Advanced Extremity Melanoma Research Articles

Evaluation of the efficacy and toxicity of upper extremity isolated limb infusion chemotherapy for melanoma: An Australian multi-center study

BackgroundIsolated limb infusion (ILI) is a minimally invasive treatment for patients with locally advanced extremity melanoma. Most studies combine results of upper-limb ILI (UL-ILI) and lower-limb ILI (LL-ILI), leaving UL-ILIs relatively underreported as LL-ILIs comprise the vast majority in these reports. However, differences between the two procedures may be clinically important. The aim of this study was to evaluate the efficacy and toxicity of UL-ILI in an Australian multi-center setting. Patients and methods316 ILI procedures for melanoma performed between 1992 and 2008 in five Australian institutions were analyzed. In all institutions melphalan (±actinomycin D) was circulated in the isolated limb for 20–30 min. ResultsBaseline patient characteristics for UL-ILI (n = 27) and LL-ILI (n = 289) were similar, except that more men underwent UL-ILI (66% vs. 38%; p = 0.007) and disease in LL-ILI was mostly located on the distal limb (p = 0.02). Median tourniquet times were shorter for UL-ILI (38 vs. 48 min; p = 0.04) and UL-ILI patients experienced less limb toxicity (Grade III/IV in 24% vs. 31%; p = 0.01). Complete response (CR) rates were similar: 33% after LL-ILI (p = 0.70), 30% after UL-ILI, while overall response (OR) rates were higher after LL-ILI: (76%) than UL-ILI (59%; p = 0.05). No difference in survival was seen. ConclusionsUL-ILI is safe to perform and effective, resulting in low limb toxicity. CR rates were similar to those for LL-ILI, but OR rates were lower for UL-ILI. It may be possible to improve OR rates achieved by UL-ILI by optimizing perioperative factors, while maintaining low toxicity.

Safety and Efficacy of Isolated Limb Infusion Chemotherapy for Advanced Locoregional Melanoma in Elderly Patients: An Australian Multicenter Study.

Isolated limb infusion (ILI) offers a minimally invasive treatment option for locally advanced extremity melanoma. The aim of the current study was to evaluate the safety and efficacy of ILI in elderly patients in an Australian multicenter setting. The results of 316 first ILI procedures, performed between 1992 and 2008 in five Australian institutions, were identified and analyzed, with the main focus on elderly patients (≥75years of age). All institutions used the same protocol: melphalan was circulated in the isolated limb for 20-30min (±actinomycin D), and toxicity, responses, and survival were recorded. Characteristics of patients aged ≥75years (n=148) were similar to those aged <75years (n=168), except that older patients had more melanoma deposits (median 4 vs. 5; p=0.035) and lower limb volumes (5.4 vs. 6.5L; p=0.001). Median drug circulation times were lower in the older group (21 vs. 24min; p=0.04), and older patients experienced less limb toxicity (grade III/IV in 22 and 37% of patients, respectively; p=0.003). A complete response (CR) was seen in 27% of patients aged ≥75years and in 38% of patients aged <75years (p=0.06), while overall response rates were 72 and 77%, respectively (p=0.30). No difference in survival was seen (p=0.69). The ILI technique proved safe and effective in elderly patients. When present, toxicity was localized, and lower compared with younger patients, possibly due to shorter drug circulation times. CR rates were higher in younger patients, although not significantly, while overall response and survival were equal. Optimization of perioperative factors in elderly patients may allow response rates to be raised further, while maintaining low toxicity.

Oncolytic vaccinia virus combined with radiotherapy induces apoptotic cell death in sarcoma cells by down-regulating the inhibitors of apoptosis.

Advanced extremity melanoma and sarcoma present a significant therapeutic challenge, requiring multimodality therapy to treat or even palliate disease. These aggressive tumours are relatively chemo-resistant, therefore new treatment approaches are urgently required. We have previously reported on the efficacy of oncolytic virotherapy (OV) delivered by isolated limb perfusion. In this report, we have improved therapeutic outcomes by combining OV with radiotherapy. In vitro, the combination of oncolytic vaccinia virus (GLV-1h68) and radiotherapy demonstrated synergistic cytotoxicity. This effect was not due to increased viral replication, but mediated through induction of intrinsic apoptosis. GLV-1h68 therapy downregulated the anti-apoptotic BCL-2 proteins (MCL-1 and BCL-XL) and the downstream inhibitors of apoptosis, resulting in cleavage of effector caspases 3 and 7. In an in vivo ILP model, the combination of OV and radiotherapy significantly delayed tumour growth and prolonged survival compared to single agent therapy. These data suggest that the virally-mediated down-regulation of anti-apoptotic proteins may increase the sensitivity of tumour cells to the cytotoxic effects of ionizing radiation. Oncolytic virotherapy represents an exciting candidate for clinical development when delivered by ILP. Its ability to overcome anti-apoptotic signals within tumour cells points the way to further development in combination with conventional anti-cancer therapies.

