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Di Raimondo C, Lozzi F, Di Domenico PP, Campione E, Bianchi L. The Diagnosis and Management of Cutaneous Metastases from Melanoma. Int J Mol Sci 2023; 24:14535. [PMID: 37833981 PMCID: PMC10572973 DOI: 10.3390/ijms241914535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Melanoma is one of the deadliest skin tumors, accounting for almost 90% of skin cancer mortality. Although immune therapy and targeted therapy have dramatically changed the prognosis of metastatic melanoma, many patients experience disease progression despite the currently available new treatments. Skin metastases from melanoma represent a relatively common event as first sign of advanced disease or a sign of recurrence. Skin metastases are usually asymptomatic, although in advanced stages, they can present with ulceration, bleeding, and superinfection; furthermore, they can cause symptoms related to compression on nearby tissues. Treatments vary from simple surgery resections to topical or intralesional local injections, or a combination of these techniques with the most recent systemic immune or target therapies. New research and studies should focus on the pathogenesis and molecular mechanisms of the cutaneous metastases of melanoma in order to shed light on the mechanisms underlying the different behavior and prognoses of different patients.
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Affiliation(s)
- Cosimo Di Raimondo
- Department of Dermatology, University of Roma Tor Vergata, 00133 Rome, Italy; (F.L.); (P.P.D.D.); (E.C.); (L.B.)
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Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature. Cancers (Basel) 2021; 13:cancers13215485. [PMID: 34771649 PMCID: PMC8583108 DOI: 10.3390/cancers13215485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. METHODS PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000-2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. RESULTS Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. DISCUSSION ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. CONCLUSIONS ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies.
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Ñamendys-Silva SA, Ruiz-Beltran AM, Barragán-Dessavre M, Bautista-Ocampo AR, Meneses-García A, González-Chon O, Herrera-Gómez A. Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion. Mol Clin Oncol 2017; 7:747-750. [PMID: 29142747 PMCID: PMC5666660 DOI: 10.3892/mco.2017.1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
The aim of the present study was to investigate the incidence of organ dysfunction, and to describe the clinical characteristics and intensive care unit (ICU) outcomes of critically ill cancer patients who were admitted to an oncological ICU during the isolated limb perfusion post-operative period. The present study was an observational investigation of 42 critically ill cancer patients who were admitted to the ICU of the Instituto Nacional de Cancerología, during the isolated limb perfusion post-operative period, between July 2010 and February 2016. The mean age of the patients was 45.7±16.9 years, and 45.2% (19 cases) were female. Soft tissue sarcoma was the most common pre-operative diagnosis (38.1%), and the mean duration of surgery was 267.6±50.1 min. Furthermore, a mean blood loss volume of 732.3±526.1 ml during the procedure was recorded, and the patients received a mean volume of 3.88±1.28 l crystalloid fluid during the surgical procedure, subsequently requiring an additional 2.95±6.28 l on the first post-operative day. The incidence of organ dysfunction was 90.5% and was most frequently noted in the respiratory (81%), hepatic (33%), hematologic (31%) and renal (11.9%) systems. No patients succumbed to the disease during the ICU and hospital stay. Nevertheless, <10% of the patients required vasopressors. Additionally, <5% of the patients required invasive mechanical ventilation. Therefore, ICU admission directly following isolated limb perfusion should not be standardized.
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Affiliation(s)
- Silvio A Ñamendys-Silva
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | - Arturo M Ruiz-Beltran
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
| | - Mireya Barragán-Dessavre
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico.,Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | | | - Abelardo Meneses-García
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
| | - Octavio González-Chon
- Department of Critical Care Medicine, Fundación Clínica Médica Sur, Mexico City 14050, Mexico
| | - Angel Herrera-Gómez
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Mexico City 14080, Mexico
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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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Deroose JP, Grünhagen DJ, Van Geel AN, De Wilt JHW, Eggermont AMM, Verhoef C. Long-term outcome of isolated limb perfusion with tumour necrosis factor-α for patients with melanoma in-transit metastases. Br J Surg 2011; 98:1573-80. [DOI: 10.1002/bjs.7621] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2011] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The use of tumour necrosis factor (TNF) α in isolated limb perfusion (ILP) for in-transit melanoma metastasis is not uniformly accepted. This article reports the long-term results of adding TNF-α to standard melphalan-based ILP (TM-ILP) for treatment of melanoma in-transit metastases.
Methods
Data for patients treated between 1991 and 2005 were retrieved from a prospectively maintained database. Hyperthermic ILP was performed with 1–4 mg TNF-α. With a median potential follow-up of 13 years, response rates, time to local progression and disease-specific survival were analysed in relation to standard baseline factors.
Results
Some 118 TM-ILPs were analysed in 105 patients, 54 for stage IIIA, 50 for stage IIIAB and 14 for stage IV disease. The overall response rate was 93·2 per cent; the response was complete in 67·8 per cent and partial in 25·4 per cent. The response rate was significantly influenced by stage of disease (IIIA versus IIIAB; P = 0·006). The complete response was maintained until the end of follow-up in 35 patients (33·3 per cent), and local control was achieved with one additional intervention in 12 others (11·4 per cent). Local progression occurred after 66 ILPs (55·9 per cent). Number of in-transit metastases (P = 0·008) and complete response after ILP (P < 0·001) were strong prognostic factors for time to local progression. The 5-year disease-specific survival rate was 27·3 per cent; survival was positively influenced by age, stage of disease, previous ILP and complete response after ILP.
Conclusion
ILP with TNF-α may obtain long-term local control in selected patients with in-transit metastases from melanoma.
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Affiliation(s)
- J P Deroose
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - D J Grünhagen
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - A N Van Geel
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - J H W De Wilt
- Division of Surgical Oncology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - A M M Eggermont
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
- Institut de Cancérologie Gustave Roussy, Villejuif-Paris, France
| | - C Verhoef
- Division of Surgical Oncology, Erasmus MC– Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Isolated limb perfusion for melanoma in-transit metastases: developments in recent years and the role of tumor necrosis factor alpha. Curr Opin Oncol 2011; 23:183-8. [PMID: 21150602 DOI: 10.1097/cco.0b013e3283424dbc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The treatment of in-transit metastasis of melanoma remains challenging and is essentially dictated by the biological behavior of melanoma. When lesions are large or numerous, isolated limb perfusion (ILP) is an attractive treatment modality. In this review an overview of literature on treatment options of melanoma in-transit metastases will be discussed. RECENT FINDINGS Most recent studies report on tumor necrosis factor (TNF) and melphalan based ILP (TM-ILP) series or mixed series of TM-ILP and melphalan only based ILP (M-ILP). After TM-ILP complete response rates of 70% (range 44-90%) have been reported, while for M-ILP this is lower with complete response rates of 54% (range 40-76%). The only randomized trial comparing TM-ILP and M-ILP revealed no clear benefit of TNF at 3 months, but improved outcome at 6 months and in patients with bulky disease. Reports on isolated limb infusion (ILI) with melphalan and actinimycin D indicate lower response rates, but similar local control rates as M-ILP at lower cost. SUMMARY ILP is an attractive treatment option in melanoma patients with multiple in-transit metastases. In our opinion TM-ILP is superior to M-ILP as it achieves higher response rates, especially in patients with bulky disease. When lesions are small and in the distal two-thirds of the leg only, ILI is a valuable alternative.
