Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593.

PURPOSE: Patients with primary cutaneous melanoma > or = 1.5 mm in thickness are at high risk of having regional micrometastases at the time of initial surgical treatment. A phase III international study was designed to evaluate whether prophylactic isolated limb perfusion (ILP) could prevent regional recurrence and influence survival. PATIENTS AND METHODS: A total of 832 assessable patients from 16 centers entered the study; 412 were randomized to wide excision (WE) only and 420 to WE plus ILP with melphalan and mild hyperthermia. Median age was 50 years, 68% of patients were female, 79% of melanomas were located on a lower limb, and 47% had a thickness > or = 3 mm. RESULTS: Median follow-up duration is 6.4 years. There was a trend for a longer disease-free interval (DFI) after ILP. The difference was significant for patients who did not undergo elective lymph node dissection (ELND). The impact of ILP was clearly on the occurrence-as first site of progression - of in-transit metastases (ITM), which were reduced from 6.6% to 3.3%, and of regional lymph node (RLN) metastases, with a reduction from 16.7% to 12.6%. There was no benefit from ILP in terms of time to distant metastasis or survival. Side effects were higher after ILP, but transient in most patients. There were two amputations for limb toxicity after ILP. CONCLUSION: Prophylactic ILP with melphalan cannot be recommended as an adjunct to standard surgery in high-risk primary limb melanoma.

Effect of melphalan and hyperthermia on cell cycle progression and cyclin B1 expression in human melanoma cells.

We have investigated the effect of mild hyperthermia (42 degrees C) on the cytotoxic activity of a 1 h melphalan exposure in human melanoma cell lines. Hyperthermia did not affect cell growth of any culture, but it increased, to a different extent, melphalan cytotoxicity in all cell lines, with a reduction in the IC50 of 1.7 to 2.6-fold. Flow cytometric analysis showed that in normal temperature conditions melphalan caused S phase cell accumulation, which was evident only at 24 h in JR8, M14 and 2/21 cell lines and was still persistent at 72 h in 2/60 cells. Moreover, in all cell lines, the delay in S phase was paralleled, or followed, by an accumulation of cells in G2+M, which was transient in JR8 and M14 cells and persisted until 72 h in 2/21 and 2/60 melanoma clones. Hyperthermia caused a stabilization and prolongation of melphalan induced G2+M accumulation in JR8 and M14 cells. Conversely, in 2/21 and 2/60 clones, cell cycle perturbations induced by the drug were similar under normothermic or hyperthermic conditions. Specifically, in JR8, for which the maximum enhancement by hyperthermia on melphalan cytotoxicity was observed, cell accumulation in G2+M was still present 120 h after treatment. The accumulation was accompanied by an inhibition in the G2-M transition, as demonstrated by the significant reduction in the mitotic index of cells exposed to combined treatment compared to controls. Moreover, a bivariate distribution of cells stained for DNA and cyclin B1 showed that, following melphalan and hyperthermia treatment, the fraction of cyclin B1-expressing cells paralleled the fraction of G2+M phase cells, thus indicating that the inability of cells to enter mitosis was not ascribable to a reduction of cyclin B1 expression. On the whole, our results indicate that hyperthermia can stabilize the G2 accumulation induced by melphalan in human melanoma cells. Such a stabilization could contribute to the enhancement of melphalan cytotoxicity by heat, even though a strict correlation was not observed between the magnitude and persistence of the cell cycle perturbations and the extent of melphalan activity.

Fludarabine as a modulator of cisplatin activity in human tumour primary cultures and established cell lines.

The potential of the purine analogue fludarabine (9-beta-D-arabinofuranosyl-2-fluoroadenine-5' monophosphate) as a modulator of cisplatin cytotoxicity was investigated in four established cell lines and 20 primary cultures of human melanoma and ovarian cancer. Tumour cells were exposed to fludarabine and cisplatin, alone or in combination, for 4 h. Fludarabine did not affect the growth of ovarian cancer cell lines, whereas it induced a marked and dose-dependent inhibition of proliferation in melanoma cell lines. In primary cultures of both histotypes, the purine analogue did not induce appreciable antiproliferative effects. Combined cisplatin-fludarabine treatment caused additive effects in all established cell lines. Conversely, a synergistic effect of the combination was seen in 5 of 10 melanoma and 4 of 10 ovarian cancer primary cultures, with a dose-modifying factor ranging from 2.1 to 3.9 for melanomas and from 4.0 to 7.5 for ovarian cancers, respectively. In the remaining cultures, the interaction between fludarabine and cisplatin was additive. The alkaline filter elution analysis performed on primary cultures showed that the synergistic interaction between the two drugs was paralleled by an increase in the extent and persistence of the cisplatin-induced DNA interstrand crosslinks. Our results indicate that fludarabine can enhance cisplatin cytotoxic activity in human tumour primary cultures from ovarian cancer and malignant melanoma. Such an effect may be partially due to an interference by fludarabine on cisplatin-induced DNA adduct metabolism and repair.

