of new therapeutic strategies in relevant animal models is an essential part of drug development. The choice of animal models of disease that are used in these studies is driven by the strength of the translational data for informing about safety, efficacy, and success or failure of human clinical trials. Hemophilia B is a monogenic, X-linked, inherited bleeding disorder that results from absent or dysfunctional coagulation factor IX (FIX). Regarding preclinical studies of adeno-associated virus (AAV)-mediated gene therapy for hemophilia B, dogs with severe hemophilia B (<1% FIX) provide well-characterized phenotypes and genotypes in which a species-specific transgene can be expressed in a mixed genetic background. Correction of the hemophilic coagulopathy by sustained expression of FIX, reduction of bleeding events, and a comprehensive assessment of the humoral and cell-mediated immune responses to the expressed transgene and recombinant AAV vector are all feasible end points in these dogs. This review compares the preclinical studies of AAV vectors used to treat dogs with hemophilia B with the results obtained in subsequent human clinical trials using muscle- and liver-based approaches.
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Affiliation(s)
- Timothy C Nichols
- 1 Francis Owen Blood Research Laboratory, Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill , Chapel Hill, NC 27516
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Nichols T, Whitford MH, Arruda VR, Stedman HH, Kay MA, High KA. Translational Data from AAV-Mediated Gene Therapy of Hemophilia B in Dogs. HUM GENE THER CL DEV 2014. [DOI: 10.1089/hum.2014.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Coventry BJ, Kroon HM, Giles MH, Henderson M, Speakman D, Wall M, Barbour A, Serpell J, Paddle P, Coventry AGJ, Sullivan T, Smithers BM. Australian multi-center experience outside of the Sydney Melanoma Unit of isolated limb infusion chemotherapy for melanoma. J Surg Oncol 2014; 109:780-5. [PMID: 24634160 DOI: 10.1002/jso.23590] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 02/08/2014] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Isolated limb infusion (ILI) is a minimally invasive alternative to isolated limb perfusion (ILP) for delivering high-dose regional chemotherapy to treat locally advanced limb melanoma. The current study aimed to evaluate the applicability of ILI in four Australian tertiary referral centers outside of its originating institution, the Sydney Melanoma Unit (SMU; currently known as the Melanoma Institute Australia). METHODS Data of 131 patients, treated between 1992 and 2008 were collectively analyzed. The ILI procedures were based on the Sydney Melanoma Unit protocol using melphalan. Response was determined using the WHO criteria and toxicity was assessed using the Wieberdink scale. RESULTS The median patient age was 74 years (range 28-100). Fifty-six percent were female. Overall response (OR) rate to ILI was 63% (CR 27%; PR 36%). Wieberdink toxicity grade III or higher was seen in 13%. No toxicity-related amputations occurred. Median follow-up was 24 months; median survival was 58 months. In patients with a complete response (CR), median survival was 101 months; in patients with a partial response (PR) this was 41 months (P = 0.026). On univariate analysis a younger age, lower-limb procedures and a lower Breslow thickness of the primary melanoma were associated with a favorable response. On multivariate analysis Breslow thickness and lower-limb ILI remained significant predictors for response. CONCLUSION In this, to date, largest multi-center study of ILI for melanoma the results are comparable to other reports and demonstrate that ILI can be widely implemented and safely applied across tertiary referral centers.
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Affiliation(s)
- Brendon J Coventry
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Nieweg OE, Kroon BB. Isolated limb perfusion with melphalan for melanoma. J Surg Oncol 2014; 109:332-7. [DOI: 10.1002/jso.23558] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Omgo E. Nieweg
- Melanoma Institute Australia; North Sydney NSW Australia
| | - Bin B.R. Kroon
- Skin and Melanoma Center and Department of Surgery; The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital; Amsterdam the Netherlands
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Kroon HM, Huismans A, Waugh RC, Kam PCA, Thompson JF. Isolated limb infusion: technical aspects. J Surg Oncol 2013; 109:352-6. [PMID: 24374797 DOI: 10.1002/jso.23540] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the technique of isolated limb infusion (ILI) for regional high dose chemotherapy in patients with advanced malignancies confined to a limb, as currently practiced at Melanoma Institute Australia (MIA). BACKGROUND ILI is progressively being used around the world but to date the reported response rates are generally lower than those reported by MIA. DISCUSSION This description of the ILI protocol at MIA provides details that may allow other surgeons to improve results.