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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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Boesch CE, Meyer T, Waschke L, Merkel S, Goehl J, Hohenberger W, Knorr C. Long-term outcome of hyperthermic isolated limb perfusion (HILP) in the treatment of locoregionally metastasised malignant melanoma of the extremities. Int J Hyperthermia 2010; 26:16-20. [DOI: 10.3109/02656730903236086] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hayes AJ, Neuhaus SJ, Clark MA, Thomas JM. Isolated Limb Perfusion With Melphalan and Tumor Necrosis Factor α for Advanced Melanoma and Soft-Tissue Sarcoma. Ann Surg Oncol 2006; 14:230-8. [PMID: 17066234 DOI: 10.1245/s10434-006-9040-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) with melphalan is used in the treatment of advanced in-transit melanoma but has no real efficacy for irresectable soft tissue sarcomas arising in the extremities. The addition of tumor necrosis factor (TNF)-alpha may increase response rates for bulky melanoma and for sarcoma, but the potential for major systemic toxicity has limited its use. METHODS Between October 2000 and April 2004, 49 ILPs were performed with melphalan and TNF-alpha. All procedures were performed with continuous leakage monitoring and regional hyperthermia. RESULTS Forty-nine ILPs were performed for melanoma (n = 30), sarcoma (n = 16), or other tumors (n = 3). The most common indications were widespread in-transit disease for melanoma (n = 29) and irresectable primary disease for sarcoma (n = 9). Complete and partial responses for melanoma were 40% and 37%, and for sarcoma they were 20% and 33%. At a median follow-up of 14 months, 66% of melanoma patients who responded had not experienced local progression, compared with only 37% of sarcoma patients. Progression-free survival was significantly less for patients with sarcoma than melanoma (P = .0476). Four of 16 patients with sarcoma subsequently required amputation for progressive disease. CONCLUSIONS ILP with melphalan and TNF-alpha is a valuable treatment for advanced in-transit melanoma. Significant response rates were also seen in irresectable sarcoma, although the duration of response was limited.
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Affiliation(s)
- Andrew J Hayes
- Department of Surgery, Sarcoma and Melanoma Unit, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, United Kingdom.
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Grünhagen DJ, de Wilt JHW, van Geel AN, Eggermont AMM. Isolated limb perfusion for melanoma patients—a review of its indications and the role of tumour necrosis factor-α. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2006; 32:371-80. [PMID: 16520016 DOI: 10.1016/j.ejso.2006.01.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Accepted: 01/27/2006] [Indexed: 11/17/2022]
Abstract
AIMS The treatment of melanoma in-transit metastases (IT-mets) can vary widely and is dependant on the size and the number of the lesions. When multiple, large lesions exist, isolated limb perfusion (ILP) has established itself as an attractive treatment option with high response rates. METHODS Review on the various methods of treatment of melanoma in-transit metastases, with a focus on isolated limb perfusion. A Medline based literature search was performed for articles relating to this topic. Additional original papers were obtained from citations in those identified by the initial search. Indications and results are discussed and the extra value of tumour necrosis factor (TNF) is evaluated. RESULTS ILP with Melphalan results in complete response rates of 40-82% and showed to be 54% in a large retrospective meta-analysis. The addition of TNF can improve these completes response rates (59-85%) and although no data from randomized controlled trials are available, it seems of particular value in large, bulky lesions or in patients with recurrent disease after previous ILP. CONCLUSIONS TNF-based ILP has earned a permanent place in the treatment of patients with melanoma IT-mets. In patients with a high tumour burden, TNF-based ILP is the most efficacious procedure to obtain local control and achieve limb salvage.
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Affiliation(s)
- D J Grünhagen
- Department of Surgical Oncology, Erasmus University MC-Daniel den Hoed Cancer Center, P.O. Box 5201, 3008 AE Rotterdam, The Netherlands
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Knorr C, Meyer T, Janssen T, Goehl J, Hohenberger W. Hyperthermic isolated limb perfusion (HILP) in malignant melanoma. Experience with 101 patients. Eur J Surg Oncol 2005; 32:224-7. [PMID: 16289716 DOI: 10.1016/j.ejso.2005.09.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Revised: 08/24/2005] [Accepted: 09/05/2005] [Indexed: 11/25/2022] Open
Abstract
AIMS To analyse results with a standardized HILP procedure in terms of response rate, recurrence pattern and complication rate. PATIENTS AND METHODS From 1992 to 2003 HILP with melphalan and dactinomycin was performed in 101 patients with loco-regional metastases of malignant melanoma of the limbs. Among these were 66 women and 35 men with a median age of 62 years. Forty patients were in M. D. Anderson stage IIIA, 51 patients in stage IIIAB and 9 had stage IV disease at the time of perfusion. If not been done before, regional lymph node dissection preceded limb perfusion in the same setting. RESULTS A complete response (CR) was observed in 58 out of 87 evaluable patients. Twenty-one patients achieved a partial response (PR) and eight patients were non-responders. The overall response rate was 90.8%. The median recurrence-free interval after CR was 21 months. Severe toxicity (Wieberdink IV/V) was observed in five patients necessitating fasciotomy in four of them and above knee amputation in one patient. All further cases presented with grade II-III toxicity. The overall survival was 42 months, with a 5-year survival rate of 38%. Survival significantly differed according to stage of disease. CONCLUSION HILP is an effective treatment for loco-regional tumour relapse of malignant melanoma of the extremities and has improved by modification of technique. In the absence of regional lymph node and distant metastases long-term survival can be achieved in responders.
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Affiliation(s)
- C Knorr
- Department of Surgery, University Hospital of Erlangen, Krankenhausstr. 12, 91054 Erlangen, Germany.
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Rossi CR, Mocellin S, Pilati P, Foletto M, Campana L, Quintieri L, De Salvo GL, Lise M. Hyperthermic Isolated Perfusion With Low-Dose Tumor Necrosis Factor α and Doxorubicin for the Treatment of Limb-Threatening Soft Tissue Sarcomas. Ann Surg Oncol 2005; 12:398-405. [PMID: 15915374 DOI: 10.1245/aso.2005.12.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Accepted: 12/22/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tumor necrosis factor (TNF)-alpha-based hyperthermic isolated limb perfusion (HILP) is one of the most active available approaches for locally advanced soft tissue sarcomas (STS) of the limbs. The aim of this study was to investigate the anticancer activity of a novel drug regimen including doxorubicin (DXR) and low-dose TNF-alpha. METHODS HILP with low-dose TNF-alpha (1 mg) and DXR (8.5 mg/L of limb volume) was given to 21 patients with limb-threatening STS: 14 had primary and 7 had recurrent STS, most of which were high grade (grade 1, n = 3; grade 2, n = 6; grade 3, n = 12). Resection of the tumor remnant was performed 6 to 8 weeks after HILP. TNF-alpha concentrations in plasma and perfusate were measured throughout perfusion. RESULTS A major tumor response was observed at histology and clinical evaluation in 90% and 62% of patients, respectively. After a median follow-up of 30 months, limb salvage and local disease control were achieved in 71% and 81% of cases, respectively. Fourteen patients had moderate regional toxicity, which was resolved in all cases. One patient had severe limb toxicity, which did not require amputation. Systemic side effects were minimal, and there were no postoperative deaths. The perfusate/plasma area under the curve ratio for TNF-alpha was 56. CONCLUSIONS HILP with low-dose TNF-alpha and DXR seems to be an active neoadjuvant drug regimen against limb-threatening STS. This therapeutic approach can achieve high limb-sparing surgery rates with acceptable local and negligible systemic toxicity.
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Affiliation(s)
- Carlo Riccardo Rossi
- Surgery Branch, Department of Oncological and Surgical Sciences, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy.
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Grünhagen DJ, Brunstein F, Graveland WJ, van Geel AN, de Wilt JHW, Eggermont AMM. One hundred consecutive isolated limb perfusions with TNF-alpha and melphalan in melanoma patients with multiple in-transit metastases. Ann Surg 2005; 240:939-47; discussion 947-8. [PMID: 15570199 PMCID: PMC1356509 DOI: 10.1097/01.sla.0000146147.89667.ed] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study is to describe the experience with 100 TNF-based ILP for locally advanced melanoma and to determine prognostic factors for response, time to local progression, and survival. METHODS One hundred TNF-based ILPs were performed between 1991 and 2003 in 87 patients for whom local control by surgery of in-transit melanoma metastases was impossible. In total, 62 iliac, 33 femoral, and 5 axillary ILPs were performed in mild hyperthermic conditions with 2 to 4 mg of TNF and 10 to 13 mg of melphalan per liter of limb volume. RESULTS Overall response was 95%, with 69% complete response, 26% partial response, and 5% no change. Complete response rate differed significantly for patients with IIIA disease versus IIIAB and IV. Local and systemic toxicity was mild to moderate in almost all cases, with no treatment-related death and one treatment-related amputation. Five-year overall survival was 32%; local progression occurred in 55% after a median of 16 months. In complete response patients, 5-year survival was 42% with local progression in 52% at a median of 22 months. Response rate and survival were significantly influenced by stage of disease; (local progression free) survival was influenced by response rate. CONCLUSIONS TNF-based ILP results in excellent response rates in this patient population with unfavorable characteristics. Response on ILP predicts outcome in patients and reflects aggressiveness of the tumor.
