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Russell M, Wilkinson M, Hayes A. Isolated Limb Perfusion for Extremity Soft Tissue Sarcoma and Malignant Melanoma. Indian J Surg Oncol 2024; 15:499-508. [PMID: 39239444 PMCID: PMC11371996 DOI: 10.1007/s13193-024-01920-2] [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: 09/27/2023] [Accepted: 03/03/2024] [Indexed: 09/07/2024] Open
Abstract
Isolated limb perfusion (ILP) is a regional chemotherapy technique used in the treatment of locally advanced or unresectable extremity soft tissue sarcoma (ESTS) or malignant melanoma (MM) of the limbs. It allows for high concentrations of chemotherapeutic agents to be perfused in the limb while minimising the risk of systemic side-effects. While the technique has been utilized for decades, the role of ILP has evolved as other treatment strategies have become available. Current indications for ILP in sarcoma include induction in unresectable ESTS to allow for future definitive limb preservation procedures as well as definitive treatment of unresectable, multifocal ESTS. In MM, ILP is typically used in unresectable in-transit melanoma, and rarely as an alternative to amputation in bulky, symptomatic extremity disease. This review seeks to summarise the current evidence base and indications for ILP as well as present some technical insights from a high-volume United Kingdom (UK) unit.
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Affiliation(s)
- Michael Russell
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Michelle Wilkinson
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Andrew Hayes
- Sarcoma and Melanoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
- Institute of Cancer Research, 237 Fulham Road, London, SW3 6JJ UK
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2
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Pereira TJ, Edgell H. The influence of oral contraceptives on the exercise pressor reflex in the upper and lower body. Physiol Rep 2024; 12:e16144. [PMID: 38991985 PMCID: PMC11239320 DOI: 10.14814/phy2.16144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 07/01/2024] [Indexed: 07/13/2024] Open
Abstract
Previous research has demonstrated that oral contraceptive (OC) users have enhanced cardiorespiratory responses to arm metaboreflex activation (i.e., postexercise circulatory occlusion, PECO) and attenuated pressor responses to leg passive movement (PM) compared to non-OC users (NOC). We investigated the cardiorespiratory responses to arm or leg metaboreflex and mechanoreflex activation in 32 women (OC, n = 16; NOC, n = 16) performing four trials: 40% handgrip or 80% plantarflexion followed by PECO and arm or leg PM. OC and NOC increased mean arterial pressure (MAP) similarly during handgrip, plantarflexion and arm/leg PECO compared to baseline. Despite increased ventilation (VE) during exercise, none of the women exhibited higher VE during arm or leg PECO. OC and NOC similarly increased MAP and VE during arm or leg PM compared to baseline. Therefore, OC and NOC were similar across pressor and ventilatory responses to arm or leg metaboreflex and mechanoreflex activation. However, some differences due to OC may have been masked by disparities in muscle strength. Since women increase VE during exercise, we suggest that while women do not display a ventilatory response to metaboreflex activation (perhaps due to not reaching a theoretical metabolite threshold to stimulate VE), the mechanoreflex may drive VE during exercise in women.
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Affiliation(s)
- T. J. Pereira
- School of Kinesiology and Health ScienceYork UniversityTorontoOntarioCanada
| | - H. Edgell
- School of Kinesiology and Health ScienceYork UniversityTorontoOntarioCanada
- Muscle Health Research CentreYork UniversityTorontoOntarioCanada
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3
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Hayes AJ, Coker DJ, Been L, Boecxstaens VW, Bonvalot S, De Cian F, de la Cruz-Merino L, Duarte C, Eggermont A, Farricha V, Fiore M, Grünhagen D, Grützmann R, Honoré C, Jakob J, Hocevar M, van Houdt W, Klauzner J, Kettelhack C, Märten A, Martinez-Said H, Matter M, Michot A, Niethard M, Pennacchioli E, Podleska LE, Rabago G, Rastrelli M, Reijers S, Ribeiro M, Schwarzbach M, Snow HA, Spacek M, Stoldt S, Testori A, Zoras O, Olofsson Bagge R. Technical considerations for isolated limb perfusion: A consensus paper. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108050. [PMID: 38498966 DOI: 10.1016/j.ejso.2024.108050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique. METHODS Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations. RESULTS The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training. CONCLUSION We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.