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Affiliation(s)
- Hidde M Kroon
- Melanoma Institute Australia, Sydney, NSW, Australia
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Duprat Neto JP, Oliveira F, Bertolli E, Molina AS, Nishinari K, Facure L, Fregnani JH. Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity. Clinics (Sao Paulo) 2012; 67:237-41. [PMID: 22473404 PMCID: PMC3297032 DOI: 10.6061/clinics/2012(03)06] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 11/23/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve. METHODS We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables. RESULTS Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204). CONCLUSION It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period.
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Deneve JL, Zager JS. Isolated regional therapy for advanced extremity soft tissue sarcomas. Surg Oncol Clin N Am 2011; 21:287-99. [PMID: 22365520 DOI: 10.1016/j.soc.2011.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Patients presenting with unresectable, large, primary or recurrent extremity soft tissue sarcoma or locally advanced extremity tumors may benefit from treatment options in the form of isolated regional perfusion therapy. Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) have proved to be efficacious with acceptable systemic and regional toxicity profiles. Both procedures are attractive as options for patients who might otherwise be facing amputation as limb salvage procedures. HILP and ILI can be offered as either definitive treatment or as neoadjuvant therapy followed by surgery and/or radiation treatment. Response rates are encouraging as are limb preservation rates after regional therapy. Ongoing multicenter collaborations and clinical trials are required to gain knowledge on HILP and ILI for unresectable extremity sarcoma and expand the indications for use in the management of advanced extremity soft tissue sarcoma.
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Affiliation(s)
- Jeremiah L Deneve
- Cutaneous Oncology Department, Moffitt Cancer Center, Tampa, FL 33612, USA
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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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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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Current trends in regional therapy for melanoma: lessons learned from 225 regional chemotherapy treatments between 1995 and 2010 at a single institution. J Am Coll Surg 2011; 213:306-16. [PMID: 21493111 DOI: 10.1016/j.jamcollsurg.2011.03.013] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) are used to manage advanced extremity melanoma, but no consensus exists as to which treatment is preferable and how to monitor patients post-treatment. STUDY DESIGN Using a prospectively maintained database, we reviewed our experience with melphalan-based HILP (which included 62 first-time and 10 second-time) and ILI (which included 126 first-time and 18 second-time) procedures performed in 188 patients. PET/CT was obtained 3 months postregional treatment for 1 year and then every 6 months thereafter. RESULTS Overall response rate (complete response [CR] + partial response) of HILP was 81% (80% CI, 73-87%), and overall response rate from ILI was 43% (80% CI, 37-49%) for first-time procedures only. HILP had a CR rate of 55% with a median duration of 32 months, and ILI had a CR rate of 30% with median duration of 24 months. Patients who experienced a regional recurrence after initial regional treatment were more likely to achieve a CR after repeat HILP (50%, n = 10) compared with repeat ILI (28%, n = 18). Although the spectrum of toxicity was similar for ILI and HILP, the likelihood of rare catastrophic complication of limb loss was greater with HILP (2 of 62) than ILI (0 of 122). PET/CT was effective for surveillance after regional therapy to identify regional nodal and pulmonary disease that was not clinically evident, but often amenable to surgical resection (25 of 49; 51% of cases). In contrast, PET/CT was not effective at predicting complete response to treatment with an accuracy of only 50%. CONCLUSIONS In the largest single-institution regional therapy series reported to date, we found that although ILI is effective and well-tolerated, HILP is a more definitive way to control advanced disease.
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Lui PCW, Fan YS, Xu G, Ngai CY, Fung KP, Tse GMK, Yu AMC, Li JY. Apoptotic and necrotic effects of tumour necrosis factor-alpha potentiated with hyperthermia on L929 and tumour necrosis factor-alpha-resistant L929. Int J Hyperthermia 2010; 26:556-64. [DOI: 10.3109/02656736.2010.486777] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Coleman A, Augustine CK, Beasley G, Sanders G, Tyler D. Optimizing regional infusion treatment strategies for melanoma of the extremities. Expert Rev Anticancer Ther 2010; 9:1599-609. [PMID: 19895244 DOI: 10.1586/era.09.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The incidence of malignant melanoma is increasing faster than any other cancer. In cases of recurrent melanoma confined to the extremities, hyperthermic isolated limb perfusion and isolated limb infusion provide a way to isolate the extremity and deliver a dose of chemotherapy several orders of magnitude higher than would be tolerated systemically. Although complete response rates of up to 80% for hyperthermic isolated limb perfusion and 44% for isolated limb infusion have been observed, there is still room for improvement and standardization in these two procedures in an attempt to optimize response while minimizing toxicity. Currently, new chemotherapy agents and small-molecule inhibitors are being investigated as a means of overcoming chemoresistance and improving response rates. In patients with advanced cutaneous disease confined to the extremities, evaluation of these new therapies can be very informative, as tissue acquisition at multiple treatment time points is easy owing to the superficial and multifocal nature of the disease. Through studying the biomolecular and genetic alterations in tumor tissue in response to these new therapies, genetically customized treatment regimens in which tumor resistance and sensitivity is predicted and treatment strategy is optimized before treatment begins may soon be available. Progress in regional therapy will prove not only beneficial for patients with disease confined to an extremity, but may also provide insight into developing novel treatment strategies for patients with systemic disease for whom current disease management options are poor.
