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DePalo DK, Zager JS. Isolated Limb Infusion for Limb-Threatening, Unresectable Sarcoma: Past Progress, Current Applications, and Future Directions. J Clin Med 2023; 12:4036. [PMID: 37373729 DOI: 10.3390/jcm12124036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Treatment of soft tissue sarcomas (STSs) is complicated by disease heterogeneity. Further, it has not benefitted much from the recent therapeutic advances in other soft tissue malignancies. Surgical resection remains the gold standard in resectable disease, but unresectable, locally advanced STS requires alternative and multimodal approaches. Isolated limb infusion (ILI) provides regional chemotherapy to extremity STS and offers the potential for limb salvage. Despite being in use for nearly 3 decades, there is limited literature on ILI in STS. This review provides an overview of patient eligibility, the procedure, significant publications in this field, and opportunities for further progress.
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Affiliation(s)
- Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Canter, Tampa, FL 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Canter, Tampa, FL 33612, USA
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Case report: Extended Isolated Stopflow Limb Infusion (EISLI) for highly malignant osteosarcoma - complete pathological tumor remission and implantation of a knee joint prosthesis. Int J Surg Case Rep 2023; 104:107918. [PMID: 36774770 PMCID: PMC9947271 DOI: 10.1016/j.ijscr.2023.107918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE An 18-year old osteosarcoma patient with a huge tumor mass at the distal femur and inguinal metastases was treated with the intention to preserve the leg and additionally treat the pelvic metastases locally. Therefore we modulated the technique of isolated limb perfusion. CASE PRESENTATION Isolated Limb Perfusion was performed as an Extended Isolated Limb Stop-Flow Infusion (EISLI) where the pelvis was included into the perfusion bed. Balloon catheters were placed in the arterial and venous bifurcation in the pelvis. For increasing the drug concentration at the tumor site, an angiographic catheter was placed arterially with the tip right in front of the tumor region. A Stop-Flow phase before the perfusion phase was applied. CLINICAL DISCUSSION After 4 cycles of EISLI the lesions in the pelvis disappeared and surgical resection of the tumor and implantation of an endoprosthesis was possible and successful. Histopathological findings showed no vital cells in the resected tumor region. Currently the patient is tumor free and does not show recurrence or pulmonal metastases for 18 months after the last induction treatment cycle. CONCLUSION With EISLI the inclusion of the pelvis is possible during isolated limb perfusion. In addition with low total dosages EISLI enabled drug concentrations many times higher at the tumor site than possible during systemic chemotherapy or standard isolated limb perfusion. It is a technique that allows limb preservation and treatment of positive lymphnodes in the groin. Quality of life is maintained during the Regional Chemotherapy (RCT).
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Hindmarch JJ, Coker DJ, Waugh R, Kam PCA, Thompson JF, Saw RPM. Treatment of in-transit Merkel cell carcinoma by isolated limb infusion with cytotoxic drugs. J Surg Case Rep 2022; 2022:rjac172. [PMID: 35422991 PMCID: PMC9005209 DOI: 10.1093/jscr/rjac172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/28/2022] [Indexed: 12/05/2022] Open
Abstract
Merkel cell carcinoma of the skin is a rare but aggressive malignancy, which predominantly affects older adults with fair skin. Isolated limb infusion (ILI) using melphalan and actinomycin D was first developed as a minimally invasive treatment option to treat unresectable metastatic melanoma confined to the limb. We report on a 62-year-old male with in-transit metastases (ITMs) treated with ILI to highlight the ongoing role this treatment has when all other therapies have been exhausted. At presentation, the patient had widespread ITMs in the right leg. Positron emission tomography scan demonstrated recurrent disease in the thigh and pelvis, and it was decided to treat the patient with ILI. The patient progressed well in the immediate post-operative period. The patient was able to mobilize from Day 6 post-ILI and was discharged on Day 10. There was an immediate clinical response seen in the lesions, with necrosis developing in the larger lesions.
