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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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2
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Zucal I, Geis S, Prantl L, Haerteis S, Aung T. Indocyanine Green for Leakage Control in Isolated Limb Perfusion. J Pers Med 2021; 11:jpm11111152. [PMID: 34834504 PMCID: PMC8619565 DOI: 10.3390/jpm11111152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Sarcomas are characterized by a high metastatic potential and aggressive growth. Despite surgery, chemotherapy plays an important role in the treatment of these tumors. Optimal anti-cancer therapy with maximized local efficacy and minimized systemic side effects has been the object of many studies for a long time. To improve the local efficacy of anti-tumor therapy, isolated limb perfusion with high-dose cytostatic agents has been introduced in surgical oncology. In order to control the local distribution of substances, radiolabeled cytostatic drugs or perfusion solutions have been applied but often require the presence of specialized personnel and result in a certain exposure to radiation. In this study, we present a novel strategy using indocyanine green to track tumor perfusion with high-dose cytostatic therapy. In a rat cadaver model, the femoral vessels were cannulated and connected to a peristaltic pump to provide circulation within the selected limb. The perfusion solution contained indocyanine green and high-dose doxorubicin. An infrared camera enabled the visualization of indocyanine green during limb perfusion, and subsequent leakage control was successfully performed. Histologic analysis of sections derived proximally from the injection site excluded systemic drug dispersion. In this study, the application of indocyanine green was proven to be a safe and cost- and time-efficient method for precise leakage control in isolated limb perfusion with a high-dose cytostatic agent.
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Affiliation(s)
- Isabel Zucal
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Clinic of Regensburg, 93053 Regensburg, Germany; (I.Z.); (S.G.); (L.P.)
- Institute for Molecular and Cellular Anatomy, University of Regensburg, 93053 Regensburg, Germany;
| | - Sebastian Geis
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Clinic of Regensburg, 93053 Regensburg, Germany; (I.Z.); (S.G.); (L.P.)
| | - Lukas Prantl
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Clinic of Regensburg, 93053 Regensburg, Germany; (I.Z.); (S.G.); (L.P.)
| | - Silke Haerteis
- Institute for Molecular and Cellular Anatomy, University of Regensburg, 93053 Regensburg, Germany;
| | - Thiha Aung
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Clinic of Regensburg, 93053 Regensburg, Germany; (I.Z.); (S.G.); (L.P.)
- Institute for Molecular and Cellular Anatomy, University of Regensburg, 93053 Regensburg, Germany;
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
- Correspondence:
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3
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Teras J, Carr MJ, Zager JS, Kroon HM. Molecular Aspects of the Isolated Limb Infusion Procedure. Biomedicines 2021; 9:biomedicines9020163. [PMID: 33562337 PMCID: PMC7915579 DOI: 10.3390/biomedicines9020163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/30/2021] [Accepted: 01/31/2021] [Indexed: 01/19/2023] Open
Abstract
For decades, isolated limb infusion (ILI) and hyperthermic isolated limb perfusion (HILP) have been used to treat melanoma in-transit metastases and unresectable sarcoma confined to the limb utilizing the effect of loco-regional high-dose chemotherapy to the isolated limb. Both procedures are able to provide high response rates in patients with numerous or bulky lesions in whom other loco-regional treatments are becoming ineffective. In comparison to systemic therapies, on the other hand, ILI and HILP have the advantage of not being associated with systemic side-effects. Although in principle ILI and HILP are similar procedures, ILI is technically simpler to perform and differs from HILP in that it takes advantage of the hypoxic and acidotic environment that develops in the isolated limb, potentiating anti-tumour activity of the cytotoxic agents melphalan +/− actinomycin-D. Due to its simplicity, ILI can be used in both preclinical and clinical studies to test new cytotoxic regimens and combinations with the aim to overcome tumour resistance. In the future, administration of cytotoxic agents by ILI, in combination with systemic treatments such as BRAF/MEK/KIT inhibitors, immunotherapy (CTLA-4 blockade), and/or programmed death (PD-1) pathway inhibitors, has the potential to improve responses further by inducing increased tumour cell death while limiting the ability of the tumour to suppress the immune response.
