Tourniquet infusion versus hyperthermic perfusion

Diagnosis and treatment of in-transit melanoma metastases

In transit metastases (ITM) from extremity or trunk melanomas are subcutaneous or cutaneous lymphatic deposits of melanoma cells, distant from the primary site but not reaching the draining nodal basin. Superficial ITM metastases develop in 5-10% of melanoma patients and are thought to be caused by cells spreading along lymphatics; ITM appear biologically different from distant cutaneous metastases, these probably due to a haematogenous dissemination. The diagnosis is usually clinical and by patients, but patients need to be adequately educated in the recognition of this clinical situation. Ultrasound or more sophisticated instrumental devices may be required if the disease develops more deeply in the soft tissues. According to AJCC 2009 staging classification, ITM are included in stages IIIb and IIIc, which are considered local advanced disease with quite poor 5-year survival rates and outcomes of 24-54% at 5 years.² Loco-regional recurrence is in fact an important risk factor for distant metastatic disease, either synchronous or metachronous. Therapy for this pattern of recurrence is less standardised then in most other clinical situations and options vary based on the volume and site of the disease. Definitive surgical resection remains the preferred therapeutic approach. However, when surgery cannot be performed with a reasonable cosmetic and functional outcome, other options must be utilized.^3-6 Treatment options are classified as local, regional or systemic. The choice of therapy depends on the number of lesions, their anatomic location, whether or not these are dermal or subcutaneous, the size and the presence or absence of extra-regional disease.

Treatment of locally advanced melanoma by isolated limb infusion with cytotoxic drugs

Since its introduction in the late 1950s, isolated limb perfusion (ILP) has been 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 tumor types. A drawback of ILP, however, is the invasive and complex character of the procedure. Isolated limb infusion (ILI) has been designed in the early 1990s as a minimally invasive alternative to ILP. Results of this simple procedure, reported by various centers around the world, show comparable response rates for melanoma and sarcoma when compared to ILP. Due to its minimally invasive character, ILI may replace ILP in the future as the preferred treatment for these locally advanced limb tumors.

Isolated limb infusion with melphalan and actinomycin D in melanoma patients: factors predictive of acute regional toxicity

IMPORTANCE OF THE FIELD

Isolated limb infusion (ILI) is a simple, minimally invasive technique of delivering high concentrations of cytotoxic drugs to a diseased limb for achieving disease control in that limb. Recent studies have suggested that mild hyperthermic (38 degrees C) ILI might be the best initial treatment for extensively recurrent limb melanoma given its simplicity, low morbidity and a complete response rate of 30 - 40%.

AREAS COVERED IN THIS REVIEW

Since 1994 when ILI was first described by Thompson et al., the procedure has been adopted by several centres around the world; research and improvements in the technique have resulted in reduction in limb toxicity without reducing its clinical efficacy. The pharmacokinetics of melphalan and the clinical efficacy and adverse effects of ILI from various centres are summarised. Minor but possibly important differences in the ILI techniques used in different institutions may be important in improving its efficacy and reducing the toxic effects.

WHAT THE READER WILL GAIN

An understanding of the efficacy and toxicity associated with ILI with cytotoxic drugs in melanoma patients and of methods to optimise regional therapy for malignant disease in a limb.

TAKE HOME MESSAGE

ILI with mild hyperthermia (38 degrees C) is well tolerated with tumour remission rates in melanoma patients similar to those achieved by isolated limb perfusion. Mild (grade I - II) and moderate/severe (grade > or = III) limb toxicities occur in 58 - 68% and 32 - 41% of patients, respectively, but long-term morbidity is rare. A high peak and high final melphalan concentration in the infusate, the AUC of melphalan concentration in the infusate and an increased postoperative serum creatine phosphokinase concentration are factors predictive of acute regional toxicity. Drug dose adjusted for ideal body weight and gender may reduce acute toxicity following ILI. It has been suggested that the use of papaverine prior to the infusion of melphalan might increase its efficacy, but it may also increase toxicity. Large prospective studies are needed to more accurately define the perioperative factors that influence acute regional toxicity after ILI and to establish strategies to optimise clinical outcome.