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Affiliation(s)
- Jake J Hindmarch
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
| | - David J Coker
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
| | - Richard Waugh
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Peter C A Kam
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
| | - Robyn P M Saw
- Melanoma Institute Australia, The University of Sydney, North Sydney, New South Wales, Australia
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Aldrink JH, Polites S, Lautz TB, Malek MM, Rhee D, Bruny J, Christison-Lagay ER, Tracy ET, Abdessalam S, Ehrlich PF, Dasgupta R, Austin MT. What's new in pediatric melanoma: An update from the APSA cancer committee. J Pediatr Surg 2020; 55:1714-1721. [PMID: 31699434 DOI: 10.1016/j.jpedsurg.2019.09.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/25/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE Melanoma is the most common skin cancer in children and often presents in an atypical fashion when compared to adults. The purpose of this review is to present an update on the epidemiology, surgical and medical management and prevention strategies in pediatric melanoma. METHODS A comprehensive review of the current literature on the epidemiology, surgical and medical management and prevention of adult and pediatric melanoma was performed by the authors and the results of this review are summarized in the manuscript. RESULTS Most recently, the incidence of melanoma in children has been declining, possibly owing to increased awareness and sun exposure prevention. The mainstay of therapy is surgical resection, often with sentinel lymph node biopsy. A positive sentinel node has prognostic value; however, completion node dissection is no longer recommended in the absence of clinically or radiographically positive nodes. Those with advanced disease also receive adjuvant systemic therapy using increasingly targeted immunologic therapies. CONCLUSIONS Sentinel lymph node positive patients no longer require completion lymph node dissection and instead may be followed by ultrasound. However, it is important to note that children have been excluded from most melanoma clinical trials to date, and therefore, recommendations for management are based on existing pediatric retrospective data and extrapolation from adult studies. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jennifer H Aldrink
- Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Stephanie Polites
- Division of Pediatric Surgery, Oregon Health and Science University, Portland, OR
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Daniel Rhee
- Division of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer Bruny
- Division of Pediatric Surgery, University of Colorado, Children's Hospital Colorado, Aurora, CO
| | | | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | - Shahab Abdessalam
- Department of Pediatric Surgery, Boys Town National Research Hospital, Omaha, NE
| | - Peter F Ehrlich
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Childrens Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Mary T Austin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Abstract
Childhood melanoma is a rare pediatric malignancy, with fewer than 500 new diagnoses annually. The incidence is increasing, particularly in the adolescent population. This review highlights the epidemiology, clinical presentation, and histopathologic challenges of pediatric melanoma. Surgical resection remains the cornerstone for localized and regionally advanced disease. Adjuvant therapies, including current options and potential novel therapeutics for this unique population will be discussed.
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Affiliation(s)
- Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children׳s Hospital, The Ohio State University College of Medicine, Nationwide Children׳s Dr, FB Suite 6B.1, Columbus, Ohio 43205.
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Damian DL, Barnetson RS, Thompson JF. Treatment of Refractory Chromomycosis by Isolated Limb Infusion with Melphalan and Actinomycin D. J Cutan Med Surg 2016; 10:48-51. [PMID: 17241574 DOI: 10.1007/7140.2006.00005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: Chromomycosis is frequently resistant to systemic and local therapies, and advanced bulky disease can compromise limb function. Methods: A man developed extensive chromomycosis of the left arm, refractory to multiple systemic and local treatments. Regional chemotherapy with the isolated limb infusion (ILI) technique using melphalan and actinomycin D markedly reduced disease bulk and greatly improved function of the arm over the next 2 months. Repeat ILI was performed 10 months later, again with good improvement in mobility of the elbow and significant debulking of disease. At the present time, there is some persistent but stable disease, which is controlled by heat therapy with disposable pocket warmers. The patient declined any further systemic therapy. Conclusion: ILI rapidly reduced disease bulk, restoring the limb to normal function within a few weeks. Although not curative, ILI could be an effective adjunctive treatment for severe chromomycosis in patients resistant to or intolerant of other therapies.
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Affiliation(s)
- Diona L Damian
- Department of Dermatology and Melanoma and Skin Cancer Research Institute, Sydney Cancer Centre, University of Sydney at Royal Prince Alfred Hospital, NSW, Australia.