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Affiliation(s)
- Jüri Teras
- Department of Surgical Oncology, North Estonia Medical Centre Foundation, 13419 Tallinn, Estonia;
- Tallinn University of Technology, 12616 Tallinn, Estonia
| | - Michael J. Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (M.J.C.); (J.S.Z.)
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
| | - Hidde M. Kroon
- Department of Surgery, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
- Correspondence: ; Tel.: +61-8-7074-2163
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Jiménez Herevia AE, Tavares de la Paz LA, Hinojosa Ugarte D, Nieves Condoy J. Isolated Limb Perfusion on Nonmelanoma Skin Cancer for Limb Salvage: A Series of Four Cases. Cureus 2020; 12:e9998. [PMID: 32983697 PMCID: PMC7511079 DOI: 10.7759/cureus.9998] [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: 12/04/2022] Open
Abstract
Nonmelanoma skin cancer (NMSC) is more prevalent than all the other cancers combined together. The most common regions affected by skin cancer are the head and neck, but there is a large proportion of the cases located on the limbs. They could be bulky, very extensive and/or located in specialized regions like the hands or near to a joint. Most of those cases should be amputated, with several compromises of the function and a negative impact on the patients' quality of life. Isolated limb perfusion is a proven alternative to limb salvage on soft tissue sarcomas, but there are just a few reports about its application on non-melanoma skin cancer. The aim of the article is to describe the outcomes and prove the benefits and effectiveness to avoid limb amputation when using isolated limb perfusion on locally advanced non-melanoma skin cancer. We present clinical, retrospective study as a case series report. The study includes four patients with locally advanced non-melanoma skin cancer in the limb - three cases with squamous cell carcinoma (SCC), and one patient with Merkel cell carcinoma (MCC) who underwent to tumor necrosis factor-alpha (TNFα) and melphalan based isolated perfusion of the limb (TM-ILP). Toxicity, clinical response, and limb salvage were described. Patients were treated in the oncological surgical department in a referral hospital in Mexico. The limb salvage rate was achieved in 75%. All patients had a favorable response to TM-ILP. Complete response of the tumor was noted on two (50%) of the patients (one with histopathological confirmation), the other 50% had a partial response to the TM-ILP. No serious toxicity related to TM-ILP was observed. One patient (25%) developed regional lymph involvement six months after perfusion. Lymphadenectomy was performed, and the patient subsequently has a six-year disease-free survival. In conclusion, TM-ILP could be an effective, reliable, and safe therapy on limb salvage in selected patients with non-melanoma skin cancer who are not adequate surgical candidates.
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Smuder AJ. Exercise stimulates beneficial adaptations to diminish doxorubicin-induced cellular toxicity. Am J Physiol Regul Integr Comp Physiol 2019; 317:R662-R672. [PMID: 31461307 DOI: 10.1152/ajpregu.00161.2019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Doxorubicin (DOX) is a highly effective antitumor agent used for the treatment of a wide range of cancers. Unfortunately, DOX treatment results in cytotoxic side effects due to its accumulation within off-target tissues. DOX-induced cellular toxicity occurs as a result of increased oxidative damage, resulting in apoptosis and cell death. While there is no standard-of-care practice to prevent DOX-induced toxicity to healthy organs, exercise has been shown to prevent cellular dysfunction when combined with DOX chemotherapy. Endurance exercise stimulates numerous biochemical adaptations that promote a healthy phenotype in several vulnerable tissues without affecting the antineoplastic properties of DOX. Therefore, for the development of an effective strategy to combat the pathological effects of DOX, it is important to determine the appropriate exercise regimen to prescribe to cancer patients receiving DOX therapy and to understand the mechanisms responsible for exercise-induced protection against DOX toxicity to noncancer cells. This review summarizes the cytotoxic effects of DOX on the heart, skeletal muscle, liver, and kidneys and discusses the current understanding of the clinical benefits of regular physical activity and the potential mechanisms mediating the positive effects of exercise on each organ system.