Australian Multicenter Study of Isolated Limb Infusion for Melanoma.

Isolated limb infusion (ILI) offers a less invasive alternative to isolated limb perfusion (ILP) for the treatment of locally advanced extremity melanoma. In Australia, ILI has essentially completely replaced ILP. The aim of this study was to collect and evaluate the results of ILI in an Australian multicenter setting. The results of 316 first ILI procedures, performed between 1992 and 2008 in five Australian institutions, were collectively analyzed, with all five institutions using the same protocol. Melphalan was circulated in the isolated limb for 20-30min (±actinomycin D). Response was determined using the World Health Organization criteria, and limb toxicity was assessed using the Wieberdink scale. The median patient age was 74years (range 28-100) and 59% of patients were female. Overall response rate was 75% (complete response [CR] 33%; partial response 42%). Stable disease was seen in 18% of patients and progressive disease in 7%. Wieberdink grade III or higher was seen in 30% of the cases. No toxicity-related amputations occurred, and median survival was 44months. In patients with a CR, median survival was 80months (p=0.014). On multivariate analysis, Breslow thickness, lower-limb ILI, and a procedure performed at the Melanoma Institute Australia remained significant predictors for response, although not for survival. This Australian multicenter study of ILI is the largest reported to date. ILI is a useful technique that can be safely and effectively performed across tertiary referral centers for the successful management of advanced extremity melanoma. Increased optimization of perioperative factors might allow response rates to be raised further, while maintaining acceptable toxicity.

Immunotherapy Following Regional Chemotherapy Treatment of Advanced Extremity Melanoma

Following regional chemotherapy (RC) for melanoma, approximately 75% of patients will progress. The role of immunotherapy after RC has not been well established. A prospective, single-institution database of 243 patients with in-transit melanoma (1995-2013) was queried for patients who had progression of disease after RC with melphalan and subsequently received systemic immunotherapy. Fifteen patients received IL-2 only, 12 received ipilimumab only, and 6 received IL-2 followed by ipilimumab. Fisher's exact test was used to determine if there was a difference in number of complete responders after immunotherapy. With IL-2 alone, all patients progressed. After ipilimumab alone, three patients had a complete response and nine had progressive disease. Six additional patients received IL-2 first then ipilimumab. All six progressed on IL-2 but three went on to have a complete response to ipilimumab while three progressed. The use of ipilimumab at any time in patients who progressed after RC was associated with higher rate of complete response compared to use of IL-2 alone (33 vs. 0%; p=0.021). Patients with progression after regional therapy for melanoma may benefit from immunologic therapy. In this group of patients, immune checkpoint blockade with ipilimumab has a higher complete response rate than T cell stimulation with IL-2, with no complete responders in the IL-2 only group. Furthermore, the complete response rate for ipilimumab in our cohort is higher than reported response rates in the literature for ipilimumab alone, suggesting that the effects of immunotherapy may be bolstered by previous regional treatment.

Src Family Kinase Inhibition as a Novel Strategy to Augment Melphalan-Based Regional Chemotherapy of Advanced Extremity Melanoma

Src kinase inhibition has been shown to augment the efficacy of chemotherapy. Dasatinib, a dual Src/Abl kinase inhibitor approved for the treatment of CML, is under investigation as monotherapy for tumors with abnormal Src signaling, such as melanoma. The goal of this study was to determine if Src kinase inhibition using dasatinib could enhance the efficacy of regionally administered melphalan in advanced extremity melanoma. The mutational status of c-kit and patterns of gene expression predictive of dysregulated Src kinase signaling were evaluated in a panel of 26 human melanoma cell lines. The effectiveness of dasatinib was measured by quantifying protein expression and activation of Src kinase, focal adhesion kinase, and Crk-associated substrate (p130(CAS)), in conjunction with in vitro cell viability assays using seven melanoma cell lines. Utilizing a rat model of regional chemotherapy, we evaluated the effectiveness of systemic dasatinib in conjunction with regional melphalan against the human melanoma cell line, DM443, grown as a xenograft. Only the WM3211 cell line harbored a c-kit mutation. Significant correlation was observed between Src-predicted dysregulation by gene expression and sensitivity to dasatinib in vitro. Tumor doubling time for DM443 xenografts treated with systemic dasatinib in combination with regional melphalan (44.8 days) was significantly longer (p = 0.007) than either dasatinib (21.3 days) or melphalan alone (24.7 days). Systemic dasatinib prior to melphalan-based regional chemotherapy markedly improves the efficacy of this alkylating agent in this melanoma xenograft model. Validation of this concept should be considered in the context of a regional therapy clinical trial.

