Intra-arterial infusion therapy with 5-(3,3-dimethyl-1-triazeno) imidazole-4-carboxamide (NSC 45388) for malignant melanoma

[Treatment of metastatic malignant melanoma localized to an extremity]

BACKGROUND

At the Norwegian Radium Hospital, most patients who were treated for metastases (localized to an extremity) from malignant melanoma in the period 1977-99 underwent intra-arterial chemotherapy combined with radiotherapy. We have evaluated the effects of this treatment, which has now been replaced by isolated limb perfusion (with melphalan and tumor necrosis factor).

MATERIAL AND METHODS

Medical records were reviewed for patients with metastatic malignant melanoma (localized to an extremity) who had been treated at the Norwegian Radium Hospital with intra-arterial chemotherapy (5-[3,3 dimethyl-1-triazeno]-imidazole-4-carboxamide [DTIC]) in the period 1977-99.

RESULTS

36 patients had received such treatment; in 30 of these the induction treatment was combined with radiation of the tumour area.. 24 patients were in complete remission after treatment (12 of these had all the metastases surgically removed before treatment). Nine patients had a partial remission while three patients had progressive disease. Median observation time was 49 months. 15 of 31 patients had an observation time of more than five years, and seven of these patients were alive after ten years. Three patients with metastasis localized to the lower extremity died of other causes. In one case the intra-arterial catheterisation caused serious aortic damage.

INTERPRETATION

It is possible to achieve long-term remission in patients with metastatic malignant melanoma localized to an extremity after intra-arterial chemotherapy combined with radiotherapy.

Pharmacokinetics of dacarbazine in the regional perfusion of extremities with melanoma

BACKGROUND

The pharmacokinetics of dacarbazine (DTIC), which has been shown to be an effective therapeutic agent against metastatic melanoma, has not been extensively studied. However, to improve the clinical use of the drug, more information on the kinetics is required.

METHODS

A pharmacokinetic study was undertaken in six patients with melanoma of an extremity who were undergoing hyperthermic isolation perfusion with DTIC in order to understand better its clinical pharmacokinetics. Plasma was sampled from the arterial and venous lines of an extracorporeal pump during the perfusion with the systemic vein and urine sampled postperfusion. Samples were analyzed for DTIC. 2-azahypoxanthine (2-AZA), and aminoimidazole carboxamide (AIC). 99(m)Tc (Technetium) human serum albumin (HSA) was used in the perfusion circuit to monitor the crossover of the perfusate into the systemic circulation during the procedure. The data were analyzed using a compartmental model of sampled body compartments incorporating the isolated extremity.

RESULTS

High tissue DTIC levels were maintained throughout the perfusion, whereas in the systemic circulation, plasma DTIC concentrations, when observed, were 40-100-fold less than those in the perfusate. Almost 70% of the DTIC administered was not recovered in the perfusate after the washout of the extremity.

CONCLUSIONS

High levels of DTIC can be maintained in an extremity (i.e., arm or leg) during perfusion.

Local hyperthermia and systemic chemotherapy for treatment of recurrent melanoma

Thirty-two patients with recurrent (skin) or metastatic (skin, node, or both) melanoma have been treated with a hyperthermia-cisplatin regimen. The hyperthermic treatment was carried out for 60 minutes at 43 degrees C with the MHS-SMA and the Sapic SVO3 ALENIA devices once a week. When the tumor temperature reached 42 degrees C, cisplatin was administered at a dosage of 50 mg/m2 given by intravenous bolus infusion. The treatment was repeated four times and the tumor response evaluated 4 weeks after the last treatment. Significant systemic or local toxicity was not seen. In terms of results, there were 9 patients with complete responses (28.1%), 13 with partial responses (40.6%), 8 with no change (25.0%), and two with disease progression (6.3%). The objective response rate was 68.7%. The response duration for those with complete responses ranged from 4 to 49 months (median 20 months). The median time to progression for patients with partial responses and those with no change was 6 and 5 months, respectively, with ranges of 1-7 and 1-10 months, respectively. The 4-year actuarial survival rates were 47.6% and 20.3% for the complete and incomplete responders, respectively. These results can be considered satisfactory, taking into account that most patients were pretreated with radiotherapy, chemotherapy or both, confirming the therapeutic potential of the hyperthermia and cisplatin regimen.

