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Zager JS, Orloff M, Ferrucci PF, Choi J, Eschelman DJ, Glazer ES, Ejaz A, Howard JH, Richtig E, Ochsenreither S, Reddy SA, Lowe MC, Beasley GM, Gesierich A, Bender A, Gschnell M, Dummer R, Rivoire M, Arance A, Fenwick SW, Sacco JJ, Haferkamp S, Weishaupt C, John J, Wheater M, Ottensmeier CH. Efficacy and Safety of the Melphalan/Hepatic Delivery System in Patients with Unresectable Metastatic Uveal Melanoma: Results from an Open-Label, Single-Arm, Multicenter Phase 3 Study. Ann Surg Oncol 2024; 31:5340-5351. [PMID: 38704501 PMCID: PMC11249544 DOI: 10.1245/s10434-024-15293-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/25/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Uveal melanoma (UM) has a poor prognosis once liver metastases occur. The melphalan/Hepatic Delivery System (melphalan/HDS) is a drug/device combination used for liver-directed treatment of metastatic UM (mUM) patients. The purpose of the FOCUS study was to assess the efficacy and safety of melphalan/HDS in patients with unresectable mUM. METHODS Eligible patients with mUM received treatment with melphalan (3.0 mg/kg ideal body weight) once every 6 to 8 weeks for a maximum of six cycles. The primary end point was the objective response rate (ORR). The secondary end points included duration of response (DOR), overall survival (OS), and progression-free survival (PFS). RESULTS The study enrolled 102 patients with mUM. Treatment was attempted in 95 patients, and 91 patients received treatment. In the treated population (n = 91), the ORR was 36.3 % (95 % confidence interval [CI], 26.44-47.01), including 7.7 % of patients with a complete response. Thus, the study met its primary end point because the lower bound of the 95 % CI for ORR exceeded the upper bound (8.3 %) from the benchmark meta-analysis. The median DOR was 14 months, and the median OS was 20.5 months, with an OS of 80 % at 1 year. The median PFS was 9 months, with a PFS of 65 % at 6 months. The most common serious treatment-emergent adverse events were thrombocytopenia (15.8 %) and neutropenia (10.5 %), treated mostly on an outpatient basis with observation. No treatment-related deaths were observed. CONCLUSION Treatment with melphalan/HDS provides a clinically meaningful response rate and demonstrates a favorable benefit-risk profile in patients with unresectable mUM (study funded by Delcath; ClinicalTrials.gov identifier: NCT02678572; EudraCT no. 2015-000417-44).
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Affiliation(s)
- Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA.
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | | | | | - Junsung Choi
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | - Evan S Glazer
- The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aslam Ejaz
- The Ohio State University, Columbus, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Ana Arance
- Hospital Clínic Barcelona, Barcelona, Spain
| | | | - Joseph J Sacco
- The Clatterbridge Cancer Center, University of Liverpool, Liverpool, UK
| | | | | | | | - Matthew Wheater
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Olofsson Bagge R, Nelson A, Shafazand A, Cahlin C, Carneiro A, Helgadottir H, Levin M, Rizell M, Ullenhag G, Wirén S, Lindnér P, Nilsson JA, Ny L. A phase Ib randomized multicenter trial of isolated hepatic perfusion in combination with ipilimumab and nivolumab for uveal melanoma metastases (SCANDIUM II trial). ESMO Open 2024; 9:103623. [PMID: 38959698 PMCID: PMC11269777 DOI: 10.1016/j.esmoop.2024.103623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/02/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Uveal melanoma (UM) is a rare malignancy where 50% of patients develop metastatic disease primarily affecting the liver. Approximately 40% of patients with metastatic UM respond to one-time isolated hepatic perfusion (IHP) with high-dose melphalan. This phase I trial investigates the safety and clinical efficacy of IHP combined with ipilimumab (IPI) and nivolumab (NIVO). PATIENTS AND METHODS Immunotherapy-naïve patients were randomized in this phase I trial to receive either IHP followed by IPI 3 mg/kg and NIVO 1 mg/kg (IPI3/NIVO1) for four cycles (post-operative arm), or one cycle of preoperative IPI3/NIVO1, IHP and then three cycles of IPI3/NIVO1 (pre-post-operative arm), followed by maintenance therapy with NIVO 480 mg for 1 year. RESULTS Eighteen patients were enrolled and randomized. Three patients did not undergo IHP as planned. In total, 11/18 patients (6 in the post-operative arm and 5 in the pre-post-operative arm) did not complete the planned four cycles of IPI3/NIVO1. Toxicity to IHP was similar in both groups, but the number of immune-related adverse events (AEs) was higher in the pre-post-operative arm. Among assessable patients, overall response rate was 57% in the post-operative arm (4/7) and 22% in the pre-post-operative arm (2/9). CONCLUSIONS Combination therapy with IHP and IPI3/NIVO1 was associated with severe AEs. The efficacy of this combination is encouraging with high response rates. One cycle of preoperative IPI/NIVO before IHP did not show potential benefits in terms of safety or efficacy.