Isolated limb infusion: a review

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.

Deliberate hypoxic pelvic and limb chemoperfusion in the treatment of recurrent melanoma

BACKGROUND

The treatment of patients with advanced or recurrent pelvic melanoma, which are often associated with lesions in the lower limbs, is still unsatisfactory and controversial. A simplified hypoxic pelvic and limb perfusion has been recently recommended to provide therapeutic options for palliation and possibly cure.

METHODS

A nonrandomized and noncontrolled phase II experimental study was performed in 11 patients with symptomatic unresectable recurrent melanoma of the pelvis and limb. Patients were submitted to hypoxic pelvic and limb perfusion with 25 mg/m(2) of melphalan, 50 mg/m(2) of cisplatin, 300 mg/m(2) of dacarbazine, and 75 mg/m(2) of epirubicin by means of a simplified balloon occlusion technique. Response rate and time to disease progression were the primary endpoints; overall survival was the secondary endpoint.

RESULTS

During the procedures there were no technical, hemodynamic, or vascular complications, and no deaths occurred during surgery or in the postoperative period. Response rate was 82% (95% confidence interval, 58% to 100%). Median time to disease progression was 12 months (range 9 to 30 months). Three-year overall survival was 34%.

CONCLUSIONS

Hypoxic pelvic and limb perfusion is a safe and good palliative treatment for patients with unresectable recurrent melanoma. Further studies are necessary to to confirm these data and to establish if refinements can be made with acceptable toxicity.

Isolated limb perfusion with tumour necrosis factor-alpha and melphalan for unresectable bone sarcomas of the lower extremity

AIMS

Isolated limb perfusion (ILP) with recombinant tumour necrosis factor-alpha (rTNF-alpha) and melphalan has recently been reported to induce major tumour responses and permit limb salvage in over 80% of patients with unresectable soft-tissue sarcomas of the extremities. We investigated whether TNF-based ILP could allow limb-sparing surgery in patients with primary, recurrent or metastatic bone sarcoma to the lower extremity who met the criteria for an amputation and had failed or refused chemotherapy.

METHODS

From August 1992 to December 1997, we employed ILP with rTNF-alpha and melphalan in 13 patients with unresectable bone sarcoma of the lower extremity, all of whom were candidates for amputation. The aim was to reduce tumour size and allow the performance of a limb-sparing surgery (LSS).

RESULTS

Following ILP, none of the patients had severe local toxicity and only one patient experienced significant systemic side-effects. LSS was subsequently performed in nine of the 13 patients. LSS was feasible in an additional three patients but was not performed because of the emergence of diffused metastatic disease.

CONCLUSIONS

ILP with rTNF-alpha and melphalan can allow limb salvage in patients wih locally advanced bone sarcomas who had failed standard treatment options. Its potential role in the treatment of unresectable bone sarcomas of the extremities merits further evaluation.

Treatment and local control of primary extremity soft tissue sarcomas

BACKGROUND AND OBJECTIVES

Modern series of adult extremity soft tissue sarcomas utilize combinations of modalities in all patients. Remaining questions: 1) is it necessary to strive for wide margins in the multimodality era; 2) to use adjuvant therapy in every high-grade sarcoma? 3) Does previous partial or marginal resection seriously interfere with the definitive resection?

METHODS

In a retrospective review of 194 extremity soft tissue sarcomas (1977-1994), limb preservation was possible in 181/194 (93%) of cases. Patients with narrow margins received adjuvant radiation. Some patients were referred after partial (n = 39) or "complete" (n = 63) excision.

RESULTS

Local recurrence was observed in 181/141 (13%) of patients treated with wide or compartmental resection, and in 10 of 42 (24%) of those treated with conservative resection plus radiation (P = 0.14). The 5-year survival rate for grade III, >/=5-cm sarcomas was not significantly different (P = 0.82) with adjuvant (46%) or without (48%) adjuvant systemic chemotherapy. Five-year survival varied (P = 0.0001) according to grade. Patients referred with partial, or "complete" (63%, 38/63, had residual tumor at reoperation) excision had a local recurrence rate of 8% and 6%, and 5-year survival rates of 75% and 84%, respectively.