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Affiliation(s)
- Dirk J Grünhagen
- Department of Surgical Oncology, Daniel den Hoed Cancer Center, PO Box 5201 3008, Rotterdam, Netherlands
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Fraker DL. Management of in-transit melanoma of the extremity with isolated limb perfusion. Curr Treat Options Oncol 2004; 5:173-84. [PMID: 15115646 DOI: 10.1007/s11864-004-0009-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In-transit metastases for melanoma are a type of stage III regional metastatic disease that are intradermal or subcutaneous nodules growing within lymphatics and not in nodal basins. If the initial diagnosis is a limited number of in-transit metastases (1-3 nodules), the optimal management is simple surgical excision with minimal negative margins and primary closures and appropriate staging to look for any distant metastases. There is no role for wide excision of in-transit lesions as there is for primary melanoma because the entire extremity or that region of the body is at risk for recurrence. Patients who are diagnosed with additional lesions in a short period of time or patients who at initial diagnosis have large numbers of nodules are candidates for isolated limb perfusion (ILP). ILP is a regional administration of high-dose chemotherapeutics within an extremity using a cardiopulmonary bypass machine similar to cardiac surgery. Once isolation is obtained surgically, the limb is heated to what is considered mild hyperthermia (38.5 degrees -40 degrees C), then chemotherapeutics are administered at very high concentrations for a 60- to 90-minute treatment. The drug recirculates and, at the end of the treatment period, it is flushed from the extremity and the circulation is re-established. The optimal regimen is melphalan dosed per limb volume (10 mg/L limb volume for lower extremities and 13 mg/L limb volume for upper extremities) with mild hyperthermia for 60 minutes. Using this regimen, overall response rates between 80% and 90% and complete response rates between 55% and 65% can be obtained. The duration of response is typically 9 to 12 months and a subgroup of complete responders, which is 20% to 25% of the total patient population, typically have sustained complete responses. The major toxicities are skin erythema, myopathy, and peripheral neuropathy. There have been several studies adding high-dose tumor necrosis factor to ILP, but there is no clear benefit in the treatment of melanoma. Other new approaches include isolated limb infusion as a percutaneous procedure to avoid the surgical toxicity.
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Affiliation(s)
- Douglas L Fraker
- Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA.
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Abstract
Isolated limb perfusion with melphalan is the treatment of choice for multiple (small) melanoma-in-transit metastases. The use of tumour necrosis factor alpha (TNFalpha) in isolated limb perfusion is successful for treatment of locally advanced limb soft-tissue sarcomas and other large tumours; this approach can avoid the need for amputation. TNFalpha was approved in Europe after a multicentre trial in patients with locally advanced soft-tissue sarcomas, deemed unresectable by an independent review committee; the response rate to isolated limb perfusion with TNFalpha plus melphalan was 76% and the limb was saved in 71% of patients. Moreover, the trial showed the efficacy of isolated limb perfusion of TNFalpha and melphalan against various other limb-threatening tumours such as skin cancers and drug-resistant bony sarcomas. Laboratory models of isolated limb perfusion have helped to elucidate mechanisms of action and to develop new treatment modalities. They have identified TNFalpha-mediated vasculotoxic effects on the tumour vasculature and have shown that addition of TNFalpha to the perfusate results in an increase of three to six times in uptake of melphalan or doxorubicin by tumours. New vasoactive drugs and new mechanisms of action are being discovered. Moreover, isolated limb perfusion is an effective modality for gene therapy mediated by an adenoviral vector. Various clinical phase I-II studies can be expected in the next few years.
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ten Hagen TLM, Eggermont AMM. Solid tumor therapy: manipulation of the vasculature with TNF. Technol Cancer Res Treat 2003; 2:195-203. [PMID: 12779350 DOI: 10.1177/153303460300200303] [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: 11/16/2022] Open
Abstract
Drug delivery to solid tumors is one of the most challenging aspects in cancer therapy. Whereas agents seem promising in the test tube, clinical trials often fail due to unfavorable pharmacokinetics, poor delivery, low local concentrations, and limited accumulation in the target cell. A major step forwards in the treatment of solid tumors is the recognition of the tumor-associated vasculature as an important target for therapy. Inhibition of tumor vascular development has a direct effect on the growth and progression of the tumor. Destruction of an existing vasculature also directly inflicts serious damage to the tumor cell. Moreover, the tumor vascular bed can be manipulated facilitating enhanced permissiveness of the tumor for administered chemotherapeutics. In this review, we focus on the use of tumor necrosis factor alpha (TNF) in local and systemic therapy in conjunction with chemotherapy. In these settings TNF demonstrates potent and selective activity on the tumor vascular bed, which strongly improves tumor response.
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Affiliation(s)
- Timo L M ten Hagen
- Department of Surgical Oncology, Laboratory for Experimental Surgical Oncology, Erasmus MC, Room Ee 0102a, PO Box 1738, 3000 DR Rotterdam, The Netherlands.
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Eggermont AMM, van Geel AN, de Wilt JHW, ten Hagen TLM. The role of isolated limb perfusion for melanoma confined to the extremities. Surg Clin North Am 2003; 83:371-84, ix. [PMID: 12744614 DOI: 10.1016/s0039-6109(02)00095-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Isolated limb perfusion with Melphalan is the best treatment option to control symptomatic multiple small in-transit metastases. When lesions are bulky, Isolated Limb Perfusion (ILP) with Tumor Necrosis Factor (TNF) + Melphalan is superior as in soft tissue sarcoma. TNF changes the pathophysiology, greatly enhances the uptake of Melphalan and destructs selectively the vasculature of large tumors. To date, ILP is not indicated in an adjuvant setting.
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Affiliation(s)
- Alexander M M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center, Rotterdam-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands.
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Eggermont AM. Isolated limb perfusion in the management of locally advanced extremity soft tissue sarcoma. Surg Oncol Clin N Am 2003; 12:469-83. [PMID: 12916464 DOI: 10.1016/s1055-3207(03)00012-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In conclusion, ILP is an interesting and important treatment option in the management of locally advanced extremity soft tissue sarcomas. Large medical centers, dealing with referrals and an important caseload of STS patients, should develop this treatment option and have it readily available to offer patients the best chances for limb salvage. In Europe, the success of TNF-based ILP has lead to the training, accreditation, and activation of TNF-based ILP programs in over 30 cancer centers since the approval of TNF for this indication in 1999. Thus, country by country centers for referral programs are established to deal with those categories of patients that can greatly benefit from the availability and integration of this treatment option in the STS treatment programs.
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Affiliation(s)
- Alexander M Eggermont
- Department of Surgical Oncology, Erasmus University Medical Center-Daniel Den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA, Rotterdam, The Netherlands. eggermont.@chih.azr.nl
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Lans TE, ten Hagen TLM, van Horssen R, Wu PC, van Tiel ST, Libutti SK, Alexander HR, Eggermont AMM. Improved antitumor response to isolated limb perfusion with tumor necrosis factor after upregulation of endothelial monocyte-activating polypeptide II in soft tissue sarcoma. Ann Surg Oncol 2002; 9:812-9. [PMID: 12374666 DOI: 10.1007/bf02574505] [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: 11/24/2022]
Abstract
BACKGROUND Experiments with tumor necrosis factor alpha (TNF) in rodents have shown that a high dose can lead to hemorrhagic necrosis in tumors. Endothelial monocyte-activating polypeptide II (EMAP-II) is a novel tumor-derived cytokine, and its expression increases the TNF-1 receptor on tumor endothelium, enhances the induction of tissue factor on tumor endothelial cells, and has an antiangiogenic effect. It has recently been shown that in vivo sensitivity of tumor vasculature to TNF is determined by tumor production of EMAP-II. METHODS We measured the level of EMAP-II in a TNF-resistant soft tissue sarcoma. We subsequently stabile-transfected this cell line with a retroviral construct containing the EMAP gene. In an extremity perfusion model in tumor-bearing rats, we measured response rates to TNF therapy. RESULTS Functional EMAP-II production was increased after this transfection. Immunostaining of paraffin-embedded tumor tissue sections in rats showed an overexpression of human EMAP-II. Results of the TNF perfusions in rats suggest that this tumor is more sensitive to TNF therapy. CONCLUSIONS EMAP-II is produced in various levels. One can increase the sensitivity of tumor for TNF therapy in vivo by upregulating the EMAP-II production. This result leaves an opportunity for enhanced TNF response of tumors in future settings.