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Affiliation(s)
- Andrew J Hayes
- Department of Academic Surgery, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK.
| | - David J Coker
- Department of Academic Surgery, Royal Marsden Hospital, London, UK; Department of Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The University of Sydney, Sydney, Australia.
| | - Lukas Been
- Department of Surgical Oncology University Medical Center Groningen, University of Groningen, the Netherlands
| | | | | | - Franco De Cian
- Policlinico San Martino, University of Genoa, Genoa, Italy Clinical Oncology Department; Italy Clinical Oncology Department, Italy
| | | | - Carlos Duarte
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | - Alexander Eggermont
- University Medical Center Utrecht and Princess Maxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center München, Technical University München & Ludwig Maximilian University, Munich, Germany
| | - Victor Farricha
- Melanoma and Sarcoma Unit, Department of Surgery, Portuguese Institute of Oncology, Lisbon, Portugal
| | - Marco Fiore
- Sarcoma Service, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dirk Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Charles Honoré
- Sarcoma Unit, Department of Cancer Medicine, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Jens Jakob
- Sarcoma Unit, Interdisciplinary Tumor Center, Mannheim University Medical Center University of Heidelberg, Mannheim, Germany
| | | | - Winan van Houdt
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, the Netherlands
| | - Joseph Klauzner
- Surgical Oncology- Melanoma, Division of Surgery, Sourasky Tel Aviv Medical Center (Ichilov Hospital), Tel Aviv University, Israel
| | - Christoph Kettelhack
- Clarunis, University Center for Gastrointestinal and Liver Disease Basel, Basel, Switzerland
| | | | - Hector Martinez-Said
- Deputy Direction of Surgical Oncology, Instituto Nacional de Cancerología, Mexico
| | - Maurice Matter
- Institut Bergonié Sarcoma Unit, '229 cours de l'Argonne, 33000, Bordeaux, France
| | - Audrey Michot
- Lausanne University Hospital and University of Lausanne Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011, Lausanne CHUV, Switzerland
| | - Maya Niethard
- Department of Orthopedic Oncology, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | | | - Lars E Podleska
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Gregorio Rabago
- Department of Cardiovascular Surgery Clinica University of Navarra, Pamplona, Spain
| | - Marco Rastrelli
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, Padua, Italy; Department of Surgery, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Sophie Reijers
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, the Netherlands
| | - Matilde Ribeiro
- Instituto Português De Oncologia De Porto, 4200 Porto, Portugal
| | | | - Hayden A Snow
- Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia
| | - Miroslav Spacek
- Second Department of Surgery-Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stephan Stoldt
- Department of Abdominal and Paediatric Surgery, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Alessandro Testori
- Chairman surgical subgroup EORTC Melanoma Group, Brussels, Belgium; Direttore divisione dermatologia Oncologica, Image Institute, Milan, Italy
| | - Odysseas Zoras
- Emeritus Professor of Surgical Oncology, University of Crete, Greece
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Krishnan CK, Arivazhagan P, Karnawat A, Raja A. Isolated Limb Perfusion of Upper Limb: How I Do It. Indian J Surg Oncol 2022; 13:776-779. [PMID: 36687241 PMCID: PMC9845483 DOI: 10.1007/s13193-022-01561-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/24/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- Chandra Kumar Krishnan
- Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai, 600036 India
| | - Punitha Arivazhagan
- Department of Anaesthesia, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai, 600036 India
| | - Anand Karnawat
- Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai, 600036 India
| | - Anand Raja
- Department of Surgical Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Adyar, Chennai, 600036 India
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Borčinová M, Ragosch V, Jarkovský J, Bajsová S, Pilka R, Glickman A, Garrido-Mallach S, Raspagliesi F, Szatkowski W, Pakiz M, Snyman LC, Kocián R, Tamussino K, Kalist V, Michal M, Segovia MG, Poka R, Kipp B, Szewczyk G, Wydra D, Tóth R, Vinnytska A, Fischerová D, Siegler K, Cibula D. Challenges in lower limb lymphoedema assessment based on limb volume change: Lessons learnt from the SENTIX prospective multicentre study. Gynecol Oncol 2021; 164:76-84. [PMID: 34763939 DOI: 10.1016/j.ygyno.2021.10.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Lower limb lymphoedema (LLL) is the most disabling adverse effect of surgical staging of pelvic lymph nodes. However, the lack of standardisation of volumetric LLL assessment hinders direct comparison between the studies and makes LLL reporting unreliable. The aim of our study is to report outcomes from a prospective trial that have implications for LLL assessment standardisation. METHODS In the prospective international multicentre trial SENTIX, a group of 150 patients with stage IA1-IB2 cervical cancer treated by uterine surgery with bilateral sentinel lymph node biopsy was prospectively evaluated by objective LLL assessment, based on limb volume change (LVC) using circumferrential limb measurements and subjective patient-reported swelling. The assessments were conducted in six-month periods over 24 months post-surgery. RESULTS Patient LVC substantially