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Khoury S, Knapp GC, Fyfe A, Monzon J, Temple-Oberle C, McKinnon GJ. Durability of Complete Response to Intralesional Interleukin-2 for In-Transit Melanoma. J Cutan Med Surg 2021; 25:364-370. [PMID: 33529083 PMCID: PMC8311908 DOI: 10.1177/1203475420988862] [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] [Indexed: 11/16/2022]
Abstract
Background Intralesional injection of interleukin-2 (IL-2) for in-transit melanoma (ITM) is associated with a high rate of complete response. However, there is a paucity of data on treatment durability and long-term outcomes. Objectives To provide long-term data on patients with a complete response to IL-2 therapy for ITM. Methods Consecutive patients with ITM, treated with intralesional IL-2 therapy, at the Tom Baker Cancer Center were identified from April 2009 to August 2019. All patients received at least 4 cycles (every 2 weeks) of IL-2 (5 MIU/mL). Complete response was defined as sustained (ie, 3 months) clinical complete remission of all known in-transit disease. Results Sixty-five patients were treated with curative intent for in-transit disease with intralesional IL-2. Complete clinical response was identified in 44.6% (29/65). In this subset of patients, the median number of lesions per patient was 9 (range 1-40). The median total dose of IL-2 was 0.8 mL (IQR 0.4-1.5) per lesion. One patient received isolated limb infusion and 13.8% (4/29) received systemic immunotherapy as part of their initial management. At a median follow-up of 27 months (IQR 16-59), 34.5% (10/29) developed recurrent disease. Of these patients, 50.0% (5/10) presented with synchronous in-transit and distant metastases. The median time to recurrence was 10.5 months (IQR 5.8-16.3). Conclusion With long-term follow-up, 65.5% of complete responders have a durable response to intralesional IL-2 therapy. In this cohort of patients, local in-transit recurrence is most likely to occur within 12 months and is often associated with concomitant distant disease.
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Affiliation(s)
- Sami Khoury
- 70401 Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gregory C Knapp
- 2129 Department of Oncology, Division of Surgical Oncology, University of Calgary, Calgary, AB, Canada
| | - Allison Fyfe
- 3146 Alberta Health Services, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Jose Monzon
- Department of Oncology, Division of Medical Oncology, University of Calgary, Calgary, AB, Canada
| | - Claire Temple-Oberle
- Department of Surgery, Division of Plastic Surgery and Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Gregory J McKinnon
- 2129 Department of Oncology, Division of Surgical Oncology, University of Calgary, Calgary, AB, Canada
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Electrochemotherapy in the treatment of melanoma. Contemp Oncol (Pozn) 2018; 22:8-13. [PMID: 29692657 PMCID: PMC5909724 DOI: 10.5114/wo.2018.74387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/16/2017] [Indexed: 12/21/2022] Open
Abstract
Electrochemotherapy is a new therapeutic option for patients with locally spread melanoma. It is based on the phenomenon of reversible electroporation, i.e. a transient increase in permeability of cell membranes under the influence of an appropriately modulated electric field. This allows multiplication of toxicity of a cytostatic agent entering the tumour cell. It is highly effective, especially in the palliative treatment of cancers located in the integument of the human body (skin and subcutaneous tissue). Available literature provides a mandate both for the application of this method in the aforementioned cases as well as for further work on its development. This paper focuses on reviewing the literature concerning the use of electrochemotherapy in the treatment of melanoma.