Management of recurrent cutaneous melanoma

Recurrent melanoma occurs in approximately one third of patients treated for cutaneous melanoma. Although the majority of recurrence occurs within the first few years of primary therapy, a significant number remains at risk beyond 10 years. With rising incidence of recurrent melanoma in Western countries, physicians will undoubtedly face the challenge of managing these patients with the limited therapeutic options currently available. Once melanoma has recurred, the overall prognosis is poor. Localized disease is best treated with complete resection, if indicated. Our existing armamentarium for systemic treatment falls short of altering the course of natural history of melanoma, but regional chemotherapy is an effective modality for in-transit disease and satellitosis. Translational research in molecular genetics and immunology will fuel new ideas for the design of rational strategies toward tumor eradication. Ongoing trials that use gene-modified melanoma cells have begun a new chapter in cancer therapeutics and lend us a closer examination of bench-top science at the bedside.

Hyperthermic antiblastic perfusion in the treatment of local recurrence or "in-transit" metastases of limb melanoma

On the basis of personal experience and a review of the literature, the authors have evaluated the results obtained with hyperthermic antiblastic perfusion (HAP) for the treatment of stage II, III and IIIAB limb melanoma. The evaluation showed that today HAP may be considered a safe and effective treatment, with a major complication rate ranging between 1% and 4%. In terms of tumor response, locoregional control and survival, this treatment has provided better results than other regional chemotherapeutic modalities and undoubtedly better results than those obtained with conventional, even radical, surgery. The multiparametric analysis showed that, of the treatment-related prognostic factors, the minimum tumor temperature influenced the percentage of complete response (CR) to the greatest extent (P < 0.03), with a positive trend also with regard to the dosage of the antiblastic drug employed (P < 0.08). In turn, the complete response rate was a determinant as far as locoregional control (75.3%; P < 0.0009) and disease-free (51.4%; P < 0.009) and overall survival (63.2%; P < 0.009) rates were concerned. Of the tumor-related prognostic factors, the number of lesions (P < 0.0014), sex (P < 0.04), and the number of disease recurrences (P < 0.01) appear to influence overall survival.

A phase II study of the efficacy of diamminedichloroplatinum (cisplatin) for the control of locally recurrent and intransit malignant melanoma of the extremities using tourniquet outflow-occlusion techniques

A phase II trial was conducted with 15 patients (mean age of 65.7 years) with locally recurrent or intransit melanoma of the extremities. After total outflow occlusion with pneumatic tourniquet, the cell-cycle nonspecific anti-neoplastic agent cis-diamminedicholoroplatinum (CDDP) was infused intra-arterially in a mean dose of 26.7 mg/m2 per infusion (2.6 infusions per patient). The aim of this study was to determine the efficacy of CDDP infusion for control of intransit and recurrent melanoma of the extremities. Three to four weeks postinfusion, all visible residual disease was resected. Partial remissions were observed in ten patients (67%); five patients achieved stable disease status. No patient had complete regression of disease. At an average follow-up interval of 18.3 months (range 4-44 months), the mean local/regional disease-free survival was 14.8 months. Eighty per cent of patients (twelve of 15) had local/regional control of disease at an average follow-up of 14.8 months after CDDP infusion and surgical resection. Of five melanoma-related deaths, three patients had had no local/regional recurrence at the time of their demise. Three compartment syndromes resulted as a complication of the infusional therapy and occurred within 1-3 days of the treatment. In vitro growth of melanoma from lymph nodes draining the infused area was seen in all subjects studied. Outgrowth from tumor within the tourniquet infusion area was observed in two patients, both of whom experienced recurrences clinically at 24-months' postinfusion. Pharmacokinetic data of total CDDP concentrations from tissue and blood (n = 4) were available from pretreatment to 1 hour post-therapy. Biopsy data from patients pre- and post-treatment suggest substantial tumor uptake of CDDP as compared to local or distal normal skin, with minimal CDDP loss to the systemic circulation. Pharmacologic and clinical data of this phase II trial suggest that intraarterial infusion with tourniquet outflow-occlusion augments tumor tissue levels of CDDP within the infused extremity and enhances local control of high-risk and intransit disease.

Toxicity and complications of vascular isolation and hyperthermic perfusion with imidazole carboxamide (DTIC) in melanoma