fluctuated in both positive and negative directions, which were comparable in frequency up to ±14% change. Thirty-eight patients experienced persistent LVC increase >10% classified as LLL, with nine months median time to onset. Some 34.2% of cases experienced onset later than one year after the surgery. Thirty-three patients (22%) experienced transient oedema characterised as LVC >10%, which resolved without intervention between two consequent follow-up visits. No significant correlation between LVC >10% and a patient-reported swelling was observed. CONCLUSIONS Given that we observed comparable fluctuations of the the lower-limb volumes after surgical treatment of cervical cancer in both positive and negative direction up to ±14%, the diagnostic threshold for LLL diagnosis based on LVC should be increased to >15% LVC. The distinction of transient oedema from persistent LLL requires repeated measurements. Also, as one-third of LLL cases are diagnosed >1-year post-surgery, a sufficient follow-up duration needs to be ensured. Patient-reported swelling correlated poorly with LVC and should only be used as an adjunct to objective LLL assessment. TRIAL REGISTRATION ClinicalTrials.gov: NCT02494063.
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Affiliation(s)
- Martina Borčinová
- Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Prague, Czech Republic
| | - Volker Ragosch
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - Jiří Jarkovský
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Sylva Bajsová
- Department of Obstetrics and Gynecology, University Hospital Ostrava, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Ostrava Poruba, Czech Republic
| | - Radovan Pilka
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, Palacky University, University Hospital Olomouc, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Olomouc, Czech Republic
| | - Ariel Glickman
- Unit of Gynecological Oncology, Institute Clinic of Gynaecology, Obstetrics, and Neonatology, Hospital Clinic-Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | | | | | - Maja Pakiz
- University medical Centre Maribor, Slovenia
| | | | - Roman Kocián
- Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Prague, Czech Republic
| | | | | | | | | | - Robert Poka
- Department of obstetrics and Gynecology, University of Debrecen, Hungary
| | - Barbara Kipp
- Neue Freuenklinik, Luzerner Kantonsspital, Switzerland
| | | | | | - Róbert Tóth
- Oncology Institute of East Slovakia, Košice, Slovakia
| | | | - Daniela Fischerová
- Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Prague, Czech Republic
| | - Kathrin Siegler
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - David Cibula
- Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, Central and Eastern European Gynecologic Oncology Group, CEEGOG, Prague, Czech Republic.
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Wedin M, Stalberg K, Marcickiewicz J, Ahlner E, Ottander U, Åkesson Å, Lindahl G, Wodlin NB, Kjølhede P. Risk factors for lymphedema and method of assessment in endometrial cancer: a prospective longitudinal multicenter study. Int J Gynecol Cancer 2021; 31:1416-1427. [PMID: 34610970 DOI: 10.1136/ijgc-2021-002890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/15/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The aim of the study was to determine risk factors for lymphedema of the lower limbs, assessed by four methods, 1 year after surgery for endometrial cancer. METHODS A prospective longitudinal multicenter study was conducted in 14 Swedish hospitals. 235 women with endometrial cancer were included; 116 underwent surgery including lymphadenectomy, and 119 had surgery without lymphadenectomy. Lymphedema was assessed preoperatively and 1 year postoperatively objectively by systematic circumferential measurements of the legs, enabling volume estimation addressed as (1) crude volume and (2) body mass index-standardized volume, or (3) clinical grading, and (4) subjectively by patient-reported perception of leg swelling. In volume estimation, lymphedema was defined as a volume increase ≥10%. Risk factors were analyzed using forward stepwise logistic regression models and presented as adjusted odds ratio (aOR) and 95% confidence interval (95% CI). RESULTS Risk factors varied substantially, depending on the method of determining lymphedema. Lymphadenectomy was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 14.42, 95% CI 3.49 to 59.62), clinical grading (aOR 2.11, 95% CI 1.04 to 4.29), and patient-perceived swelling (aOR 2.51, 95% CI 1.33 to 4.73), but not when evaluated by crude volume. Adjuvant radiotherapy was only a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 15.02, 95% CI 2.34 to 96.57). Aging was a risk factor for lymphedema when assessed by body mass index-standardized volume (aOR 1.07, 95% CI 1.00 to 1.15) and patient-perceived swelling (aOR 1.06, 95% CI 1.02 to 1.10), but not when assessed by crude volume or clinical grading. Increase in body mass index was a risk factor for lymphedema when estimated by crude volume (aOR 1.92, 95% CI 1.36 to 2.71) and patient-perceived swelling (aOR 1.36, 95% CI 1.11 to 1.66), but not by body mass index-standardized volume or clinical grading. The extent of lymphadenectomy was strongly predictive for the development of lymphedema when assessed by body mass index-standardized volume and patient-perceived swelling, but not by crude volume or clinical grading. CONCLUSION Apparent risk factors for lymphedema differed considerably depending on the method used to determine lymphedema. This highlights the need for a 'gold standard' method when addressing lymphedema for determining risk factors.