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Hassan S, Petrella TM, Zhang T, Kamel-Reid S, Nordio F, Baccarelli A, Sade S, Naert K, Habeeb AA, Ghazarian D, Wright FC. Pathologic complete response to intralesional interleukin-2 therapy associated with improved survival in melanoma patients with in-transit disease. Ann Surg Oncol 2014; 22:1950-8. [PMID: 25366584 DOI: 10.1245/s10434-014-4199-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Melanoma patients with in-transit disease have a high mortality rate despite various treatment strategies. The aim of this study was to validate the role of intralesional interleukin (IL)-2, to understand its mechanism of action, and to better understand factors that may influence its response. METHODS We retrospectively collected the clinicopathological data of 31 consecutive patients who presented to a tertiary care cancer center for treatment of in-transit melanoma with intralesional IL-2. Kaplan-Meier survival curves and multivariable Cox regression analysis were performed. Immunohistochemistry (IHC) was used to better understand the immune response to localized IL-2 therapy. Targeted next-generation sequencing was performed to genomically characterize the tumors. RESULTS Ten patients (10/31, 32 %) achieved a pathologic complete response (pCR), 17/21 (55 %) had a partial response, and 4/21 (19 %) had progressive disease on treatment. pCR to IL-2 therapy was associated with overall survival (log-rank p = 0.004) and improved progression-free survival (PFS) [adjusted hazard ratio (HR) 0.11; 95 % CI 0.02-0.47; p = 0.003). A higher CD8+ T cell infiltrate was identified in in-transit lesions with a pCR compared with the other lesions (mean IHC score 3.78 vs. 2.61; p = 0.01). Patients with an elevated CD8+ infiltrate demonstrated an improved PFS (unadjusted HR 0.08; 95 % CI 0.01-0.52; p = 0.008). CONCLUSIONS Thirty-two percent of patients achieved pCR with intralesional IL-2 therapy and had a significantly improved PFS compared with the rest of the cohort, which may be explained by a systemic CD8+ T-cell response.
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Affiliation(s)
- Saima Hassan
- Division of Surgical Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, ON, Canada
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Rashid OM, Sloot S, Zager JS. Regional therapy in metastatic melanoma: an update on minimally invasive intraarterial isolated limb infusion and percutaneous hepatic perfusion. Expert Opin Drug Metab Toxicol 2014; 10:1355-64. [DOI: 10.1517/17425255.2014.951330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Nieweg OE, Kroon BB. Isolated limb perfusion with melphalan for melanoma. J Surg Oncol 2014; 109:332-7. [DOI: 10.1002/jso.23558] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/16/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Omgo E. Nieweg
- Melanoma Institute Australia; North Sydney NSW Australia
| | - Bin B.R. Kroon
- Skin and Melanoma Center and Department of Surgery; The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital; Amsterdam the Netherlands
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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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Selimovic D, Badura HE, El-Khattouti A, Soell M, Porzig BBOW, Spernger A, Ghanjati F, Santourlidis S, Haikel Y, Hassan M. Vinblastine-induced apoptosis of melanoma cells is mediated by Ras homologous A protein (Rho A) via mitochondrial and non-mitochondrial-dependent mechanisms. Apoptosis 2014; 18:980-97. [PMID: 23564313 DOI: 10.1007/s10495-013-0844-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite the availability of melanoma treatment at the primary site, the recurrence of local melanoma can metastasize to any distant organ. Currently, the available therapies for the treatment of metastatic melanoma are of limited benefit. Thus, the functional analysis of conventional therapies may help to improve their efficiency in the treatment of metastatic melanoma. In the present study, the exposure of melanoma cells to vinblastine was found to trigger apoptosis as evidenced by the loss of mitochondrial membrane potential, the release of both cytochrome c and apoptosis inducing factor, activation of caspase-9 and 3, and cleavage of Poly (ADP-ribose)-Polymerase. Also, vinblastine enhances the phosphorylation of Ras homologous protein A, the accumulation of reactive oxygen species, the release of intracellular Ca(2+), as well as the activation of apoptosis signal-regulating kinase 1, c-jun-N-terminal kinase, p38, inhibitor of kappaBα (IκBα) kinase, and inositol requiring enzyme 1α. In addition, vinblastine induces the DNA-binding activities of the transcription factor NF-κB, HSF1, AP-1, and ATF-2, together with the expression of HSP70 and Bax proteins. Moreover, inhibitory experiments addressed a central role for Rho A in the regulation of vinblastine-induced apoptosis of melanoma cells via mitochondrial and non-mitochondrial-dependent mechanisms. In conclusion, the present study addresses for the first time a central role for Rho A in the modulation of vinblastine-induced apoptosis of melanoma cells and thereby provides an insight into the molecular action of vinblastine in melanoma treatment.