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Affiliation(s)
- R Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; Department of Surgery, Sahlgrenska University Hospital, Gothenburg; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg.
| | - A Nelson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg; Department of Oncology, Sahlgrenska University Hospital, Gothenburg
| | - A Shafazand
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg
| | - C Cahlin
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg
| | - A Carneiro
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital Comprehensive Cancer Center, Lund
| | - H Helgadottir
- Department of Oncology, Karolinska University Hospital, Stockholm
| | - M Levin
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg; Department of Oncology, Sahlgrenska University Hospital, Gothenburg
| | - M Rizell
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg
| | - G Ullenhag
- Department of Radiology, Immunology, Genetics, and Pathology, Uppsala University, Uppsala
| | - S Wirén
- Department of Radiation Sciences, Umeå University Hospital, Umeå, Sweden
| | - P Lindnér
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg
| | - J A Nilsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Australia
| | - L Ny
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg; Department of Oncology, Sahlgrenska University Hospital, Gothenburg
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Shannon AB, Zager JS, Perez MC. Clinical Characteristics and Special Considerations in the Management of Rare Melanoma Subtypes. Cancers (Basel) 2024; 16:2395. [PMID: 39001457 PMCID: PMC11240680 DOI: 10.3390/cancers16132395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
Rare histologic subtypes of melanoma, including acral, mucosal, uveal, and desmoplastic melanomas, only make up 5% of all diagnosed melanomas and are often underrepresented in large, randomized trials. Recent advancements in systemic therapy have shown marked improvement in pathologic response rates, improving progression-free and overall survival among cutaneous melanoma patients, but there are limited data to demonstrate improved survival among rarer subtypes of melanoma. Acral melanoma has a poor response to immunotherapy and is associated with worse survival. Mucosal melanoma has a large variability in its presentation, a poor prognosis, and a low mutational burden. Uveal melanoma is associated with a high rate of liver metastasis; recent adoption of infusion and perfusion therapies has demonstrated improved survival among these patients. Desmoplastic melanoma, a high-risk cutaneous melanoma, is associated with high locoregional recurrence rates and mutational burden, suggesting this melanoma may have enhanced response to immunotherapy. While these variants of melanoma represent distinct disease entities, this review highlights the clinicopathologic characteristics and treatment recommendations for each of these rare melanomas and highlights the utility of modern therapies for each of them.
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Affiliation(s)
- Adrienne B Shannon
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Matthew C Perez
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Koch EAT, Heppt MV, Berking C. The Current State of Systemic Therapy of Metastatic Uveal Melanoma. Am J Clin Dermatol 2024:10.1007/s40257-024-00872-1. [PMID: 38907174 DOI: 10.1007/s40257-024-00872-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/23/2024]
Abstract
Uveal melanoma (UM) is genetically a distinct tumor compared to cutaneous melanoma (CM), and due to its low mutational burden, it is far less perceptible to the immune system. Thus, treatments that have revolutionized the treatment of CM remain widely inefficient in metastatic UM or only demonstrate effectiveness in a small subpopulation of patients. To this end, the therapeutic benefit of immune checkpoint blockade is very limited and may come at the expense of severe immune-related adverse events that could potentially affect all organ systems. Notably, tebentafusp, an entirely novel class of anti-cancer drugs, has received official authorization for the treatment of metastatic UM. It is the first agent that demonstrated a survival advantage in a randomized controlled trial of metastatic UM patients. Despite the survival benefit and approval, the restriction of tebentafusp to HLA-A*02:01-positive patients and the low objective response rate indicate the persistent need for additional therapies. Thus, liver-directed therapies are commonly used for tumor control of hepatic metastases and represent a central pillar of the daily management of liver-dominant disease. Further, promising data from targeted therapies independent of MEK-inhibitors, such as the combination of darovasertib and crizotinib, raise hope for additional options in metastatic UM in the future. This narrative review provides a timely and comprehensive overview of the current treatment landscape for metastatic UM.