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7
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Shaw C, Grobmyer SR. Melanoma. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fong Z, Tanabe K. Comparison of melanoma guidelines in the U.S.A., Canada, Europe, Australia and New Zealand: a critical appraisal and comprehensive review. Br J Dermatol 2014; 170:20-30. [DOI: 10.1111/bjd.12687] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 12/24/2022]
Affiliation(s)
- Z.V. Fong
- Division of Surgical Oncology; Department of Surgery; Massachusetts General Hospital; Harvard Medical School; Boston MA U.S.A
| | - K.K. Tanabe
- Division of Surgical Oncology; Department of Surgery; Massachusetts General Hospital; Harvard Medical School; Boston MA U.S.A
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Byrne CM, Thompson JF. Role of electrochemotherapy in the treatment of metastatic melanoma and other metastatic and primary skin tumors. Expert Rev Anticancer Ther 2014; 6:671-8. [PMID: 16759159 DOI: 10.1586/14737140.6.5.671] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Electroporation is a novel therapeutic modality that uses pulsed electrical currents to enhance the uptake of drugs, vaccines and genes into cells, and has been used for over 20 years. Electroporation therapy using cytotoxic drugs is called electrochemotherapy. Electrochemotherapy has been studied in vitro, in vivo and in clinical trials. It is potentially useful for treating patients with metastatic tumors, such as melanoma, and even select primary tumors, such as head and neck squamous cell carcinomas and basal cell carcinoma. Various chemotherapeutic agents have been tested with electroporation therapy, but bleomycin and cisplatin are the two most widely used. The biological basis of electroporation therapy is outlined in this review and basic science studies and the limited clinical studies that have involved electrochemotherapy are reviewed. Particular focus is placed on trials involving melanoma, head and neck cancers and other primary and metastatic skin cancers.
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Affiliation(s)
- Christopher M Byrne
- Department of Colorectal Surgery, Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.
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Seinen JM, Hoekstra HJ. Isolated limb perfusion of soft tissue sarcomas: A comprehensive review of literature. Cancer Treat Rev 2013; 39:569-77. [DOI: 10.1016/j.ctrv.2012.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 10/22/2012] [Accepted: 10/28/2012] [Indexed: 12/28/2022]
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Vohra NA, Turaga KK, Gonzalez RJ, Conley A, Reed D, Bui MM, Cheong D, Letson DG, Zager JS. The use of isolated limb infusion in limb threatening extremity sarcomas. Int J Hyperthermia 2012. [PMID: 23205633 DOI: 10.3109/02656736.2012.740548] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED This paper reports a single-institution experience with the use of isolated limb infusion for limb salvage in locally advanced, unresectable, recurrent limb threatening soft tissue sarcomas. BACKGROUND Locally advanced, limb threatening soft tissue sarcomas (STS) pose a significant treatment challenge. We report our experience using isolated limb infusion (ILI) in patients with unresectable extremity STS. METHODS A total of 22 patients with extremity STS underwent 26 ILIs with melphalan and dactinomycin. Patient characteristics, intra-operative parameters and toxicity were recorded. Outcome measures included limb-salvage and in-field response rates. RESULTS Of the 19 lower and 7 upper extremity ILIs, Wieberdink grade III toxicity or less was observed in all. Median followup was 11 months. A total of 17 patients were evaluable at 3 months post-ILI with an overall response rate of 42%. Four (24%) had complete response (CR), three (18%) partial response (PR), three (18%) stable disease (SD) and seven (41%) progressive disease (PD). Twelve of 17 (71%) underwent successful limb preservation at a median of 9 months post-ILI. Two (12%) were downstaged to resectable disease and remain showing no evidence of disease (NED) after surgery at 30 and 22 months post-ILI. CONCLUSIONS ILI is an attractive modality that provides regional disease control and limb preservation in patients with limb threatening sarcoma. Although short-term results appear encouraging, long-term follow-up is needed to fully assess the role of ILI in unresectable extremity STS.
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Affiliation(s)
- Nasreen A Vohra
- Department of Sarcoma Oncology, Moffitt Cancer Center, Tampa, Florida 33612, USA
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Deneve JL, Zager JS. Isolated regional therapy for advanced extremity soft tissue sarcomas. Surg Oncol Clin N Am 2011; 21:287-99. [PMID: 22365520 DOI: 10.1016/j.soc.2011.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Patients presenting with unresectable, large, primary or recurrent extremity soft tissue sarcoma or locally advanced extremity tumors may benefit from treatment options in the form of isolated regional perfusion therapy. Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) have proved to be efficacious with acceptable systemic and regional toxicity profiles. Both procedures are attractive as options for patients who might otherwise be facing amputation as limb salvage procedures. HILP and ILI can be offered as either definitive treatment or as neoadjuvant therapy followed by surgery and/or radiation treatment. Response rates are encouraging as are limb preservation rates after regional therapy. Ongoing multicenter collaborations and clinical trials are required to gain knowledge on HILP and ILI for unresectable extremity sarcoma and expand the indications for use in the management of advanced extremity soft tissue sarcoma.