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Affiliation(s)
- T E Lans
- University Hospital Rotterdam-Daniel den Hoed Cancer Centre, Department of Surgical Oncology, Rotterdam, The Netherlands.
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Rossi CR, Foletto M, Pilati P, Mocellin S, Lise M. Isolated limb perfusion in locally advanced cutaneous melanoma. Semin Oncol 2002; 29:400-9. [PMID: 12170443 DOI: 10.1053/sonc.2002.34119] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Isolated limb perfusion (ILP) is a well-established locoregional procedure to deliver high doses of cytostatics to an extremity with multiple in-transit lesions from cutaneous melanoma, with minimal systemic and mild local toxicity. This approach is quite sophisticated and requires accurate monitoring of systemic leakage and of the temperature of the affected limb in order to avoid major systemic and local side effects. Mephalan (L-PAM) is considered the reference drug, although complete responses are reported in only about 50% of patients. Since the early 1990s, tumor necrosis factor-alpha (TNF-alpha) was administered with melphalan in ILP aiming to improve the therapeutic index of this procedure. However, despite the impressive results reported, its role still remains controversial, seemingly confined to large tumor bulk. Fotemustine ILP was proposed as a less toxic alternative to L-PAM, after the results of a pilot experience claiming similar response rates with less local toxicity. A formal phase 1-2 study is now underway to confirm these findings. More straightforward procedures, such as isolated limb infusion, are appealing, as they seem capable of achieving good response rates, are easily repeatable, and are less costly. Larger series are required to validate such results. As potential agents to be delivered through ILP, new vasoactive drugs and agents with new mechanisms of action that interplay with chemotherapy, as well as virus-mediated gene therapy, are being developed.
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Affiliation(s)
- Carlo Riccardo Rossi
- Department of Surgical and Oncological Sciences Clinica Chirurgica II, University of Padova, Padova, Italy
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Abstract
Thousands of patients die annually from unresectable metastatic or primary hepatic cancers confined to liver. Isolated hepatic perfusion (IHP) is a regional treatment strategy in which the vascular supply to the liver is isolated and perfused with a therapeutic regimen using an extracorporeal circuit consisting of a reservoir, heat exchanger, and oxygenator. Drug doses that would cause severe toxicities if delivered systemically can be confined to the liver by isolated hepatic perfusion, resulting in the ability to intensify treatment to the cancer-burdened region of the body. Agents and mechanisms commonly used in IHP include melphaIan, hyperthermia, and tumor necrosis factor. IHP appears to be efficacious for patients with advanced disease, as reflected by large tumor size, high number of lesions, or significant overall tumor burden in the liver. In addition, responses are observed for patients whose cancer is refractory to systemic and hepatic arterial infusion chemotherapy. Recent clinical trials have demonstrated that IHP has anti-tumor efficacy against primary hepatic neoplasms and metastases from various primary tumors, such as colorectal carcinoma, ocular melanoma, and neuroendocrine tumors. Current studies demonstrate that combining hepatic arterial infusion with floxuridine after IHP for patients with colorectal cancer metastases is associated with significant and durable response rates. Continued clinical evaluation is warranted for the use of IHP in the treatment of unresectable liver metastases.
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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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Eggermont AM, ten Hagen TL. Isolated limb perfusion for extremity soft-tissue sarcomas, in-transit metastases, and other unresectable tumors: credits, debits, and future perspectives. Curr Oncol Rep 2001; 3:359-67. [PMID: 11389822 DOI: 10.1007/s11912-001-0090-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Isolated limb perfusion (ILP) with melphalan is effective against melanoma in-transit metastases but has failed in the treatment of limb-threatening extremity sarcomas. Tumor necrosis factor-alpha (TNF) has changed this situation completely. Now, ILP with TNF + melphalan is a very successful treatment to prevent amputation. In a multicenter European trial, ILP with TNF + melphalan resulted in a 76% response rate and a 71% limb salvage rate in patients with limb-threatening soft-tissue sarcomas, deemed unresectable by independent review committees, leading to approval of TNF in Europe. We have also reported on the success of this regimen against bulky melanomas, multifocal skin cancers, and drug-resistant bony sarcomas. High-dose TNF destructs tumor vasculature, and, most importantly, it enhances tumor-selective drug uptake (ie, melphalan and doxorubicin) by threefold to sixfold. Similar synergy is observed in well-vascularized liver metastases after isolated hepatic perfusion with TNF and melphalan. New (vasoactive) drugs and mechanisms of action and interaction with chemotherapy are in development. ILP is also a promising treatment modality for adenoviral vector-mediated gene therapy. Many clinical phase I/II evaluations in ILP are now underway.
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Affiliation(s)
- A M Eggermont
- Department of Surgical Oncology, University Hospital Rotterdam, Daniel den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA Rotterdam, The Netherlands. E-mail:
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Finley JW, Hanypsiak B, McGrath B, Kraybill W, Gibbs JF. Clear cell sarcoma: the Roswell Park experience. J Surg Oncol 2001; 77:16-20. [PMID: 11344475 DOI: 10.1002/jso.1057] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Clear cell sarcoma of the tendons and aponeuroses (CCSTA) is an aggressive, rare soft-tissue tumor with approximately 300 reported cases. Although it appears to be histogenetically related to melanoma, its clinical behavior resembles soft tissue sarcoma with a propensity for lymph node metastases. We report our experience at a tertiary cancer center. METHODS Eight cases of CCSTA evaluated at Roswell Park Cancer Institute between 1970 and 1998 were reviewed retrospectively. Patient data analyzed included patient age, gender, anatomic location, size of tumor, development of local, regional and distant recurrence, and patient status at last follow up. RESULTS Six of eight patients were alive at 2 years, while three of seven patients were alive at 5 years. Of the patients alive with no evidence of recurrence, two had tumors of less than 2 cm, and the remaining patient had incomplete information regarding tumor size. Five patients recurred within 2 years of definitive surgical management. Four had tumors > 5 cm. All five patients progressed to metastatic disease at a median follow up of 20 months (range 1-108 months) following definitive surgical management and all eventually died of their disease at a median of 3 months (range 0-24 months) from presentation with metastatic disease. Four of five patients with lesions > 5 cm received adjuvant chemotherapy with intent to cure, but all eventually died of disease at 4, 22, 34, and 41 months from initial presentation. CONCLUSIONS CCSTA is an aggressive tumor of the soft tissues. Early recognition and management are associated with an excellent long-term prognosis. Tumors greater than 5 cm warrant aggressive surgical management and treatment, and are at high risk of the development of distant disease. Aggressive multiagent chemotherapy appeared to have no impact on outcome. Other adjuvant therapeutic options including immunotherapy should be investigated.
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Affiliation(s)
- J W Finley
- Division of General Surgery, Geisinger Medical Center, Penn State Geisinger Health System, Danville, Pennsylvania, USA
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Eroglu A, Kocaoglu H, Demirci S, Akgül H. Isolated limb perfusion with cisplatin and doxorubicin for locally advanced soft tissue sarcoma of an extremity. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2000; 26:213-21. [PMID: 10753532 DOI: 10.1053/ejso.1999.0779] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS To identify independent adverse clinico-pathological factors for disease-free and overall survival in patients undergoing isolated limb perfusion (ILP) with cisplatin and doxorubicin for locally advanced soft tissue sarcoma (STS) of an extremity. METHODS A retrospective analysis was carried out, using a univariate method and a multivariate analysis, to look at the patient, tumour and treatment associated with prognostic factors in 37 patients with locally advanced STSs of the limbs who underwent ILP with cisplatin and doxorubicin. Patient's age, gender, presenting status, tumour location, tumour grade, tumour stage according to TNM classification, tumour size and radiotherapy (RT) were analysed. Survival curves were calculated according to the Kaplan-Meier method. A Cox proportional hazard model was used to indicate which factors related to overall survival and the recurrence-free interval after ILP. RESULTS No major systemic toxicity was seen. Regional toxicity was limited. Limb salvage was achieved in 94.6% of the patients. The estimated 5-year overall and disease-free survival rates were 62% and 54%, respectively. It was found that tumour stage, tumour grade, presenting status, RT and tumour size were associated with cumulative overall survival when the Kaplan-Meier method was applied (P<0.05). By Cox proportional hazards model, only tumour grade (P=0. 0254) was found to have significant influence on overall survival; however, tumour stage (P=0.0157) and RT (P=0.0014) were related to disease-free survival. CONCLUSIONS ILP and delayed excision followed by RT achieves good limb salvage rates and may improve survival.