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Affiliation(s)
- Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
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Neuwirth MG, Song Y, Sinnamon AJ, Fraker DL, Zager JS, Karakousis GC. Isolated Limb Perfusion and Infusion for Extremity Soft Tissue Sarcoma: A Contemporary Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3803-3810. [PMID: 29022281 DOI: 10.1245/s10434-017-6109-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) and isolated limb infusion (ILI) have been variably used in recent years for the treatment of locally advanced or marginally resectable extremity soft tissue sarcomas (STSs). We performed a systematic review and meta-analysis of contemporary studies to further characterize treatment patterns and outcomes. METHODS PubMed was queried for articles published in or after the year 2000, in the English language, with > 10 patients, and with adequate outcome data following ILP/ILI. Descriptive aggregate statistics were performed. RESULTS Nineteen studies that met the inclusion criteria were identified, with a total of 1288 patients. Weighted mean patient age was 55.9 years and 52% were male. The majority underwent ILP (88%) versus 12% for ILI, and chemotherapeutic regimens used were as follows: (1) melphalan with tumor necrosis factor (TNF)-α (78%), (2) melphalan ± actinomycin (10%), and (3) other regimens (12%). Most common histologies treated were malignant fibrous histiocytoma (21%), liposarcoma (16%), synovial (11%) and leiomyosarcoma (7%). Aggregate overall response rate (ORR) post-procedure was 73.3%, with 25.8% demonstrating a complete response (CR). Similar unadjusted ORRs were noted in the melphalan treatment groups with and without TNFα (72.0 and 67.0%, respectively; p = 0.27). Grade III toxicity was observed in 15.4% of patients, and grade IV/V toxicity was observed in 6.0% of patients. Overall limb salvage rate was 73.8% and median time to local (in-field) progression ranged from 4 to 28 months (weighted median 22.1 months). CONCLUSION ILP and ILI for extremity STS can be safely performed with appreciable response rates and significant limb salvage rates. Further study is needed to identify optimal treatment regimens by histology.
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Affiliation(s)
- Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Isolated Limb Infusion as a Limb Salvage Strategy for Locally Advanced Extremity Sarcoma. J Am Coll Surg 2017; 224:635-642. [PMID: 28214556 DOI: 10.1016/j.jamcollsurg.2016.12.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Treatment-resistant, locally advanced soft tissue sarcomas often require amputation for complete tumor extirpation. Isolated limb infusion (ILI) selectively delivers high-dose chemotherapy to the extremity in an attempt to achieve limb salvage. The aim of this study was to report perioperative and oncologic outcomes after ILI in patients with extremity soft tissue sarcomas. STUDY DESIGN From 1994 to 2016, 77 patients underwent 84 ILIs at a total of 5 institutions. Melphalan and actinomycin D were circulated for 30 minutes after complete tourniquet occlusion of the limb, then actively washed out to prevent systemic exposure. RESULTS The procedure was performed in an upper extremity on 19 patients (21 infusions) and in a lower extremity on 58 patients (63 infusions). The 3-month overall response rate (ORR) for the entire cohort was 58%, and there was a statistically significant difference (p = 0.03) between upper (37%) and lower extremity (66%) ORR. With median follow-up of 20.6 months (range 0.6 to 146.1 months), the overall limb salvage rate was 77.9%. For those who underwent amputation due to progression of disease, the median time to amputation was 4.5 months. With a median follow-up of 20.6 months, the median overall survival for the entire cohort was 44.3 months. The distant metastatic-free survival was longer for responders than nonresponders (p = 0.01), though the disease-specific survival was not different for the same groups (p = 0.2). CONCLUSIONS Isolated limb infusion for extremity soft tissue sarcoma results in an objective response for half of the patients who are otherwise facing amputation, and offers prolonged limb salvage for the vast majority of patients. The procedure is well tolerated without serious complications.