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Affiliation(s)
- Denis Selimovic
- Institut National de la Santé et de la Recherche Médicale, U 977, Faculty of Medicine and Dental Faculty, 11 Rue Humann, 67000 Strasbourg, France
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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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Han D, Beasley GM, Tyler DS, Zager JS. Minimally invasive intra-arterial regional therapy for metastatic melanoma: isolated limb infusion and percutaneous hepatic perfusion. Expert Opin Drug Metab Toxicol 2011; 7:1383-94. [PMID: 21978383 PMCID: PMC4630979 DOI: 10.1517/17425255.2011.609555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION In-transit melanoma or melanoma presenting as unresectable liver metastases are clinical situations with limited therapeutic options. Regional intra-arterial therapies provide efficacious treatment alternatives for these patients. Through surgical techniques of vascular isolation, regional therapies deliver high-dose chemotherapy to tumor cells while minimizing systemic exposure. However, percutaneous techniques such as isolated limb infusion (ILI) and percutaneous hepatic perfusion (PHP) have been developed, which provide a minimally invasive means of obtaining vascular isolation of target organs. AREAS COVERED Areas covered in this review include the techniques of ILI and PHP, the chemotherapeutic agents utilized during these regional therapies and the clinical responses seen after ILI and PHP. The pharmacokinetics of regional chemotherapy utilized during ILI and PHP is also reviewed with an additional focus on novel ways to optimize drug delivery to improve response rates and attempts to define the potential systemic manifestations of regional therapeutics. EXPERT OPINION Unresectable hepatic and limb in-transit metastases from melanoma are very difficult to treat. Systemic chemotherapy has largely been ineffective. Both the minimally invasive, percutaneous techniques of ILI and PHP are excellent methods used to deliver extremely high-dose chemotherapy regionally to patients harboring metastatic melanoma confined to an extremity or liver, respectively. Studies, from prospectively maintained databases as well as Phase II and III trials, have shown the great efficacy of these techniques.
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Affiliation(s)
- Dale Han
- Surgical Oncology Fellow, Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Mail Stop: Cut-Prog, Tampa, SRB4.24012, FL 33612, USA
| | - Georgia M Beasley
- Surgery Resident, Duke University Medical Center, Department of Surgery, Box 3118, Durham, NC 27710, USA
| | - Douglas S Tyler
- Professor of Surgery, Duke University Medical Center, Department of Surgery, Box 3118, Durham, NC 27710, USA
| | - Jonathan S Zager
- Associate Professor of Surgery, Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Mail Stop: Cut-Prog, SRB4.24012, Tampa, FL 33612, 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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Abstract
For in-transit melanoma confined to the extremities, regional chemotherapy in the form of hyperthermic isolated limb perfusion and isolated limb infusion are effective treatment modalities carrying superior response rates to current standard systemic therapy. Despite high response rates, most patients will eventually recur, supporting the role for novel research aimed at improving durable responses and minimizing toxicity. Although the standard cytotoxic agent for regional chemotherapy is melphalan, alternative agents such as temozolomide are currently being tested, with promising preliminary results. Current strategies for improving chemosensitivity to regional chemotherapy are aimed at overcoming classic resistance mechanisms such as drug metabolism and DNA repair, increasing drug delivery, inhibiting tumor-specific angiogenesis, and decreasing the apoptotic threshold of melanoma cells. Concurrent with development and testing of these agents, genomic profiling and biomolecular analysis of acquired tumor tissue may define patterns of tumor resistance and sensitivity from which personalized treatment may be tailored to optimize efficacy. In this article rational strategies for treatment of in-transit melanoma are outlined, with special emphasis on current translational and clinical research efforts.