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Affiliation(s)
- A Eroglu
- Department of Surgical Oncology, Ankara University Medical School, Ankara, Turkey
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Issakov J, Merimsky O, Gutman M, Kollender Y, Lev-Chelouche D, Abu-Abid S, Lifschitz-Mercer B, Inbar M, Klausner JM, Meller I. Hyperthermic isolated limb perfusion with tumor necrosis factor-alpha and melphalan in advanced soft-tissue sarcomas: histopathological considerations. Ann Surg Oncol 2000; 7:155-9. [PMID: 10761796 DOI: 10.1007/s10434-000-0155-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hyperthermic isolated limb perfusion with tumor necrosis factor-alpha and melphalan was used as induction treatment in locally advanced extremity soft-tissue sarcomas for limb sparing surgery. The typical histopathological changes that occur in these tumoral masses are described in a series of 30 patients. METHODS Fresh tumor specimens of 27 high grade extensive soft-tissue sarcomas and 3 recurrent desmoid tumors of the extremities were collected 6 to 8 weeks after hyperthermic isolated limb perfusion with tumor necrosis factor-alpha plus melphalan. The specimens were studied for surgical margins, extent and type of tumor necrosis, lymph node involvement, perineural and vascular invasion, and the effects on adjacent normal tissues such as nerves, muscles, and blood vessels. RESULTS The typical histological changes were central cystic hemorrhagic necrosis with pericystic extensive fibrosis. Some nonspecific changes were noted in the soft tissues around the mass. In eight cases, more than 90% necrosis was found. In 17 cases, the extent of necrosis ranged between 60% and 90% (80%-90% in 4 of 17 cases). In five cases, less than 60% necrosis was noted. The best responses (>90% necrosis) were observed in distally located tumors. The responsive types were malignant fibrous histiocytoma, followed by myxoid liposarcoma and synovial sarcoma. Desmoid tumors showed less necrosis than high grade sarcomas. Vascular invasion was observed in two cases and intralesional venous thrombosis in one case. No perineural invasion or lymph nodes involvement were observed. The soft tissues adjacent to the tumor bed did not show major morphological changes. No correlation was found between the histological changes and each of the following: the anatomical (upper vs. lower limb) or compartmental location of the tumor; whether the tumor was primary or recurrent; and the types of previous treatment (systemic chemotherapy or radiotherapy) and tumor size. CONCLUSIONS This is the first serial histological description of the effects of tumor necrosis factor-alpha and melphalan administered via hyperthermic isolated limb perfusion on the tumoral masses of limb soft-tissue sarcomas. The small number of specimens and, especially, the variability of tumors preclude definite conclusions. Larger numbers and more homogeneity are needed in future studies.
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Affiliation(s)
- J Issakov
- Department of Pathology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Israel
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Liong E, Kong SK, Au KK, Li JY, Xu GY, Lee YL, Kwok TT, Choy YM, Lee CY, Fung KP. Enhanced cytotoxicity and suppression of glucose transport rate by combined treatment of recombinant human tumour necrosis factor-alpha and hyperthermia on L929 cells. Life Sci 1999; 65:PL81-6. [PMID: 10466752 DOI: 10.1016/s0024-3205(99)00313-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Combined treatment with human recombinant TNF-alpha (rhTNF-alpha) and hyperthermia at 43 degrees C arrested the growth of mouse fibrosarcoma L929 cells in vitro. The cytotoxic effect was enhanced in combined treatment compared with that following administration of rhTNF-alpha or hyperthermia alone. When the cells were subjected to hyperthermia at 43 degrees C for 3 hours and then incubated with 0.4 ng/ml rhTNF-alpha at 37 degrees C for 24 hours, a statistically significant 65% decrease in the rate of cellular glucose uptake was observed. This suppressive effect was synergistic in terms of effect achieved by rhTNF-alpha or hyperthermia individually. Since the growth of tumour cells depends mainly on catabolism of glucose, our findings indicate that one manner by which combined rhTNF-alpha and hyperthermia treatment inhibits L929 cell growth may be by reducing the supply of glucose to the cells.
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Affiliation(s)
- E Liong
- Department of Biochemistry, The Chinese University of Hong Kong, NT
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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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Urano M, Kuroda M, Nishimura Y. For the clinical application of thermochemotherapy given at mild temperatures. Int J Hyperthermia 1999; 15:79-107. [PMID: 10323618 DOI: 10.1080/026567399285765] [Citation(s) in RCA: 195] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
It has been demonstrated in vitro and in vivo that hyperthermia can enhance the cytotoxicity of some chemotherapeutic agents. This paper summarizes the authors' own laboratory studies on the effect of chemotherapeutic agents given at elevated temperatures, experimental results obtained using animal tumour systems in other laboratories, and clinical trials of thermochemotherapy reported in literature. The in vivo studies have demonstrated that the thermal enhancement of cytotoxicity of many chemotherapeutic agents is maximized at mild temperatures such as at 40.5-43 degrees C. Comparison of in vitro and in vivo results using five agents show that the in vivo thermal enhancement increases with an increase in the activation energy obtained in the temperature range between 40.5 and 43.0 degrees C. A summary of experimental results obtained by various investigators indicates a potentially wide variation in the thermal enhancement of a given agent among the different types of tumours and suggests potential agents useful at moderately elevated temperatures. In vivo studies on nine different agents indicate that the drug(s) of choice at physiological temperatures may not be the drug(s) of choice at elevated temperatures. It is also shown that drug concentration in the target must be high for sufficient thermal enhancement. Clinical trials of thermochemotherapy have employed various heating methods, including local heating, hyerthermic perfusion and whole body hyperthermia. Extensive trials have been made in the treatment of melanoma and soft tissue sarcoma in the extremity. Hyperthermic isolated perfusion with chemotherapeutic(s) provides much higher drug concentration than a systemic drug administration in the target(s), resulting in a high tumour response rate and an increased survival of the patients. It is of interest that the most successful agent used in the treatment of both melanomas and sarcomas is melphalan and is the drug of choice at moderately elevated temperatures among the nine agents tested in the in vivo studies. Current results using the tumour necrosis factor with melphalan are impressive. In several institutes, techniques have been developed to uniformly heat the localized tumour, but studies are needed to find an agent effective at elevated temperatures to each type of tumours and to establish the methods for obtaining a sufficient drug concentration in the target tissue.
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Affiliation(s)
- M Urano
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Abstract
Cutaneous melanoma represents the main cause of death among skin cancers. Early diagnosis gives, for the time being, the only possibility for high rate of curative treatment. Diagnosis is based on pathological findings, and at primary tumor stage. Breslow thickness of the lesion is the best prognostic index. At local stage of the disease, treatment is precisely codified by international recommendations and consensus conferences. Follow-up after surgical treatment is also well codified. Treatment of lymph node invasion or metastatic disease is, on the other hand, less codified. Despite recent advances, especially in immunotherapy, treatment of advanced stages of melanoma remains difficult.