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Affiliation(s)
- Jeremiah L Deneve
- Cutaneous Oncology Department, Moffitt Cancer Center, Tampa, FL 33612, USA
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Cai S, Bagby TR, Forrest ML. Development of regional chemotherapies: feasibility, safety and efficacy in clinical use and preclinical studies. Ther Deliv 2011; 2:1467-84. [PMID: 22229080 PMCID: PMC3249754 DOI: 10.4155/tde.11.112] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Conventional oral and intravenous chemotherapies permeate throughout the body, exposing healthy tissues to similar cytotoxic drug levels as tumors. This leads to significant dose-limiting toxicities that may prevent patients from receiving sufficient treatment to overcome cancers. Therefore, a number of locoregional drug-delivery strategies have been evaluated and implemented in preclinical studies, clinical trials and in practice, in the past decades to minimize systemic toxicities from chemotherapeutic agents and to improve treatment outcomes. Localized treatment is beneficial because many cancers, such as melanoma, peritoneal cancer and breast cancer, advance locally adjacent to the site of the primary tumors prior to their circulatory invasion. In this article, we will review the feasibility, safety and efficacy of multiple localized chemotherapies in clinical use and preclinical development.
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Affiliation(s)
- Shuang Cai
- Department of Pharmaceutical Chemistry, University of Kansas, 2095 Constant Ave, Lawrence, KS 66047 USA
| | - Taryn R Bagby
- Department of Pharmaceutical Chemistry, University of Kansas, 2095 Constant Ave, Lawrence, KS 66047 USA
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, University of Kansas, 2095 Constant Ave, Lawrence, KS 66047 USA
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Sanki A, Kroon HM, Kam PCA, Thompson JF. Isolated limb perfusion and isolated limb infusion for malignant lesions of the extremities. Curr Probl Surg 2011; 48:371-430. [PMID: 21549235 DOI: 10.1067/j.cpsurg.2011.02.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Amira Sanki
- Senior Registrar in Plastic and Reconstructive Surgery, Sydney, Australia
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Sondak VK, Gonzalez RJ, Kudchadkar R. Adjuvant Therapy for Melanoma: A Surgical Perspective. Surg Oncol Clin N Am 2011; 20:105-14. [DOI: 10.1016/j.soc.2010.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pencavel T, Seth R, Hayes A, Melcher A, Pandha H, Vile R, Harrington KJ. Locoregional intravascular viral therapy of cancer: precision guidance for Paris's arrow? Gene Ther 2010; 17:949-60. [PMID: 20445580 DOI: 10.1038/gt.2010.48] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Viral therapy of cancer includes strategies such as viral transduction of tumour cells with 'suicide genes', using viral infection to trigger immune-mediated tumour cell death and using oncolytic viruses for their direct anti-tumour action. However, problems still remain in terms of adequate viral delivery to tumours. A role is also emerging for single-organ isolation and perfusion. Having begun with the advent of isolated limb perfusion for extremity malignancy, experimental systems have been developed for the perfusion of other organs, particularly the liver, kidneys and lungs. These are beginning to be adopted into clinical treatment pathways. The combination of these two modalities is potentially significant. Locoregional perfusion increases the exposure of tumour cells to viral agents. In addition, the avoidance of systemic elimination through the immune and reticulo-endothelial systems should provide a mechanism for increased transduction/infection of target cells. The translation of laboratory research to clinical practice would occur within the context of perfusion programmes, which are already established in the clinic. Many of these programmes include the use of vasoactive cytokines such as tumour necrosis factor-alpha, which may have an effect on viral uptake. Evidence of activation of specific anti-tumour immunological responses by intratumoural and other existing methods of viral administration raises the intriguing possibility of a locoregional therapy, with the ability to affect distant sites of disease. In this review, we examined the state of the literature in this area and summarized current findings before indicating likely areas of continuing interest.