CONCLUSIONS

1) It is important to strive for wide margins even when adjuvant radiation is intended. 2) When a wide margin is possible, adjuvant radiation may not be necessary. 3) Adjuvant systemic chemotherapy may be considered for high-grade tumors, preferably within a prospective protocol. 4) A partial or "complete" excision of the tumor before referral to a tertiary center does not appear to compromise the limb preservation, local control, or survival rates of these patients.

Isolated limb infusion with cytotoxic agents: a simple alternative to isolated limb perfusion

Isolated limb perfusion (ILP) with cytotoxic agents is an effective but complex procedure. Isolated limb infusion (ILI) has been developed as a simpler alternative. Catheters are inserted percutaneously into the axial artery and vein of the affected limb and a pneumatic tourniquet is inflated proximally. Cytotoxic agents are then infused through the arterial catheter and circulated with a syringe for 15 to 20 minutes. Progressive hypoxia occurs, but normothermia is maintained. To date, 175 ILIs have been performed: 164 for melanoma and 11 for other tumours. Results obtained are similar to those obtained by conventional ILP. Morbidity is low and treatment of frail and elderly patients who would not tolerate ILP is possible. An elective double ILI protocol can be used to obtain the additional benefits of fractionated chemotherapy. The possibility of increasing ILI response rates by using other drugs and drug combinations and by multiple fractionated dosing is being investigated.

Tourniquet infusion chemotherapy for extremity in-transit lesions in malignant melanoma

BACKGROUND

Perfusion remains the standard of regional chemotherapy for extremity in-transit lesions from melanoma. However, there is an interest in other forms of intraarterial chemotherapy due to the simplicity and feasibility of repeat administration of the latter.

METHODS

Review of 51 patients with extremity in-transit lesions from melanoma treated with the tourniquet infusion (TI) method on the basis of a prospective protocol. Drugs used were either Adriamycin (group A) or Dacarbazine (DTIC) + cisDDP (group B). The median number of courses was two. Lesions were resected at the same time as TI (n = 27) or after a month or more of observation in the absence of complete regression.

RESULTS

There was no significant difference in response rates between groups A and B. The overall objective response rate in 24 evaluable patients was 75%, being complete in seven (29%), partial (> 50%) in 11 (46%), minor (< 50%) in three (12.5%), and progression of disease in three (12.5%). At a mean follow-up time of 40 months, no recurrence was observed in the treated extremity in 18 patients (35%), but further recurrences were noted in 31 patients (61%). The 5-year survival rate was 30%.

CONCLUSION

TI provides an objective response rate of 75% for in-transit lesions, but after TI and resection of in-transit lesions as needed, the recurrence rate in the treated extremity is high (61%). Further work is needed with higher drug doses, local hyperthermia, or the administration of suitable doses of new regimens that are more successful with perfusion.

Thirty-five years of isolated limb perfusion for melanoma: indications and results

Isolated limb perfusion (ILP) for limb melanoma remains controversial despite its frequent use for over 35 years. To determine whether it has proven benefits, reported results have been reviewed. The value of adjuvant ILP cannot be determined from the multitude of retrospective studies on this subject. Preliminary results of the large European Organization for Research and Treatment of Cancer-World Health Organization-North American Perfusion Group trial suggest that patients with melanomas of 1.5-3.0 mm in thickness who do not undergo elective lymph node dissection may have a locoregional control benefit from ILP. However, as long as a definite survival advantage for ILP has not been demonstrated, such treatment does not seem justified for these patients. The value of prophylactic ILP after resection of recurrent limb melanoma is also scientifically unproven. The potential prevention of further limb recurrence for only a limited period of time, as demonstrated in a rather small Swedish trial, probably does not justify routine use of ILP in these patients; a large international trial will be needed to assess whether ILP provides a survival advantage. For those with locally inoperable limb melanoma, ILP appears to be the treatment of choice since it results in complete disappearance of all macroscopic disease in a substantial proportion of patients, removing the need for amputation and providing palliation of symptoms. However, high limb recurrence rates and short duration of response need improvement. Results of alternative treatments should be compared prospectively with those of ILP in this clinical situation.