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Affiliation(s)
- Andrew Coleman
- Duke University School of Medicine, Durham, NC 27710, USA.
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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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ten Hagen TLM, Eggermont AMM. Changing the pathophysiology of solid tumours: The potential of TNF and other vasoactive agents. Int J Hyperthermia 2009; 22:241-6. [PMID: 16754345 DOI: 10.1080/02656730600738616] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Solid tumour therapy with chemotherapeutic drugs is hampered by a number of factors resulting in poor results and failure of initially promising drugs. From the application of Tumour Necrosis Factor alpha in the melphalan-based Isolated Limb perfusion some lessons could be learned. Most importantly, combination of treatment approaches, certainly when multiple targets are involved, increases the effectiveness of the therapy. Clinical outcome may improve dramatically when the tumour pathophysiology is changed in such a way that co-administered chemotherapeutics are more active or are capable of reaching the tumour cells better. Here some of the methodologies and drug combinations which improve solid tumour therapy through acting on the tumour pathophysiology are discussed.
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Affiliation(s)
- Timo L M ten Hagen
- Department of Surgical Oncology, Erasmus University Medical Center, Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Beasley GM, Ross MI, Tyler DS. Future directions in regional treatment strategies for melanoma and sarcoma. Int J Hyperthermia 2009; 24:301-9. [DOI: 10.1080/02656730701827573] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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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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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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Beasley GM, Caudle A, Petersen RP, McMahon NS, Padussis J, Mosca PJ, Zager JS, Hochwald SN, Grobmyer SR, Delman KA, Andtbacka RH, Noyes RD, Kane JM, Seigler H, Pruitt SK, Ross MI, Tyler DS. A multi-institutional experience of isolated limb infusion: defining response and toxicity in the US. J Am Coll Surg 2009; 208:706-15; discussion 715-7. [PMID: 19476821 DOI: 10.1016/j.jamcollsurg.2008.12.019] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 12/02/2008] [Indexed: 12/22/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive approach for treating in-transit extremity melanoma, with only two US single-center studies reported. Establishing response and toxicity to ILI as compared with hyperthermic isolated limb perfusion is important for optimizing future regional chemotherapeutic strategies in melanoma. STUDY DESIGN Patient characteristics and procedural variables were collected retrospectively from 162 ILIs performed at 8 institutions (2001 to 2008) and compared using chi-square and Student's t-test. ILIs were performed for 30 minutes in patients with in-transit melanoma. Melphalan dose was corrected for ideal body weight (IBW) in 42% (n = 68) of procedures. Response was determined at 3 months by Response Evaluation Criteria in Solid Tumors; toxicity was assessed using the Wieberdink Limb Toxicity Scale. RESULTS In 128 evaluable patients, complete response rate was 31%, partial response rate was 33%, and there was no response in 36% of patients. For all patients (n = 162), 36% had Wieberdink toxicity grade >or=3 with one toxicity-related amputation. On multivariate analysis, smaller limb volumes were associated with better overall response (p = 0.021). Use of papaverine in the circuit to achieve cutaneous vasodilation was associated with better response (p < 0.001) but higher risk of grade >or=3 toxicity (p = 0.001). Correction of melphalan dose for ideal body weight did not alter complete response (p = 0.345), but did lead to marked reduction in toxicity (p < 0.001). CONCLUSIONS In the first multi-institutional analysis of ILI, a complete response rate of 31% was achieved with acceptable toxicity demonstrating this procedure to be a reasonable alternative to hyperthermic isolated limb perfusion in the management of advanced extremity melanoma.