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Affiliation(s)
- T Pencavel
- Targeted Therapy Team, The Institute of Cancer Research, and Sarcoma/Melanoma Unit, Royal Marsden Hospital, London, UK
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Vyas A, Avritscher R, Ensor J, Ross M, Wallace MJ. Isolated limb infusion with cytotoxic agents: a simplified approach for venous access. Cancer 2010; 116:459-64. [PMID: 19924798 DOI: 10.1002/cncr.24736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) of cytotoxic agents is a regional therapy for cutaneous malignancies in a single extremity. Conventional ILI technique requires retrograde catheterization of the contralateral femoral vein. A novel modified ILI technique uses an ipsilateral popliteal venous approach. The purpose of this study was to compare the performance of ILI using the 2 different approaches. METHODS Data from patients who underwent lower-extremity ILI at the authors' institution between October 2005 and June 2008 were retrospectively reviewed. The authors compared the 2 ILI approaches with regard to overall procedure time, fluoroscopy time, and the number of callbacks to the operating room (OR) for flow-related issues. The Student t test and Fisher exact test were used. Adverse events, including deep venous thrombosis (DVT) in the treated limb, were recorded. RESULTS Between October 2005 and June 2008, 67 lower-extremity ILI procedures (15 using a contralateral venous access approach and 52 using an ipsilateral venous access approach) were performed in 62 patients (28 men and 34 women aged 31-82 years). The mean fluoroscopy times for the contralateral and ipsilateral groups were 17.9 and 8.3 minutes, respectively (P = .0019). No significant difference in the overall procedure time and number of callbacks to the OR for flow-related issues between the 2 groups was identified. CONCLUSIONS The ipsilateral popliteal venous approach is a simplified and safe ILI technique with significantly lower overall fluoroscopy procedure times required for catheter placement and no difference in catheter-related adverse events, when compared with the conventional contralateral approach.
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Affiliation(s)
- Ajit Vyas
- Department of Diagnostic Radiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA
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Padsis J, Turley R, Tyler D. Pharmacotherapy of regional melanoma therapy. Expert Opin Pharmacother 2009; 11:79-93. [DOI: 10.1517/14656560903428003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Abstract
Isolated limb perfusion is the preferred treatment option for locally advanced melanoma and sarcoma confined to a limb. This treatment results in high response rates with a satisfying duration of response in both tumours. A drawback of isolated limb perfusion, however, is the invasive and complex character of the procedure.Isolated limb infusion has been designed as a minimally invasive alternative to isolated limb perfusion. Treatment results of this simple technique, reported by various centres worldwide, show comparable response rates for melanoma and sarcoma. Therefore isolated limb infusion may replace isolated limb perfusion in the future as the preferred treatment option for these locally advanced limb tumours.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Melanoma Institute Australia, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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I. Ross M. Current status of hyperthermic limb perfusion for in-transit melanoma. Int J Hyperthermia 2009; 24:205-17. [DOI: 10.1080/02656730801944930] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Safety and Efficacy of Isolated Limb Infusion With Cytotoxic Drugs in Elderly Patients With Advanced Locoregional Melanoma. Ann Surg 2009; 249:1008-13. [DOI: 10.1097/sla.0b013e3181a77ce5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kroon HM, Moncrieff M, Kam PCA, Thompson JF. Factors Predictive of Acute Regional Toxicity After Isolated Limb Infusion with Melphalan and Actinomycin D in Melanoma Patients. Ann Surg Oncol 2009; 16:1184-92. [DOI: 10.1245/s10434-009-0323-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 12/02/2008] [Accepted: 12/03/2008] [Indexed: 11/18/2022]
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Kroon HM, Lin DY, Kam PCA, Thompson JF. Isolated Limb Infusion as Palliative Treatment for Advanced Limb Disease in Patients with AJCC Stage IV Melanoma. Ann Surg Oncol 2009; 16:1193-201. [DOI: 10.1245/s10434-009-0326-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 11/18/2022]
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Demierre MF, Sabel MS, Margolin KA, Daud AI, Sondak VK. State of the science 60th anniversary review: 60 Years of advances in cutaneous melanoma epidemiology, diagnosis, and treatment, as reported in the journal Cancer. Cancer 2008; 113:1728-43. [PMID: 18798543 DOI: 10.1002/cncr.23643] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Marie-France Demierre
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, USA
