Journal of Surgical Oncology 2011;104:718–723

Results of Isolated Lower Limb Perfusion for Loco-Regional Advanced/

Recurrent Melanoma Using Borderline True Hyperthermia Plus Additional

Bolus of Melphalan. A Critical Analysis of Homogeneous Cases

MARCELLO PACE, MD,1* RICCARDO GATTAI, MD,1 ERMINIA M. MASCITELLI,1y AND LUIGI MILLANTA2z1Department of Medical and Surgical Critical Care, University of Florence, Regional Reference Centre of Tuscany for Locoregional Perfusion

Therapies in Oncology, Florence, Italy2Department of Electronics and Telecommunications, University of Florence, Florence, Italy

Background and Objective: This study was conducted to assess the safety and efficacy of our modified ILP treatment with borderline true

hyperthermia and high melphalan concentration in stage III lower limb melanoma.

Methods: Between March 1990 and December 2006, 91 consecutive patients were given ILP treatment. Forty three patients were treated with

double L-PAM bolus combined with D-actinomicin; 48 patients were treated with additional L-PAM bolus alone.

Results: The mean follow-up period is 68.5 months. The acute regional toxicity occurred with grade II (54%), III (38%), IV (2.1%). The

systemic toxic effects were present with transitory hematological disorders. Complete response (CR) rate was observed in 89.2% of stage

IIIA-IIIAB unexcised IT-mets. The overall limb recurrent disease in stage III was 39%. In patients with CR recurrent rate occurred in 44%

with a mean limb recurrence-free interval (LRFI) of 23.8 months. Distant metastases was attained with a mean time of 29.2 months. After

CR, the interval was 32.1 months. The 5-year survival rate was 45%; in patients with CR, was 48%.

Conclusions: Our procedure is an important therapeutic option. The results suggest a marked local control of the recurrent disease. The LRFI

is longer than for those treated with other treatment schedules.

J. Surg. Oncol. 2011;104:718–723. � 2011 Wiley Periodicals, Inc.

KEY WORDS: melanoma; melphalan; borderline true hyperthermia; limb perfusion; clinical results

INTRODUCTION

Since 1982, our institution has performed over 200 HILP, for

lower limb advanced melanoma under borderline true hyperthermic

(40–41.88C) condition (BTH-ILP). The main purpose of our research

activity was the optimization of the technical and methodological

requirements in order to assure more safe and effective treatments.

The research team was made up of physicians, engineers, physicists,

and perfusion technicians (Technical Reference Group or TRG).

Various problems and proposed solutions for BTH-ILP procedure

were described in our previous works [1–3] whose reference integra-

tes the information enclosed in our recent reviews and clinical

research [4–6]. Clinical criteria, technical previsions, and specifica-

tions that have been improved and implemented were delineated in

Reference 4. Borderline true hyperthermal regimen required critical

control and temperature measurement accuracy in order to obtain an

isothermal situation in all the tissue of the treated limb, which

intrinsically implies uniformity in space and time. For this purpose a

dedicated support system was required to assure an accurate, effec-

tive, and user-friendly control in addition to an on-line panoramic

vision of the treatment’s parameters. The project for the advance-

ment of the apparatus was conceived by the TRG as for our

requirements.

The methodological improvements that we implemented in order

to control the factors influencing the systemic drug leakage were

reported in Reference 5. In addition, we pointed out the relevant

advantages of the ‘‘abdominal tourniquet’’ technique that we carried

out for the limb isolation. This surface vascular isolation modality

allows the extension of the treatment up to the limb root and above

all, the real possibility to avoid neurological lesions by pressure-

induced resultant from the Esmarch’s bandage applied according to

the standard technique [7–9].

To verify the risks of a higher toxicity using high hyperthermia

combined with cytostatic drugs, we analyzed and compared the

clinical results with regard to toxicity, morbility, and post-operative

complications in three patient’s groups treated with different HT

regimen and L-PAM concentration as in Reference 6.