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Affiliation(s)
- Georgia M Beasley
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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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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26
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Die isolierte Extremitätenperfusion bei regional metastasierendem Melanom und fortgeschrittenen Weichgewebssarkomen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0671-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Kroon BB, Noorda EM, Vrouenraets BC, van Slooten GW, Nieweg OE. Isolated Limb Perfusion for Melanoma. Surg Oncol Clin N Am 2008; 17:785-94, viii-ix. [DOI: 10.1016/j.soc.2008.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current Clinical and Research Approaches to Optimizing Regional Chemotherapy: Novel Strategies Generated Through a Better Understanding of Drug Pharmacokinetics, Drug Resistance, and the Development of Clinically Relevant Animal Models. Surg Oncol Clin N Am 2008; 17:731-58, vii-viii. [DOI: 10.1016/j.soc.2008.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Chimeric form of tumor necrosis factor-alpha has enhanced surface expression and antitumor activity. Cancer Gene Ther 2008; 16:53-64. [PMID: 18654609 DOI: 10.1038/cgt.2008.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Tumor necrosis factor (TNF)-alpha is a type-II transmembrane protein that is cleaved by TNF-alpha-converting enzyme (TACE/ADAM-17) to release soluble TNF, a cytokine with potent antitumor properties whose use in clinical applications is limited by its severe systemic toxicity. We found that human cells transfected with vectors encoding TNF without the TACE cleavage site (DeltaTACE-TNF) still released functional cytokine at substantial levels that varied between transfected cell lines of different tissue types. Vectors encoding membrane-associated domains of CD154, another TNF-family protein, conjoined with the carboxyl-terminal domain of TNF, directed higher-level surface expression of a functional TNF that, in contrast to DeltaTACE-TNF, was resistant to cleavage in all cell types. Furthermore, adenovirus vectors encoding CD154-TNF had significantly greater in vivo biological activity in inducing regression of established, syngeneic tumors in mice than adenovirus vectors encoding TNF, and lacked toxicity associated with soluble TNF. As such, CD154-TNF is a novel TNF that appears superior for treatment of tumors in which high-level local expression of TNF is desired.
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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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31
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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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32
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Regional Therapy of Cancer. Surgery 2008. [PMCID: PMC7122175 DOI: 10.1007/978-0-387-68113-9_104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bonvalot S, Missana MC, Le Cesne A, Missenard G, Vanel D, Terrier P, Le Péchoux C. Chirurgie des sarcomes des tissus mous des membres chez l'adulte : historique et avancées thérapeutiques. Cancer Radiother 2006; 10:416-24. [PMID: 16890005 DOI: 10.1016/j.canrad.2006.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
In the seventies, limb-sparing surgery and radiation therapy appeared capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremities. No survival benefit could be demonstrated in the patients selected for amputation. Microscopically positive surgical margins are related to a greater risk of local recurrence, whereas overall survival is compromised by high grade and large tumor size. Presurgery multidisciplinary discussion, management in reference center and management within cancer network independently predict conformity to the clinical practice guidelines. Reoperation should be a planned part of definitive management whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. Soft tissue flap reconstruction facilitates therapy for patients with locally advanced tumors so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Vascular reconstruction is a feasible option in case of involvement of major vessels. Isolated limb perfusion (ILP) with TNF and chemotherapy is an efficient limb-sparing neoadjuvant therapy for locally advanced limb soft tissue sarcomas. Efficacy and safety of low-dose TNFalpha could greatly facilitate ILP procedures in the near future.
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Affiliation(s)
- S Bonvalot
- Département de Chirurgie, Institut Gustave-Roussy, 39, Rue Camille-Desmoulins, 94805 Villejuif Cedex, France.
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Ko SH, Ueno T, Yoshimoto Y, Yoo JS, Abdel-Wahab OI, Abdel-Wahab Z, Chu E, Pruitt SK, Friedman HS, Dewhirst MW, Tyler DS. Optimizing a Novel Regional Chemotherapeutic Agent against Melanoma: Hyperthermia-Induced Enhancement of Temozolomide Cytotoxicity. Clin Cancer Res 2006; 12:289-97. [PMID: 16397054 DOI: 10.1158/1078-0432.ccr-05-0210] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Previous preclinical studies have shown that regional temozolomide therapy via isolated limb infusion is more effective than melphalan, the current drug of choice for regional chemotherapy for advanced extremity melanoma. The aim of this study was to determine whether hyperthermia could further augment the efficacy of temozolomide, an alkylating agent, against melanoma and improve its therapeutic index in a rat model of isolated limb infusion. EXPERIMENTAL DESIGN Athymic rats bearing s.c. human melanoma xenografts (DM6) in their hind limbs were randomized to a 15-minute isolated limb infusion procedure with or without temozolomide at room temperature, normothermic (37.5 degrees C), or hyperthermic (43 degrees C) conditions. RESULTS The concomitant administration of hyperthermia during an infusion with temozolomide led to the greatest increase in tumor growth delay, decreased proliferative index, and increased cell death. Isolated limb infusion treatment with a low dose (350 mg/kg) of temozolomide was ineffective at producing tumor growth delay (P = 0.07). Similarly, temozolomide infusion under normothermia yielded minimal tumor growth delay (P = 0.08). In contrast, the combination of hyperthermia plus temozolomide treatment produced marked tumor growth delay of 10.4 days (P = 0.02) with minimal toxicity. The addition of heat to temozolomide treatment yielded the smallest proliferative index (P = 0.001), while markedly increasing the level of apoptosis 48 hours after isolated limb infusion. CONCLUSION This study, the first to examine the interaction between hyperthermia and temozolomide, shows a strong, synergistic antitumor effect when hyperthermia is combined with temozolomide for regional treatment of melanoma confined to an extremity. The mechanism of this synergy seems to be through an augmentation, by hyperthermia, of the antiproliferative and proapoptotic effects of temozolomide.