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Affiliation(s)
- L Thomas
- Unité de dermatologie, Hôtel-Dieu, université Claude-Bernard-Lyon, France
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Abstract
Because a relationship between toxicity and treatment outcome has never been demonstrated for isolated limb perfusion (ILP) with melphalan, it is important to keep the side-effects of the procedure restricted to a minimum. Risk factors for more severe acute regional toxicity have recently been identified with tissue temperature above 40 degrees C and a high melphalan peak concentration being the most important. Acute regional toxicity should be mild taking into account these factors and maintaining the normal physiological conditions in the limb during ILP. This should also decrease the incidence of long-term morbidity, especially ankle stiffness and muscle atrophy, since a relation between the severity of the acute regional tissue reactions and long-term morbidity has been demonstrated. Lymphedema is strongly linked to a concomitant regional lymph node dissection and this operation may be delayed until the acute regional tissue reactions have faded. It is not yet clear whether the addition of tumor necrosis factor-alpha (TNF-alpha) to melphalan increases regional toxicity. In the absence of melphalan leakage to the systemic circulation, systemic toxicity is minimal; this is also true with TNF-alpha. Compared to ILP with melphalan +/- TNF-alpha, ILP with other drugs is less effective and often is associated with increased regional toxicity.
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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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Rossi CR, Foletto M, Vecchiato A, Alessio S, Menin N, Lise M. Management of cutaneous melanoma M0: state of the art and trends. Eur J Cancer 1997; 33:2302-12. [PMID: 9616272 DOI: 10.1016/s0959-8049(97)00358-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article reviews the epidemiology, diagnosis and treatment of cutaneous melanoma, including the most recent developments. The combination of positive family history, fair complexion, number of nevi, exposure to sun and/or chromosomal alterations seem to be implicated in the pathogenesis of cutaneous melanoma. Melanomas can be classified according to their growth patterns, and tumour microstaging is of straightforward predictive value for survival and risk of metastasis, although new factors are also being investigated. As yet, surgical excision is the only effective treatment available for primary tumours, resection margins varying according to tumour thickness. Elective node dissection is, however, no longer advocated for melanomas thinner than 1.5 mm, and there is disagreement as to its role for thicker lesions. In contrast, selective node dissection at the time of definitive surgery is becoming more widely accepted, with regional node dissection being restricted to positive cases. Therapeutic dissection is required for lymph node involvement, the most common pattern of recurrence from melanoma, which affects nearly 30% of all patients. Complete remission rates from isolated limb perfusion, which has been employed in patients with multiple recurrences or in-transit metastases, range from 40 to 90%, depending on drugs and techniques used in different series; the best responses so far have been obtained with tumour necrosis factor in combination with melphalan. Patients with thick lesions (> 4 mm) or lymph node metastases have a high risk of micrometastases that would warrant adjuvant therapy. The only agent found to affect survival is interferon alpha-2.
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Affiliation(s)
- C R Rossi
- Dipartimento di Scienze Oncologiche e Chirurgiche, Università di Padova, Italy
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Würl P, Eichfeld U, Pauer HD, Gläser A, Rose U, Dralle H. Technique and results of regional hyperthermic cytostatic arm perfusion for malignant melanoma. Surg Today 1997; 27:719-25. [PMID: 9306586 DOI: 10.1007/bf02384984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Isolated hyperthermic cytostatic limb perfusion has been established as an efficient procedure for the treatment of malignant melanoma of the limbs. However, perfusions of the upper extremities are generally carried out much less frequently than would be expected given the distribution pattern of malignant melanoma and sarcoma. Thus, isolated descriptions of treatment results for perfusion of the upper extremities are not available. Between 1991 and 1994, arm perfusions using melphalan 1.0 mg/kg body weight were given to 14 patients with malignant melanoma, using the standardized method of perfusion described herein. Within an average observation period of 34.9 months (range, 12-65 months), 11 (78.7%) of the 14 patients who had M.D. Anderson stage II-IV melanoma remained free of local recurrence. In fact, 10 (71.6%) of the patients were still alive at the end of the observation period. None of the 14 patients showed any systemic adverse effects, although 1 patient developed a lymphedema 32 months after perfusion and 2 patients showed a postoperative temporary neurologic deficit. These results demonstrate that isolated perfusion of the upper limb with heat and melphalan under standardized conditions remains the treatment of choice for melanoma of the arm, as for melanoma of the leg, without a higher rate of complications.
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Affiliation(s)
- P Würl
- Department of General Surgery, Martin-Luther-University Halle, Germany
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Hohenberger P, Haier J, Schlag PM. Rhabdomyolysis and renal function impairment after isolated limb perfusion--comparison between the effects of perfusion with rhTNF alpha and a 'triple-drug' regimen. Eur J Cancer 1997; 33:596-601. [PMID: 9274441 DOI: 10.1016/s0959-8049(97)00013-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The aim of this study was to monitor serum and perfusate levels of myoglobin (MB) and creatine kinase (CK) during isolated limb perfusion (ILP) in order to identify those at risk of renal failure. We investigated the release of MB and CK in 40 patients who underwent ILP for melanoma (n = 15) or sarcoma (n = 25) using rhTNF alpha/melphalan (n = 28) or a triple-drug regimen (n = 12). Serial determinations of CK and MB were performed in both perfusate and systemic circulation during and after ILP and renal function was assessed. A significant increase of MB could be detected in the perfusate during ILP. After ILP, an up to 100-fold increase with a double peak of MB at 4 h and 24 h postoperatively was observed. The maximum elevation of serum activity of CK was at 30 h. The increase for both proteins was highly significant (P < 0.001). ILP with rhTNF alpha/melphalan yielded significantly (P < 0.001) higher serum values of MB and CK and also the impairment of the renal function was more pronounced. The peak values of MB after ILP occur early and allow the patients most at risk of developing renal failure to be identified. Rhabdomyolysis can be detected early by determination of MB from the perfusate. Further measurements twice daily for 2-3 days post ILP from serum samples as well as daily assessment of MB in the urine is helpful for detecting myoglobinuria and imminent renal failure.
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Affiliation(s)
- P Hohenberger
- Division of Surgery and Surgical Oncology, Robert-Rössle Hospital and Tumor Institute, Max-Delbrück Center for Molecular Medicine, Virchow Klinikum, Humboldt University of Berlin, Germany
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Gutman M, Inbar M, Lev-Shlush D, Abu-Abid S, Mozes M, Chaitchik S, Meller I, Klausner JM. High dose tumor necrosis factor-alpha and melphalan administered via isolated limb perfusion for advanced limb soft tissue sarcoma results in a >90% response rate and limb preservation. Cancer 1997; 79:1129-37. [PMID: 9070490 DOI: 10.1002/(sici)1097-0142(19970315)79:6<1129::aid-cncr11>3.0.co;2-1] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recombinant tumor necrosis factor-alpha (rTNF-alpha) is a highly potential antineoplastic agent. However, its systemic administration in humans has resulted in a life-threatening septic shock-like syndrome, and its use has been abandoned. The administration of high dose rTNF-alpha and melphalan via isolated limb perfusion (ILP) eliminated the systemic side effects and was shown to be very effective for metastatic melanoma confined to the limb. The purpose of the current study was to assess the role of rTNF-alpha and melphalan administered via ILP in patients with soft tissue sarcoma. Amputation is unavoidable in 10% of these patients despite aggressive conventional therapy. Limb preservation was the objective in this select group of candidates for amputation or mutilating surgery. METHODS During a 36-month period, 35 patients with high grade soft tissue sarcoma underwent 41 ILPs with high dose rTNF-alpha (3-4 mg) and melphalan (1-1.5 mg/kg). There were 21 males and 14 females. The mean age was 48 years (range, 14-80 years). Histologic subtypes included malignant fibrous histiocytoma, synovial, liposarcoma, malignant schwannoma, desmoid, clear cell, epithelioid, rhabdomyosarcoma, leiomyosarcoma, and unclassifiable. Twenty-one patients presented with recurrent and 14 with very extensive primary tumors. The tumors were located in the upper extremity in 8 patients and in the lower extremity in 27 patients. Twenty-five patients were candidates for amputation and 10 for extensive mutilating surgery. ILP was performed via the corresponding vessels proximal to the tumor. Six patients with partial response (PR) insufficient to render them resectable underwent a second ILP. With the exception of 4 of 9 patients with multifocal lesions and 1 who refused surgery, resection of the residual tumor or tumor bed or limb was performed 6-8 weeks after ILP. RESULTS Marked tumor softening occurred within 48 hours, and in tumors protruding through the skin hemorrhagic necrosis was evident within 24 hours. The overall response rate was 91%. Thirteen patients (37%) had a complete response and 19 (54%) had a PR; in 5 of these patients > 90% necrosis of the tumor occurred. In 3 patients (8.5%), only minimal regression was observed (stabilization of disease). The rate of limb sparing was 85% (29 of 34 patients). CONCLUSIONS The combination of high dose rTNF-alpha and melphalan given via ILP appears to be effective in patients with advanced soft tissue sarcoma confined to the limb, achieving a high response rate and limb preservation.