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Abstract
The management of recurrent soft tissue sarcoma is a challenging problem for clinicians and has a significant physical, mental, emotional, and oncologic impact for the patient. Despite excellent limb-preservation therapies, approximately one-quarter of patients may eventually develop recurrence of disease. How to most appropriately manage these patients is a matter of debate. Several treatment options exist, including surgical resection, irradiation, systemic chemotherapy, amputation, and regional therapies. This article highlights the management of recurrent extremity soft tissue sarcoma.
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Affiliation(s)
- Whitney M Guerrero
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN 38163, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Ave, Suite 300, Memphis, TN 38163, USA; Division of Surgical Oncology, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 300, Memphis, TN 38163, USA.
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Testori A, Ribero S, Bataille V. Diagnosis and treatment of in-transit melanoma metastases. Eur J Surg Oncol 2016; 43:544-560. [PMID: 27923593 DOI: 10.1016/j.ejso.2016.10.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023] Open
Abstract
In transit metastases (ITM) from extremity or trunk melanomas are subcutaneous or cutaneous lymphatic deposits of melanoma cells, distant from the primary site but not reaching the draining nodal basin. Superficial ITM metastases develop in 5-10% of melanoma patients and are thought to be caused by cells spreading along lymphatics; ITM appear biologically different from distant cutaneous metastases, these probably due to a haematogenous dissemination. The diagnosis is usually clinical and by patients, but patients need to be adequately educated in the recognition of this clinical situation. Ultrasound or more sophisticated instrumental devices may be required if the disease develops more deeply in the soft tissues. According to AJCC 2009 staging classification, ITM are included in stages IIIb and IIIc, which are considered local advanced disease with quite poor 5-year survival rates and outcomes of 24-54% at 5 years.2 Loco-regional recurrence is in fact an important risk factor for distant metastatic disease, either synchronous or metachronous. Therapy for this pattern of recurrence is less standardised then in most other clinical situations and options vary based on the volume and site of the disease. Definitive surgical resection remains the preferred therapeutic approach. However, when surgery cannot be performed with a reasonable cosmetic and functional outcome, other options must be utilized.3-6 Treatment options are classified as local, regional or systemic. The choice of therapy depends on the number of lesions, their anatomic location, whether or not these are dermal or subcutaneous, the size and the presence or absence of extra-regional disease.
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Affiliation(s)
- A Testori
- Divisione di Chirurgia Dermatoncologica, Istituto Europeo di Oncologia, Milano, Italy.
| | - S Ribero
- Dermatologia, Dipartimentto di Scienze mediche, Università di Torino, Italy
| | - V Bataille
- West Herts NHS Trust, London, UK; Mount Vernon Cancer Centre, Northwood, UK
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10
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Colombo C, Baratti D, Kusamura S, Deraco M, Gronchi A. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) and isolated perfusion (ILP) interventions in sarcoma. J Surg Oncol 2014; 111:570-9. [PMID: 25351775 DOI: 10.1002/jso.23808] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/13/2014] [Indexed: 01/28/2023]
Abstract
Locally advanced sarcomas in the extremity and in the retroperitoneum/abdominal cavity (peritoneal sarcomatosis, PS) can be managed administering chemotherapy locally using isolated limb perfusion (ILP) and hyperthermic intraperitoneal chemotherapy (HIPEC), respectively. In this review, the authors discuss the pros and cons of the use of these locoregional therapies in locally advanced soft tissue sarcoma, with a view to establishing their role in the multidisciplinary approach to these difficult diseases.
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Affiliation(s)
- Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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11
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Kroon HM, Huismans A, Waugh RC, Kam PCA, Thompson JF. Isolated limb infusion: technical aspects. J Surg Oncol 2013; 109:352-6. [PMID: 24374797 DOI: 10.1002/jso.23540] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the technique of isolated limb infusion (ILI) for regional high dose chemotherapy in patients with advanced malignancies confined to a limb, as currently practiced at Melanoma Institute Australia (MIA). BACKGROUND ILI is progressively being used around the world but to date the reported response rates are generally lower than those reported by MIA. DISCUSSION This description of the ILI protocol at MIA provides details that may allow other surgeons to improve results.