Resection of Residual Disease after Isolated Limb Infusion (ILI) Is Equivalent to a Complete Response after ILI-Alone in Advanced Extremity Melanoma

Isolated limb infusion (ILI) is a limb-preserving treatment for in-transit extremity melanoma. The benefit of resecting residual disease after ILI is unclear. A multi-institutional experience was analyzed comparing patients who underwent ILI plus resection of residual disease (ILI + RES) versus ILI-alone. A total of 176 patients were included, 154 with ILI-alone and 22 with ILI + RES. There were no differences between the groups with respect to gender, age, extremity affected, or time from diagnosis to ILI. All surgical resections were performed as an outpatient procedure, separate from the ILI. Within the ILI + RES group, 15 (68%) had a partial response (PR), 2 (9%) stable disease (SD), and 5 (23%) progressive disease (PD). The ILI-alone group had 52 (34%) CR, 30 (19%) PR, 15 (10%) SD, and 46 (30%) PD. Eleven (7%) ILI-alone patients did not have 3-month response available for review. Evaluating overall survival (OS) from date of ILI, the ILI-alone group had a median OS of 30.9 months, whereas the ILI + RES group had not reached median OS, p = 0.304. Although the ILI + RES group had a slightly longer disease-free survival (DFS) compared to those with a CR after ILI-alone (12.4 vs. 9.6), this was not statistically significant, p = 0.978. Within the ILI + RES group, those with an initial PR after ILI had improved DFS versus those with SD or PD after ILI, p < 0.0001. Resection of residual disease after ILI offers a DFS and OS similar to those who have a CR after ILI-alone. It may offer a treatment strategy that benefits patients undergoing ILI.

Plasma Cytokine Analysis in Patients with Advanced Extremity Melanoma Undergoing Isolated Limb Infusion

Preprocedure clinical and pathologic factors have failed to consistently differentiate complete response (CR) from progressive disease (PD) in patients after isolated limb infusion (ILI) with melphalan for unresectable in-transit extremity melanoma. Multiplex immunobead assay technology (Milliplex MAP Human Cytokine/Chemokine Magnetic Bead Panel, Millipore Corp., Billerica, MA; and Magpix analytical test instrument, Luminex Corp., Austin, TX) was performed on pre-ILI plasma to determine concentrations of selected cytokines (MIP-1α, IL-1Rα, IP-10, IL-1β, IL-1α, MCP-1, IL-6, IL-17, EGF, IL-12p40, VEGF, GM-CSF, and MIP-1β) on a subset of patients (n=180) who experienced CR (n=23) or PD (n=24) after ILI. Plasma from normal donors (n=12) was also evaluated. Of 180 ILIs performed, 28 % (95 % confidence interval 22-35, n=50) experienced a CR, 14 % (n=25) experienced a partial response, 11 % (n=21) had stable disease, 34 % (n=61) had PD, and 13 % (n=23) were not evaluable for response. Tumor characteristics and pharmacokinetics appeared similar between CR (n=23) and PD (n=24) patients who underwent cytokine analysis. Although there were no differences in cytokine levels between CR and PD patients, there were differences between the melanoma patients and controls. MIP-1α, IL-1Rα, IL-1β, IL-1α, IL-17, EGF, IL-12p40, VEGF, GM-CSF, and MIP-1β were significantly higher in normal controls compared to melanoma patients, while IP-10 was lower (p<0.001) in controls compared to melanoma patients. Patients with unresectable in-transit melanoma appear to have markedly decreased levels of immune activating cytokines compared to normal healthy controls. This further supports a potential role for immune-targeted therapies and immune monitoring in patients with regionally advanced melanoma.

Bevacizumab-Induced Alterations in Vascular Permeability and Drug Delivery: A Novel Approach to Augment Regional Chemotherapy for In-Transit Melanoma

To investigate whether the systemically administered anti-VEGF monoclonal antibody bevacizumab could improve regional chemotherapy treatment of advanced extremity melanoma by enhancing delivery and tumor uptake of regionally infused melphalan (LPAM). After treatment with systemic bevacizumab or saline, changes in vascular permeability were determined by spectrophotometric analysis of tumors infused with Evan's blue dye. Changes in vascular structure and tumor hemoglobin-oxygen saturation HbO(2) were determined by intravital microscopy and diffuse reflectance spectroscopy, respectively. Rats bearing the low-VEGF secreting DM738 and the high-VEGF secreting DM443 melanoma xenografts underwent isolated limb infusion (ILI) with melphalan (LPAM) or saline via the femoral vessels. The effect of bevacizumab on terminal drug delivery was determined by immunohistochemical analysis of LPAM-DNA adducts in tumor tissues. Single-dose bevacizumab given three days before ILI with LPAM significantly decreased vascular permeability (50.3% in DM443, P < 0.01 and 35% in DM738, P < 0.01) and interstitial fluid pressure (57% in DM443, P < 0.01 and 50% in DM738, P = 0.01). HbO(2) decreased from baseline in mice following treatment with bevacizumab. Systemic bevacizumab significantly enhanced tumor response to ILI with LPAM in two melanoma xenografts, DM443 and DM738, increasing quadrupling time 37% and 113%, respectively (P = 0.03). Immunohistochemical analyses of tumor specimens showed that pretreatment with systemic bevacizumab markedly increased LPAM-DNA adduct formation. Systemic treatment with bevacizumab before regional chemotherapy increases delivery of LPAM to tumor cells and represents a novel way to augment response to regional therapy for advanced extremity melanoma.

