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Perez MC, Depalo DK, Zager JS. A safety review of recently approved and late-stage trial treatments for metastatic melanoma: systemic and regional therapies. Expert Opin Drug Saf 2023; 22:789-797. [PMID: 37551723 DOI: 10.1080/14740338.2023.2245333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/30/2023] [Accepted: 08/03/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Advanced melanoma accounts for the majority of skin cancer-associated deaths. Over the past 15 years, there has been a dramatic change in the treatment options and prognosis for patients with advanced melanoma secondary to the development of novel systemic immunotherapies (IO) and targeted therapies. In addition to these novel systemic therapies, regional therapies (intralesional and perfusional) also continue to play a major role in the management of these patients. AREAS COVERED In this article, we review recent updates in the management of advanced melanoma via Medline (PubMed) and Google Scholar, including recently published trials in the metastatic, adjuvant, and neoadjuvant settings. We also review recently published trials for regional therapies and discuss future directions in the management of patients with advanced melanoma. EXPERT OPINION A significant portion of patients with advanced melanoma will develop recurrent or progressive disease following treatment with IO or targeted therapy. Therefore, identifying not only the appropriate therapeutic agent but also the sequence and duration of treatment is pivotal for these patients.
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Affiliation(s)
- Matthew C Perez
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
| | - Danielle K Depalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
| | - Jonathan S Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa FL, United States of America
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Soares KC, Jolissaint JS, McIntyre SM, Seier KP, Gönen M, Sigel C, Nasar N, Cercek A, Harding JJ, Kemeny NE, Connell LC, Koerkamp BG, Balachandran VP, D'Angelica MI, Drebin JA, Kingham TP, Wei AC, Jarnagin WR. Hepatic disease control in patients with intrahepatic cholangiocarcinoma correlates with overall survival. Cancer Med 2023. [PMID: 37062071 DOI: 10.1002/cam4.5925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 04/17/2023] Open
Abstract
PURPOSE The role of locoregional therapy compared to systemic chemotherapy (SYS) for unresectable intrahepatic cholangiocarcinoma (IHC) remains controversial. The importance of hepatic disease control, either as initial or salvage therapy, is also unclear. We compared overall survival (OS) in patients treated with resection, hepatic arterial infusion pump (HAIP) chemotherapy, or SYS as it relates to hepatic recurrence or progression. We also evaluated recurrence after resection to determine the efficacy of locoregional salvage therapy. PATIENTS AND METHODS In this single-institution retrospective analysis, patients with biopsy-proven IHC treated with either curative-intent resection, HAIP (with or without SYS), or SYS alone were analyzed. Propensity score matching (PSM) was used to compare patients with liver-limited, advanced disease treated with HAIP versus SYS. The impact of locoregional salvage therapies in patients with liver-limited recurrence was analyzed in the resection cohort. RESULTS From 2000 to 2017, 714 patients with IHC were treated, 219 (30.7%) with resectable disease, 316 (44.3%) with locally advanced disease, and 179 (25.1%) with metastatic disease. Resected patients were less likely to recur or progress in the liver (hazard ratio [HR] 0.41, 95% CI 0.34-0.45) versus those that received HAIP or SYS (HR 0.58, 95% CI 0.50-0.65 vs. HR 0.63, 95% CI 0.57-0.69, respectively). In resected patients, 161 (64.4%) recurred, with 65 liver-only recurrences. Thirty of these patients received subsequent locoregional therapy. On multivariable analysis, locoregional therapy was associated with improved OS after isolated liver recurrence (HR 0.46, 95% CI 0.29-0.75; p = 0.002). In patients with locally advanced unresectable or multifocal liver disease (with or without distant organ metastases), PSM demonstrated improved hepatic progression-free survival in patients treated with HAIP versus SYS (HR 0.65; 95% CI 0.46-0.91; p = 0.01), which correlated with improved OS (HR 0.59, 95% CI 0.43-0.80; p < 0.001). CONCLUSION In patients with liver-limited IHC, hepatic disease control is associated with improved OS, emphasizing the potential importance of liver-directed therapy.