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Kam PCA, Thompson JF. Isolated limb infusion with melphalan and actinomycin D in melanoma patients: factors predictive of acute regional toxicity. Expert Opin Drug Metab Toxicol 2011; 6:1039-45. [PMID: 20604735 DOI: 10.1517/17425255.2010.503703] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Isolated limb infusion (ILI) is a simple, minimally invasive technique of delivering high concentrations of cytotoxic drugs to a diseased limb for achieving disease control in that limb. Recent studies have suggested that mild hyperthermic (38 degrees C) ILI might be the best initial treatment for extensively recurrent limb melanoma given its simplicity, low morbidity and a complete response rate of 30 - 40%. AREAS COVERED IN THIS REVIEW Since 1994 when ILI was first described by Thompson et al., the procedure has been adopted by several centres around the world; research and improvements in the technique have resulted in reduction in limb toxicity without reducing its clinical efficacy. The pharmacokinetics of melphalan and the clinical efficacy and adverse effects of ILI from various centres are summarised. Minor but possibly important differences in the ILI techniques used in different institutions may be important in improving its efficacy and reducing the toxic effects. WHAT THE READER WILL GAIN An understanding of the efficacy and toxicity associated with ILI with cytotoxic drugs in melanoma patients and of methods to optimise regional therapy for malignant disease in a limb. TAKE HOME MESSAGE ILI with mild hyperthermia (38 degrees C) is well tolerated with tumour remission rates in melanoma patients similar to those achieved by isolated limb perfusion. Mild (grade I - II) and moderate/severe (grade > or = III) limb toxicities occur in 58 - 68% and 32 - 41% of patients, respectively, but long-term morbidity is rare. A high peak and high final melphalan concentration in the infusate, the AUC of melphalan concentration in the infusate and an increased postoperative serum creatine phosphokinase concentration are factors predictive of acute regional toxicity. Drug dose adjusted for ideal body weight and gender may reduce acute toxicity following ILI. It has been suggested that the use of papaverine prior to the infusion of melphalan might increase its efficacy, but it may also increase toxicity. Large prospective studies are needed to more accurately define the perioperative factors that influence acute regional toxicity after ILI and to establish strategies to optimise clinical outcome.
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Affiliation(s)
- Peter C A Kam
- The University of Sydney, Royal Prince Alfred Hospital, Department of Anaesthetics, Camperdown, NSW 2050, Australia
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Coleman A, Augustine CK, Beasley G, Sanders G, Tyler D. Optimizing regional infusion treatment strategies for melanoma of the extremities. Expert Rev Anticancer Ther 2010; 9:1599-609. [PMID: 19895244 DOI: 10.1586/era.09.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The incidence of malignant melanoma is increasing faster than any other cancer. In cases of recurrent melanoma confined to the extremities, hyperthermic isolated limb perfusion and isolated limb infusion provide a way to isolate the extremity and deliver a dose of chemotherapy several orders of magnitude higher than would be tolerated systemically. Although complete response rates of up to 80% for hyperthermic isolated limb perfusion and 44% for isolated limb infusion have been observed, there is still room for improvement and standardization in these two procedures in an attempt to optimize response while minimizing toxicity. Currently, new chemotherapy agents and small-molecule inhibitors are being investigated as a means of overcoming chemoresistance and improving response rates. In patients with advanced cutaneous disease confined to the extremities, evaluation of these new therapies can be very informative, as tissue acquisition at multiple treatment time points is easy owing to the superficial and multifocal nature of the disease. Through studying the biomolecular and genetic alterations in tumor tissue in response to these new therapies, genetically customized treatment regimens in which tumor resistance and sensitivity is predicted and treatment strategy is optimized before treatment begins may soon be available. Progress in regional therapy will prove not only beneficial for patients with disease confined to an extremity, but may also provide insight into developing novel treatment strategies for patients with systemic disease for whom current disease management options are poor.
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Affiliation(s)
- Andrew Coleman
- Duke University School of Medicine, Durham, NC 27710, USA.