The authors have used imidazole carboxamide (DTIC) in vascular isolation and hyperthermic perfusion for melanoma. The regional and systemic toxicity and complications of this procedure were studied in 40 cases with Stage III (15) and Stage I (25) melanoma. Technetium 99m-labelled serum albumin crossover and pharmacokinetic studies were done simultaneously to see if these correlate with toxicity. Local toxicity on muscles, nerves, skin, and arteries was conspicuously absent despite using dosages of 2 g/m2 (40-45 mg/kg) for the lower extremity and 1.2 g/m2 (24-28 mg/kg) for the upper extremity. Skin and core temperature were raised to 39 degrees C to 40 degrees C. Deep vein thrombosis was noted in three patients. No death or gangrene of the extremities occurred. Local infection was noted in only one patient. Fourteen patients (35%) manifested bone marrow toxicity (leukocyte count of 4000/mm3 or platelets of 100,000/mm3) in the second or third week after perfusion. Severe hematologic toxicity was seen in two instances. Dosages of DTIC greater than 40 mg/kg were associated with toxicity in 65% of the patients. No bleeding complications occurred in seven patients with thrombocytopenia. Measurement of crossover and recovery of radionuclide were not reliable indicators of subsequent systemic toxicity. Perfusion fluid balance data also were of no predictive value. Forty-seven percent of the administered DTIC was recovered in washout fluid. Of this, less than 2% was converted to its metabolites, that is aminoimidazole carboxamide and 2-azahypoxanthine. Thirty-five of 40 patients experienced mild nausea and vomiting. Transient and mild hepatotoxicity was noted in seven patients. It appears that DTIC hyperthermic isolation perfusion is a safe procedure, however, the total dosage should be below 40 mg/kg to avoid hematologic toxicity.

Dosimetry of cytostatics in hyperthermic regional isolated perfusion

During the period from February to October 1983, 21 patients with malignant melanoma of the extremities were treated by hyperthermic regional isolated perfusion with L-phenylalanine mustard (melphalan). The melphalan dose for each patient was determined by the tissue volume of the perfused region, using a dose of 10 mg/l perfused tissue. Despite an average increase of melphalan dosage of 18% above the maximum for iliac perfusions recommended in the literature, no increase in toxic tissue reactions was observed after hyperthermic iliac perfusions. The same dose of 10 mg/l perfused tissue was used in hyperthermic axillary perfusions, resulting in an average decrease of melphalan dosage of 14% below the minimum recommended in the literature. By applying a constant dose per unit tissue volume, a standardization of treatment is achieved. This excludes variations like body weight, age, type of complexion, and hair color, which so far have determined dosimetry.

Better prognosis of many cancers in female: a phenomenon not explained by study of steroid receptors

Experimental evidence indicates that specific sex hormonal imbalance, deficiency, and excess may be causes of tumors or at least contribute in some way to their development. Clinical observations show that the prognoses of patients with various malignancies differ among males and females, and some cancers can be alleviated and partially controlled by altering the accustomed hormonal environment. Although beneficial effects usually are only temporary, there is no doubt that some cancers are hormone-dependent to a degree. A significant number of prostatic carcinoma in males and breast carcinoma in both sexes have been treated with various additive or ablative endocrine manipulations. The detection and quantitation of specific steroid binding proteins in hormone-sensitive tumors have enhanced our understanding of the mechanism of endocrinal therapy. Excluding carcinoma of the breast and of the sex organs (ovary and uterus in females, testis and prostate in males), many other solid tumors have been tested for the presence of estrogen and other steroid receptors. A fair number of solid cancers contains estrogen and progesterone receptors (ER, PR), even those from male patients. Thus, the better prognosis of females with sarcoma, melanoma, liver, colorectal and other cancers cannot simply be explained by the presence or absence of estrogen or progesterone receptors. This review attempts to summarize clinical reports of this interesting phenomenon, including therapeutic results with estrogenic, antiestrogenic, and other hormonal approaches.

Thermochemotherapy for melanoma metastases in liver

Metastatic melanoma in the liver has carried an extremely poor prognosis regardless of therapy. Because transient responses (1/6 disease regressions and 2/6 disease stabilizations for four months) in selected patients treated with intraarterial (IA) DTIC infusion were encouraging and because localized hyperthermia may be both tumoricidal and synergistic with chemotherapy, these modalities were combined for treatment of patients with advanced liver metastases. Of 10 patients treated with IA-DTIC plus heat, three (30%) had disease-regression and five (50%) had disease stabilization for 3-14 months (median 6.5 months) and survived 3.5-18 months (median 8.5 months). During treatment, 4/5 patients had pain relief and 7/10 retained or acquired normal activities. Myelosuppression was minimal and no hyperthermia toxicity occurred. A retrospective review of 10 patients with similar disease levels who were treated with conventional intravenous (IV)-DTIC indicated no responses, and no responses were seen in five patients treated with IV-DTIC plus heat. However, this latter group may have been selected patients due to the inability to place a percutaneous hepatic artery infusion catheter. This pilot study suggests that combination IA-DTIC and hyperthermia has a high response rate, is safe, and can provide quality survival for many patients.