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Affiliation(s)
- Elias A T Koch
- Department of Dermatology, Deutsches Zentrum Immuntherapie (DZI), Bavarian Cancer Research Center (BZKF), Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), CCC Erlangen-EMN, 91054, Erlangen, Germany
| | - Markus V Heppt
- Department of Dermatology, Deutsches Zentrum Immuntherapie (DZI), Bavarian Cancer Research Center (BZKF), Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), CCC Erlangen-EMN, 91054, Erlangen, Germany
| | - Carola Berking
- Department of Dermatology, Deutsches Zentrum Immuntherapie (DZI), Bavarian Cancer Research Center (BZKF), Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), CCC Erlangen-EMN, 91054, Erlangen, Germany.
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Tong TML, Fiocco M, van Duijn-de Vreugd JJ, Lutjeboer J, Speetjens FM, Tijl FGJ, Sitsen ME, Zoethout RWM, Martini CH, Vahrmeijer AL, van der Meer RW, van Rijswijk CSP, van Erkel AR, Kapiteijn E, Burgmans MC. Quality of Life Analysis of Patients Treated with Percutaneous Hepatic Perfusion for Uveal Melanoma Liver Metastases. Cardiovasc Intervent Radiol 2024; 47:741-750. [PMID: 38587534 PMCID: PMC11164794 DOI: 10.1007/s00270-024-03713-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Percutaneous hepatic perfusion with melphalan (M-PHP) is a minimally invasive therapy with proven efficacy in patients with uveal melanoma (UM) liver metastases. M-PHP is associated with a short hospital admission time and limited systemic side effects. In this study, we assessed quality of life (QoL) in UM patients treated with M-PHP. MATERIALS AND METHODS A prospective, single-center study including 24 patients treated with M-PHP for UM metastases to the liver. QoL questionnaires were collected at baseline, on day 2/3 after M-PHP, and on day 7 and day 21 after M-PHP, according to study protocol. The results were scored according to EORTC-QLQ C30 global health status (GHS), functional scales, and symptom scales. The difference in scores at baseline and subsequent time points was analyzed with the Wilcoxon signed-rank test and multiple testing Bonferroni correction. Adverse events (AE) were registered up to 30 days after M-PHP according to CTCAE v5.0. RESULTS Twenty-four patients (14 males; median age 63.0 years) completed 96 questionnaires. Most scores on all scales declined on day 2/3 after M-PHP. On day 21 after M-PHP, 12 out of 15 scores returned to baseline, including median GHS scores. Three variables were significantly worse on day 21 compared to baseline: fatigue (6-33; p = 0.002), physical functioning (100 vs 86.7; p = 0.003), and role functioning (100 vs 66.7; p = 0.001). Grade 3/4 AEs consisted mainly of hematological complications, such as leukopenia and thrombopenia. CONCLUSION M-PHP causes fatigue and a decline in physical and role functioning in the 1st weeks after treatment, but GHS returns to baseline levels within 21 days. LEVEL OF EVIDENCE 3: Cohort study.