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Affiliation(s)
- Kevin C Soares
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joshua S Jolissaint
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah M McIntyre
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kenneth P Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Carlie Sigel
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Naaz Nasar
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrea Cercek
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James J Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nancy E Kemeny
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louise C Connell
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Vinod P Balachandran
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael I D'Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jeffrey A Drebin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alice C Wei
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - William R Jarnagin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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DePalo DK, Zager JS. Advances in Intralesional Therapy for Locoregionally Advanced and Metastatic Melanoma: Five Years of Progress. Cancers (Basel) 2023; 15:cancers15051404. [PMID: 36900196 PMCID: PMC10000422 DOI: 10.3390/cancers15051404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Locoregionally advanced and metastatic melanoma are complex diagnoses with a variety of available treatment options. Intralesional therapy for melanoma has been under investigation for decades; however, it has advanced precipitously in recent years. In 2015, the Food and Drug Administration (FDA) approved talimogene laherparepvec (T-VEC), the only FDA-approved intralesional therapy for advanced melanoma. There has been significant progress since that time with other oncolytic viruses, toll-like receptor agonists, cytokines, xanthene dyes, and immune checkpoint inhibitors all under investigation as intralesional agents. Further to this, there has been exploration of numerous combinations of intralesional therapies and systemic therapies as various lines of therapy. Several of these combinations have been abandoned due to their lack of efficacy or safety concerns. This manuscript presents the various types of intralesional therapies that have reached phase 2 or later clinical trials in the past 5 years, including their mechanism of action, therapeutic combinations under investigation, and published results. The intention is to provide an overview of the progress that has been made, discuss ongoing trials worth following, and share our opinions on opportunities for further advancement.
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Affiliation(s)
- Danielle K. DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33612, USA
- Correspondence: ; Tel.: +1-(813)-745-1085; Fax: +1-(813)-745-5725
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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] [What about the content of this article? (0)] [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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Beekman KE, Parker LM, DePalo DK, Elleson KM, Sarnaik AA, Tsai KY, Withycombe BM, Zager JS. Four cases of disseminated herpes simplex virus following talimogene laherparepvec injections for unresectable metastatic melanoma. JAAD Case Rep 2023; 33:56-58. [PMID: 36860805 PMCID: PMC9969237 DOI: 10.1016/j.jdcr.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
| | - Lily M. Parker
- USF Health, Morsani College of Medicine, Tampa, Florida,Correspondence to: Lily M. Parker, BS, USF Health Morsani College of Medicine, 10920 N. McKinley Dr, Room 4123, Tampa, FL 33612
| | - Danielle K. DePalo
- Department of Cutaneous Oncology, Moffitt Cancer Center, Wesley Chapel, Florida
| | - Kelly M. Elleson
- Department of Cutaneous Oncology, Moffitt Cancer Center, Wesley Chapel, Florida
| | - Amod A. Sarnaik
- USF Health, Morsani College of Medicine, Tampa, Florida,Department of Cutaneous Oncology, Moffitt Cancer Center, Wesley Chapel, Florida
| | - Kenneth Y. Tsai
- Department of Anatomic Pathology and Tumor Biology, Moffitt Cancer Center, Wesley Chapel, Florida
| | | | - Jonathan S. Zager
- USF Health, Morsani College of Medicine, Tampa, Florida,Department of Cutaneous Oncology, Moffitt Cancer Center, Wesley Chapel, Florida
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Aigner K, Vashist YK, Selak E, Gailhofer S, Aigner KR. Efficacy of Regional Chemotherapy Approach in Peritoneal Metastatic Gastric Cancer. J Clin Med 2021; 10:jcm10225322. [PMID: 34830604 PMCID: PMC8624731 DOI: 10.3390/jcm10225322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/04/2021] [Accepted: 11/13/2021] [Indexed: 12/22/2022] Open
Abstract
Peritoneal spread is frequent in gastric cancer (GC) and a palliative condition. After failure to systemic chemotherapy (sCTx) remaining therapeutic options are very limited. We evaluated the feasibility and efficacy of locoregional chemotherapy (RegCTx) in peritoneal metastatic GC. In total, 38 (23 male and 15 female) patients with peritoneal metastatic GC after failure of previous sCTx and unresectable disease were enrolled in this study. Using the hypoxic abdominal stop-flow perfusion, upper abdominal perfusion and intraarterial infusion technique in total 114 cycles with Cisplatin, Adriamycin and Mitomycin C were applied. No significant procedure related toxicity was noticed- especially no Grade 3 or 4 toxicity occurred. With the RegCTx approach a median overall survival of 17.4 months was achieved. Patients who had undergone previously resection of the GC the median overall survival was even better with 23.5 months. RegCTx is a promising, safe and efficient approach in diffuse metastatic GC. The evaluation of RegCTx in the setting of multimodal treatment approach at less advanced stages is also warranted.