Since 1988, our BTH-ILP procedure has not been modified and is

performed under standardized conditions. The basic targets BTH-ILP

were covered limb high temperatures, close to the upper tolerability

limit (41.5 � 0.38C typically) and maximum temperature in the per-

fused circuit as low as possible (�42.0 8C typically).

Between March 1990 and December 2008, 120 BTH-ILPs for

lower limb melanoma were performed with a standard dose of

10 mg/L limb volume of melphalan with or without D-actinomicin

(D-act) plus an additional bolus of 5 mg/L of L-PAM (2M-BTH

protocol). A preliminary pilot study we carried out verified that our

BTH-ILP procedure would be accompanied by unacceptable toxicity

[10].

This paper analyzes the clinical results with 2M-BTH

protocol � D-act. Patients were prospectively followed in terms of

response rate, recurrence pattern, and survival.

yPerfusionist.zEngineer.

*Correspondence to: Prof. Marcello Pace, MD, Department of Medicaland Surgical Care, University of Florence, Viale Morgagni, 85 - 50134Florence, Italy. Fax: 0390554379572. E-mail: marcello.pace@unifi.it

Received 2 April 2010; Accepted 30 March 2011

DOI 10.1002/jso.21949

Published online 30 June 2011 in Wiley Online Library(wileyonlinelibrary.com).

� 2011 Wiley Periodicals, Inc.

PATIENTS AND METHODS

Ninety one consecutive patients (pts) with loco-regionally

advanced/recurrent lower limb melanoma were collected for this

study and they were treated with 2M BTH-ILP up until December

31, 2006. Patients included in the analysis were subject to a follow-

up period of at least 30 months. All pts were admitted to the Tuscan

Regional Reference Center of Florence University—Careggi Hospital

and treated with the same method and by the same team of surgeons

and perfusion technicians. Several patients were submitted to our

center after the treatment of the primary melanoma and/or after the

multimodal treatments that include: surgery (i.e., excision of in

transit metastases, regional lymph nodes dissection), immunotherapy,

and/or systemic chemotherapy.

Patients’ Characteristics, Staging, and Treatments

Table I summarizes the patients and tumors’ characteristics, the

clinical staging, and therapeutic schedules. The disease stage was

classified according to the MD Anderson Classification System at the

time of the perfusion. Two pts had stage II disease (local bulky and

ulcerated recurrence or satellitosis), 46 pts had stage IIIA melanoma

(in-transit metastases), 32 cases had stage IIIAB disease (in-transit

and regional lymph node metastases), and 10 had stage IIIB disease

(bulky inguinal lymph node metastases with advanced local mela-

noma). One patient with stage IV disease (locoregional plus extrare-

gional metastases) was treated with palliative intent for extensive

and ulcerated recurrence in the lower limb.

The cutaneous and/or subcutaneous in-transit metastases (IT-mets)

were found in 79 patients. When HILP was performed, 15 pts had

no clinical evidence of in-transit metastases as they were previously

treated with surgical excision in another hospital, 27 pts had IT-mets

�3, 21 pts IT-mets >3 in a limited area and 16 pts with extension to

the whole limb and multiple in-transit metastases (IT-mets >10).

All patients, with reference to the drugs protocol, were included

in two groups: in Group 1 (G-1) 43 patients were treated until July

1994 with BTH-ILP and double L-PAM bolus in combination with D-

act (DM-BTH-ILP). This cytostatic (D-act) was commonly used over

past years in combination with melphalan in the clinical setting. The

last 48 patients, Group 2 (G-2) were treated with double L-PAM

bolus alone (M-BTH-ILP). All pts were treated with an HT schedule

consisting of 1 hr of true hyperthermic regime (40–41.88C). The two

groups had different drug administration times as well as hyperther-

mic tissue temperatures. In the IIIAB and IIIB patients’ stage, the

femoral lymph nodes were removed with therapeutic intent at the

end of the perfusional treatment.

