title: Efficacy of repeat isolated limb perfusions with tumor necrosis factor alpha and melphalan for multiple in-transit metastases in patients with prior isolated limb perfusion failure.
abstract: BACKGROUND
  Isolated limb perfusion (ILP) is an effective treatment modality for multiple in-transit melanoma metastases confined to the limb. Recurrences after ILP, however, occur in approximately 50% of patients and are a challenge for further treatment. The efficacy of repeat ILPs to prolong local control in this patient category is evaluated in this article.
  
  
  METHODS
  We used a prospective database in a tertiary referral center. Out of 100 tumor necrosis factor (TNF)-based ILPs with TNF and melphalan (TM-ILPs) in melanoma patients between March 1991 and July 2003, 25 repeat ILP procedures were performed in 21 patients in whom prior ILP treatment failed. All patients had bulky and/or numerous lesions and were treated with mild hyperthermic TM-ILP by using 2 to 4 mg of TNF and 10 to 13 mg/L of limb volume for the leg and arm, respectively.
  
  
  RESULTS
  The complete response rate was 76%, a partial response occurred in 20%, and no change was recorded in 4%. There was no difference in the complete response rate or local toxicity between first and repeat perfusions. Local recurrence occurred in 72%; the median time to local progression was 14 months. The 5-year survival rate was 47%, which compares favorably with known survival rates of stage IIIA/AB patients. The median follow-up of the patients was 26 months.
  
  
  CONCLUSIONS
  Patients who experience treatment failure after previous ILP treatment respond very well to repeat perfusion, and prolonged local control can thus be obtained. The subgroup of patients qualifying for repeat ILP represents a relatively favorable biological behavior of the melanoma.
authors.affiliation: Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, PO Box 5201, 3008 AE, Rotterdam, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Grünhagen
authors.forename: Boudewijn
authors.initials: B
authors.lastname: van Etten
authors.forename: Flavia
authors.initials: F
authors.lastname: Brunstein
authors.forename: Wilfried J
authors.initials: WJ
authors.lastname: Graveland
authors.forename: Albertus N
authors.initials: AN
authors.lastname: van Geel
authors.forename: Johannes H W
authors.initials: JH
authors.lastname: de Wilt
authors.forename: Alexander M M
authors.initials: AM
authors.lastname: Eggermont
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018906:Antineoplastic Agents, Alkylating / Q000008:administration & dosage*; D001132:Arm; D010478:Chemotherapy, Cancer, Regional Perfusion; D018450:Disease Progression; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007866:Leg; D008297:Male; D008545:Melanoma / Q000188:drug therapy* / Q000401:mortality; D008558:Melphalan / Q000008:administration & dosage*; D008875:Middle Aged; D009366:Neoplasm Seeding; D019233:Retreatment; D012878:Skin Neoplasms / Q000188:drug therapy* / Q000401:mortality; D017211:Treatment Failure; D014409:Tumor Necrosis Factor-alpha / Q000008:administration & dosage*
chemical_list: D018906:Antineoplastic Agents, Alkylating; D014409:Tumor Necrosis Factor-alpha; D008558:Melphalan