Isolated limb perfusion with the tumor‐targeting human monoclonal antibody–cytokine fusion protein L19‐TNF plus melphalan and mild hyperthermia in patients with locally advanced extremity melanoma

L19-TNF is a tumor-targeting immunocytokine composed of the human L19 antibody binding to extra domain B (ED-B) of fibronectin of newly formed blood vessels, and of human TNF. This exploratory trial evaluates safety and clinical activity of L19-TNF plus melphalan-containing isolated limb perfusion (ILP) in extremity melanoma patients. Seven and 10 patients received 325 µg and 650 µg of L19-TNF, respectively, during the ILP. Patients were studied for safety, tolerability, and clinical activity of this experimental L19-TNF ILP procedure. Non-hematologic toxicity of L19-TNF ILP was very low, but severe myelosuppression was seen in four patients. Although L19-TNF was administered at a TNF-equivalent dose of only 3.13 and 6.25% of the approved TNF (Beromun®) dose of 4 mg, L19-TNF ILP induced objective responses in 86 and 89% of patients, respectively, including a complete response (CR) in 5/10 patients treated with L19-TNF ILP at 650 µg that was durable at 12 months in four patients. No CR was seen at 325 µg of L19-TNF. ILP with L19-TNF had a favorable safety and a promising activity profile at a dose of 650 µg of L19-TNF, supporting the exploration of higher L19-TNF doses and a Phase II trial comparing L19-TNF ILP with standard melphalan-containing ILP.

Current Trends in Regional Therapy for Melanoma: Lessons Learned from 225 Regional Chemotherapy Treatments between 1995 and 2010 at a Single Institution

Hyperthermic isolated limb perfusion (HILP) and isolated limb infusion (ILI) are used to manage advanced extremity melanoma, but no consensus exists as to which treatment is preferable and how to monitor patients post-treatment. Using a prospectively maintained database, we reviewed our experience with melphalan-based HILP (which included 62 first-time and 10 second-time) and ILI (which included 126 first-time and 18 second-time) procedures performed in 188 patients. PET/CT was obtained 3 months postregional treatment for 1 year and then every 6 months thereafter. Overall response rate (complete response [CR] + partial response) of HILP was 81% (80% CI, 73-87%), and overall response rate from ILI was 43% (80% CI, 37-49%) for first-time procedures only. HILP had a CR rate of 55% with a median duration of 32 months, and ILI had a CR rate of 30% with median duration of 24 months. Patients who experienced a regional recurrence after initial regional treatment were more likely to achieve a CR after repeat HILP (50%, n = 10) compared with repeat ILI (28%, n = 18). Although the spectrum of toxicity was similar for ILI and HILP, the likelihood of rare catastrophic complication of limb loss was greater with HILP (2 of 62) than ILI (0 of 122). PET/CT was effective for surveillance after regional therapy to identify regional nodal and pulmonary disease that was not clinically evident, but often amenable to surgical resection (25 of 49; 51% of cases). In contrast, PET/CT was not effective at predicting complete response to treatment with an accuracy of only 50%. In the largest single-institution regional therapy series reported to date, we found that although ILI is effective and well-tolerated, HILP is a more definitive way to control advanced disease.

Standardizing Regional Therapy: Developing a Consensus on Optimal Utilization of Regional Chemotherapy Treatments in Melanoma