Complete disappearance of a leiomyosarcoma of the lower extremity following preoperative hyperthermia and intra-arterial doxorubicin

Leiomyosarcoma of the extremities is an unusual tumor. Herein we report a unique and what we believe is the first case of a patient in whom there was complete disappearance of such a tumor following regional hyperthermia and chemotherapy.

Results of a double perfusion schedule with melphalan in patients with melanoma of the lower limb

From 1985 to 1990 43 patients with measurable locally inoperable or recurrent melanoma of the lower limb were treated according to a double perfusion schedule. The dose of melphalan given in the first perfusion was low (6 mg/l; 1 h; normothermic) in order to make it possible to carry out a second perfusion (9 mg/l; 1 h; normothermic) with a planned short interval of 3-4 weeks. The toxicity after the first perfusion was slight; after the second it was higher with a Wieberdink grade III reaction in 15 patients. A clinical complete remission (CR) was seen in 33 patients (77%) and a partial one in 6 patients. 16 of the 33 patients with a CR recurred in the perfused area after 5 months (range 1-29); the others remained limb recurrence-free (7-44+ months). The overall 3-year survival rate is 50%, 19 patients are alive with no evidence of disease. The double perfusion schedule shows a high CR rate, an acceptable toxicity and is technically feasible.

Neoadjuvant intraarterial chemotherapy of soft tissue sarcomas

A group of 51 patients with extremity sarcomas of soft-tissue origin received preoperative intraarterial (i.a.) chemotherapy via a percutaneously placed catheter. Treatments were performed as a series of chemotherapy cycles, giving a total of 129, and were carried out in the form of short-term infusions consisting of doxorubicin and cisplatin, which lasted for 20-40 min. These i.a. infusions were combined with complementary methods, such as a tourniquet, occlusion-infusion and chemoembolization. In 3 patients complete remission and in 21 partial remission was registered, while in 27 patients only minimal response could be achieved, although in this latter group necrosis of eight tumors proved to be of significant value. In 43 of 51 patients successful limb salvage surgery was carried out.

Tumour uptake of monoclonal antibody after regional intraarterial injection. Biokinetics in the nude rat heterotransplanted with malignant melanoma

Nude rats were heterotransplanted with human melanoma metastases on both thighs. Ten days later a bolus of 125I-labelled monoclonal antibody (MAb) 96.5 was injected through a catheter in the common femoral artery. The femoral vein was clamped for 15 min to obstruct the venous outflow from the injected leg. The specific tissue uptake (%/g) in the tumour on the injected side compared to the non-injected side showed initially higher uptake (ratio 7.2 at 3 h). After 24 h there were no side differences. The tumour to muscle ratio was 2.8 at 3 h when injected and control sides were compared. Intravenous or subcutaneous injection gave similar specific tissue uptake as regional arterial injection after 24 h. Tissue to plasma ratios were similar after intravenous and subcutaneous injection of monoclonal antibodies. Intraarterial injection of a bolus of labelled monoclonal antibodies and obstructing the venous outflow thus increased the tumour uptake during a short period of time during which the contrast enhancement was three-fold.

Therapy for cutaneous melanoma: an update

This article reviews the current therapy for cutaneous melanoma. Diagnosis, staging, and prognostic evaluation, which are crucial to proper management, are discussed. Surgical excision is the treatment of choice for primary melanoma. The resection margins should be tailored to tumor thickness. Guidelines for surgery are presented. The controversy about elective regional lymph node dissections is discussed. Limb perfusion, chemotherapy, immunotherapy, radiotherapy, and hormonal therapy as adjuvant treatments of primary melanomas as well as the treatment of disseminated melanomas are reviewed and new developments are highlighted. Guidelines for the management of metastatic melanoma at various sites are given. Special issues such as "pregnancy/estrogen and melanoma" and "borderline melanoma" are discussed and approaches to these problems are suggested. Recommendations are given for the follow-up and counseling of patients with melanoma.