G-1 group. The treatment schedule was: D-act (0.1 mg/L, up to

a maximum dose of 1 mg) performed in the arterial line when the

limb temperature reached the range of 38–398C. L-PAM (10 mg/L)

was administered 10 min later. The target limb temperature was

41.5–41.88C. The hyperthermic phase started when all the limb tem-

peratures had reached �408C. This phase was maintained for

60 min; the additional L-PAM bolus (5 mg/L) was administered

30 min after the start of the hyperthermic phase.

G-2 group. The first L-PAM bolus (10 mg/L) was administered

in the arterial line when the limb temperatures reached 40 � 0.38C(start of the ‘‘active phase’’) and then the temperatures progressively

and homogeneously reached up to 41.5 � 0.38C (‘‘steady state

phase’’). An additional L-PAM bolus (5 mg/L) was administered

30 min after the first L-PAM bolus (Fig. 1).

ILP was performed through the external iliac vassels in order to

plan a treatment up to the limb root and to assure the essential

requirements for the limb heating by high perfusate flow. The extrac-

orporeal circuit was primed with plasma-expander (1000 ml), which

pre-heats up to 408C during the time of surgical vascular isolation.

L-PAM dosage was calculated according to the limb volume plus 1 L

of prime volume. The external iliac and the obturator lymph node

dissection were performed in all ILPs during the vascular iliac iso-

lation. The femoral lymph node dissection and/or the excision of the

primary tumor were performed simultaneously after ILP, when

required. At the end of the perfusion treatment no heparin neutraliz-

ation was adopted [6].

Eligibility Criteria, Response Assessment,

and Statistical Analysis

The inclusion criteria envisaged up to age 80, the performance

status grade 0–1 (WHO scale), the absence of vascular diseases or

severe organ dysfunctions and other malignancies. A written

informed consent was obtained.

TABLE I. Patients Characteristics, Clinical Staging, Therapeutic Schedules

Groups G-1 (L-PAM þ D-act) G-2 (L-PAM alone) Total n (%)

Patients 43 48 91

Gender (M/F) 8/35 16/32 24/67

Age: median years (range) 61.88 (34.3–79.2) 61.21 (32.9–77.4) 61.68 (32.9–79.2)

Location of primary tumor: Lower limb Lower limb

Thigh 2 4 6 (6.60)

Leg 33 36 69 (75.82)

Foot 8 8 16 (17.58)

MD Anderson Class

Stage II 1 1 2 (2.20)

Stage IIIA 26 20 46 (50.55)

Stage IIIAB 12 20 32 (35.15)

Stage IIIB 4 6 10 (11.00)

Stage IV 0 1 1 (1.10)

HT schedule 38.5–41.88C 40–41.88CHT ‘‘active phase’’ start (SD) 38–398C 40(�0.3)8CHT steady state (SD) 41.5(�0.3)8C 41.5(�0.3)8C

Drugs

L-PAM mg/L limb vol. 10 10 —

mg for 1 L of prime 10 10 —

mg/L limb vol. 5 (add. bolus) 5 (add. bolus) —

Mean L-PAM mg (range) 179.9 (120–240) 148.5 (120–210) 161 (120–240)

D-actinomicin (mg) 1 0 —

Results of Isolated Lower Limb Perfusion 719

Journal of Surgical Oncology

The follow-up was performed through personal contact with the

patients with a mean time of 68.48 months (range 2.06–229.33). The

follow-up data were collected and reviewed from thirty days after

HILP until June 2009 or at the patients’ death. No patients were lost

to follow-up. The follow-up plan included clinical examination, hem-

atological parameters, which were carried out every 3 months, chest

X-rays and hepatic ultrasonography every 6 months. When it was

clinically required, other investigations were performed.