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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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Beasley GM, Ross MI, Tyler DS. Future directions in regional treatment strategies for melanoma and sarcoma. Int J Hyperthermia 2009; 24:301-9. [DOI: 10.1080/02656730701827573] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Santillan AA, Delman KA, Beasley GM, Mosca PJ, Hochwald SN, Grobmyer SR, Andtbacka RH, Noyes RD, Kane JM, Ross MI, Tyler DS, Zager JS. Predictive factors of regional toxicity and serum creatine phosphokinase levels after isolated limb infusion for melanoma: a multi-institutional analysis. Ann Surg Oncol 2009; 16:2570-8. [PMID: 19543771 DOI: 10.1245/s10434-009-0563-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/08/2009] [Accepted: 05/05/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a minimally invasive technique delivering regional chemotherapy to treat in-transit extremity melanoma. Determining perioperative factors that could predict toxicity is important to optimize strategies to improve clinical outcomes after regional chemotherapy in melanoma. METHODS Perioperative factors from 171 ILI patients performed at eight centers from 2001 to 2008 were reviewed. The Wieberdink limb toxicity scale and creatine phosphokinase (CK) levels were used to measure toxicity. Logistic regression analysis was used to estimate the association between toxicity and perioperative parameters. RESULTS Mild (grades I-II) and severe (grades >or=III) limb toxicity developed in 68% and 32% of patients, respectively. Melphalan adjusted for ideal body weight (aIBW) and papaverine were used in 47% and 63% of patients, respectively. Median peak CK for all patients was 563 U/l, and median peak occurred at postoperative day 4. On univariate analysis, papaverine and high CK levels (>563 U/l) were significantly associated with higher toxicity. On the contrary, aIBW was significantly associated with a lower risk of severe toxicity. Perfusate blood gas at 30 min [pH, PaO(2), and base excess (BE) ], limb temperature, and ischemia time were not predictive of limb toxicity. On multivariate analysis, severe toxicity was associated with female sex (P = 0.01), papaverine (P = 0.01), and high peak CK levels (P < 0.01). Independent predictors of high CK levels included younger age, unadjusted melphalan dose, and low PaO(2) at 30 min. CONCLUSIONS ILI can be performed with an acceptable morbidity. Papaverine use, female gender, and high peak CK were associated with higher limb toxicity. CK levels can be diminished significantly with aIBW.
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Affiliation(s)
- Alfredo A Santillan
- Division of Cutaneous Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Kroon HM, Lin DY, Kam PCA, Thompson JF. Efficacy of repeat isolated limb infusion with melphalan and actinomycin D for recurrent melanoma. Cancer 2009; 115:1932-40. [PMID: 19288571 DOI: 10.1002/cncr.24220] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND : Isolated limb infusion (ILI) is an effective and minimally invasive treatment option for delivering regional chemotherapy in patients with metastatic melanoma confined to a limb. Recurrent or progressive disease after an ILI, however, presents a challenge for further treatment. The value of repeat ILI in this situation has not been well documented. METHODS : Forty-eight patients were identified who had been treated with a repeat ILI. In all patients, a cytotoxic combination of melphalan and actinomycin D was used. RESULTS : The median time between the 2 procedures was 11 months. The complete response (CR) rate after repeat ILI was 23%, compared with 31% after the initial ILI (P = .36). The overall response was 83%, compared with 75% after the first procedure (P = .32). The median duration of response was 11 months (10 months for patients with CR; P = .80), and median survival was 38 months. In those patients achieving a CR, the median survival was 68 months (P = .003). Toxicity after repeat ILI was increased, with 20 patients experiencing Wieberdink grade III limb toxicity (considerable erythema and edema with blistering) and 5 patients experiencing grade IV toxicity (threatened or actual compartment syndrome), whereas after the initial ILI these toxicity grades occurred in 14 patients and 1 patient, respectively (P = .03). No patient experienced grade V toxicity (requiring amputation). CONCLUSIONS : Repeat ILI is an attractive treatment option to achieve limb salvage in patients with inoperable recurrent or progressive melanoma after a previous ILI. It can be associated with significant short-term regional toxicity, but is well tolerated by most patients, with satisfactory response rates. Cancer 2009. (c) 2009 American Cancer Society.