Changes in fibrinolysis in patients with localized tumors.

An array of fibrinolysis tests was applied to the plasmas of 125 untreated patients with breast carcinoma and malignant melanoma, localized or spread to regional lymph nodes with no detectable distant metastases, to see whether or not there may be changes related to the type or to the stage of malignancy. Breast carcinoma (a mucin secreting tumor) and melanoma (a neuroectodermal tumor) were chosen as examples of tumors that can be accurately staged for localization or spread. Forty healthy subjects matched for age served as controls. The most marked differences between malignant tumors and controls were elevated plasma levels of tissue plasminogen activator antigen (P less than 0.005), plasminogen activator inhibitor (P less than 0.01), cross-linked fibrin degradation products (P less than 0.001), fragment B beta 15-42 (P less than 0.001) and histidine-rich glycoprotein (P less than 0.005). For no fibrinolysis test were results significantly different between patients with localized and spread tumors. Our data indicate that in these tumors fibrinolytic alterations are an early phenomenon unrelated to spreading.

Relevance of cell kinetic and ploidy characteristics for the thermal response of malignant-melanoma primary cultures.

We investigated die relation between the thermal sensitivity and the cell kinetics and ploidy of human malignant melanoma primary cultures. Cell suspensions from lymph node and/or cutaneous metastases of 49 patients were exposed for 1 h to 42-degrees-C. The effect of hyperthermia was assessed by an antiproliferative assay based on H-3-thymidine incorporation of cells grown in agarose for 4 days. Thermal sensitivity was observed in 10 of the 49 tumors studied (20%). In vitro thermal response as a function of proliferative activity (H-3-thymidine labeling index) was investigated in 36 melanomas. The median H-3-thymidine labeling index of sensitive tumors was 4-fold (8.1% vs 2.0%) that of resistant tumors. The relation between in vitro thermal sensitivity and flow cytometric DNA content was possible to find in 21 malignant melanomas. Thermosensitivity was found in 2 of the 3 diploid melanomas and in 2 of the 10 tumors with only one aneuploid subpopulation, whereas all multiploid tumors showed in vitro thermosistance. Our findings suggest that cell kinetic characteristics and, ploidy could be considered potential indicators of thermoresponsiveness in human malignant melanoma.

Reliability of a primary culture system to test cytotoxic drug activity in human-malignant melanoma.

Optimal conditions have been defined to grow primary cultures of malignant melanoma suitable for in vitro pharmacological studies. A feasibility of primary cultures was observed in 60% of 62 clinical melanoma lymph node metastases. The neoplastic nature of the cells grown in culture, as assessed by the highly specific monoclonal antibodies anti-S100 and HMB45, was confirmed in 100% and 65% of the cases, respectively. Flow cytometric analysis showed a high stability of DNA content profiles observed in clinical samples through all the methodologic steps used to obtain in vitro cultures. The intertumor variability of the degree of the antiproliferative effect of melphalan and its relation with DNA interstrand cross-links (DNA ISC) provided preliminary evidence of the reliability of the experimental system for in vitro evaluation of anticancer drug activity.

Hypoxic pelvic perfusion with mitomycin C using a simplified balloon-occlusion technique in the treatment of patients with unresectable locally recurrent rectal cancer.