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Affiliation(s)
- Madelene Wedin
- biomedical and clinical science, Linköping University, Linkoping, Sweden
| | - Karin Stalberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Eva Ahlner
- Department of Oncology, and Department of Biomedical and Clinical Science, Linköping University Hospital, Linkoping, Sweden
| | - Ulrika Ottander
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Åsa Åkesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Institute of clinical sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Gabriel Lindahl
- Department of Oncology, and Department of Biomedical and Clinical Scienses, Linköping University, Linköping, Sweden
| | - Ninnie Borendal Wodlin
- Department of Obstetrics and Gynecology in Linköping and Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
| | - Preben Kjølhede
- Department of Obstetrics and Gynecology in Linköping and Department of Biomedical and Clinical Science, Linköping University, Linköping, Sweden
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Assadpour E, Ivry I, Wasef S, Adeyinka B, Murray KR, Edgell H. Oral contraceptives and menstrual cycle influence autonomic reflex function. Physiol Rep 2021; 8:e14550. [PMID: 32889781 PMCID: PMC7507440 DOI: 10.14814/phy2.14550] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/31/2022] Open
Abstract
Progesterone and its analogues are known to influence ventilation. Therefore, the purpose of this study was to investigate the role of endogenous and pharmaceutical female sex hormones in ventilatory control during the activation of the metaboreflex, mechanoreflex, and CO2 chemoreflex. Women aged 18–30 taking (n = 14) or not taking (n = 12) oral contraceptives (OC and NOC, respectively) were tested in the low hormone (LH) and high hormone (HH) conditions corresponding to the early follicular and mid‐luteal phases (NOC) or placebo and high‐dose pills (OC). Women underwent three randomized trials: (a) 3 min of passive leg movement (PLM), (b) 2 min of 40% maximal voluntary handgrip exercise followed by 2 min of post‐exercise circulatory occlusion (PECO), and (c) 5 min of breathing 5% CO2. We primarily measured hemodynamics and ventilation. During PLM, the OC group had a smaller pressor response (p = .012). During PECO, the OC group similarly exhibited a smaller pressor response (p = .043) and also exhibited a greater ventilatory response (p = .024). Lastly, in response to breathing 5% CO2, women in the HH phase had a greater ventilatory response (p = .022). We found that OC use attenuates the pressor response to both the metaboreflex and mechanoreflex while increasing the ventilatory response to metaboreflex activation. We also found evidence of an enhanced CO2 chemoreflex in the HH phase. We hypothesize that OC effects are from the chronic upregulation of pulmonary and vascular β‐adrenergic receptors. We further suggest that the increased cyclic progesterone in the HH phase enhances the chemoreflex.