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.

Preoperative intra-arterial chemotherapy

The major factors affecting prognosis of patients with soft tissue sarcomas are local control, size of the primary tumor, and the grade of the tumor. The only factor that can be influenced following appropriate diagnostic procedures is local control. Surgery alone, even radical surgery or amputation, is insufficient to control large, poorly differentiated tumors in many cases. Preoperative therapy has been shown to be a highly effective method for local disease control. Intra-arterial therapy appears to have several advantages in the treatment of extremity sarcomas. (1) Intra-arterial therapy results in at least a sixfold increase in the concentration of drug in the blood perfusing the tumor. If combined with proximal occlusion of blood flow (balloon occlusion or tourniquet occlusion), the concentration of drug being delivered to the tumor may increase by 30-fold [32]. This high local concentration of chemotherapy is achieved in most cases without the high systemic toxicity that would be required by intravenous therapy. (2) Chemotherapy infusion prior to surgery allows administration of cytotoxic therapy through an undisturbed blood supply. This allows for an improved effect of therapy at the tumor margin, which is the area at risk for seeding the wound at the time of extirpative surgery. This may facilitate limb salvage in patients with bulky tumors. (3) Responses to this preoperative therapy allows an in vivo evaluation of the efficacy of the drug against the individual tumor. This may aid in determining efficacy of using the drug for postoperative adjuvant therapy. (4) Preoperative therapy allows treatment of the tumor while awaiting construction of custom prostheses, especially in patients with osteosarcomas of the extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraarterial chemotherapy of soft-tissue sarcomas

This review compares the results of preoperative intraarterial chemotherapy delivered by various methods, such as intraarterial injection/infusion, tourniquet infusion, and isolation perfusion, with the results achieved by pre- and postoperative radiotherapy. The histological heterogeneity of soft tissue sarcomas adds to the inherent difficulties of comparing results across studies. There is a clear need for randomized studies to directly compare these treatment modalities in similar patient populations. Patients with these rare tumors would benefit from the expertise of multidisciplinary teams available at the larger centers. Metastatic spread, which even with the highest rates of local control, occurs in approximately 30% of high grade soft tissue sarcomas, represents a continuing challenge, and innovative approaches are needed to control systemic disease.

The safe use of cisplatin in hyperthermic isolated limb perfusion systems

A patient presenting with aggressive squamous cell carcinoma successfully received cisplatin chemotherapy via hyperthermic, isolated limb perfusion (renal impairment ruled out systemic use). Human tumor stem cell assay identified cisplatin as the drug of choice and supports the potential benefit of this procedure in single therapeutic situations. The case illustrates the safety of cisplatin and the ability to give large doses of the nephrotoxic drug with no damage to renal function. The potential efficacy over systemic cisplatin has yet to be established except when systemic use is limited from renal dysfunction.

A clinical and pharmacokinetic study of isolated limb perfusion with heat and melphalan for melanoma

The pharmacokinetics of isolated limb perfusion were studied to see what melphalan concentrations were achieved and how effective the isolation was. Twenty-eight patients received 32 limb perfusions with heat and melphalan for locally recurrent or level V melanoma. Melphalan was given 0.75 mg/kg for axillary/popliteal or 1.2 mg/kg for femoral perfusions with heat (perfusate 42 degrees C, limb 40 degrees C) for 1 hour. Melphalan concentratives were measured by high-performance liquid chromatography in seven patients. Peak perfusate melphalan concentrations were 6.1 to 115 mg/ml, which was one to two logs higher than peak systemic concentratives of melphalan. Isolation of the perfusate circuit from the systemic circulation was better for axillary and popliteal perfusions than for femoral perfusions (P less than 0.05). Complete responses were seen in 81% of evaluable patients; long-term local control was achieved in most patients, although many developed hematogenous metastases. Toxicity included erythema and edema in all, mild leukopenia in two, neuropathy in two, and amputation was required in one patient. Improvements in surgical technique include regional anesthesia to reduce vasospasms and transcutaneous measurement of fluorescein to measure leak. Perfusion with heat and melphalan remains the treatment of choice for in-transit metastases from melanoma.