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Affiliation(s)
- Sae Hee Ko
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina 27710, USA
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35
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Arruda VR, Stedman HH, Nichols TC, Haskins ME, Nicholson M, Herzog RW, Couto LB, High KA. Regional intravascular delivery of AAV-2-F.IX to skeletal muscle achieves long-term correction of hemophilia B in a large animal model. Blood 2004; 105:3458-64. [PMID: 15479726 PMCID: PMC1895010 DOI: 10.1182/blood-2004-07-2908] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In earlier work, we showed that adeno-associated virus-mediated delivery of a Factor IX gene to skeletal muscle by direct intramuscular injection resulted in therapeutic levels of circulating Factor IX in mice. However, achievement of target doses in humans proved impractical because of the large number of injections required. We used a novel intravascular delivery technique to achieve successful transduction of extensive areas of skeletal muscle in a large animal with hemophilia. We provide here the first report of long-term (> 3 years, with observation ongoing), robust Factor IX expression (circulating levels of 4%-14%) by muscle-directed gene transfer in a large animal, resulting in essentially complete correction of the bleeding disorder in hemophilic dogs. The results of this translational study establish an experimental basis for clinical studies of this delivery method in humans with hemophilia B. These findings also have immediate relevance for gene transfer in patients with muscular dystrophy.
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Affiliation(s)
- Valder R Arruda
- The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, 302 Abramson Research Center, Philadelphia, PA 19104, USA.
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Zimmermann VS, Bondanza A, Monno A, Rovere-Querini P, Corti A, Manfredi AA. TNF-α Coupled to Membrane of Apoptotic Cells Favors the Cross-Priming to Melanoma Antigens. THE JOURNAL OF IMMUNOLOGY 2004; 172:2643-50. [PMID: 14764739 DOI: 10.4049/jimmunol.172.4.2643] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The cross-presentation of Ags derived from apoptotic cell processing contributes to peripheral tolerance. Environmental signals possibly modify this default outcome, favoring cross-priming. In this study, we anchored via a biotin-avidin-biotin bridge soluble TNF-alpha to the membrane of apoptotic melanoma cells and studied in vivo and in vitro the interaction with Ag-presenting phagocytes. TNF-alpha-coated apoptotic melanoma cells injected s.c. had a faster and more efficient access to draining lymph nodes, with cross-priming of melanoma-specific CTLs and delayed outgrowth of melanomas in all treated animals. Twenty percent of the animals, in the absence of further adjuvant, did not develop the tumor. Immature dendritic cells challenged with TNF-alpha-coated apoptotic melanoma cells secreted proinflammatory cytokines in an autocrine/paracrine fashion, efficiently matured, as assessed functionally and by flow cytometry and cross-presented with enhanced efficiency melanoma Ags to MHC class I- and II-restricted T cells. The results indicate that TNF-alpha targeted to apoptotic membranes, at concentrations that can be safely reached in growing tumors without undue systemic toxicity, influences the outcome of the disposal of dying cells and enhances tumor immunogenicity.