In this issue of Annals of Surgical Oncology, Huismans et al. describe their extensive experience with isolated limb infusion (ILI) in the treatment of 185 patients with intransit melanoma over a 15-year period (1992–2007). The group initially described and introduced the technique of ILI in the early 1990s as a minimally invasive alternative to hyperthermic isolated limb perfusion (HILP) whereby placement of percutaneously placed catheters allows delivery of regional chemotherapy (usually melphalan plus dactinomycin) to an isolated limb. Because of the safety and efficacy of the treatment as well as disappointing results of a multicenter HILP trial, ILI is now utilized at several major U.S. centers and has been demonstrated to be a well-tolerated treatment alternative for patients with advanced extremity melanoma. As with any new technique, evidenceand observationbased modifications have been applied to ILI with the goal of maximizing response in conjunction with minimizing toxicity from the procedure. In this study, the authors compare outcomes after initial ILI from their early experience (1992–1999) in 94 patients to their subsequent, or late, experience in 91 patients after several modifications were incorporated into the ILI protocol (2000–2007). The authors conclude that the study’s results support the use of the modifications, although no significant changes in response or toxicity were seen with the modifications. Despite the lack of change, the underlying response rates over the entire period still support a role for ILI as a safe treatment in the armamentarium of therapeutic options for patients with advanced extremity melanoma. There are many aspects of ILI in need of standardization, as is shown in Table 1. Some of these issues revolve around the following: optimal method of drug dosing, technical aspects of performing the ILI procedure, and how best to define toxicity and response after the procedure. Currently, theoretical evidence suggests that the hypoxia and acidosis of ILI may be beneficial by optimizing how melphalan is metabolized and leads to an antitumor response. Hyperthermia is also thought to improve clinical response induced by alkylating agents like melphalan, but within a narrow therapeutic window such that excessive heat may increase the toxicity of melphalan to normal tissue. Finally, papaverine is thought to improve response by maximizing subcutaneous vasodilation and thereby improving melphalan delivery to the tumor, as was suggested in a U.S. multicenter analysis. In the current study, modifications to the ILI protocol included increasing drug circulation time from 20 to 30 min, the use of a hot air blanket cocoon and a radiant overhead heater to achieve more efficient limb warming, use of a higher melphalan dose (5–7 mg/l for early vs. 7–8 mg/l for late), and routine use of papaverine. These changes did result in some not unexpected measurable differences between the early and late groups, including median difference in PCO2 in the limb blood between the start and the end of the procedure, which increased from 8.8 to 14.7 mm Hg (P 0.0001), and an increase in peak subcutaneous temperature (37.7 vs. 38.7) (P 0.0001). These changes, however, did not appear to significantly affect overall tumor response or limb toxicity. There was no significant difference between complete or partial response (PR) in the early versus late group with a trend toward a lower complete response (CR) rate (36%, 38 Society of Surgical Oncology 2011

Prospective Multicenter Phase II Trial of Systemic ADH-1 in Combination With Melphalan via Isolated Limb Infusion in Patients With Advanced Extremity Melanoma

Isolated limb infusion (ILI) with melphalan (M-ILI) dosing corrected for ideal body weight (IBW) is a well-tolerated treatment for patients with in-transit melanoma with a 29% complete response rate. ADH-1 is a cyclic pentapeptide that disrupts N-cadherin adhesion complexes. In a preclinical animal model, systemic ADH-1 given with regional melphalan demonstrated synergistic antitumor activity, and in a phase I trial with M-ILI it had minimal toxicity. Patients with American Joint Committee on Cancer (AJCC) stage IIIB or IIIC extremity melanoma were treated with 4,000 mg of ADH-1, administered systemically on days 1 and 8, and with M-ILI corrected for IBW on day 1. Drug pharmacokinetics and N-cadherin immunohistochemical staining were performed on pretreatment tumor. The primary end point was response at 12 weeks determined by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. In all, 45 patients were enrolled over 15 months at four institutions. In-field responses included 17 patients with complete responses (CRs; 38%), 10 with partial responses (22%), six with stable disease (13%), eight with progressive disease (18%), and four (9%) who were not evaluable. Median duration of in-field response among the 17 CRs was 5 months, and median time to in-field progression among 41 evaluable patients was 4.6 months (95% CI, 4.0 to 7.1 months). N-cadherin was detected in 20 (69%) of 29 tumor samples. Grade 4 toxicities included creatinine phosphokinase increase (four patients), arterial injury (one), neutropenia (one), and pneumonitis (one). To the best of our knowledge, this phase II trial is the first prospective multicenter ILI trial and the first to incorporate a targeted agent in an attempt to augment antitumor responses to regional chemotherapy. Although targeting N-cadherin may improve melanoma sensitivity to chemotherapy, no difference in response to treatment was seen in this study.