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Affiliation(s)
- Elnaz Assadpour
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Ilana Ivry
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Sara Wasef
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Baithat Adeyinka
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Kevin R Murray
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Heather Edgell
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
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8
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Martin-Tellez KS, van Houdt WJ, van Coevorden F, Colombo C, Fiore M. Isolated limb perfusion for soft tissue sarcoma: Current practices and future directions. A survey of experts and a review of literature. Cancer Treat Rev 2020; 88:102058. [PMID: 32619864 DOI: 10.1016/j.ctrv.2020.102058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
Abstract
Soft tissue sarcomas constitute 1% of adult malignant tumors. They are a heterogeneous group of more than 50 different histologic types. Isolated limb perfusion is an established treatment strategy for locally advanced sarcomas. Since its adoption for sarcomas in 1992, after the addition of TNFα, few modifications have been done and although indications for the procedure are essentially the same across centers, technical details vary widely. The procedures mainly involves a 60 min perfusion with melphalan and TNFα under mild hyperthermia, achieving a limb preservation rate of 72-96%; with an overall response rates from 72 to 82.5% and an acceptable toxicity according to the Wieberdink scale. The local failure rate is 27% after a median follow up of 14-31 months compared to 40% of distant recurrences after a follow up of 12-22 months. Currently there is no consensus regarding the benefit of ILP per histotype, and the value of addition of radiotherapy or systemic treatment. Further developments towards individualized treatments will provide a better understanding of the population that can derive maximum benefit of ILP with the least morbidity.
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Affiliation(s)
- K S Martin-Tellez
- Fellow of the European School of Soft Tissue Sarcoma, Department of Surgical Oncology, The American British Cowdray Medical Center ABC, Mexico city, Mexico.
| | - W J van Houdt
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F van Coevorden
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - C Colombo
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - M Fiore
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Farzaliyev F, Hamacher R, Steinau Professor HU, Bertram S, Podleska LE. Secondary angiosarcoma: A fatal complication of chronic lymphedema. J Surg Oncol 2019; 121:85-90. [PMID: 31236970 DOI: 10.1002/jso.25598] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/31/2019] [Accepted: 06/01/2019] [Indexed: 12/13/2022]
Abstract
Secondary Angiosarcoma (Stewart-Treves Syndrome) is a rare malignant cutaneous lesion, which arises in chronic lymphedema of the extremity, often observed after breast cancer treatment. We reviewed the history and the oncological outcome of two patients with this disease. Multimodal therapy including hyperthermic isolated limb perfusion with TNF-alpha and Melphalan, combined with radical resection of the affected skin and subcutaneous tissue including the fascia, with large safety margins may probably lead to better survival.
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Affiliation(s)
- Farhad Farzaliyev
- Department of General, Visceral and Transplantation Surgery, Division of Plastic, Reconstructive and Hand Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - Rainer Hamacher
- Department of Medical Oncology, Sarcoma Center, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Hans-Ulrich Steinau Professor
- Department of General, Visceral and Transplantation Surgery, Division of Plastic, Reconstructive and Hand Surgery, University Hospital Essen, University Essen-Duisburg, Germany
| | - Stefanie Bertram
- Institute of Pathology and Neuropathology, University Hospital of Essen, University of Duisburg-Essen, Germany
| | - Lars Erik Podleska
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, University Essen-Duisburg, Germany
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Teras J, Mägi A, Teras M, Pata P, Teras RM, Randhawa N, Kalling K. Soft Tissue Cancer Management: Isolated Limb Infusion for Sarcoma. Visc Med 2019; 35:373-379. [PMID: 31934586 DOI: 10.1159/000495888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Sarcoma is a heterogeneous group of malignancies comprising almost 80 subtypes of bone and soft tissue cancers. Previously, all subtypes were managed identically. Advancements in biological and genetic studies have revealed that sarcoma subtypes display varying characteristics and therefore require tailored treatments. Locally advanced soft tissue malignancies of both the trunk and the extremities can present significant challenges for treatment. At present, a negative surgical resection margin is the only definitive treatment despite attempts to use neoadjuvant and adjuvant therapies. In patients with locally advanced non-resectable soft tissue sarcoma (STS), the current practice would advocate amputation. However, studies suggest that limb salvage may be possible with radiotherapy or regional chemotherapy using isolated limb perfusion or isolated limb infusion (ILI). An ideal treatment modality for non-resectable STS would strive for preservation of anatomy and functionality as well as improve quality of life. The aim of the study was to investigate the efficacy of isolated limb infusion as an alternative treatment modality for non-resectable locally advanced STS. Methods The efficacy of ILI was retrospectively investigated in 10 patients with STS. All patients received ILI with melphalan and actinomycin at the North Estonia Medical Centre Foundation, Tallinn, Estonia from September 1, 2014 to May 31, 2018. The procedures were performed in a lower extremity in 8 patients and in an upper extremity in 2 patients. The 6-month overall response rate was 78% and the overall limb salvage rate was 100%. The distant metastatis-free survival was longer for responders than for non-responders. Results and Conclusions ILI is an alternative treatment modality for regional disease control and limb preservation in patients with cutaneous and soft tissue malignant neoplasms of the extremities. The short-term response rates are encouraging and the median overall survival shows good results in this highly complex patient population.