Tourniquet infusion chemotherapy for osseous malignant lesions

Two patients with osseous malignant lesions were treated with the tourniquet infusion method. The first patient, with two metastatic lesions in the left femur resulting from a renal adenocarcinoma, had three courses of intra-arterial Adriamycin. Biopsies of these lesions showed that the distal lesion, which was perfused during each treatment, was histologically negative, whereas the proximal lesion, which was not perfused because of the position of the catheter, contained the viable tumor. The second patient, a 12-year-old girl with osteogenic sarcoma of the proximal portion of the right tibia, had three courses of intra-arterial chemotherapy with Adriamycin and cisplatinum, and then underwent open biopsy, which was histologically negative. Another open biopsy six months later was also histologically negative. She has normal use of her extremity and, at eleven months since the initiation of treatment, she remains disease free. The evaluation of the tourniquet infusion technique in greater numbers of patients with bone tumors under carefully controlled conditions, appears warranted.

Pelvic perfusion hyperthermia for advanced pelvic malignancies

Pelvic perfusion hyperthermia (PPH) for malignant gynecologic diseases in the pelvis was performed for four hours with favorable results. Serial monitoring of chemotherapeutic drug concentrations in the blood, tissues and circuit showed that the drugs were satisfactorily incorporated into the tumor bearing area and that the systemic leak was minimal with no demonstrable systemic side effects. The temperature of the tumor was kept between 41.8 degrees C and 42.7 degrees C for over three hours. The esophageal temperature was maintained below 40 degrees C throughout the procedure. In one patient, there was an eighty percent reduction in tumor size and in the other, a complete regression of the tumor. We conclude that the PPH is a procedure that warrants further attention as an adjunct to cancer therapy for malignant pelvic tumors.

Experimental and clinical observations of the effects of cytotoxic chemotherapeutic drugs on wound healing

The administration of perioperative doxorubicin HCl (Adriamycin) had profound effects on wound healing for 5 out of 7 breast cancer patients and 5 of 5 melanoma patients following intravenous and intra-arterial infusional chemotherapy, respectively. The clinical observation of significant reduction in wound tear strength (WTS) and wound tear energy ( WTE ) in the group of patients with cutaneous melanoma initiated this experimental analysis. A study of WTS ( kNm -2) in nontumor-bearing (non-TB) and Morris Hepatoma (MH)-7777 (TB) rats treated with therapeutic doses of Adriamycin (ADR) and methotrexate (MTX) was compared with saline-treated controls. Mean tumor volume (cm3) was unaffected by MTX, while significant tumor inhibition (p less than 0.01) was evident for ADR-treated TB animals. A correlation (r = 0.516, p less than 0.01) was observed for tumor volume and WTS. Separate analysis of TB and non-TB animals identified a significant correlation (r = 0.6259, p less than 0.01) between advancing cachexia in TB rats and WTS. A 21-day analysis was done for 160 animals to determine the effect of MTX and ADR on WTS ( kNm -2) and WTE ( Ncm -1). The presence of MH-7777 significantly (p less than 0.01) reduced WTE for TB animals not treated with chemotherapy. TB animals treated with ADR had significant (p less than 0.01) improvement in WTE at day 21 compared with TB controls. This enhancement in WTE was not observed in rats treated with MTX. These clinical and experimental observations suggest significant retardation of the early phases of wound fibroplasia as determined by WTS and WTE following operative trauma and subsequent administration of therapeutic dosages of cytotoxic agents.