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Kam PC, Thompson JF. Pharmacokinetics of Regional Therapy: Isolated Limb Infusion and Other Low Flow Techniques for Extremity Melanoma. Surg Oncol Clin N Am 2008; 17:795-804, ix. [DOI: 10.1016/j.soc.2008.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Moncrieff MD, Kroon HM, Kam PC, Stalley PD, Scolyer RA, Thompson JF. Isolated limb infusion for advanced soft tissue sarcoma of the extremity. Ann Surg Oncol 2008; 15:2749-56. [PMID: 18648882 DOI: 10.1245/s10434-008-0045-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique for delivering high-dose regional chemotherapy. We report our experience with ILI for the treatment of soft tissue sarcoma (STS). METHODS From our prospective database, 21 patients with STS of the limb treated with ILI between 1994 and 2007 were identified. In all patients, a high-dose cytotoxic drug combination was used. RESULTS There were 14 men, and the median age was 60 years (range, 18-85 years). Eighteen patients (86%) had lower limb tumors. All patients had advanced local disease. The procedure was well tolerated. Fourteen patients (67%) received ILI before definitive surgery. The overall response rate was 90% (complete response [CR] rate 57%, partial response rate 33%). The disease-specific overall survival was 61.9% (median follow-up, 28 months). Only American Joint Committee on Cancer stage was associated with overall survival. The local recurrence rate was 42%. CR and malignant fibrous histiocytoma tumor subtype were associated with a lower local recurrence rate. A lower initial skin temperature (median 35.8 degrees C) was associated with a CR (P = .033). Patients who had a steep increase in intramuscular temperature during the procedure were more likely to have a CR (P = .055). Classification tree analysis identified patients with an initial PaO(2) of >/=194 mmHg as being more likely to have a CR. Ultimately, the overall limb salvage rate was 76%. CONCLUSION The outcomes after ILI are comparable to those achieved by conventional isolated limb perfusion. ILI is a minimally invasive alternative to isolated limb perfusion for patients with advanced STS of the extremity.
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Affiliation(s)
- Marc D Moncrieff
- The Sydney Melanoma Unit, Gloucester House, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Mcloughlin JM, Zager JS, Sondak VK, Berk LB. Treatment Options for Limited or Symptomatic Metastatic Melanoma. Cancer Control 2008; 15:239-47. [DOI: 10.1177/107327480801500307] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Patients who develop metastatic melanoma often have limited effective treatment options. However, a select group of patients will benefit from aggressive surgery or a multidisciplinary approach, depending on the site of metastasis. Methods The current literature was reviewed and summarized regarding the collective recommendations for staging and treating patients with metastatic melanoma. Results A thorough preoperative staging includes positron-emission tomography, MRI of the brain, and CT of the chest, abdomen, and pelvis. Tumor biology ultimately determines the success of intervention. A long disease-free interval is a good indicator of potential benefit from resection of metastatic disease. If surgery is performed, no less than a complete resection will affect the overall survival of the patient. Surgery and other multimodality treatment options can be used for symptomatic palliation but will not affect survival. Chemotherapy and radiation are often used to control the symptoms of brain and bony metastases but have limited if any impact on survival. Conclusions A select group of patients with metastatic melanoma will benefit from aggressive surgery. Identifying which patients will benefit from treatment requires good clinical judgment and a thorough radiologic evaluation to identify the true extent of disease.
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Affiliation(s)
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Vernon K. Sondak
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Immunology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Lawrence B. Berk
- Radiation Oncology Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Möller MG, Lewis JM, Dessureault S, Zager JS. Toxicities associated with hyperthermic isolated limb perfusion and isolated limb infusion in the treatment of melanoma and sarcoma. Int J Hyperthermia 2008; 24:275-89. [PMID: 18393005 DOI: 10.1080/02656730701805520] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) may play a significant role in the treatment of patients with recurrent or in transit extremity melanoma or sarcoma that is unresectable. These procedures may be indicated when patients are otherwise faced with the possibility of a debilitating amputation. Not entirely benign treatment modalities, HILP and ILI can be associated with regional and systemic toxicities. We conducted a literature search of published studies using HILP and ILI for the treatment of extremity sarcomas and melanomas, and associated toxicities was performed. The regional toxicities of HILP and ILI are similar. The most common toxicities reported are mild to moderate. However, when severe regional toxicity occurs, albeit infrequently (<5%), fasciotomies or even amputation may be necessary. Some studies have showed a relationship between acute regional toxicities and long term regional morbidity. Systemic toxicity appears to be more frequent when TNF-alpha is used in combination with other drugs during HILP, however the use of TNF-alpha in the United States is limited to trials. Although regional toxicities are similar, systemic toxicity of ILI is minimal compared to HILP. ILI is easier to repeat, technically less complex, and may be more acceptable in infirmed patients. Long term morbidity and outcomes for ILI are still being evaluated. Both of these techniques may be suitable options in patients with unresectable advanced or recurrent, or in transit extremity melanoma or sarcoma.