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Affiliation(s)
- T M L Tong
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - M Fiocco
- Mathematical Institute, Leiden University, Leiden, The Netherlands
- Medical Statistics Section, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - J J van Duijn-de Vreugd
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - J Lutjeboer
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - F M Speetjens
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - F G J Tijl
- Department of Extra Corporal Circulation, Leiden University Medical Center, Leiden, The Netherlands
| | - M E Sitsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - R W M Zoethout
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - C H Martini
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - R W van der Meer
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - C S P van Rijswijk
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - A R van Erkel
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - E Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Burgmans
- Interventional Radiology Research (IR2) Group, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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Dugan MM, Shannon AB, DePalo DK, Perez MC, Zager JS. Intralesional and Infusional Updates for Metastatic Melanoma. Cancers (Basel) 2024; 16:1957. [PMID: 38893078 PMCID: PMC11171204 DOI: 10.3390/cancers16111957] [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: 04/06/2024] [Revised: 05/13/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Locoregionally advanced and metastatic melanoma represent a challenging clinical problem, but in the era of immune checkpoint blockade and intralesional and infusional therapies, more options are available for use. Isolated limb infusion (ILI) was first introduced in the 1990s for the management of advanced melanoma, followed by the utilization of isolated extremity perfusion (ILP). Following this, intralesional oncolytic viruses, xanthene dyes, and cytokines were introduced for the management of in-transit metastases as well as unresectable, advanced melanoma. In 2015, the Food and Drug Administration (FDA) approved the first oncolytic intralesional therapy, talimogene laherparepvec (T-VEC), for the treatment of advanced melanoma. Additionally, immune checkpoint inhibition has demonstrated efficacy in the management of advanced melanomas, and this improvement in outcomes has been extrapolated to aid in the management of in-transit metastatic disease. Finally, percutaneous hepatic perfusion (PHP), also approved by the FDA, has been reported to have a significant impact on the treatment of hepatic disease in uveal melanoma. While some of these treatments have less utility due to inferior outcomes as well as higher toxicity profiles, there are selective patient profiles for which these therapies carry a role. This review highlights intralesional and infusional therapies for the management of metastatic melanoma.
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Affiliation(s)
- Michelle M. Dugan
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Adrienne B. Shannon
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Danielle K. DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
- Department of General Surgery, University of Massachusetts Chan Medical School, Boston, MA 01655, USA
| | - Matthew C. Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA; (M.M.D.); (A.B.S.); (D.K.D.); (M.C.P.)
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33602, USA
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Khan SA, Almalki WH, Arora S, Kesharwani P. Recent approaches for the treatment of uveal melanoma: Opportunities and challenges. Crit Rev Oncol Hematol 2024; 193:104218. [PMID: 38040071 DOI: 10.1016/j.critrevonc.2023.104218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023] Open
Abstract
Uveal melanoma (UM) is the most prevalent primary intraocular cancer in adult population. Primary methods for treatment of UM involves surgery Proton Beam Therapy (PBT), Plaque Brachytherapy, phototherapy, and Charged Particle Radiation Therapy (CPT). It has been found that approximately 50 % of patients diagnosed with UM ultimately experience development of metastatic disease. Furthermore, it has been identified that majority of the patient experience metastasis in liver with a prevalence of 95 %. Management of metastatic UM (MUM) involves various therapeutic modalities, including systemic chemotherapy, molecular targeted therapy, immunotherapy and liver directed interventions. We outline gene mutation in UM and addresses various treatment modalities, including molecular targeted therapy, miRNA-based therapy, and immunotherapy. Additionally, inclusion of ongoing clinical trials aimed at developing novel therapeutic options for management of UM are also mentioned.
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Affiliation(s)
- Sauban Ahmed Khan
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India
| | - Waleed H Almalki
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Swaranjeet Arora
- Department of Finance and Management, Lal Bahadur Shastri Institute of Management, 11/07 Dwarka Sector 11, Near Metro Station, New Delhi, Delhi 110075, India
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India.
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Huibers A, DePalo DK, Perez MC, Zager JS, Olofsson Bagge R. Isolated hyperthermic perfusions for cutaneous melanoma in-transit metastasis of the limb and uveal melanoma metastasis to the liver. Clin Exp Metastasis 2023:10.1007/s10585-023-10234-6. [PMID: 37843790 DOI: 10.1007/s10585-023-10234-6] [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: 05/18/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Patients with cutaneous melanoma can develop in-transit metastases (ITM), most often localized to limbs. For patients with uveal melanoma that develop metastatic disease, the overall majority develop isolated liver metastases. For these types of metastases, regional cancer therapies have evolved as effective treatments. Isolated limb perfusion (ILP), isolated limb infusion (ILI), isolated hepatic perfusion (IHP) and percutaneous hepatic perfusion (PHP) achieve a high local concentration of chemotherapy with minimal systemic exposure. This review discusses the mechanism and available literature on locoregional treatment modalities in the era of modern immunotherapy.