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Affiliation(s)
- M Gutman
- Department of Surgery, Sackler Faculty of Medicine, Tel Aviv University, Israel
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38
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Eggermont AM, Schraffordt Koops H, Klausner JM, Schlag PM, Kroon BB, Ben-Ari G, Lejeune FJ. Isolated limb perfusion with high-dose tumor necrosis factor-alpha for locally advanced extremity soft tissue sarcomas. Cancer Treat Res 1997; 91:189-203. [PMID: 9286497 DOI: 10.1007/978-1-4615-6121-7_13] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- A M Eggermont
- Department of Surgery, Rotterdam Cancer Institute (Dr. Daniel den Hoed Kliniek, The Netherlands
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Krementz ET, Sutherland CM, Muchmore JH. Isolated hyperthermia chemotherapy perfusion for limb melanoma. Surg Clin North Am 1996; 76:1313-30. [PMID: 8977553 DOI: 10.1016/s0039-6109(05)70517-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Safe techniques for regional chemotherapy of the limbs by perfusion are now available. The method is effective in obtaining regionally confined high levels of toxic drugs or chemotherapeutic agents in the isolated areas. The best responses have been observed in limb melanoma with recurrent or intransit disease. Chemotherapy by perfusion as an adjunct to surgical excision reduces the local recurrence and the regional and lymph node metastases. Our survivals for adjunctive perfusion for Stage I melanomas with Level V and lesions 5 mm thick and thicker are better than usually reported. Regional chemotherapy has had an important role in reduction of major amputations for the control of limb melanoma. Multiple chemotherapeutic limb perfusions can further extent survival in patients with recurring melanoma.
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Affiliation(s)
- E T Krementz
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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40
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Abstract
The technique of isolated limb perfusion for treatment of extremity melanoma has been used in the United States for almost 40 years. The treatment is based upon the ability to isolate the circulation of the afflicted extremity from the systemic circulation, thereby allowing dose-intensive delivery of anti-cancer agents to the limb while eliminating systemic exposure and toxicity. A number of agents have been used in ILP, however, the bulk of clinical experience has been with the alkylating agent melphalan, typically used under conditions of mild hyperthermia. Despite considerable clinical experience, there has been a lack of agreement about the role of ILP in the prophylaxis against or the treatment of recurrent extremity melanoma. Recently there has been renewed interest in the use of ILP based upon the very promising results using a combination of tumor necrosis factor, melphalan, and interferon-gamma which have produced complete response (CR) rates of almost 90%. The utility of this regimen in extremity melanoma is actively being evaluated by clinical trials in the United States and Europe.
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Affiliation(s)
- H R Alexander
- Surgery Branch, National Cancer Institute, NIH, Bethesda, Maryland 20892-1502, USA
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41
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Schmidt-Ullrich RK, Johnson CR. Role of radiotherapy and hyperthermia in the management of malignant melanoma. SEMINARS IN SURGICAL ONCOLOGY 1996; 12:407-15. [PMID: 8914205 DOI: 10.1002/(sici)1098-2388(199611/12)12:6<407::aid-ssu6>3.0.co;2-e] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The overall response rates of malignant melanoma (MM) to ionizing radiation are similar to those of other malignant neoplasms. This is based on recent radiobiological data on MM cell lines and radiobiological analyses of large clinical experiences, using a spectrum of fractionation schedules on diverse MM lesions. In contrast to other carcinomas, MM exhibits an unusual spectrum of radiobiological responses characteristic for early- and late-response tissues implying that there is a wide range of sensitivities to radiation fraction sizes. This is confirmed by clinical response and tumor control data from prospective trials in which different fractionation schedules produced control rates between 40 and > 90%. These experiences suggest that primary MM lesions as well as skin and lymph node metastases may be more responsive to larger fraction sizes than parenchymal metastases. The same holds true when irradiation is used as an adjuvant for locoregional treatment of the primary MM and draining lymphatics. Total doses for maximum tumor control rates remain to be established for the different fractionation schemes of proven effectiveness. Hyperthermia in combination with regionally applied cytotoxic agents or irradiation has produced encouraging enhancements in MM cytotoxicity. However, due to contradicting results, these data need to be validated by additional clinical investigation.
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Affiliation(s)
- R K Schmidt-Ullrich
- Department of Radiation Oncology, Medical College of Virginia/VCU, Richmond 23298-0058, USA
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42
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Vrouenraets BC, Nieweg OE, Kroon BB. Thirty-five years of isolated limb perfusion for melanoma: indications and results. Br J Surg 1996; 83:1319-28. [PMID: 8944445 DOI: 10.1002/bjs.1800831004] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- B C Vrouenraets
- Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, The Netherlands
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43
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Sonneveld EJ, Vrouenraets BC, van Geel BN, Eggermont AM, Klaase JM, Nieweg OE, van Dongen JA, Kroon BB. Systemic toxicity after isolated limb perfusion with melphalan for melanoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:521-7. [PMID: 8903497 DOI: 10.1016/s0748-7983(96)93085-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Systemic exposure to melphalan is minimized during isolated limb perfusion (ILP) by isolating a limb from the rest of the body. Consequently, there should be no toxicity to vital organs. At present systemic toxicity after ILP has not been studied in detail. Therefore, the incidence, nature and risk factors of systemic toxicity was retrospectively studied in 368 patients who underwent a single ILP with melphalan between 1978-1990. Some form of systemic toxicity occurred in 98 patients (27%). Nausea and vomiting after the 1st post-ILP day was seen in 73 patients (20%), and in seven (2%) treatment was required. Bone marrow depression was encountered in seven patients (2%): WHO grade II in five, and grade III in two. Miscellaneous systemic side-effects, including fever and minimal scalp hair loss, occurred in 19 patients (5%). Leakage from the isolated circuit to the systemic circulation was measured with radioactive tracers. Mean cumulative leakage during ILP was 0.9%. Systemic toxicity was not increased in patients with leakage greater than 1% or 5%. Female sex was associated with an increased incidence of systemic toxicity (P<0.05). Age over 60 years (P<0.05) and more severe acute regional toxicity (P<0.05) were correlated with nausea and vomiting. The miscellaneous systemic side-effects were more frequently encountered in women than in men (P<0.05). In conclusion, systemic toxicity was rarely severe, with nausea and vomiting being the most frequently encountered side-effects. Age over 60 years, female sex and more severe acute regional toxic reactions were correlated with an increased incidence of systemic side-effects. Systemic leakage during ILP was not associated with toxicity, probably due to the low incidence of significant leakage.
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Affiliation(s)
- E J Sonneveld
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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44
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Kristensen CA, Nozue M, Boucher Y, Jain RK. Reduction of interstitial fluid pressure after TNF-alpha treatment of three human melanoma xenografts. Br J Cancer 1996; 74:533-6. [PMID: 8761366 PMCID: PMC2074665 DOI: 10.1038/bjc.1996.397] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Tumour necrosis factor-alpha (TNF-alpha) reduced the interstitial fluid pressure (IFP) to 54-64% (P < 0.05) and the mean arterial blood pressure (MABP) to 70% (P < 0.01) of control values after 5 h in three human melanoma tumour lines transplanted to nude mice.
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Affiliation(s)
- C A Kristensen
- Edwin L Steele Laboratory, Harvard Medical School, Massachusetts General Hospital, Boston 02114, USA
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45
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Abstract
Melanoma is a malignant neoplasia of melanocyte origin appearing mainly in the skin. About one third of all melanomas detected disseminate, with the metastatic spread occurring either via lymphatic or blood vessels. In the treatment of advanced melanoma the conventional chemotherapy or radiotherapy has not been very successful. Melanoma is known to have immunologically provocative features. In recent years immunological therapies, mainly cytokines, have been applied in the treatment of melanoma. The most widely used cytokines are Interferons and interleukin-2. These agents are used either alone or in combination with each other or with chemotherapeutics. Interferon and interleukin-2 therapies have yielded response rates of 15-20% on average, whereas combinations of immunotherapy and chemotherapy offer response rates as high as 50-60%. Unfortunately, average survival of patients with disseminated melanoma has been short, from 6 to 12 months. The immunotherapy approach has yielded some long-term responses and probably even a cure for a small proportion of patients. Understanding of basic mechanisms of tumour destruction by cytokines and new agents coming into clinical use will undoubtedly further improve treatment results.