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Affiliation(s)
- Mecker G Möller
- H Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa. FL 33612, USA
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Kroon HM, Moncrieff M, Kam PCA, Thompson JF. Outcomes following isolated limb infusion for melanoma. A 14-year experience. Ann Surg Oncol 2008; 15:3003-13. [PMID: 18509706 DOI: 10.1245/s10434-008-9954-6] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 03/25/2008] [Accepted: 04/16/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique for delivering regional chemotherapy in patients with advanced and metastatic melanoma confined to a limb. It is essentially a low-flow isolated limb perfusion (ILP) performed via percutaneous catheters without oxygenation. METHODS From our prospective database 185 patients with advanced metastatic melanoma of the limb treated with a single ILI between 1993 and 2007 were identified. In all patients a cytotoxic drug combination of melphalan and actinomycin-D was used. Drug circulation time was 20-30 min under mild hyperthermic conditions (38-39 degrees C). RESULTS The majority of patients (62%) were female. Their average age was 74 years (range 29-93 years). Most patients had MD Anderson stage III disease (134/185). The overall response rate was 84% [complete response (CR) rate 38%, partial response rate 46%]. Median response duration was 13 months (22 months for patients with CR; P = 0.01). Median follow-up was 20 months and median survival was 38 months. In those patients with a CR, the median survival was 53 months (P = 0.005). CR rate and survival time decreased with increasing stage of disease. On multivariate analysis significant factors for a favorable outcome were achievement of CR, stage of disease, thickness of primary melanoma, the CO(2 )level in the isolated circuit, and a Wieberdink limb toxicity score of III (considerable erythema and edema). CONCLUSION The response rates and duration of response after ILI are comparable to those achieved by conventional ILP. ILI is a minimally invasive alternative to the much more complex and morbid conventional ILP technique for patients with advanced metastatic melanoma confined to a limb.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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31
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Regional Therapy of Cancer. Surgery 2008. [PMCID: PMC7122175 DOI: 10.1007/978-0-387-68113-9_104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Melanoma and Other Cutaneous Malignancies. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
For most solid tumors therapy has evolved from surgery alone to a multidisciplinary approach. Malignant melanoma remains an exception, with surgery maintaining the principal role not only for treatment of the primary lesion but also staging and the management of advanced disease. The surgical management of melanoma has evolved over the years, resulting in a substantial decrease in the morbidity associated with treatment without a compromise in outcome. This article will review the changes that have occurred leading to the current surgical approach to melanoma, the evidence behind these recommendations, and new questions that need to be addressed.
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Affiliation(s)
- Dan G Blazer
- Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Sanki A, Kam PCA, Thompson JF. Long-term results of hyperthermic, isolated limb perfusion for melanoma: a reflection of tumor biology. Ann Surg 2007; 245:591-6. [PMID: 17414608 PMCID: PMC1877051 DOI: 10.1097/01.sla.0000251746.02764.fc] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the long-term duration of limb tumor complete remission (CR) and patient survival following therapeutic hyperthermic isolated limb perfusion (ILP) with cytotoxic drugs for melanoma. METHODS A retrospective case series of 124 ILPs performed in 111 patients. RESULTS There were 120 assessable ILPs. Patient staging (M.D. Anderson system) was stage II 11.7%, stage IIIA 44.2%, stage IIIAB 33.3%, and stage IV 10.8%. CR was initially attained after 83 ILPs (69.2%) and partial remission (PR) after 19 ILPs (15.8%). Limb CR was maintained in 28 (33.7%) of the 83 cases. Disease recurred in the perfused limb after an initial CR in the remaining 55 cases (median time to recurrence, 11 months); in 19 of these cases, the limb was disease-free at last follow-up after further locoregional treatment. A long-term CR was achieved, with or without further treatment, in 47 (56.6%) of the 83 cases in which an initial CR had occurred (mean follow-up, 97 months; median, 65 months). There was no significant difference in long-term local remission for stage IIIA and IIIAB patients. Five-year survival for those who had a partial or no response to ILP was 7%. Ten-year survival for those who had a long-term CR was 49%. CONCLUSIONS ILP, with or without further locoregional treatment, achieved long-term control of recurrent and metastatic limb disease in 56.6% of cases in which an initial CR was achieved. A complete response to ILP was a positive prognostic indicator for survival, probably reflecting more favorable tumor biology in this subset of patients.