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Affiliation(s)
- Anne Huibers
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden
| | - Danielle K DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncologic Sciences, University of South Florida Morsani, College of Medicine, Tampa, FL, USA
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 90, Gothenburg, Sweden.
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Olofsson Bagge R, Nelson A, Shafazand A, All-Eriksson C, Cahlin C, Elander N, Helgadottir H, Kiilgaard JF, Kinhult S, Ljuslinder I, Mattsson J, Rizell M, Sternby Eilard M, Ullenhag GJ, Nilsson JA, Ny L, Lindnér P. Isolated Hepatic Perfusion With Melphalan for Patients With Isolated Uveal Melanoma Liver Metastases: A Multicenter, Randomized, Open-Label, Phase III Trial (the SCANDIUM Trial). J Clin Oncol 2023; 41:3042-3050. [PMID: 36940407 PMCID: PMC10414734 DOI: 10.1200/jco.22.01705] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/09/2023] [Indexed: 03/22/2023] Open
Abstract
PURPOSE About half of patients with metastatic uveal melanoma present with isolated liver metastasis, in whom the median survival is 6-12 months. The few systemic treatment options available only moderately prolong survival. Isolated hepatic perfusion (IHP) with melphalan is a regional treatment option, but prospective efficacy and safety data are lacking. METHODS In this multicenter, randomized, open-label, phase III trial, patients with previously untreated isolated liver metastases from uveal melanoma were randomly assigned to receive a one-time treatment with IHP with melphalan or best alternative care (control group). The primary end point was overall survival at 24 months. Here, we report the secondary outcomes of response according to RECIST 1.1 criteria, progression-free survival (PFS), hepatic PFS (hPFS), and safety. RESULTS Ninety-three patients were randomly assigned, and 87 patients were assigned to either IHP (n = 43) or a control group receiving the investigator's choice of treatment (n = 44). In the control group, 49% received chemotherapy, 39% immune checkpoint inhibitors, and 9% locoregional treatment other than IHP. In an intention-to-treat analysis, the overall response rates (ORRs) were 40% versus 4.5% in the IHP and control groups, respectively (P < .0001). The median PFS was 7.4 months versus 3.3 months (P < .0001), with a hazard ratio of 0.21 (95% CI, 0.12 to 0.36), and the median hPFS was 9.1 months versus 3.3 months (P < .0001), both favoring the IHP arm. There were 11 treatment-related serious adverse events in the IHP group compared with seven in the control group. There was one treatment-related death in the IHP group. CONCLUSION IHP treatment resulted in superior ORR, hPFS, and PFS compared with best alternative care in previously untreated patients with isolated liver metastases from primary uveal melanoma.
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Affiliation(s)
- Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Axel Nelson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Amir Shafazand
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Alingsås Hospital, Alingsås, Sweden
| | - Charlotta All-Eriksson
- Department of Ophthalmology, Mölndal Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Cahlin
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nils Elander
- Department of Oncology and Department of Clinical and Biomedical Sciences, Linköping University, Linköping, Sweden
| | - Hildur Helgadottir
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Jens Folke Kiilgaard
- Department of Ophthalmology, Rigshospitalet, Copenhagen University Hospital Copenhagen, Copenhagen, Denmark
| | - Sara Kinhult
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Ingrid Ljuslinder
- Department of Radiation Sciences, Oncology, Umeå University Hospital, Umeå, Sweden
| | - Jan Mattsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Rizell
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Malin Sternby Eilard
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gustav J. Ullenhag
- Department of Immunology, Genetics and Pathology (IGP), Science for Life Laboratories, Uppsala University, Uppsala, Sweden
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | - Jonas A. Nilsson
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Ny
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Lindnér
- Transplant Institute, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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10
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Tao YX, Li HW, Luo JT, Li Y, Wei WB. Regional chemotherapy for uveal melanoma liver metastases. Int J Ophthalmol 2023; 16:293-300. [PMID: 36816216 PMCID: PMC9922637 DOI: 10.18240/ijo.2023.02.18] [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: 11/04/2022] [Accepted: 12/26/2022] [Indexed: 02/05/2023] Open
Abstract
Chemotherapy remains an important approach for the treatment of liver metastases from uveal melanoma (UM). Compared with systemic chemotherapy, regional chemotherapy has similar efficacy and fewer systemic adverse effects. Regional chemotherapy for UM liver metastases includes hepatic artery infusion (HAI), transarterial chemoembolization (TACE), and isolated hepatic perfusion (IHP). In this review, we aim to examine the efficacy of regional chemotherapy and compare HAI, TACE, and IHP in terms of overall survival (OS). The three approaches showed no obvious difference in OS results.