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Affiliation(s)
- K Villikka
- Department of Oncology, Helsinki University Central Hospital, Finland
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46
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Treatment of melanoma in-transit metastases confined to the limb. Eur Surg 1996. [DOI: 10.1007/bf02625948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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47
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de Kossodo S, Moore R, Gschmeissner S, East N, Upton C, Balkwill FR. Changes in endogenous cytokines, adhesion molecules and platelets during cytokine-induced tumour necrosis. Br J Cancer 1995; 72:1165-72. [PMID: 7577463 PMCID: PMC2033935 DOI: 10.1038/bjc.1995.481] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The aim of this study was to investigate mechanisms of anti-tumour activity and necrosis induced by combinations of tumour necrosis factor alpha (TNF-alpha) and interferon gamma (IFN-gamma). In a breast cancer xenograft model, locally injected recombinant human TNF-alpha arrested growth of established tumours in the absence of overt necrosis. Macroscopic necrosis occurred when rat IFN-gamma, which had no anti-tumour activity as a single agent, was given systemically. Treatment with TNF-alpha and IFN-gamma caused focal engorgement of tumour capillaries with erythrocytes, intravascular recruitment of polymorphonuclear cells and platelet adherence to the tumour vascular endothelium 4 h after the combined treatment. This was followed by destruction of tumour vascular endothelium and both necrosis and apoptosis of tumour cells. Concomitant with these changes, semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) analysis revealed the increase of stromal (murine) mRNA levels for TNF-alpha, TNF receptor 55 kDa, TNF receptor 75 kDa, intracellular adhesion molecule 1, vascular cell adhesion molecule 1, P-selectin and interleukin 6 (IL-6). Thus, the effect of the combined TNF-alpha and IFN-gamma therapy involved the selective destruction of the tumour vasculature, death of tumour cells and increased expression of a series of stromal cytokines, cytokine receptors and adhesion molecules, which could be implicated in the observed events.
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MESH Headings
- Adenocarcinoma, Mucinous/blood supply
- Adenocarcinoma, Mucinous/metabolism
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/therapy
- Animals
- Antigens, CD/biosynthesis
- Antigens, CD/genetics
- Apoptosis/drug effects
- Base Sequence
- Breast Neoplasms/blood supply
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Cell Adhesion Molecules/biosynthesis
- Cell Adhesion Molecules/genetics
- Chemotaxis, Leukocyte/drug effects
- Connective Tissue/drug effects
- Connective Tissue/metabolism
- Cytokines/biosynthesis
- Cytokines/genetics
- Drug Synergism
- Endothelium, Vascular/cytology
- Endothelium, Vascular/drug effects
- Female
- Gene Expression Regulation, Neoplastic/drug effects
- Hemorrhage/chemically induced
- Hemorrhage/pathology
- Humans
- Immunologic Factors/pharmacology
- Immunologic Factors/therapeutic use
- Interferon-gamma/pharmacology
- Interferon-gamma/therapeutic use
- Mice
- Mice, Nude
- Microcirculation/drug effects
- Molecular Sequence Data
- Necrosis
- Neoplasm Transplantation
- Platelet Adhesiveness/drug effects
- Polymerase Chain Reaction
- RNA, Messenger/biosynthesis
- RNA, Neoplasm/biosynthesis
- Rats
- Receptors, Tumor Necrosis Factor/biosynthesis
- Receptors, Tumor Necrosis Factor/genetics
- Receptors, Tumor Necrosis Factor, Type I
- Receptors, Tumor Necrosis Factor, Type II
- Recombinant Proteins/pharmacology
- Recombinant Proteins/therapeutic use
- Specific Pathogen-Free Organisms
- Tumor Cells, Cultured
- Tumor Necrosis Factor-alpha/biosynthesis
- Tumor Necrosis Factor-alpha/genetics
- Tumor Necrosis Factor-alpha/pharmacology
- Tumor Necrosis Factor-alpha/therapeutic use
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Affiliation(s)
- S de Kossodo
- Biological Therapies Laboratory, Imperial Cancer Research Fund, London, UK
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48
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Lejeune FJ. High dose recombinant tumour necrosis factor (rTNF alpha) administered by isolation perfusion for advanced tumours of the limbs: a model for biochemotherapy of cancer. Eur J Cancer 1995; 31A:1009-16. [PMID: 7646901 DOI: 10.1016/0959-8049(94)00512-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- F J Lejeune
- Fondation du Centre Pluridisciplinaire d'Oncologie, CHUV, Lausanne, Switzerland
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49
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Villani F, Galimberti M, Mazzola G, Stifani I, Santinami M, Rizzi M, Manzi R. Cardiac and Pulmonary Effects of Alpha Tumor Necrosis Factor Administered by Isolation Perfusion. TUMORI JOURNAL 1995; 81:197-200. [PMID: 7571028 DOI: 10.1177/030089169508100309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims We studied cardiac and pulmunaty function in 22 patients affected by in transit metastases from cutaneous melanoma and metastases from soft tissue sarcoma of the limbs and treated with isolation perfusion in extracorporeal circulation with rTNF alpha at doses ranging from 0.5 to 4 mg/m2 in mild hyperthermia. Patients and methods All patients experienced a septic-like shock syndrome of variable severity: this feature lasted from 24 to 72 h and was controlled by the infusion of dopamine. Seventeen patients suffered from respiratory insufficiency, which required assisted ventilation (7 cases mechanical ventilation for 1 day, 8 cases for 2 days, and 2 cases synchronized intermittent mandatory ventilation). Results Spirometrie parameters recorded 7-15 days after treatment did not change from baseline values. In contrast, lung transfer factor for carbon monoxide significantly declined in a dose dependent fashion. Conclusions Our data confirm that rTNF alpha administered by isolation perfusion technique induces systemic cardiovascular and pulmonary side effects. Further studies are required to better define time course and reversibility of impaired pulmunary function.
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Affiliation(s)
- F Villani
- Divisione di Cardiologia e Fisiopatologia Respiratoria, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
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50
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Lasek W, Wańkowicz A, Kuc K, Feleszko W, Gołab J, Giermasz A, Wiktor-Jedrzejczak W, Jakóbisiak M. Potentiation of antitumor effects of tumor necrosis factor alpha and interferon gamma by macrophage-colony-stimulating factor in a MmB16 melanoma model in mice. Cancer Immunol Immunother 1995; 40:315-21. [PMID: 7600564 PMCID: PMC11037724 DOI: 10.1007/bf01519632] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/1994] [Accepted: 01/23/1995] [Indexed: 01/26/2023]
Abstract
The efficacy of systemic infusion of recombinant human macrophage-colony-stimulating factor (M-CSF) in combination with local treatment with human recombinant tumor necrosis factor (TNF) alpha and mouse recombinant interferon (IFN) gamma was studied in vivo on a subclone of B16 melanoma (MmB16) in mice. Short-term intravenous administration of M-CSF at a dose of 10(6) units daily had no antitumor effect in vivo. Similarly, local treatment of tumor with TNF alpha (5 micrograms daily) did not produce any therapeutic effect. However, simultaneous administration of the same dose of TNF alpha with IFN gamma (1000 units daily) resulted in a synergistic effects manifested by the retardation of tumor growth. Addition of systemic infusion of M-CSF to the local therapy with TNF alpha and IFN gamma induced further augmentation of antitumor efficacy and delayed progression of MmB16 melanoma. The strengthened antitumor effect of combination therapy including M-CSF, TNF alpha and IFN gamma was most probably due to the increased release of monocytes from the bone marrow, their recruitment into the site of tumor growth and subsequent local stimulation of their antitumor activity.
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Affiliation(s)
- W Lasek
- Department of Immunology, Medical School of Warsaw, Poland
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