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Affiliation(s)
- Amira Sanki
- Sydney Melanoma Unit, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Riker AI, Kirksey L, Thompson L, Morris A, Cruse CW. Current surgical management of melanoma. Expert Rev Anticancer Ther 2007; 6:1569-83. [PMID: 17134362 DOI: 10.1586/14737140.6.11.1569] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The surgical management of melanoma has changed dramatically over the last few decades. Through the development and conduction of well-designed, prospective, randomized trials, we have been able to refine the way that we surgically manage patients with melanoma. Indeed, many important issues have been addressed through such trials: the proper surgical margins for the primary melanoma, utility of the elective lymph node dissection and the role for selective lymphadenectomy, to name a few. This review will also discuss what we have learned from past clinical trials and address several issues with regards to where we are going in the future.
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Affiliation(s)
- Adam I Riker
- Surgical Oncology Services and Associate Professor of Surgery, University of South Alabama--Mitchell Cancer Institute, Cutaneous Oncology Program, 307 North University Blvd, MSB 2015, Mobile, Alabama 36688, USA.
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Rajpar SF, Martin-Clavijo A, Marsden JR, Byrne D. Palliation of skeletal melanoma metastases with isolated limb perfusion chemotherapy. Dermatol Surg 2006; 32:1199-201. [PMID: 16970706 DOI: 10.1111/j.1524-4725.2006.32266.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sajjad F Rajpar
- Skin Oncology Service, University Hospital Birmingham, Selly Oak, Birmingham, England.
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Palliation of Skeletal Melanoma Metastases with Isolated Limb Perfusion Chemotherapy. Dermatol Surg 2006. [DOI: 10.1097/00042728-200609000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The rapid increase in incidence of malignant melanoma has not been associated with better therapeutic options over the years. Single-agent chemotherapy or immunotherapy remain the treatments of choice when systemic therapy is offered. Dacarbazine (DTIC) is the chemotherapy of choice with a response rate of 16%. Other chemotherapies, including cisplatinum, paclitaxel, docetaxel and the DTIC analogue temozolomide, have shown activity in this disease. Based on their single-agent activity, several combination chemotherapies have been investigated with preliminary results that appeared promising. However, in randomized phase III trials the two most active chemotherapy combination regimens, cisplatin, vinblastine, and DTIC (CVD) and the Dartmouth regimen (DTIC, cisplatin, bischloroethylnitrosourea , and tamoxifen), did not prove to be superior to single-agent DTIC for overall survival. Immunotherapy with either interleukin (IL)-2 or interferon (IFN) has demonstrated response rates of 10% to 15% in appropriately selected patients. In patients who achieve a complete response, responses can be of greater durability than those with chemotherapy. However, IL-2 and IFN administration are associated with multiple side effects, and only physicians experienced in the management of such therapies should administer them. The potential benefit of combining chemotherapy with immunotherapy has led to multiple phase II trials of biochemotherapy that appeared to be associated with higher response rates and longer median survivals. However, several phase III trials have been completed that have not consistently demonstrated an improvement in either response rates or overall survival, and these approaches to therapy cannot be routinely recommended outside the context of a clinical trial. The surgical resection of isolated metastatic disease has demonstrated an important palliative benefit in those patients who present with solitary single-organ disease with the exception of the liver. Radiation has an important role in the palliative management of brain metastasis and symptomatic bony metastasis. Both stereotactic radiosurgery and whole brain radiotherapy have been used alone and in combination to benefit patients in this troubling clinical circumstance. Isolated limb perfusion and a newer technique, isolated limb infusion have demonstrated high response rates for those uncommon patients who develop recurrent disease isolated to a limb. In our opinion, if complete metastasectomy is not feasible and in the absence of brain metastases, single-agent IL-2 is a good initial treatment choice in appropriately selected patients. Single-agent chemotherapy with DTIC is the treatment of choice for patients who are not candidates for IL-2. Adoptive immunotherapy combining nonmyeloablative chemotherapy with high-dose IL-2 is a potentially promising therapeutic strategy under investigation. Targeted therapy is also an area of promising development as single agents, in combination, and combined with chemotherapy. The latter will be the focus of at least one upcoming cooperative group phase III trial.
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Affiliation(s)
- Ehab Atallah
- Karmanos Cancer Institute, Wayne State University, 4100 John R, Detroit, MI 48201, USA
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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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