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Affiliation(s)
- Hidde M Kroon
- Melanoma Institute Australia, Sydney, NSW, Australia
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12
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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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Wong J, Chen YA, Fisher KJ, Zager JS. Isolated limb infusion in a series of over 100 infusions: a single-center experience. Ann Surg Oncol 2013; 20:1121-7. [PMID: 23456376 DOI: 10.1245/s10434-012-2782-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb infusion (ILI) is a therapeutic option for patients with recurrent, unresectable extremity malignancies. METHODS A prospectively collected single-institution database of patients undergoing ILI was analyzed for preoperative, intraoperative, and postoperative parameters and outcomes. RESULTS From May 2007 to January 2012, a total of 76 patients successfully underwent initial ILI, and 28 after either previous hyperthermic isolated limb perfusion or ILI. Seventy-nine patients (74 %) had melanoma, 24 (22 %) sarcoma, 3 (3 %) Merkel cell, and 1 (1 %) squamous cell carcinoma. There were 55 (72 %) initial and 22 (79 %) repeat lower extremity (LE) ILIs, and 21 (78 %) initial and 6 (22 %) repeat upper extremity (UE) ILIs. Serologic toxicity, measured by serum creatine kinase (CK), peaked higher and later in LE ILIs, median 620 versus 124 IU/L, and postoperative day 4 versus 2, respectively (P < 0.05). LE ILIs had a longer hospital length of stay (LOS), median 6 versus 5 days (P < 0.0001). A median grade II Wieberdink regional toxicity was observed. Three-month follow-up was available in 94 (90 %). A response (overall response rate, ORR) was seen in 72 % of ILIs performed for melanoma and 58 % for sarcoma. No difference in response was observed between UE versus LE or between initial versus repeat ILIs. Repeat UE ILIs, however, appeared to have an improved ORR than repeat LE ILIs, 83 versus 64 %. CONCLUSIONS ILI may be successfully performed for cutaneous and soft tissue malignancies. LE ILIs have higher CK levels and slightly longer LOS. Repeat ILIs are not associated with increased toxicity and similar ORR. UE ILIs may have better ORR.
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Affiliation(s)
- Joyce Wong
- Department of Cutaneous Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, USA
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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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15
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Trabulsi NH, Patakfalvi L, Nassif MO, Turcotte RE, Nichols A, Meguerditchian AN. Hyperthermic isolated limb perfusion for extremity soft tissue sarcomas: systematic review of clinical efficacy and quality assessment of reported trials. J Surg Oncol 2012; 106:921-8. [PMID: 22806575 DOI: 10.1002/jso.23200] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 05/29/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Extremity soft tissue sarcomas (STS) are managed with radiotherapy and limb-sparing surgery however aggressive or recurrent cases require amputation. Hyperthermic isolated limb perfusion (HILP) has been proposed as an alternative. Our aim was to systematically review phase II HILP trials, assess tumor response, limb salvage (LS), and quality of scientific publications on this technique. METHODS We conducted a literature search of electronic databases (MEDLINE, EMBASE, Scopus, Cochrane Library) and clinical trial registries for phase II HILP trials on non-resectable extremity STS. Outcomes of interest were complete response (CR), partial response (PR), and LS rates. Quality of published trials was assessed using a quality checklist. RESULTS Of 518 patients across 12 studies, 408 had some response (CR or PR), and 428 had the limb spared. Median CR, PR, and LS rates were 31%, 53.5%, and 82.5%, respectively. Median Wieberdink loco-regional toxicity rates were 3.8%, 45.5%, 17%, 1%, and 0% for levels 1-5, respectively. No trial fulfilled either all ideal or essential quality criteria. Seven trials did not include statistical methodology. CONCLUSION HILP seems effective in treating advanced extremity STS. However, poor publication quality hinders results validity. Technical and methodological standardization, well-designed, multi-institutional trials are warranted.