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Affiliation(s)
- Hidde M Kroon
- Sydney Melanoma Unit, Sydney Cancer Center, Royal Prince Alfred Hospital, Sydney, Australia
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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, 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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Current Clinical and Research Approaches to Optimizing Regional Chemotherapy: Novel Strategies Generated Through a Better Understanding of Drug Pharmacokinetics, Drug Resistance, and the Development of Clinically Relevant Animal Models. Surg Oncol Clin N Am 2008; 17:731-58, vii-viii. [DOI: 10.1016/j.soc.2008.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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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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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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Gimbel MI, Delman KA, Zager JS. Therapy for Unresectable Recurrent and In-Transit Extremity Melanoma. Cancer Control 2008; 15:225-32. [DOI: 10.1177/107327480801500305] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Unresectable recurrent and in-transit extremity melanoma presents a dilemma for the treating physician. While the disease is confined to the involved limb, the survival mimics that of multiple nodal metastases, with a 10-year survival rate of approximately 40%. This represents late-stage disease for which curative treatment options are limited. Methods To review the current treatment strategies for stage IIIB (N2c) in-transit and recurrent melanoma focusing on the options for unresectable disease, MEDLINE was searched for studies of known and experimental treatments for in-transit and recurrent extremity melanoma. Further results were obtained after review of the initial citations. Results For unresectable recurrences and in-transit metastases, therapies are limited to palliative (radiation), local (intratumoral injection, laser ablation and electroporation), regional (isolated limb perfusion/infusion), and systemic (chemotherapy) when local or regional techniques are not feasible. Conclusions In this patient population, intratumoral techniques have a limited role with current treatment regimens, but with the development of new drugs, these techniques may have more utility. If not contraindicated, regional techniques provide the greatest control and have minimal operative morbidity. Until new regimens are available, systemic therapy continues to be associated with considerable toxicity and only marginal response rates.
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Affiliation(s)
- Mark I. Gimbel
- Surgical Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Keith A. Delman
- Department of Surgery at Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan S. Zager
- Cutaneous Oncology at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Sarcoma Programs at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Errico JA, Trumble TN, Bueno ACD, Davis JL, Brown MP. Comparison of two indirect techniques for local delivery of a high dose of an antimicrobial in the distal portion of forelimbs of horses. Am J Vet Res 2008; 69:334-42. [DOI: 10.2460/ajvr.69.3.334] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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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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28
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Thompson JF, Kam PCA. Current status of isolated limb infusion with mild hyperthermia for melanoma. Int J Hyperthermia 2008; 24:219-25. [DOI: 10.1080/02656730701827565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
Isolated limb infusion involves administrating cytotoxic drugs in a patient with malignant melanoma confined to one limb, and which is not surgically resectable. It provides palliation in cases where cutaneous disease is extensive.
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Affiliation(s)
- Z Al-Hilli
- Department of Surgery, Royal College of Surgeons in Ireland, Beaumont Hospital, Ireland
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30
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Noorda EM, Vrouenraets BC, Nieweg OE, van Geel AN, Eggermont AMM, Kroon BBR. Repeat isolated limb perfusion with TNFα and melphalan for recurrent limb melanoma after failure of previous perfusion. Eur J Surg Oncol 2006; 32:318-24. [PMID: 16412605 DOI: 10.1016/j.ejso.2005.10.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Revised: 10/13/2005] [Accepted: 10/20/2005] [Indexed: 11/20/2022] Open
Abstract
AIM To assess the effectiveness of isolated limb perfusion (ILP) with tumour necrosis factor-alpha (TNFalpha) and melphalan for recurrent or persistent melanoma lesions after previous ILP. METHODS Between 1978 and 2001, 21 patients (mean age 65, range 29-83 years) underwent repeat ILP for recurrent or persistent melanoma after a previous ILP. First ILPs had been performed with melphalan alone in 13 patients and with addition of TNFalpha in eight, for a median of nine lesions (interquartile (IQ) range 2-23 lesions). Repeat ILP was performed with TNFalpha and melphalan in all 21 patients for a median of nine lesions (IQ range 5-25 lesions). Median follow-up after repeat ILP was 18 months (IQ range 6-36 months). RESULTS Thirteen patients attained a complete response (CR) after repeat ILP compared to 11 of 17 with measurable lesions after the first ILP. Nine patients relapsed after CR. Median limb recurrence-free survival was 13 months. Fourteen patients had mild acute regional toxicity after repeat ILP compared to 18 after the first ILP (n.s.). One patient underwent amputation for critical limb ischemia 10 months following repeat ILP. The limb salvage rate was 95%. Overall median survival was 62 months after CR compared to 13 months for those without CR (P=0.05). CONCLUSION Repeat ILP with TNFalpha and melphalan is feasible after previous ILP with mild regional toxicity. The CR rate is relatively high and comparable to the first procedure with good limb recurrence-free survival and high limb salvage rate.
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Affiliation(s)
- E M Noorda
- Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Slotervaartziekenhuis, Louwesweg 6, 1006 BK Amsterdam, The Netherlands.
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