A prospective multicenter phase II trial of systemic ADH-1 in combination with melphalan via isolated limb infusion (M-ILI) in patients with advanced extremity melanoma

9025^ Background: ILI with melphalan dosing corrected for ideal body weight (IBW) is a well tolerated treatment for patients with in-transit extremity melanoma with an approximate 30% CR and 44% overall response rate. ADH-1 is a cyclic pentapeptide that disrupts N-cadherin adhesion complexes. ADH-1 when given systemically in a preclinical model with regional melphalan demonstrated synergistic antitumor activity and had minimal toxicity in a Phase I trial with M-ILI. Methods:AJCC stage IIIB or IIIC extremity melanoma patients were treated with 4000mg of ADH-1 administered systemically on Day 1 and 8 in addition to standard dose M-ILI corrected for IBW on Day 1. Drug pK, and N-cadherin IHC staining were performed on pretreatment tumor from all patients. The primary endpoint was response at 12 weeks determined by modified RECIST. Results: 46 patients were enrolled over 15 months at 4 institutions. Thirty-four patients are presently evaluable for 12 week response. In field responses include 14 CRs (41.2%%), 9 PRs (26.5%), 5 SDs (14.7%), and 6 PDs (17.6%). The OR rate was 67.7% and at a median follow-up of 30 weeks, 8 patients have sustained CRs over 6 months. Of 34 patients, 9 have developed disease outside the region of infusion (median time to progression 12 weeks) at median follow-up 36 weeks. N-cadherin was detected in 20 of 25 (80%) pretreatment tumor samples. Grade IV toxicities included CPK elevation (4), neutropenia (1), acute respiratory distress syndrome (1), pneumonitis (1), and pulmonary infiltrate (1). There were no limb losses or compartment syndromes. Conclusions:This study is not only the first prospective multi-center ILI trial but also the first ILI study to incorporate a targeted agent in an attempt to augment anti-tumor responses. The treatment was well tolerated with CR and OR rates that appear to be significantly improved from standard M-ILI alone. Targeting N-cadherin may represent a novel strategy for improving melanoma sensitivity to chemotherapeutic agents and warrants further investigation in a large randomized multi-center trial. [Table: see text] ASCO Conflict of Interest Policy and Exceptions In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting. For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings. For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

A Multi-Institutional Experience of Isolated Limb Infusion: Defining Response and Toxicity in the US

Isolated limb infusion (ILI) is a minimally invasive approach for treating in-transit extremity melanoma, with only two US single-center studies reported. Establishing response and toxicity to ILI as compared with hyperthermic isolated limb perfusion is important for optimizing future regional chemotherapeutic strategies in melanoma. Patient characteristics and procedural variables were collected retrospectively from 162 ILIs performed at 8 institutions (2001 to 2008) and compared using chi-square and Student's t-test. ILIs were performed for 30 minutes in patients with in-transit melanoma. Melphalan dose was corrected for ideal body weight (IBW) in 42% (n = 68) of procedures. Response was determined at 3 months by Response Evaluation Criteria in Solid Tumors; toxicity was assessed using the Wieberdink Limb Toxicity Scale. In 128 evaluable patients, complete response rate was 31%, partial response rate was 33%, and there was no response in 36% of patients. For all patients (n = 162), 36% had Wieberdink toxicity grade >or=3 with one toxicity-related amputation. On multivariate analysis, smaller limb volumes were associated with better overall response (p = 0.021). Use of papaverine in the circuit to achieve cutaneous vasodilation was associated with better response (p < 0.001) but higher risk of grade >or=3 toxicity (p = 0.001). Correction of melphalan dose for ideal body weight did not alter complete response (p = 0.345), but did lead to marked reduction in toxicity (p < 0.001). In the first multi-institutional analysis of ILI, a complete response rate of 31% was achieved with acceptable toxicity demonstrating this procedure to be a reasonable alternative to hyperthermic isolated limb perfusion in the management of advanced extremity melanoma.