HYPOTHESIS: To evaluate the role of hypoxic pelvic perfusion in providing therapeutic options for palliation without relevant complications in a homogeneous group of patients with unresectable locally recurrent rectal cancer who are nonresponders or have disease progression after the standard treatments. DESIGN: Nonrandomized and noncontrolled phase II experimental study. SETTING: University hospital, L'Aquila, and the National Cancer Institute, Naples and Milan, Italy. PATIENTS: Eleven patients had symptomatic unresectable pelvic recurrent rectal cancer. The mean +/- SD product of the 2 maximum perpendicular diameters of the recurrent cancer was 24.2 +/- 11.0 cm(2) (range, 10-48 cm(2)). Tumor fixation to the pelvic side walls or proximal sacrum were the main criteria for unresectability. All patients were free from extrapelvic disease and had a life expectancy longer than 3 months. INTERVENTION: Patients were submitted to one course of pelvic perfusion with mitomycin C (MMC) (25 mg/m(2)) by means of a simplified balloon occlusion technique. A pharmacokinetic evaluation of the procedure was also performed. MAIN OUTCOME MEASURES: Response rate and time to disease progression were the primary endpoints; overall survival was the secondary endpoint. RESULTS: Mean +/- SD value of the ratios of pelvic MMC area under the plasma concentration curve (0 to 20 minutes) (AUC(0-20)) to systemic MMC AUC(0-20) was 13.30 +/- 6.52. During the procedures there were no technical, hemodynamic, or vascular complications, and no deaths occurred during surgery or in the postoperative period. The response rate was 36.3% (95% confidence interval [CI], 6.5%-66.1%). Pain response rate was 45.4% (95% CI, 16.6%-76.2%). Median survival was 12.2 months (range, 5.7-19.5 months). Median time to disease progression was 6 months (range, 3-8 months). Two-year overall survival was 9.1%. CONCLUSIONS: Hypoxic pelvic perfusion with MMC is a safe and good palliative treatment for patients with unresectable locally recurrent rectal cancer. Further studies are necessary to establish if a different sequence in the multimodular treatment of these patients could be more useful.

Hypercoagulability and hyperfibrinolysis in patients with melanoma.

The purpose of this study was to evaluate whether or not, using sensitive analytical methods for the measurement of coagulation and fibrinolysis enzyme activity, there was a hypercoagulable state in patients with melanoma, and whether differences existed between those with or without metastases. Seventy-one patients were studied, 45 with localized tumors (stages Ia and Ib) and 26 with metastases (stages II-IV). Plasma level of activated factor VII, prothrombin fragment 1 + 2, thrombin-antithrombin complex, fibrinopeptide A, plasmin-antiplasmin complex and D-dimer were much higher in the whole group of 71 patients than in 45 controls with benign nevi. However, when melanoma patients with or without metastases were compared, there were smaller differences, with only thrombin-antithrombin complex, plasmin-antiplasmin and D-dimer significantly higher in metastatic melanoma. These results indicate that in patients carrying a tumor endowed with high procoagulant activity in vitro, there is a laboratory picture of hypercoagulability with secondary hyperfibrinolysis in vivo. However, differences between patients with localized and metastatic tumors for markers of hypercoagulability are not striking, in spite of the fact that metastatic cells support greater coagulant activity than primary cells in vitro.

Intraperitoneal hyperthermic perfusion (IPHP).

Intraperitoneal hyperthermic perfusion (IPHP) with a solution that contains CDDP (25 mg/m(2)/l) and MMC (3.3 mg/m(2)/l) was clinically introduced in the treatment of peritoneal carcinomatosis. Twenty-six patients underwent surgical treatment and IPHP. Peritoneal carcinomatosis was classified at laparotomy using the Japanese classification: P1 (n=3), P2 (n=5), P3 (n=15), unclassifiable (n=3). In this series of patients only the creatinine and amylase values were significant in biological toxicity evaluation. The surgical complication rate (2 duodenal fistulas) does not differ from the general extensive abdominal surgery.

TNF-alpha and doxorubicin in hyperthermic perfusion for limb sarcomas.

Eighteen patients, subdivided into groups of three, were perfused for 90 min with escalating doses of TNF-alpha (0.5-3.3 mg) and standard doses of doxorubicin (bolus 0.7-1.4 mg/kg) at a tumor temperature of at least 41 degrees C, with the aim to ascertain the maximum tolerable dose (MTD) and the activity of TNF-alpha combined with doxorubicin in hyperthermic antiblastic perfusion (HAP) for patients with limb sarcomas, candidates for amputation. Tumor response was assessed both pathologically and radiologically. Severe systemic toxicity (WHO) was observed in only 2 patients. Locoregional toxicity (Wieberdink's) was grade I in 3 patients, grade II or III in 10 and grade IV in 5. A strict correlation between the TNF dosage and the grade of limb reaction was found, grade IV being retrieved only with TNF dose >1 mg and/or muscular temperature >41.5 degrees C. Tumor necrosis was evaluated in 16 patients: in 11 (68.8%) it scored more than 75% while in 5 it was 25 to 75%. Four cases (25%) had 100% tumor histological necrosis. Limb sparing surgery was feasible in 13 (81%). Our findings suggest that this is a well-tolerated and highly active regimen in HAP.