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11
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Kliem P, Ebel S, Werdehausen R, Girrbach F, Bösemann D, van Bömmel F, Denecke T, Stehr S, Struck MF. [Anesthesiological and postinterventional management in percutaneous hepatic melphalan perfusion (chemosaturation)]. DIE ANAESTHESIOLOGIE 2023; 72:113-120. [PMID: 36477906 PMCID: PMC9892165 DOI: 10.1007/s00101-022-01235-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 12/13/2022]
Abstract
Percutaneous hepatic melphalan perfusion (PHMP) is a last-line treatment of inoperable primary or secondary liver tumors. Selective perfusion and saturation (chemosaturation) of the liver with the chemotherapeutic agent melphalan is performed via catheterization of the hepatic artery without affecting the rest of the body with its cytotoxic properties. Using an extracorporeal circulation and balloon occlusion of the inferior vena cava, the venous hepatic blood is filtered and returned using a bypass procedure. During the procedure, considerable circulatory depression and coagulopathy are frequent. The purpose of this article is to review the anesthesiological and postprocedural management of patients undergoing PHMP with consideration of the pitfalls and special circumstances.
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Affiliation(s)
- Peter Kliem
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Sebastian Ebel
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Robert Werdehausen
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Felix Girrbach
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Denis Bösemann
- Klinik für Herz- und Thoraxchirurgie, Kardiotechnik, Universitätsklinikum Jena, Jena, Deutschland
| | - Florian van Bömmel
- Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Bereich Hepatologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Timm Denecke
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Sebastian Stehr
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Manuel F Struck
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
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12
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Vogel A, Ochsenreither S, Zager JS, Wacker F, Saborowski A. Chemosaturation for primary and secondary liver malignancies: A comprehensive update of current evidence. Cancer Treat Rev 2023; 113:102501. [PMID: 36587472 DOI: 10.1016/j.ctrv.2022.102501] [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: 11/04/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/25/2022]
Abstract
Regional therapies for primary and secondary liver tumors have garnered interest in recent years and several types of treatment approaches have been pursued to control disease, palliate symptoms, and extend survival. Chemosaturation is an innovative way to deliver high-dose chemotherapy to the liver via the hepatic artery. Within the last decade, "isolated hepatic perfusion" (IHP) has evolved from an open surgical approach to a minimally invasive procedure, now termed "chemosaturation" (CS) with "percutaneous hepatic perfusion (PHP)". The most conclusive data on CS-PHP is currently available for patients with hepatic metastases from uveal melanoma (UM) - a rare but devastating disease with a poor long-term survival rate. A global phase-3 study and several cohort studies have provided compelling evidence that CS-PHP is an effective salvage treatment for liver-dominant metastatic UM in institutions with appropriate expertise. In this review we provide an overview on the technique, available clinical data, including safety and efficacy, and potential indications for CS-PHP.