Optimizing Regional Therapy for Melanoma

In this issue of Annals of Surgical Oncology, Kroon et al. describe the toxicity of isolated limb infusion with melphalan and actinomycin D in their experience with 185 patients over 15 years. This work continues to expand on the group’s notable contributions to regional chemotherapeutics for extremity melanoma including their initial description and utilization of isolated limb infusion (ILI) in the early 1990s. ILI has been explored as a minimally invasive alternative to hyperthermic isolated limb perfusion (HILP) for advanced extremity melanoma whereby placement of percutaneously placed catheters allows delivery of regional chemotherapy to an isolated limb. In the current study, ILI was found to be a safe alternative to HILP with less long-term morbidity than HILP. Previously, the Sydney Melanoma Group has reported response rates that are less than traditional response rates to HILP but certainly not outside the range of reported studies of HILP. Due to the safety and efficacy of the treatment as well as disappointing results of a multicenter HILP trial, ILI is now utilized at several major US centers and has been demonstrated to be a well-tolerated treatment alternative for patients with advanced extremity melanoma. As with any new regional treatment, the goal should be to define the procedure’s therapeutic index, which balances the treatment’s toxicity with its ability to control disease. Results of the current study suggest that there may be additional methods to reduce toxicity from ILI by altering modifiable factors which were found to be predictive of higher grades of toxicity. In addition this study’s results further support a role for ILI as a safe treatment in the armamentarium of therapeutic options for patients with advanced extremity melanoma. ILI is essentially a low-flow HILP performed by insertion of percutaneous catheters in the contralateral limb, in contrast to HILP where open surgical cannulation of the artery and vein are performed. ILI is performed attempting to achieve temperatures in the range 37–38.5 C and the blood is not oxygenated, leading to hypoxia and acidosis in the limb. The hypoxia and acidosis of ILI have previously been suggested to be beneficial in terms of response. In HILP, the catheters are connected to a cardiopulmonary bypass circuit which maintains physiologic oxygenation and pH. Temperatures in HILP generally range from 38.5 C to 40 C. While hyperthermia is well documented to increase the cytotoxicity induced by melphalan, excessive heat can also increase the toxicity of melphalan to normal tissue. ILI also differs from HILP in that ILI uses less melphalan per liter of extremity treated, circulates blood in an isolated extremity at a much slower rate than HILP (50– 100 mL/min in ILI versus 350–1,000 mL/min in HILP), and treatment is only for 30 min as compared with 60 min in HILP. These differences in the method of drug delivery are important to consider when comparing toxicity and response between the two procedures. In both ILI and HILP, there appears to be no relationship between significant limb toxicity and response to treatment. As such, minimizing toxicity from these procedures as discussed by the authors should be a goal of therapy. In the current study, high-grade limb toxicity (Wiberdink toxicity C grade 3) occurred in 42% (n = 77) of patients. Only 3% (n = 5) of patients had grade IV toxicities and there were no grade V toxicities (grade V toxicity is a toxicity necessitating amputation). Systemic toxicities were minimal and melphalan was detected in the systemic circulation in only 6% of patients. There were no systemic effects clearly associated with leakage of the small amounts of melphalan into the systemic circulation. Low circulating volumes seen in ILI were not related to increased limb toxicity. Overall toxicity from this study is in a similar range to the spectrum of toxicity after HILP. However, as the authors point out, long-term morbidity and severe toxicity (grade V) appear to be less with ILI. In a Society of Surgical Oncology 2009

Optimizing Melphalan Pharmacokinetics in Regional Melanoma Therapy: Does Correcting for Ideal Body Weight Alter Regional Response or Toxicity?

This study aims to determine what effect correcting melphalan dosing for ideal body weight (IBW) has on toxicity and response in isolated limb infusion (ILI) in patients with advanced extremity melanoma. This was an open observational study examining whether correcting the melphalan dose for IBW will influence response and toxicity in patients undergoing ILI for advanced extremity melanoma in 41 patients undergoing 42 procedures (13 without correction for IBW; and 29 with correction for IBW). Melphalan pharmacokinetics, limb toxicity, serologic toxicity, and response at 3 months were compared. The corrected group had a lower estimated limb volume (V (esti)) to melphalan volume at steady state (V (ss)) (P < .0001) ratio as well as lower incidence of grade > or =3 regional toxicity, serologic toxicity, and compartment syndrome (P = .0249, P = .027, P = .02). There was a positive correlation of V (esti)/V (ss) to toxicity (P = .0127, r = .382). No significant difference in response (P = .3609) between the groups was found, although there was a trend of association between V (esti)/V (ss) and response (P = .051, r = .3383). Correcting for IBW in ILI lowers toxicity without significantly altering response rates.

Regional Therapeutic Strategies in Melanoma: Not Just Local Disease Control, but an Opportunity to Develop Novel Therapeutic Strategies with Potential Implications for Systemic Therapy

Since the initial description of isolated regional chemotherapeutic perfusion therapy in 1958 by Creech et al., there have been surprisingly few modifications to this therapeutic intervention for advanced extremity melanoma over the last 50 years. In this issue of Annals of Surgical Oncology, Kroon et al. publish their manuscript entitled ‘‘Outcomes following isolated limb infusion for melanoma. A 14-year experience,’’ which summarizes the Sydney Melanoma Unit’s experience using melphalan and dactinomycin for regionally advanced melanoma administered through a minimally invasive regional chemotherapy procedure that they developed and initially described. The initial results and subsequent follow-up suggest that isolated limb infusion (ILI) may be a reasonable alternative to hyperthermic isolated limb perfusion (HILP) in the management of regionally advanced melanoma, in the form of intransit disease or local recurrence. However, as with any technique that is initially described in a large single-institutional fashion, care must be taken in defining the place for this treatment modality until its efficacy is tested on a wider scale. ILI differs from HILP in several ways. ILI involves isolating an extremity by placing catheters into the affected extremity percutaneously, in contrast to HILP, which requires an open surgical procedure. ILI has a very small circuit volume and generates flow rates of only 55–75 ml/min. HILP has not only a much larger circuit volume, which usually necessitates priming the circuit with one or two units of packed red blood cells, but is also able to generate much greater flow rates than ILI, usually in the 500– 700 ml/min range. The higher flow rates of HILP probably lead to a wider and more uniform distribution of melphalan throughout the isolated extremity. While both techniques use melphalan as the core chemotherapeutic agent, the melphalan dose used in ILI is approximately 25% lower than that used in HILP. Furthermore, the ILI technique circulates the melphalan for only 30 min, in contrast to HILP where the standard drug circulation time is 60 min. While both techniques involve the addition of hyperthermia, ILI usually initiates treatment at 37 C, while with HILP, the higher flow rates allow the limb to heat up faster and thus treatments are usually started at 38.5 C. The environment in which the melphalan circulates is also different between the two techniques. ILI circulates melphalan in a hypoxic, acidotic environment unlike HILP, where, using the bypass machine, the acid–base status of the treated limb and the oxygenation status are maintained in or above the physiologic range. Despite these marked differences, there is little clear scientific data to determine which technique delivers melphalan in a method that will optimize its effectiveness. As the procedure for ILI is more widely adopted for managing regionally advanced disease, it will be important to examine the results of other centers to determine how reproducible the results of the Sydney Melanoma Unit (SMU) will be. There are currently Published online August 19, 2008. Address correspondence and reprint requests to: Douglas Tyler, MD; E-mail: tyler002@acpub.duke.edu