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Affiliation(s)
- N H Trabulsi
- Department of Clinical Epidemiology, McGill University, Montreal, Canada
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16
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Ferrone ML, Raut CP. Modern surgical therapy: limb salvage and the role of amputation for extremity soft-tissue sarcomas. Surg Oncol Clin N Am 2011; 21:201-13. [PMID: 22365515 DOI: 10.1016/j.soc.2011.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Historically the surgical management of extremity soft-tissue sarcomas (ESTS) commonly involved amputation. Nowadays limb-sparing, function-preserving surgery is the standard of care for ESTS. Adjuvant therapies such as radiation therapy and chemotherapy are used selectively in an effort to minimize both local recurrence and distant spread. Less common modalities, such as isolated limb perfusion, isolated limb infusion, and hyperthermia are being evaluated to potentially expand the cohort of individuals who may be eligible for limb-sparing surgery and to improve outcomes. This article reviews the standard and evolving approaches to the management of ESTS.
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Affiliation(s)
- Marco L Ferrone
- Department of Orthopedics, Brigham and Women's Hospital, Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA
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17
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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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Turaga KK, Beasley GM, Kane JM, Delman KA, Grobmyer SR, Gonzalez RJ, Letson GD, Cheong D, Tyler DS, Zager JS. Limb preservation with isolated limb infusion for locally advanced nonmelanoma cutaneous and soft-tissue malignant neoplasms. ACTA ACUST UNITED AC 2011; 146:870-5. [PMID: 21768436 DOI: 10.1001/archsurg.2011.139] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To demonstrate the efficacy of isolated limb infusion (ILI) in limb preservation for patients with locally advanced soft-tissue sarcomas and nonmelanoma cutaneous malignant neoplasms. BACKGROUND Locally advanced nonmelanoma cutaneous and soft-tissue malignant neoplasms, including soft-tissue sarcomas of the extremities, can pose significant treatment challenges. We report our experience, including responses and limb preservation rates, using ILI in cutaneous and soft-tissue malignant neoplasms. METHODS We identified 22 patients with cutaneous and soft-tissue malignant neoplasms who underwent 26 ILIs with melphalan and dactinomycin from January 1, 2004, through December 31, 2009, from 5 institutions. Outcome measures included limb preservation and in-field response rates. Regional toxic effects were measured using the Wieberdink scale and serum creatinine phosphokinase levels. RESULTS The median age was 70 years (range, 19-92 years), and 12 patients (55%) were women. Fourteen patients (64%) had sarcomas, 7 (32%) had Merkel cell carcinoma, and 1 (5%) had squamous cell carcinoma. The median length of stay was 5.5 days (interquartile range, 4-8 days). Twenty-five of the 26 ILIs (96%) resulted in Wieberdink grade III or less toxicity, and 1 patient (4%) developed grade IV toxicity. The median serum creatinine phosphokinase level was 127 U/L for upper extremity ILIs and 93 U/L for lower extremity ILIs. Nineteen of 22 patients (86%) underwent successful limb preservation. The 3-month in-field response rate was 79% (21% complete and 58% partial), and the median follow-up was 8.6 months (range, 1-63 months). Five patients underwent resection of disease after an ILI, of whom 80% are disease free at a median of 8.6 months. CONCLUSIONS Isolated limb infusion provides an attractive alternative therapy for regional disease control and limb preservation in patients with limb-threatening cutaneous and soft-tissue malignant neoplasms. Short-term response rates appear encouraging, yet durability of response is unknown.