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Campbell R, Shim H, Choi J, Park M, Byun E, Islam S, Song SH, Kim A. Implantable Cisplatin Synthesis Microdevice for Regional Chemotherapy. Adv Healthc Mater 2021; 10:e2001582. [PMID: 33326178 DOI: 10.1002/adhm.202001582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Cisplatin, the first platinum chemotherapy agent to obtain Food and Drug Administration (FDA) approval in 1978, is widely used for a number of cancers. However, the painful side effects stemming from systemic delivery are the inevitable limitation of cisplatin. A possible solution is regional chemotherapy using various drug delivery systems, which reduces the systemic toxicity and increases drug accumulation in the tumor. In this paper, a rice-grain sized, ultrasonically powered, and implantable microdevice that can synthesize cisplatin in situ is presented. The microdevice produces 0.7 mg of cisplatin within 1 h under ultrasonic irradiation (400 mW cm-2 ). The effect of the microdevice-synthesized cisplatin is evaluated using in vitro murine breast cancer cells and ex vivo liver tissue. The results suggest that cytotoxic activities of the microdevice-mediated cisplatin delivery are significantly higher in both in vitro and ex vivo experiments. Overall, the proposed cisplatin synthesis microdevice represents a strong alternative treatment option for regional chemotherapy.
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Affiliation(s)
- Rebecca Campbell
- Department of Electrical and Computer Engineering Temple University Philadelphia PA 19122 USA
| | - Hyunji Shim
- Department of Electronics Engineering Sookmyung Women's University Seoul 04310 Republic of Korea
| | - Je Choi
- Department of Electrical and Computer Engineering Temple University Philadelphia PA 19122 USA
| | - Moonchul Park
- Department of Electrical and Computer Engineering Temple University Philadelphia PA 19122 USA
| | - Eunjeong Byun
- Department of Electronics Engineering Sookmyung Women's University Seoul 04310 Republic of Korea
| | - Sayemul Islam
- Department of Electrical and Computer Engineering Temple University Philadelphia PA 19122 USA
| | - Seung Hyun Song
- Department of Electronics Engineering Sookmyung Women's University Seoul 04310 Republic of Korea
| | - Albert Kim
- Department of Electrical and Computer Engineering Temple University Philadelphia PA 19122 USA
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Abstract
INTRODUCTION Since 1968, inhaled chemotherapy has been evaluated and has shown promising results up to phase II but has not yet reached the market. This is due to technological and clinical challenges that require to be overcome with the aim of optimizing the efficacy and the tolerance of drug to re-open new developments in this field. Moreover, recent changes in the therapeutic standard of care for treating the patient with lung cancer also open new opportunities to combine inhaled chemotherapy with standard treatments. AREAS COVERED Clinical and technological concerns are highlighted from the reported clinical trials made with inhaled cytotoxic chemotherapies. This work then focuses on new pharmaceutical developments using dry powder inhalers as inhalation devices and on formulation strategies based on controlled drug release and with sustained lung retention or based on nanomedicine. Finally, new clinical strategies are described in regard to the impact of the immunotherapy on the patient's standard of care. EXPERT OPINION The choice of the drug, inhalation device, and formulation strategy as well as the position of inhaled chemotherapy in the patient's clinical care are crucial factors in optimizing local tolerance and efficacy as well as in its scalability and applicability in clinical practice.