The use of 2M-BTH protocol with or without D-act required a

previous careful rating of the side effects and post-operative compli-

cations that were separately assessed in both groups (G-1/G-2)

before evaluating the efficacy of this more aggressive treatment. The

acute local and systemic toxicity and complications were evaluated

until 30 days after the postoperative time. The tumor response,

defined according to the standard WHO criteria [11], was observed

following 30 and 60 days after ILP. Limb recurrence free interval

(LRFI) was computed from the complete remission (CR) after ILP to

the next recurrence or at the end of the follow-up. Local and distant

recurrence and survival, as well as disease-free interval were

measured from the perfusion treatment date and were established

according to the Kaplan–Meier method [12]. The follow-up was

stopped on July 31, 2009. Values of P � 0.05 were considered stat-

istically significant.

CLINICAL RESULTS

Toxicity and Complications

Table II indicates the regional and systemic toxicity and post-

operative complications data, the clinical reactions and the hospital

stay of the two groups of patients. A second ILP with a vascular

femoral isolation procedure was performed in eight patients with a

new recurrent regional disease. In this study, the toxicity data of

second ILPs was not included.

The acute regional toxicity after ILP was graded according to

Wieberdink [13]. The limb reactions were evaluated until subsided

(8–12 days) and the worst observed data were recorded. Local acute

toxicity was presented with grade II (54.3%) and grade III (38.2%).

The grade II reaction was moderate and transient (7–10 days). In pts

with grade III mild erythema and/or edema occurred. Some

superficial and limited burned areas occurred in four cases (G-1)

with restitutio ad integrum within 5–8 days. Erythema and/or edema

were especially more intense when the inguinal lymph node dissec-

tion was performed. One patient (G-2), grade III toxicity with blis-

tering, suffered from permanent diffused pain of the entire limb,

caused by neurological toxic effects. Another patient(G-2), with

grade IV, suffered from wide blistering of the thigh, moderate and

transitory nerve palsy. No grade V reaction occurred. No fasciotomy

was performed in any patients.

Acute systemic toxicity was evaluated according to the WHO

criteria [14]. The hematologic parameters were performed at least

every three days for the early postoperative time (10 days) and when

required according to the clinical conditions, until the completion of

30 days. The most frequent hematologic disorders that may be typi-

cally observed after the ILP treatments were systematically tested.

The systemic toxic effects data presented here was grouped accord-

ing to the toxic grades �2 (included 0, 1, and 2 grade) and grades

�3 (included 3 and 4 grades). The biohumoral data of the hemo-

poietic function showed a transient (5–8 days) but remarkable

toxicity increase (3–4 grades). In a previous report [6] we stressed

that the toxic grades increase were dependent on the administration

of the double L-PAM bolus with an extended high drug concentration

during the active phase of the treatments. In spite of this, it is

important to point out the considerable reduction of the toxic grades

3 and 4 (G-2 vs. G-1) that occurred in the patients treated in two

different periods (G-1 up to July 1994, G-2 since 1996 up to

December 2006). Monitoring the enzymes (ALT/AST, CPK, creati-

nin), considered as the indicators of systemic toxic effects caused by

a local muscular damage, showed contained values (within 0–2

grades).

Fig. 1. P.L.-ILP (16.01.09)—Typical temperature profile duringlower limb BTH-ILP with L-PAM bolus (10 mg/L) plus additionalbolus (5 mg/L).

TABLE II. Loco-Regional and Systemic Side Effects and

Complications in 91 pts Treated with BTH-ILP and Double Bolus

of L-PAM � D-actinomicin

Groups G-1 G-2

Patients (¼n) 43 48

Regional toxicity grade.

Tissue reaction (%):

Grade I 3.0 8.3

Grade II 57.6 52.1

Grade III 39.6 37.5

Grade IV� — 2.1

Grade V — —

Systemic toxicity grade.