Current results of pelvic perfusion for non-resectable relapsing of pelvic cancer.

Twenty-eight patients affected by non-resectable pelvic recurrence of a primary pelvic malignant neoplasm were treated by isolated pelvic perfusion, at mean hyperthermia, with different drugs, chosen taking into account tumor chemosensitivity. All patients had been previously treated. Four complete and six partial responses were observed; nine patients had stable disease and four other patients were non-responders and died due to progression in a few months. Two patients were lost to follow-up, one patients died for other reasons and two recent patients are not yet assessable.

The role of parotidectomy in the treatment of nodal metastases from cutaneous melanoma of the head and neck.

Forty-six patients affected by head and neck melanoma were submitted to elective or therapeutic parotidectomy associated with laterocervical dissection from 1980 to 1983 at the National Cancer Institute of Milan. The study showed that parotidectomy is indicated in the presence of clinically palpable nodes or where primaries originate in the temporo-zygomatic area. It also demonstrated that survival is not affected by type of dissection performed and that cervical lymphadenectomy must always be associated with parotidectomy because of the high incidence of occult metastases in other nodal groups in these cases.

Hyperthermic antiblastic perfusion with DTIC in stage IIIA-IIIAB melanoma of the extremities.

The aim of this paper is to evaluate the effectiveness of DTIC when employed at a local level in hyperthermic antiblastic perfusion (HAP) for stage IIIA-IIIAB melanoma patients. Twenty-seven consecutive patients have been treated at the National Cancer Institute of Milan from October 1983 to June 1985. All the patients were submitted to HAP at 40 degrees for 60' with DTIC at the dosage of 2.5 g/m2 [corrected] for lower extremities and 1.5 g/m2 [corrected] for upper extremities. We observed a complete local response in three patients and a partial local response 50% in seven patients, 10 patients has a response less than 50% and 4 patients did not show any response. After surgical removal of the residual tumor when possible, 14 patients are alive without detectable disease while 11 are alive with disease and two dead for progression. No serious complications were observed. These data indicate that DTIC seems able to obtain in HAP, results superimposable to L-PAM without any significant toxicity.

Treatment of in-transit metastases from cutaneous melanoma by isolation perfusion with tumour necrosis factor-alpha (TNF-alpha), melphalan and interferon-gamma (IFN-gamma). Dose-finding experience at the National Cancer Institute of Milan.

From December 1991 to July 1993, 22 consecutive patients with grade IIIA-IIIAB melanoma underwent isolation perfusion with TNF-alpha (0.5-4 mg), melphalan (10 mg/l perfused limb) and, in the first 12 cases, IFN-gamma (1.5 x 10(6) U). The first series of 12 patients received a total dosage TNF-alpha of 2-4 mg, and the second series of 10 cases received an escalating dosage of TNF-alpha (1.5-1.0-0.5 mg) and no IFN-gamma before or during surgery. The perfusion lasted 90 min and was conducted in mild hyperthermia (39-39.5 degree C muscle temperature). The results of the first series included seven patients in complete remission, four with stable disease and one case not evaluable for local toxicity. Fifty per cent of cases developed a regional relapse from 3 to 4 months after surgery. Presently with a median follow up of 10 months, five patients of this group have no evidence of disease, four are alive with disease, two died from melanoma and one died of complications likely due to treatment (multi-organ failure syndrome). In the second series, the immediate responses included seven patients in complete remission and three in partial remission; with a median follow up of 3 months, two patients developed a regional relapse, respectively, 3 and 5 months after surgery. So far our experience of perfusion with TNF-alpha has not reproduced the data reported by other investigators. Further clinical and biological findings and a longer follow-up period are needed to draw any conclusion, and a decreasing TNF-alpha dose should be carefully evaluated.

Hyperthermic antiblastic perfusion in the treatment of stage IIIA-IIIAB melanoma patients. Comparison of two experiences.