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Affiliation(s)
- Nathalie Wauthoz
- Unit of Pharmaceutics and Biopharmaceutics, Université Libre De Bruxelles, Brussels, Belgium
| | - Rémi Rosière
- Unit of Pharmaceutics and Biopharmaceutics, Université Libre De Bruxelles, Brussels, Belgium
| | - Karim Amighi
- Unit of Pharmaceutics and Biopharmaceutics, Université Libre De Bruxelles, Brussels, Belgium
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Abstract
Introduction Therapy of malignant pleural mesothelioma and especially the adequate role of surgery in this context remain the subject of controversial discussions. Radical surgery in particular, which is associated with substantial morbidity, failed to translate into a definite survival advantage. We report on interim results of an ongoing Phase II study of regional chemotherapy in terms of isolated thoracic perfusion with chemofiltration (ITP-F). Patients and methods Twenty-eight patients (25 male, 3 female, mean age 63.4 years) with advanced pleural mesothelioma were included in this study. Isolation of the chest was achieved by insertion of a venous and arterial stop-flow balloon catheter via a femoral access. The aorta and inferior vena cava were blocked at the level of the diaphragm and the upper arms were blocked by pneumatic cuffs. Chemotherapy, consisting of 60 mg/m2 cisplatin and 15 mg/m2 mitoxantrone, was administered directly into the aorta. The isolated circuit was maintained for 15 minutes followed bŷ45 minutes of chemofiltration with a hemoprocessor until 5 L of filtrate were reached. The endpoints of the study were overall survival and quality of life (QoL). Results Out of 28 patients enrolled in the study, 5 had prior surgeries, 10 patients had systemic chemotherapy, and 5 patients additional irradiation. In all patients in restaging, clinical progress was noted. In all, 162 cycles were administered. Due to chemofiltration, toxicity was within tolerable limits, revealing World Health Organization grade I leucopenia and thrombocytopenia in 9 patients and mucositis grade I in 6 patients. The major surgical complication was inguinal lymphatic fistula in 40% of the cases. Gastrointestinal toxicity and/or neurotoxicity were never observed. One-year survival was 49%, 2-year and 3-year survival was 31%, and 5-year survival was 18%. Median overall survival was 12 months and progression-free survival 9 months. Conclusion ITP-F for patients with advanced pleural mesothelioma, progressive after standard therapies, is an effective and well-tolerated treatment modality, offering comparably long survival data at a good QoL.
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Affiliation(s)
| | - Emir Selak
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany
| | - Sabine Gailhofer
- Department of Surgical Oncology, Medias Klinikum, Burghausen, Germany
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Abstract
Malignant peritoneal mesothelioma (MPM) is a rare neoplastic condition that arises, usually diffusely, from the serosal membranes of the abdominal cavity. MPM represents about 7% to 10% of all mesothelioma diagnoses and this translates into approximately 800 cases per year in the United States. The disease has variable tumor biology but progression, when it occurs, is almost always within the abdominal cavity. Although many patients can be successfully treated at initial presentation, the disease is almost always fatal in time. It afflicts men and women almost equally and the median age at presentation is 50 years. The diagnosis is made when a diffuse malignant process within the abdominal cavity is observed and a tissue sample reveals the characteristic histopathology and immunohistochemical profile of mesothelioma. Initial staging is usually via a cross sectional imaging study of the abdomen and pelvis making sure that the lower thorax is also assessed. If the disease burden and distribution is favorable then operative exploration, cytoreduction, and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered first line treatment in selected patients. Systemic pemetrexed and cisplatin (or gemcitabine) have modest response rates that are of limited duration. Research advances with novel systemic or intraperitoneal agents hold promise.