Hematological parameters (%):

�2/�3 �2/�3

RBC� 33.3/66.7 58.4/41.6

Hb� 54.5/45.5 75.0/25.0

WBC� 12.1/87.9 58.4/41.7

PLT� 39.4/60.6 89.6/10.4

ALT/AST 88.0�/6.0 97.9�/2.1CPK� 78.8/21.2 91.6/8.4

Creatin 100.0/0.0 97.9/2.1

Complications (¼n)

Lymph fistula/Lymphocele 8 11

Bleeding (necessitating surgery)� 3 —

Deep venous thrombosis 2 1

Pain — 1

Peripheral nerve pulsy — 1

Death

ARDS — 1

MOF 1 —

Hospital stay-days

Mean (range)� 28.46 (12–61) 23.64 (9–47)

�P value < 0.05.

720 Pace et al.

Journal of Surgical Oncology

The regional and systemic post-operative complications occurred

with low rate and no significant difference between G-1 and G-2.

Persisting lymphatic secretion and lymphoceles were more frequent

when the femoral lymph node dissection was performed after the

perfusion procedure. These complications were treated with punctu-

res or repeated placement of a suction drain during the follow-up.

Retroperitoneal bleeding occurred in three cases (G-1) and required

a second operation. Deep venous thrombosis of the treated limb was

recorded in three patients with complete recovery through a standard

medical therapy without sequelae. Post-operative mortality occurred

in 2/91 patients (2.19%). A 66-year old woman (stage IIIAB) with

grade III local reaction suffering from severe ARDS, died 22 days

after ILP. The other case was a 63-year old man (IIIAB stage) with

grade IV local reaction and early severe bone marrow toxicity fol-

lowed by septic shock, who died 10 days after DM-BTH-ILP from

multiple organ failure. In the present study, long-term morbidity was

never observed in any patient. No significant statistical different

reaction rate was observed in the two groups. The hospital stay after

perfusional treatment showed a time reduction rate in G-2 compared

to G-1 (mean days 23.64 vs. 28.46).

Response Rate, Recurrent Pattern, and Survival

To evaluate the efficacy of the treatments, we analyzed the data

of the stage III patients (n ¼ 86, excluded two dead pts). In the two

groups respectively treated with or without D-act, the results demon-

strated that there was no significant difference between G-1 and G-2.

Therefore the cumulative data results of the two groups were

reported.

Response Rate

Fifty-six IIIA/AB patients with IT-mets at the time of ILP were

eligible for an objective tumor response after BTH-ILP. In 50/56

patients (89.2%) the clinical evaluation indicated a complete

response (Table III). Only three pts showed a partial response and

three cases showed no regression of tumor. The overall response rate

(CRþPR) was 94.6%. Complete response was 91.2% in IIIA

patients, 86.5% in IIIAB stage. The correlation between the CR rate

and the number of in-transit recurrence checked in pts before ILP,

was 95.2% when IT-mets were from 1 to 3 nodules, 85.0% if greater

than 3 nodules, and 86.6% if >10 nodules widespread through the

limb.

Recurrent Pattern

The overall loco-regional recurrence disease in stage III (n ¼ 82

pts), excluded partial or no response after the 2M-BTH schedule,

was 39% with a mean of 22.6 months and a median of 15.5 months.

The limb recurrence was observed in 22/50 patients (44%) after CR

with a mean LRFI of 23.8 months (median 17 months). 12/46

patients with stage IIIA (26%), 10/32 (IIIAB) pts (31%), and 7/10

(IIIB) pts (70%) died during the follow-up from distant metastasis

without any signs of locoregional recurrence (mean of 28.6 months,

median of 18.5 months).

Systemic Recurrence

Among 86 (stage III) patients treated with our schedule, distant

metastases occurred in 39.5% after 3-years of follow-up and 51.8%

after 5-years of follow-up. Distant metastases after 2M-BTH ILP

were attained with a mean time of 29.2 months (median 16.6) during

the follow-up time. The mean interval until the distant metastasis of

patients with CR was 32.1 months, median 19.7 months); for stage

IIIA 44.6 months, for stage IIIAB the mean was 13.9 months

(P ¼ 0.031).