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MESH Headings
- Adjuvants, Immunologic/administration & dosage
- Adjuvants, Immunologic/metabolism
- Adjuvants, Immunologic/physiology
- Animals
- Antigen Presentation/immunology
- Antigens, Neoplasm/administration & dosage
- Antigens, Neoplasm/immunology
- Antigens, Neoplasm/metabolism
- Apoptosis/immunology
- Cancer Vaccines/administration & dosage
- Cancer Vaccines/immunology
- Cancer Vaccines/metabolism
- Cell Line
- Cell Line, Tumor
- Cell Membrane/immunology
- Cell Membrane/metabolism
- Cell Movement/immunology
- Dendritic Cells/immunology
- Dendritic Cells/metabolism
- Lymph Nodes/immunology
- Lymph Nodes/pathology
- Melanoma, Experimental/immunology
- Melanoma, Experimental/pathology
- Melanoma, Experimental/prevention & control
- Mice
- Mice, Inbred C57BL
- Tumor Necrosis Factor-alpha/administration & dosage
- Tumor Necrosis Factor-alpha/metabolism
- Tumor Necrosis Factor-alpha/physiology
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Affiliation(s)
- Valérie S Zimmermann
- Cancer Immunotherapy and Gene Therapy Program, H San Raffaele Scientific Institute and San Raffaele Vita-Salute University, Milano, Italy
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37
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Carroll NM, Elaraj DM, Puhlmann M, Weinreich DM, Turner EM, Xu H, Alexander HR. Alterations in tumor necrosis factor-induced endothelial cell procoagulant activity by hyperthermia. Int J Cancer 2004; 111:457-62. [PMID: 15221977 DOI: 10.1002/ijc.20272] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
TNF is a cytokine with potent antitumor activity in murine models and when administered clinically via regional perfusion. There is substantial evidence that this antitumor activity depends in large part on TNF's procoagulant effect on tumor neovasculature, which is mediated by induction of endothelial cell tissue factor (TF), a component of the extrinsic clotting cascade. In regional perfusion of a cancer-bearing limb or organ, TNF is always administered under hyperthermic temperatures; however, little is known about the effect of hyperthermia on TNF-mediated procoagulant activity in endothelium. We examined the effects of hyperthermia on TNF-mediated procoagulant activity in human umbilical vein endothelial cells (HUVECs). HUVECs were exposed to TNF at normothermic (37 degrees C) and hyperthermic (41 degrees C) temperatures for 90 min, then assayed for clotting activity, TF protein production and mRNA production of TF and tissue factor pathway inhibitor-2 (TFPI-2), an endogenous inducible inhibitor of TF activity in HUVECs. TNF treatment at 41 degrees C significantly reduced clotting activity, TF protein and mRNA as well as TFPI-2 mRNA compared to treatment at 37 degrees C. These data show that hyperthermia significantly reduces the procoagulant effects of TNF on endothelial tissue compared to normothermia, which may have important clinical implications for the use of TNF in regional perfusion.
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Affiliation(s)
- Nancy M Carroll
- Surgical Metabolism Section, Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-1502, USA
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38
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Cheng TY, Grubbs E, Abdul-Wahab O, Leu SY, Hung CF, Petros W, Aloia T, Fedrau R, Pruitt S, Colvin M, Friedman H, Tyler D. Marked variability of melphalan plasma drug levels during regional hyperthermic isolated limb perfusion. Am J Surg 2003; 186:460-7. [PMID: 14599607 DOI: 10.1016/j.amjsurg.2003.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hyperthermic isolated limb perfusion (HILP) with melphalan as treatment for locally recurrent or in-transit malignant melanoma is frequently performed but the principle for calculating drug dosage remains poorly understood. METHODS This study examined the pharmacokinetic profile of 14 consecutive patients to determine what variables were associated with toxicity and tumor responses. RESULTS Marked fourfold variability was noted in patient plasma melphalan concentrations. We defined a factor--the ratio of estimated limb volume (Vesti) to melphalan volume of distribution (Vss), Vesti/Vss--that was much more strongly correlated with acute regional toxicity than either area under concentration-time curve or peak plasma concentration. In addition, we found that AUX2 was the best correlate of tumor response. CONCLUSIONS Pharmacokinetic evaluation of prospective HILP trials is critical to not only understand response and toxicity outcomes but also to potentially improve the therapeutic index of regional perfusion.