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Affiliation(s)
- Kiran K Turaga
- Division of Surgical Oncology, Medical College of Wisconsin Clinical Cancer Center, Milwaukee, USA
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Testori A, Verhoef C, Kroon HM, Pennacchioli E, Faries MB, Eggermont AM, Thompson JF. Treatment of melanoma metastases in a limb by isolated limb perfusion and isolated limb infusion. J Surg Oncol 2011; 104:397-404. [DOI: 10.1002/jso.22028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Curtis KK, Ashman JB, Beauchamp CP, Schwartz AJ, Callister MD, Dueck AC, Gunderson LL, Fitch TR. Neoadjuvant chemoradiation compared to neoadjuvant radiation alone and surgery alone for Stage II and III soft tissue sarcoma of the extremities. Radiat Oncol 2011; 6:91. [PMID: 21827676 PMCID: PMC3170220 DOI: 10.1186/1748-717x-6-91] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 08/09/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCR) prior to resection of extremity soft tissue sarcoma (STS) has been studied, but data are limited. We present outcomes with NCR using a variety of chemotherapy regimens compared to neoadjuvant radiation without chemotherapy (NR) and surgery alone (SA). METHODS We conducted a retrospective chart review of 112 cases. RESULTS Treatments included SA (36 patients), NCR (39 patients), and NR (37 patients). NCR did not improve the rate of margin-negative resections over SA or NR. Loco-regional relapse-free survival, distant metastases-free survival, and overall survival (OS) were not different among the treatment groups. Patients with relapsed disease (OR 11.6; p = 0.01), and tumor size greater than 5 cm (OR 9.4; p = 0.01) were more likely to have a loco-regional recurrence on logistic regression analysis. Significantly increased OS was found among NCR-treated patients with tumors greater than 5 cm compared to SA (3 year OS 69 vs. 40%; p = 0.03). Wound complication rates were higher after NCR compared to SA (50 vs. 11%; p = 0.003) but not compared to NR (p = 0.36). Wet desquamation was the most common adverse event of NCR. CONCLUSIONS NCR and NR are acceptable strategies for patients with STS. NCR is well-tolerated, but not clearly superior to NR.
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Affiliation(s)
- Kelly K Curtis
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ 85259, 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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22
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Lewandowski RJ, Geschwind JF, Liapi E, Salem R. Transcatheter intraarterial therapies: rationale and overview. Radiology 2011; 259:641-57. [PMID: 21602502 PMCID: PMC3400295 DOI: 10.1148/radiol.11081489] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transcatheter intraarterial therapies have proved valuable in the battle against primary and secondary hepatic malignancies. The unique aspects of all such therapies are their reduced toxicity profiles and highly effective tumor responses. These unique characteristics coupled with their minimally invasive nature provide an attractive therapeutic option in patients who may have previously had few alternatives. The concept of all catheter-based intraarterial therapies is to selectively deliver anticancer treatment to tumor(s). These therapies, which include transarterial embolization, intraarterial chemoinfusion, transarterial chemoembolization with or without drug-eluting beads, and radioembolization with use of yttrium 90, inflict lethal insult to tumors while preserving normal hepatic parenchyma. This is possible because hepatic neoplasms preferentially derive their blood supply from an arterial source while the majority of noncancerous liver is supplied by the portal vein. As part of the interventional oncology review series, in this article we describe the rationale behind each of these transcatheter therapies and provide a review of the existing medical literature.
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Affiliation(s)
- Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St Clair St, Suite 800, Chicago, IL 60611, USA.
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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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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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Kaushal A, Citrin D. The role of radiation therapy in the management of sarcomas. Surg Clin North Am 2008; 88:629-46, viii. [PMID: 18514703 DOI: 10.1016/j.suc.2008.03.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Sarcomas represent a heterogeneous, challenging, and rare group of tumors that present many management challenges. In this article, the authors concentrate on the radiotherapeutic management of sarcomas occurring in the most common locations: the extremities, the trunk, and the retroperitoneum. An overview of the current radiotherapeutic management of soft tissue sarcoma is presented in addition to a discussion of how surgical management may affect radiotherapeutic management. Finally, the authors describe current controversies surrounding the appropriate management of sarcomas with radiotherapy and describe ongoing studies and future areas of research.
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Affiliation(s)
- Aradhana Kaushal
- Radiation Oncology Branch, National Cancer Center, National Cancer Institute, Building 10, Hatfield CRC, B2-3500, 10 Center Drive, Bethesda, MD 20892, USA
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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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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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