Perspectives of cytokine treatment in malignant skin tumors

20 years experience of TNF-based isolated limb perfusion for in-transit melanoma metastases: TNF dose matters

Background

Approximately 5–8% of melanoma patients will develop in-transit metastases (IT-mets). Tumor necrosis factor-α (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is an attractive treatment modality in melanoma patients with multiple IT-mets. This study reports on a 20 years experience and outlines the evolution and major changes since the introduction of TNF in ILP.

Methods

A total of 167 TM-ILPs were performed in 148 patients, between 1991 and 2009. TM-ILPs were performed at high doses of TNF (3–4 mg) from 1991 to 2004 (n = 99) and at low doses of TNF (1–2 mg) from 2004 to 2009 (n = 68) under mild hyperthermic conditions (38°C–39.5°C.). Melphalan doses were unchanged at 10–13 mg/l (leg and arm, respectively). Characteristics for the 167 ILPs were: 81 stage IIIB, 65 stage IIIC, and 21 stage IV disease.

Results

The overall response rate was 89% (n = 148). (Complete response [CR] = 61%; partial response [PR] = 28%). CR rates correlated with stage (P = .001) and with high-dose vs. low-dose TNF (70% vs. 49%; P < .006). High-dose TNF prolonged local control (median 16 months vs. 11 months; P = .076). Survival was not influenced by TNF dose. CR after ILP and number of lesions also correlated with local progression-free interval. Overall survival did correlate with stage of disease (P < .001), size of the lesions (P = .001), and a CR (P < .001).

Conclusions

This 2-decade single-center experience demonstrates that TM-ILP is a safe and effective treatment modality for melanoma patients with multiple IT-mets. Higher dose of TNF was associated with significantly higher CR rates and prolonged local control without an effect on overall survival.

Long-term outcome of isolated limb perfusion with tumour necrosis factor-α for patients with melanoma in-transit metastases

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 &lt; 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.

Isolated limb perfusion for melanoma in-transit metastases: developments in recent years and the role of tumor necrosis factor alpha

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.

A novel microarray to evaluate stress-related genes in skin: effect of ultraviolet light radiation

We tested transcriptional responses to ultraviolet radiation in epidermal keratinocytes using microarray chips containing more than 700 neuroendocrine-immune-related genes. The gene expression pattern was nonrandom and time-dependent; it included increased expression of genes involved in water and salt balance, prostaglandin synthesis, keratinocyte differentiation as well as genes coding for stress effectors, cytokines and metalloproteinases (MMPs). In contrast, expression was decreased for genes coding for growth factors and their receptors and for elements of extracellular matrix. This pattern suggests that transcriptional responses are coordinated and aimed at the preservation of epidermal barrier function, prevention of early carcinogenic events and remodeling of extracellular matrix. In summary, we have developed a microarray chip that can be used for simultaneous testing of transcriptional responses to cutaneous stressors in the context of neuroendocrine-immune functions of the skin.

Acute-phase proteins and hematologic values in ovine lentivirus-infected lambs treated with recombinant ovine IFN-tau

To evaluate changes in complete blood cell (CBC) counts, haptoglobin and fibrinogen in ovine lentivirus (OvLV)-infected lambs treated with recombinant ovine interferon-tau (rOVIFN-tau), 24 lambs were allocated to one of four groups (n = 6 per group): (1) virus + rOvIFN-tau, VI, (2) virus + placebo, VP, (3) no virus + rOVIFN-tau, NVI, and (4) no virus + placebo, NVP. Three lambs in each group were treated once a day for 12 weeks, and the remaining 3 lambs were treated for 33 weeks. Blood was collected at days 0, 7, and 10 and at weeks 2-10, 12, 32, and 33 to determine CBC counts, as well as haptoglobin and fibrinogen levels. Hematologic values remained within normal limits in all groups. However, hemoglobin (Hb), mean corpuscular volume (MCV), mean corpuscular hemoglobin concentration (MCHC), and packed cell volume (PCV) values decreased (p < 0.05) in the two rOvIFN-tau-treated groups (VI and NVI) compared with the placebo-treated (VP and NVP) groups. Both rOvIFN-upsilon and OvLV had a mild negative effect on neutrophil numbers. Although Hb, MCV, MCHC, PCV, and neutrophil values declined in the rOvIFN-tau-treated lambs compared with the placebo-treated lambs, these values remained within the reference range for sheep. Experimental lambs did not show adverse clinical signs associated with OvLV infection or as a result of rOvIFN-tau treatment. The lack of significant side effects of high-dose rOvIFN-tau in sheep and previous reports of broad-spectrum and cross-species antiviral activity suggest that rOvIFN-tau warrants further investigation as an antiviral therapeutic agent.

What is new in clinical research of viral diseases of the skin

Viral diseases of the skin have become a much more serious problem with the increasing number of patients immunosuppressed by either AIDS or cancer chemotherapy. The emphasis in research on the diagnosis and treatment of these diseases is similar to that on the bacterial diseases several decades ago.