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Affiliation(s)
- Tsung-Yen Cheng
- Department of Surgery, Box 3118, Duke University Medical Center, Durham, NC 27710, USA
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39
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Noorda EM, Vrouenraets BC, Nieweg OE, van Coevorden F, van Slooten GW, Kroon BBR. Isolated limb perfusion with tumor necrosis factor-? and melphalan for patients with unresectable soft tissue sarcoma of the extremities. Cancer 2003; 98:1483-90. [PMID: 14508836 DOI: 10.1002/cncr.11648] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Since 1992, isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNFalpha) and melphalan has been used for the treatment of patients with unresectable soft tissue sarcomas of the extremities. The authors retrospectively studied the results of limb salvage surgery using TNFalpha-ILP at their institution. METHODS From 1992 to 2001, 49 patients (mean age, 51 years; range, 14-85 years) underwent ILP for unresectable soft tissue sarcomas of the extremities. All patients received melphalan and TNFalpha (four patients also received interferon-gamma). The median follow-up was 26 months (range, from 2 days to 103 months). RESULTS In 1 patient (2%) who died 2 days after undergoing ILP, response and acute limb toxicity could not be assessed. One patient (2%) attained a clinical complete response (2%), 23 patients (47%) attained a clinical partial response, 17 patients (35%) demonstrated no change, and 7 patients (14%) had tumor progression. Thirty-one patients (63%) underwent tumor resection. Histologic material also was available from eight amputations and three punctures/biopsies. Pathologic response was complete in 4 patients (8%), partial in 14 patients (29%), and no change was observed in 24 patients (49%). Final response, based on both clinical and pathologic assessment in which pathology was decisive, was complete in 4 patients (8%) and partial in 27 patients (55%), resulting in a final overall response rate of 63%. Local control with preservation of the limb was attained in 28 patients (57%). Four of 32 patients (13%) who had been rendered tumor free by ILP with or without undergoing resection and radiation therapy, developed a local recurrence. The 5-year disease specific survival rate was 48% for the 49 patients. Acute limb toxicity after ILP was a mild Grade 1-2 reaction in 35 patients (71%) patients, a Grade 3 reaction in 12 patients (25%), and a Grade 4 reaction in 1 patient (2%). Three major ILP-related complications were encountered, including arterial thrombosis in two patients and a fulminant Clostridial infection leading to death in one patient. There were no severe cardiovascular reactions after ILP. CONCLUSIONS In patients with unresectable soft tissue sarcomas of the limbs who underwent ILP with TNFalpha and melphalan followed by resection of the tumor remnant when possible, a 63% overall tumor response rate and a 57% local control rate with limb preservation was achieved.
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Affiliation(s)
- Eva M Noorda
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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40
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Rossi CR, Mocellin S, Pilati P, Foletto M, Nitti D, Lise M. TNFalpha-based isolated perfusion for limb-threatening soft tissue sarcomas: state of the art and future trends. J Immunother 2003; 26:291-300. [PMID: 12843791 DOI: 10.1097/00002371-200307000-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The management of limb-threatening soft tissue sarcomas has not yet been standardized. Although local disease control does not affect overall survival, amputation or highly mutilating surgery may be required, which impairs the patient's quality of life. Various neoadjuvant approaches have been proposed to allow limb-sparing surgery for these locally advanced tumors. With TNFalpha-based hyperthermic isolated limb perfusion, the majority of patients can be spared amputation, with acceptable rates of locoregional and systemic complications. As yet, no other available treatment seems to give comparable results when applied to limb-threatening soft tissue sarcomas. Nevertheless, several issues remain to be addressed, such as the type and dose of drugs, repeatability of the procedure, association with radiotherapy, further indications, and evaluation of response. The authors describe the principles underlying TNFalpha-based hyperthermic isolated limb perfusion, review the worldwide experience so far published, and discuss the above issues. The potential future developments of this locoregional therapeutic approach will also be reported.
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Affiliation(s)
- Carlo Riccardo Rossi
- Department of Oncological and Surgical Sciences, University of Padova, Italy. carlor.rossi2unipd.it
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41
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Sadrian R, Niederbichler AD, Friedman J, Vogt PM, Steinau HU, Reece G, Chang D, Robb G, Evans GRD. Intraarterial chemotherapy: the effects on free-tissue transfer. Plast Reconstr Surg 2002; 109:1254-8. [PMID: 11964975 DOI: 10.1097/00006534-200204010-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Multimodal therapy including intraarterial chemotherapy is recognized as state-of-the art therapy for soft-tissue cancer. Multimodal therapy often involves regional limb perfusion followed by sarcoma surgery with reconstruction of the resulting defect. This study was performed in an effort to evaluate the potential of free flap reconstruction after intraarterial therapy. A retrospective chart review of 52 patients who had undergone limb perfusion between 1988 and 1998 at the University of Texas M. D. Anderson Cancer Center and the Division of Plastic Surgery, University of Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion that was then followed by surgical resection and free flap reconstruction. There were seven women and nine men, with an average age of 37.9 years. All sixteen patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor recipient anastomosis had been previously perfused. A vein graft was used in one case. Split-thickness skin grafting over the free flaps was used in four cases. The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis. Three patients developed partial split-thickness skin graft loss and one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The overall surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation on the basis of both the patient self-evaluation and the physical therapy evaluation. Seven patients had recurrence of their disease. The overall mean survival time after surgery was 20.6 months. Currently, 10 patients are alive and six have died from their disease. The results of this study indicate that preoperative intraarterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although our numbers are small, we believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be performed to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free flap reconstruction.