Pharmacokinetics of dacarbazine (DTIC) and its metabolite 5-aminoimidazole-4-carboxamide (AIC) following different dose schedules

The pharmacokinetics of dacarbazine (DTIC) and its main metabolite 5-aminoimidazole-4-carboxamide (AIC) have been studied in eight patients with malignant melanoma or sarcoma receiving 2.65--6.85 mg DTIC/kg body weight by intravenous bolus injection or by continuous 0.5--6-h infusions on 5 consecutive days. The plasma disappearance of DTIC was biphasic, with a terminal half-life of 41.4 min (range 30.3--51.6 min). The mean distribution volume of DTIC was 0.632 liters/kg and the total clearance was 15.4 ml/kg . min (range 8.7--23.3 ml/kg . min). The renal clearance of DTIC was 5.2--10.9 ml/kg . min, indicating that about 50% of DTIC was eliminated by extrarenal mechanisms. The plasma decay of AIC was mono-exponential with a half-life of 43.0--116 min. A renal clearance of 2.6--5.3 ml/kg . min was calculated for AIC. The urinary recovery was 46%--52% for DTIC and 9%--18% for AIC. The plasma concentrations of DTIC observed during 0.5--6-h infusions of DTIC (5.45--6.85 mg/kg) were 0.66--6.2 micrograms/ml. Comparison of various dosage schedules within the same patient did not reveal relevant differences of the areas under the concentration-time curves. Immunotherapy with Bacillus Calmette-Guérin (BCG) did not significantly influence the pharmacokinetics of DTIC. During isolated extremity perfusion with DTIC (75--130 mg/kg extremity) for treatment of malignant tumors of the extremities concentrations of DTIC ranged from 150--500 micrograms/ml perfusate. There was no evidence of AIC formation. In isolated liver perfusion experiments in anesthetized dogs metabolic degradation of DTIC to AIC was demonstrated.

The surgical management of anorectal malignant melanoma

The biological vagaries of anal malignant melanoma are illustrated by four cases in Chinese patients. All four died within five years. Their poor prognosis emphasizes the value of preoperative studies to detect clinically occult metastases and obviate futile radical surgery. Many patients already have disseminated disease at the time of diagnosis, and local excision of the tumour provides acceptable palliation. For localized disease, abdominoperineal resection prevents local recurrence and removes the mesenteric nodes which are frequently involved. Palpable inguinal nodes necessitate therapeutic groin dissection, but we perform elective resection only when affected nodes are found at laparotomy. Pelvic lymphadenectomy should be performed in conjunction with abdominoperineal resection. The efficacy of chemotherapy for anorectal melanoma remains uncertain.

Treatment of malignant melanoma with dacarbazin (DTIC-DOME) with special reference to urinary excretion of 5-S-cysteinyldopa

Seventeen patients were given DTIC, 200 mg/m2/day in five-day courses every four to six weeks. In four patients (stage II) treated on an adjuvant basis, tumor recurrence has been verified in three. Four of the palliatively treated patients were also given DTIC by regional intra-arterial infusion with minimal positive tumor effect and minimal toxicity. 5-S-cysteinyldopa excretion in urine was checked continuously in all patients. Tumor recurrence was revealed in two patients given DTIC on an adjuvant basis three and four months before clinical signs of tumor. In the palliatively treated patients, 5-S-cysteinyldopa excretion increased in 5/6 patients judged to have stable disease, before tumor progression was clinically detectable. The use of 5-S-cysteinyldopa examination is a valuable adjunct to the follow-up of the effect of DTIC therapy in melanoma patients.

Effect of cobalt-60 gamma rays and DTIC (5-(3,3 dimethyl-1-triazeno)-imidazole-r-carboxamide) on human malignant melanomas grown in athymic nude mice

The effects of 60Co gamma rays and DTIC on two human malignant melanomas, inoculated and passed serially in athymic mutant nude mice, were studied in vivo. Dose-response curves determined after single exposures to 60Co gamma radiation indicate that human malignant melanomas remain radioresistant after transplantation in mutant nude mice. A fractionated irradiation régime, used in the treatment of patients suffering from malignant melanomas, had a considerable effect but did not cure. A corresponding treatment régime with DTIC inhibited the tumour growth, but less effectively than 60Co gamma rays. These two treatments combined were more effective than either alone. The results obtained show no disagreement with results from clinical practice regarding treatment of disseminated malignant melanomas. This suggests that human malignant tissue, transplanted to mutant nude mice, retains its properties with respect to response to therapy. The mutant nude mouse may therefore be valuable in developing new treatment régimes for cancer.