Many reports have been published concerning the efficacy of hyperthermic antiblastic perfusion (HAP) for the treatment of recurrent limb melanoma. In terms of tumour response, loco-regional control and survival, the results vary greatly even in patients with the same disease stage treated with the same technique. The aim of the present report was therefore to compare the experiences of two institutes, the Regina Elena National Cancer Institute of Rome and the National Tumour Institute of Milan, in treating a total of 327 patients with stage IIIA and IIIAB melanoma with HAP. The study also examined whether, and to what extent some prognostic factors influence the course of the disease. The tumour temperature proved to be the most important parameter for obtaining a complete tumour response which, in turn, positively affected survival. A direct relationship was found between the rates of complete tumour response and the clinical status of the patients. The complete response rates obtained in patients with no evidence of disease were 62.5% at the Rome institute and 70.1% at the Milan institute as opposed to 23.6% and 39%, respectively, in patients who died of the disease.

Combined effects of lonidamine and hyperthermia on malignant melanoma and lung carcinoma surgical specimens.

The in vitro cytotoxic activity of a 1 hr-treatment with lonidamine alone or combined with hyperthermia was investigated on primary cultures obtained from 12 human malignant melanomas and 9 lung carcinomas. The study was carried out by an antiproliferative assay based upon the inhibition of incorporation of 3H-thymidine into DNA of cells grown in agarose for 4 days. Under normothermic conditions the drug did not have any cytotoxic effect on either tumor type. Hyperthermia alone also failed to influence proliferation of melanoma and lung carcinoma cells. When the same tumors were exposed to lonidamine at 42 degrees C, there was significant enhancement of drug activity in both tumor types. There was also a synergistic interaction in a percentage of tumors, which increased as a function of drug concentration.

Prospective randomized trial in advanced malignant melanoma with cis-platinum, vindesine, and etoposide vs. cis-platinum, vindesine, and lomustine.

Thirty-seven consecutive patients with disseminated malignant melanoma and previously untreated with chemotherapy were randomly allocated to receive vindesine, cis-platinum, and etoposide (Regimen A) or vindesine, cis-platinum, and lomustine (Regimen B). In 31 evaluable patients, Regimen A induced an overall response rate of 31% and a complete response rate of 6%; with Regimen B the corresponding findings were 20% and 20%, respectively. The median duration of complete response was 12 months with both regimens and the comparative median total survivals were 8 and 6 months, respectively. In no case was toxicity so severe to require treatment discontinuation, and the major dose-limiting side effect was myelosuppression, especially in the patients treated with Regimen B. Present results confirm once more the limited activity of drugs and regimens presently utilized in the treatment of advanced malignant melanoma.

[A case of thyroid metastasis from hypernephroma (author's transl)]. / Un caso di metastasi tiroidea da ipernefroma

The literature on the subject is reviewed and a case of isolated thyroid metastasis from hypernephroma is presented. Although isolated metastases are very rare, the possibility of long survival justifies aggressive surgery.

Malignant pleural mesothelioma.

A series of 12 cases of mesothelioma is presented, and the data in the literature is reviewed in an attempt to formulate a program of treatment for this malignant, fast-growing and rapidly fatal tumor.

Intraperitoneal hyperthermic chemotherapy in gastric cancer: rationale for a new approach.

There is preliminary evidence from experience in the treatment of various abdominal malignancies that intraperitoneal chemotherapy alone or combined with hyperthermia may attain a role in the therapeutic strategy. This paper considers the rationale for such an approach, as well as its current results and potential indications in patients with gastric cancer. The literature is critically reviewed, with special emphasis on specific topics such as patterns of tumor spread, mechanisms of local recurrence, the rationale for intraperitoneal chemotherapy and intraperitoneal hyperthermic chemotherapy, toxicity, and results from non-controlled as well as randomized clinical trials in patients with gastric cancer. There is some evidence that intraperitoneal hyperthermic chemotherapy has a favorable effect on clinical outcome in patients with limited peritoneal carcinomatosis or malignant ascitis and in those at risk of future peritoneal spread, such as patients with pT3-pT4 cancers or with positive cytology of the peritoneal fluid. Hyperthermic chemotherapy should be considered a promising approach in limited or impending peritoneal carcinomatosis, and should be included in the multidisciplinary approach to the treatment of locally advanced gastric cancer.