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Affiliation(s)
- Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
| | - Sebastian Ochsenreither
- Department of Hematology, Oncology and Tumor Immunology, Charité Campus Benjamin Franklin, Berlin, Germany; Charité Comprehensive Cancer Center, Berlin, Germany
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, United States; Department of Oncological Sciences, University of South Florida, Morsani School of Medicine, Tampa, FL, United States
| | - Frank Wacker
- Department of Radiology, Hannover Medical School, Hannover, Germany
| | - Anna Saborowski
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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13
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Kaprin AD, Ivanov SA, Unguryan VM, Kazantsev AN, Belov YV. [Isolated liver perfusion with melphalan followed by pembrolizumab therapy for unresectable metastases of uveal melanoma to the liver]. Khirurgiia (Mosk) 2023:94-99. [PMID: 37379411 DOI: 10.17116/hirurgia202307194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Uveal melanoma accounts for 80% of all ocular melanomas, and 30-60% of patients have metastases to the liver. A few patients are candidates for liver resection, and this disease is associated with poor prognosis. There are few data on optimal management of metastatic uveal melanoma. Isolated hepatic perfusion is a perspective method for regional treatment of inoperable metastatic liver lesions with uveal melanoma. We present a patient with uveal melanoma who underwent previous enucleation of the eye. Cancer progressed 15 years later as an isolated inoperable metastatic liver lesion. The patient underwent isolated liver perfusion with melphalan, hyperthermia and oxygenation. Subsequently, the patient received systemic therapy with pembrolizumab. Partial response was achieved 1 month after the procedure. There was no progression for 20 months after surgery under systemic therapy with pembrolizumab. Thus, isolated liver chemoperfusion with melphalan is advisable in these patients.
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Affiliation(s)
- A D Kaprin
- Herzen Moscow Research Institute of Oncology, Moscow, Russia
| | - S A Ivanov
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | | | - A N Kazantsev
- Kostroma Oncology Center, Kostroma, Russia
- Korolev Kostroma Regional Clinical Hospital, Kostroma, Russia
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - Yu V Belov
- Petrovsky National Research Center of Surgery, Moscow, Russia
- Sechenov First Moscow State Medical University, Moscow, Russia
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14
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Prognostic Biomarkers in Uveal Melanoma: The Status Quo, Recent Advances and Future Directions. Cancers (Basel) 2021; 14:cancers14010096. [PMID: 35008260 PMCID: PMC8749988 DOI: 10.3390/cancers14010096] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 01/18/2023] Open
Abstract
Simple Summary Although rare, uveal melanoma (UM) is the most common cancer that develops inside adult eyes. The prognosis is poor, since 50% of patients will develop lethal metastases in the first decade, especially to the liver. Once metastases are detected, life expectancy is limited, given that the available treatments are mostly unsuccessful. Thus, there is a need to find methods that can accurately predict UM prognosis and also effective therapeutic strategies to treat this cancer. In this manuscript, we initially compile the current knowledge on epidemiological, clinical, pathological and molecular features of UM. Then, we cover the most relevant prognostic factors currently used for the evaluation and follow-up of UM patients. Afterwards, we highlight emerging molecular markers in UM published over the last three years. Finally, we discuss the problems preventing meaningful advances in the treatment and prognostication of UM patients, as well as forecast new roadblocks and paths of UM-related research. Abstract Uveal melanoma (UM) is the most common malignant intraocular tumour in the adult population. It is a rare cancer with an incidence of nearly five cases per million inhabitants per year, which develops from the uncontrolled proliferation of melanocytes in the choroid (≈90%), ciliary body (≈6%) or iris (≈4%). Patients initially present either with symptoms like blurred vision or photopsia, or without symptoms, with the tumour being detected in routine eye exams. Over the course of the disease, metastases, which are initially dormant, develop in nearly 50% of patients, preferentially in the liver. Despite decades of intensive research, the only approach proven to mildly control disease spread are early treatments directed to ablate liver metastases, such as surgical excision or chemoembolization. However, most patients have a limited life expectancy once metastases are detected, since there are limited therapeutic approaches for the metastatic disease, including immunotherapy, which unlike in cutaneous melanoma, has been mostly ineffective for UM patients. Therefore, in order to offer the best care possible to these patients, there is an urgent need to find robust models that can accurately predict the prognosis of UM, as well as therapeutic strategies that effectively block and/or limit the spread of the metastatic disease. Here, we initially summarized the current knowledge about UM by compiling the most relevant epidemiological, clinical, pathological and molecular data. Then, we revisited the most important prognostic factors currently used for the evaluation and follow-up of primary UM cases. Afterwards, we addressed emerging prognostic biomarkers in UM, by comprehensively reviewing gene signatures, immunohistochemistry-based markers and proteomic markers resulting from research studies conducted over the past three years. Finally, we discussed the current hurdles in the field and anticipated the future challenges and novel avenues of research in UM.
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