Defining regional infusion treatment strategies for extremity melanoma: comparative analysis of melphalan and temozolomide as regional chemotherapeutic agents

Five different human melanoma xenografts were used in a xenograft model of extremity melanoma to evaluate the variability of tumor response to regionally administered melphalan or temozolomide and to determine if various components of pertinent drug resistance pathways for melphalan [glutathione S-transferase (GST)/glutathione] and temozolomide [O(6)-alkylguanine DNA alkyltranferase (AGT)/mismatch repair (MMR)] could be predictive of tumor response. Xenograft-bearing rats underwent regional isolated limb infusion with either melphalan (90 mg/kg) or temozolomide (2,000 mg/kg). The levels of AGT activity, GST activity, glutathione level, and GST/AGT expression were examined in this group of xenografts and found to be quite heterogeneous. No correlation was identified between melphalan sensitivity and the GST/glutathione cellular detoxification pathway. In contrast, a strong correlation between the levels of AGT activity and percentage increase in tumor volume on day 30 (r = 0.88) was noted for tumors treated with temozolomide. Regional therapy with temozolomide was more effective when compared with melphalan for the xenograft with the lowest AGT activity, whereas melphalan was more effective than temozolomide in another xenograft that had the highest AGT activity. In three other xenografts, there was no significant difference in response between the two chemotherapy agents. This study shows that AGT activity may be useful in predicting the utility of temozolomide-based regional therapy for advanced extremity melanoma tumors. Our observations also point out the limited ability of analysis of the GST/glutathione pathway to predict response to chemotherapies like melphalan whose resistance is primarily mediated through a complex mechanism of detoxification.

Randomized Multicenter Trial of Hyperthermic Isolated Limb Perfusion With Melphalan Alone Compared With Melphalan Plus Tumor Necrosis Factor: American College of Surgeons Oncology Group Trial Z0020

To determine in a randomized prospective multi-institutional trial whether the addition of tumor necrosis factor alpha (TNF-alpha) to a melphalan-based hyperthermic isolated limb perfusion (HILP) treatment would improve the complete response rate for locally advanced extremity melanoma. Patients with locally advanced extremity melanoma were randomly assigned to receive melphalan or melphalan plus TNF-alpha during standard HILP. Patient randomization was stratified according to disease/treatment status and regional nodal disease status. The intervention was completed in 124 patients of the 133 enrolled. Grade 4 adverse events were observed in 14 (12%) of 129 patients, with three (4%) of 64 in the melphalan-alone arm and 11 (16%) of 65 in the melphalan-plus-TNF-alpha arm (P = .0436). There were two toxicity-related lower extremity amputations in the melphalan-plus-TNF-alpha arm, and one disease progression-related upper extremity amputation in the melphalan-alone arm. There was no treatment-related mortality in either arm of the study. One hundred sixteen patients were assessable at 3 months postoperatively. Sixty-four percent of patients (36 of 58) in the melphalan-alone arm and 69% of patients (40 of 58) in the melphalan-plus-TNF-alpha arm showed a response to treatment at 3 months, with a complete response rate of 25% (14 of 58 patients) in the melphalan-alone arm and 26% (15 of 58 patients) in the melphalan-plus-TNF-alpha arm (P = .435 and P = .890, respectively). In locally advanced extremity melanoma treated with HILP, the addition of TNF-alpha to melphalan did not demonstrate a significant enhancement of short-term response rates over melphalan alone by the 3-month follow-up, and TNF-alpha plus melphalan was associated with a higher complication rate.