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Affiliation(s)
- H Richard Alexander
- 1 Department of Surgery, 2 Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Allen P Burke
- 1 Department of Surgery, 2 Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Paulsen IF, Chakera AH, Schmidt G, Drejøe J, Klyver H, Oturai PS, Hesse B, Drzewiecki K, Mortensen J. Radionuclide leakage monitoring during hyperthermic isolated limb perfusion for treatment of local melanoma metastasis in an extremity. Clin Physiol Funct Imaging 2014; 35:301-5. [PMID: 24902761 DOI: 10.1111/cpf.12164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 04/24/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The aim is to describe the importance of leakage monitoring in hyperthermic isolated limb perfusion (ILP). It is generally recommended that leakage should not exceed 10% because of risk of systemic toxicity. MATERIAL AND METHODS Data retrieved by retrospective analysis of 131 perfusions performed in 115 consecutive patients (77 women and 38 men; median age 66 years) with recurrent and/or clinically apparent, cutaneous or subcutaneous melanoma metastases in an extremity. Radionuclide monitoring was performed with continuous, precordial count rate determinations of an intravascular (99m) Tc-labelled tracer infused into the isolated limb circulation. RESULTS One hundred and sixteen of 131 procedures were completed. In 13%, a leakage of ≥10% was detected; in 6% (n = 8), the cytotoxic drug was never infused because of constant leakage; in 7% (n = 9), leakage ≥10% was measured during the perfusion resulting in two perfusions being terminated before 30 min, 5 perfusions were considered completed though with early termination (after 30 min, before 60 min), and 2 fully completed. No patients had systemic toxicity requiring treatment, whereas considerable or serious local toxicity were observed in 14%. Three of the patients with leakage ≥10% were successfully treated in a repeated procedure. CONCLUSION Leakage monitoring using a threshold of 10% during ILP saves the patients from systemic toxicity, however, at the expense of early termination or cancellation of ILP treatment in a few patients and repeated ILP procedures in some.
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Affiliation(s)
- Ida F Paulsen
- Clinic for Plastic Surgery, Burn Treatment and Breast Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Grethe Schmidt
- Clinic for Plastic Surgery, Burn Treatment and Breast Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jennifer Drejøe
- Clinic for Plastic Surgery, Burn Treatment and Breast Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Helle Klyver
- Clinic for Plastic Surgery, Burn Treatment and Breast Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Peter S Oturai
- Clinic for Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Birger Hesse
- Clinic for Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Krystztof Drzewiecki
- Clinic for Plastic Surgery, Burn Treatment and Breast Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jann Mortensen
- Clinic for Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Denmark
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Valentino J, Helton WB, Unnikrishnan R, Kudrimoti M, Arnold SM, Gal TJ. Microvascular reconstruction after intra-arterial chemotherapy with concomitant radiation. Otolaryngol Head Neck Surg 2013; 149:541-6. [PMID: 23894148 DOI: 10.1177/0194599813497923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE While the success of microvascular reconstruction is well established, even in the setting of prior radiotherapy, the outcomes in the setting of prior chemoradiation are less well documented. We present our experience with microvascular reconstruction in a unique cohort of patients previously treated with concomitant hyperfractionated radiation and intra-arterial chemotherapy (HYPERRADPLAT). Despite the observation in prior studies of minimal vessel damage in this setting, the hypothesis of this study is that in the late setting of most salvage surgical therapy, either for recurrence or osteoradionecrosis, a different, progressive level of vessel injury may be encountered. STUDY DESIGN Case series with chart review. SETTING Tertiary referral academic medical center practice. SUBJECTS AND METHODS Eighty-four patients received primary treatment for advanced head and neck squamous cell carcinoma with HYPERRADPLAT. Of these, 8 patients (10%) underwent free tissue transfer reconstruction and a total of 11 free flaps. RESULTS Wound breakdown, fistula, or both occurred postoperatively in 50% (4/8) of these patients. No complications of the venous anastomoses occurred. Fifty percent (4/8) of patients required return to surgery for arterial failure due to thrombosis of the anastomosis. Two cases of these flaps could not be salvaged. CONCLUSION Microvascular reconstruction following HYPERRADPLAT appears to result in a high number of arterial related complications. This experience implies an important delayed treatment effect of HYPERRADPLAT occurs upon recipient arteries. The manner in which this effect may occur in recipient arteries in the setting of more conventional chemoradiation requires further study.