Survival

Figure 2 shows the survival of overall stage III patients (n ¼ 86)

and IIIA, IIIAB, and IIIB stages, respectively. Median overall sur-

vival was 37 months and the mean was 67.5 months. Overall 5-year

survival was 45%. In pts with CR overall 5-year survival was 48%.

The patients with complete response who died at 12 months were,

respectively, 2/31 in IIIA patients (6.4%) and 2/19 in IIIAB pts

(10.5%); at 36 months, 2/29 in stage IIIA (6.8%) and 5/17 in stage

IIIAB (29.4%). The 5-year survival rate in stage IIIA-AB with a

number of IT-mets n � 3 at the treatment was 56%, with n > 3 IT-

mets was 44% and with n > 10 IT-mets 45%.

DISCUSSION

Our treatment’s strategy showed significant advantages in the

prevention of local/systemic adverse effects. Safe and effective HILP

requires not only meticulous attention to every aspect of the

procedure, but also experienced staff and a large patients’ volume.

The use of borderline true hyperthermia (41.5 � 0.38C) during

the entire ‘‘active phase’’ of the treatment (60 min) did not cause

high toxicity effects and complications. Severe local toxicity

occurred in a much smaller number of patients treated with our pro-

tocol compared to the results published in the literature for the

normo/mild hyperthermic perfusion with L-PAM standard dosage.

Local toxicity and complications rates compared to the literature

data (10–28%) were markedly low with a high reduction of the acute

and long-term adverse effect [15–20]. In our findings the higher

systemic toxicity grade with transitory (5–8 days) hematological dis-

orders was due to the increase of the L-PAM dosage. In a previous

article [6], we stressed that with the same hyperthermic regime and

conditions, the toxicity grade rate of the hematological disorders

increased in patients treated with the L-PAM additional bolus. A high

HT/L-PAM dosage did not affect the morbidity of the treatments.

We support that, as the standard ILP technique, the leakage

monitoring during the treatment’s time, a share of the drugs leaks in

the systemic circulation depend on many factors (i.e. deep and sur-

face vascular isolation, perfusate flow rate). The continuous preoper-

ative leakage monitoring allows a more careful and real-time

treatment control, comparing the drugs leakage data to physical

parameters (pressure, perfusate flow). The on-line monitoring of

these parameters using the support system makes it possible to take

prompt corrective actions on leakage by reducing the perfusate

flow (typically from 600–800 ml/min to 300–400 ml/min) [5].

TABLE III. Loco-Regional Disease Response Rate in 56 Patients After BTH-ILP

Response Total n ¼ (%)

According to M.D. Anderson IIIA/AB stage According to the number (N8) of in-transit metastasis

IIIA n ¼ 34 (%) IIIAB n ¼ 22 (%) N � 3 (%) N > 3 (%) N > 10 (%)

Complete 50 (89.2) 31 (91.2) 19 (86.5) 20 (95.2) 17 (85.0) 13 (86.6)

Partial 3 (5.4) 2 (5.8) 1 (4.5) 0 (0.0) 2 (10.0) 1 (6.7)

None 3 (5.4) 1 (3.0) 2 (9.0) 1 (4.8) 1 (5.0) 1 (6.7)

Results of Isolated Lower Limb Perfusion 721

Journal of Surgical Oncology

The hospital length stay data are supported by the short-term mor-

bidity rate decreasing in G-2 treated in a subsequent time during our

clinical experience. Based on our experience, we believe that the

results regarding the safety and tolerability of the perfusional treat-

ment essentially depend on the quality insurance of the procedure

used for its realization and on methodological strictness.