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Affiliation(s)
- Jyri Teras
- North Estonian Medical Centre Foundation, Tallinn.,Tallinn University of Technology, Tallinn
| | | | - Marina Teras
- North Estonian Medical Centre Foundation, Tallinn.,Tallinn University of Technology, Tallinn
| | - Pille Pata
- Tallinn University of Technology, Tallinn.,IVEX Lab, Tallinn, Estonia
| | | | - Neena Randhawa
- Nottingham University Hospital NHS Trust, Nottingham, UK
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Podleska LE, Schwindenhammer B, Grabellus F, Bauer S, Steinau HU, Taeger G. [Isolated limb perfusion for liposarcoma : Histopathological response and subgroup analysis after TNF melphalan-based ILP]. Chirurg 2017; 88:429-436. [PMID: 28083602 DOI: 10.1007/s00104-016-0362-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tumor necrosis factor alpha (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is one of the most effective treatment modalities for unresectable soft tissue sarcoma (STS) of the extremities. Liposarcomas (LS) are a large and heterogeneous subgroup of STS with different biological behavior and prognoses. The aim of this study was to evaluate LS and the different subentities with respect to their responsiveness towards TM-ILP. METHODS We matched our ILP database with our pathology database to identify patients who received TM-ILP due to STS followed by resection of the residual tumor. We identified 126 patients who matched these inclusion criteria. In this patient group we identified 24 patients with a LS. Histopathological regression was assessed from all resection specimens and was compared between groups: LS vs. non-LS and for myxoid and non-myxoid LS subgroups. RESULTS There were no significant differences in the overall tumor regression comparing non-LS (median 95%, mean 77%) and LS (median 90%, mean 74%). For the subgroup analysis, a higher grade of regression after TM-ILP was found in myxoid-LS (median 95%, mean 79% ± 31.5) compared to the non-myxoid LS (median 75%, mean 72% ± 24.6). Atypical lipomatous tumors (ALT) were less responsive to TM-ILP treatment (median 40%, mean 40%). CONCLUSION The histopathological response of LS toward TM-ILP is equally good compared to non-lipomatous STS. Myxoid LS seem to have a tendency towards a better response to TM-ILP compared to non-myxoid LS and ALT showed the lowest response rate in the liposarcoma subgroup. Furthermore, we found that TM-ILP seems to facilitate successful R0 resection. Due to the low number of cases in the subgroups we advocate further research on this topic.
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Affiliation(s)
- L E Podleska
- Sektion Sarkomchirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland.
| | - B Schwindenhammer
- Institut für Pathologie und Neuropathologie, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland
| | - F Grabellus
- Institut für Pathologie und Neuropathologie, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland
| | - S Bauer
- Innere Klinik/Tumorforschung, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland
| | - H-U Steinau
- Sektion Sarkomchirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland
| | - G Taeger
- Sektion Sarkomchirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Westdeutsches Tumorzentrum (WTZ), Hufelandstr. 55, 45147, Essen, Deutschland
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Cecchin D, Negri A, Frigo A, Bui F, Zucchetta P, Bodanza V, Gregianin M, Campana L, Rossi C, Rastrelli M. Calculating regional tissue volume for hyperthermic isolated limb perfusion: Four methods compared. Eur J Surg Oncol 2016; 42:1898-1905. [DOI: 10.1016/j.ejso.2016.02.250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/26/2016] [Accepted: 02/22/2016] [Indexed: 01/13/2023] Open
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Abstract
In-transit melanoma is an uncommon pattern of recurrence, but presents unique management challenges and opportunities for treatment. The clinical presentation usually involves from 1 to more than 100 small subcutaneous or cutaneous nodules, ranging from submillimeter to multiple centimeters in diameter. Regional chemotherapy techniques are a mainstay of treatment of patients without systemic disease spread. Future applications of regional therapy are likely to involve combination therapy with cytotoxic agents and novel immune modulators. Regional therapy provides distinct opportunities for the treatment of unresectable disease, and offers a unique platform for investigation of novel therapeutics in early-stage clinical trials.
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Affiliation(s)
- Paul J Speicher
- Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Claire H Meriwether
- Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Douglas S Tyler
- Department of Surgery, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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