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Affiliation(s)
- Joseph Valentino
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Duprat Neto JP, Oliveira F, Bertolli E, Molina AS, Nishinari K, Facure L, Fregnani JH. Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity. Clinics (Sao Paulo) 2012; 67:237-41. [PMID: 22473404 PMCID: PMC3297032 DOI: 10.6061/clinics/2012(03)06] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 11/23/2011] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve. METHODS We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables. RESULTS Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204). CONCLUSION It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period.
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Thompson JF, Siebert GA, Anissimov YG, Smithers BM, Doubrovsky A, Anderson CD, Roberts MS. Microdialysis and response during regional chemotherapy by isolated limb infusion of melphalan for limb malignancies. Br J Cancer 2001; 85:157-65. [PMID: 11461070 PMCID: PMC2364039 DOI: 10.1054/bjoc.2001.1902] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This study sought to use a microdialysis technique to relate clinical and biochemical responses to the time course of melphalan concentrations in the subcutaneous interstitial space and in tumour tissue (melanoma, malignant fibrous histiocytoma, Merkel cell tumour and osteosarcoma) in patients undergoing regional chemotherapy by Isolated Limb Infusion (ILI). 19 patients undergoing ILI for treatment of various limb malignancies were monitored for intra-operative melphalan concentrations in plasma and, using microdialysis, in subcutaneous and tumour tissues. Peak and mean concentrations of melphalan were significantly higher in plasma than in subcutaneous or tumour microdialysate. There was no significant difference between drug peak and mean concentrations in interstitial and tumour tissue, indicating that there was no preferential uptake of melphalan into the tumours. The time course of melphalan in the microdialysate could be described by a pharmacokinetic model which assumed melphalan distributed from the plasma into the interstitial space. The model also accounted for the vascular dispersion of melphalan in the limb. Tumour response in the whole group to treatment was partial response: 53.8% (n = 7); complete response: 33.3% (n = 5); no response: 6.7% (n = 1). There was a significant association between tumour response and melphalan concentrations measured over time in subcutaneous microdialysate (P< 0.01). No significant relationship existed between the severity of toxic reactions in the limb or peak plasma creatine phosphokinase levels and peak melphalan microdialysate or plasma concentrations. It is concluded that microdialysis is a technique well suited for measuring concentrations of cytotoxic drug during ILI. The possibility of predicting actual concentrations of cytotoxic drug in the limb during ILI using our model opens an opportunity for improved drug dose calculation. The combination of predicting tissue concentrations and monitoring in microdialysate of subcutaneous tissue could help optimise ILI with regard to post-operative limb morbidity and tumour response.
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Affiliation(s)
- J F Thompson
- Department of Surgery, University of Sydney and Sydney Melanoma Unit, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
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Wu ZQ, Fan J, Qiu SJ, Zhou J, Tang ZY. Value of postoperative hepatic regional chemotherapy in prevention of recurrence after radical resection of primary liver cancer. World J Gastroenterol 2000; 6:131-133. [PMID: 11819541 PMCID: PMC4723581 DOI: 10.3748/wjg.v6.i1.131] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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