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Affiliation(s)
- Reza Sadrian
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas, USA
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Thompson JF, de Wilt JH. Isolated limb perfusion in the management of patients with recurrent limb melanoma: an important but limited role. Ann Surg Oncol 2001; 8:564-5. [PMID: 11508616 DOI: 10.1007/s10434-001-0564-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kim CJ, Puleo C, Letson GD, Reintgen D. Hyperthermic isolated limb perfusion for extremity sarcomas. Cancer Control 2001; 8:269-73. [PMID: 11378653 DOI: 10.1177/107327480100800307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The treatment options available for extremity sarcomas are amputation or limb-sparing surgery with radiation, which may incur significant morbidity and body disfigurement. Hyperthermic isolated limb perfusion (HILP) may be an attractive option in extremity sarcomas for unresectable lesions to preserve limb function and maintain quality of life. METHODS We report the outcomes of 5 patients who underwent HILP for unresectable primary or recurrent extremity sarcomas from 1994 to 2000 at our institution. RESULTS All patients had initial complete clinical responses to HILP, and the limb was salvaged in 4 of the 5 patients. Complications included chronic lymphedema, neuropathic pain, and prolonged wound healing. CONCLUSIONS HILP with melphalan is a safe and effective treatment option for selected patients with locally advanced and unresectable extremity sarcomas. The response rates are high, with limb salvage occurring in most patients. Further studies of larger groups of patients are warranted.
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Affiliation(s)
- C J Kim
- Cultaneous Oncology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla. 33612-9497, USA
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Isolated limb perfusion: is it a useful technique or a futile last gasp? CURRENT SURGERY 2000; 57:209-214. [PMID: 10930617 DOI: 10.1016/s0149-7944(00)00213-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Vrouenraets BC, Kroon BB, Ogilvie AC, van Geel AN, Nieweg OE, Swaak AJ, Eggermont AM. Absence of severe systemic toxicity after leakage-controlled isolated limb perfusion with tumor necrosis factor-alpha and melphalan. Ann Surg Oncol 1999; 6:405-12. [PMID: 10379864 DOI: 10.1007/s10434-999-0405-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Severe systemic toxicity and hemodynamic changes after isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF-alpha) and melphalan, with or without interferon-gamma, have been reported in several series. We studied whether these side effects could be precluded by preventing leakage from the isolated circuit into the systemic circulation. METHODS Clinical and pharmacokinetic data for 20 consecutive patients with recurrent melanoma of the limbs who were treated by ILP with TNF-alpha (3-4 mg) and melphalan, with or without interferon-gamma, were studied. Leakage rates and TNF-alpha levels were determined during and after ILP and were correlated with systemic toxicity and hemodynamic changes. RESULTS Only two patients experienced leaks (2% and 13%) during ILP. For 18 patients without leakage, the mean peak systemic TNF-alpha level was 2.8 ng/ml at 10 minutes after ILP. After leakage, the peak systemic TNF-alpha levels were 31.9 and 88.3 ng/ml at 5 minutes. Toxicity was mild and consisted mainly of fever (n = 17) and nausea/vomiting (n = 19) during the first day after ILP. Some patients developed tachycardia (n = 6), hypotension (n = 3; responding immediately to fluid challenge), a decrease in the WBC count (n = 3; grade I) or thrombocyte count (n = 11; grade I/II, no hemorrhage or therapeutic intervention), or hepatotoxicity [cytolysis (n = 15; 14 grade I/II and 1 grade IV) or hyperbilirubinemia (n = 7; grade I/II, all resolving spontaneously)]. Patients with tachycardia or hepatotoxicity exhibited significantly higher TNF-alpha levels after ILP, compared with other patients. CONCLUSIONS Systemic toxicity after ILP with TNF-alpha is minimal and does not differ from that after ILP with melphalan alone when leakage is adequately controlled.
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Affiliation(s)
- B C Vrouenraets
- Department of Surgery, The Netherlands Cancer Institute (Antoni van Leeuwenhoek ziekenhuis), Amsterdam
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