Our CR rate of 89.2% is markedly higher than that reported (54–

63%) for normo/mild hypertermic L-PAM ILP and therefore suggests

the superiority of our treatment regimen used in the present study

[21–27]. A wide range of CR rates (36–81%) have been reported on

L-PAM HILP using high hyperthermia [20–22,24,28–30]. The syner-

gic effect of BTH in combination with the high dose-concentration

of melphalan in our treatment protocol showed a significant local

benefit. A longer drug exposure time during the ‘‘active phase’’ of

the treatment may be associated with the higher response rate. In

spite of the improved CR rates (from 60 to 78%) that have been

reported with the addition of TNF in patients with multiple IT-mets

or with bulky disease [26,31–37], comparative studies in the litera-

ture have failed to demonstrate any significant difference in the long

term results between ILP with melphalan alone and a regimens with

L-PAM combined with TNF [38–40]. In the present study the median

time of complete response of 17 months is comparable to the 12–17

months reported after TNFa-L-PAM [38,41–43].

Our finding supports that the tumor response rate depends on the

disease stage and on the number of the IT-mets. The data suggest

that the CR and the outcome after 2M-BTH-ILP may be improved

when perfusion treatment is performed early when disease volume is

minimal. This activity may improve the prognosis when new IT-mets

relapse after the excision of the first limb recurrence. Likewise, the

number of patients with unresecable limb melanoma will be reduced

[27]. The significant increase of the complete response rate attained

with our ILP schedule depends on both high dose of hyperthermia

and L-PAM concentration. According to our experience, the addition

of D-actinomicin had no significant effect on the response rate using

L-PAM alone.

The overall locoregional recurrence rate in stage III patients was

registered in the 39% of the patients during our follow-up. In the

literature reported limb recurrence developed in 46–70% of the pts

using L-PAM [43–45]. The LRFI in overall stage III patients was

22.6 months compared with 9.5–6 months reported in other studies

[41,45]. In our patients with CR the LRFI was 44% with a mean of

23.8 months. The increase of LRFI observed using the 2M-BTH pro-

tocol depends on the high dosage of the therapeutic agents

(hyperthermia plus drug). In addition, the LRFI increase can be

attributed to the effects of the treatment on the regional microscopic

disease. The power to stop or slow down the process of ongoing

recurrence by eradication of micrometastases is assured by the

homogeneous extension of the treatment up to the entire limb. In

stage IIIA–IIIAB patients with CR we found systemic metastases

with a median time of 32 months compared to the median interval of

30 months recently reported by Knorr et al. using high hyperthermia

with L-PAM [20]. We may consider our results as satisfactory, taking

into account that distant metastasis can be explained by a distant

spread that was probably present since the time of ILP.

The 5-year overall survival rate for stage III patients was 45%

with the mean time of 67.5 months compared to the results (28–

46%) for normo/mild hyperthermia ILP with melphalan reported in

literature [46,47]. Five-year survival was 52.5% in stage IIIA, 36.1%

in stage IIIB, and 45.2% in stage IIIAB (Fig. 2). Noorda et al. [19]

reported the 5-year survival in each stage of disease, respectively,

48% in stage IIIA, 25% in stage IIIB, and 20% in stage IIIAB. The

IIIA-AB stage data demonstrated a moderate increase of the values

in each stage, which may be explained through the increase of the

disease free-interval pleading to local response after ILP treatment.

Five-year survival between 28 and 73% reported in literature [22,46]

suggest that these disomogeneous data would not be considered sig-

nificant taking into consideration that ILP is a locoregional treatment

with the primary objective of obtaining disease limb control.

In conclusion, our ILP schedule using BTH combined with a high

melphalan concentration for advanced/recurrent limb melanoma

demonstrates a very significant result in terms of safety with moder-

ate and transitory morbidity and local response, recurrence pattern,

and survival data attest to the treatment’s effectiveness. Our findings

suggest that ILP must be carried out earlier when tumor burden is

minimal in order to optimize the outcome using a treatment with

very low morbidity. The 2M-BTH schedule used in the present study

could be a real alternative to the TNF-ILP with L-PAM in terms of

safety, clinical results, and cost/benefits. However, wider studies are

needed to confirm our data.

ACKNOWLEDGMENTS

This work was partially supported by Research Budgets of the

University of Florence.

REFERENCES

1. Pace M: Optimization of the vascular isolation in isolatedregional perfusion of the limbs. Reg Cancer Treat 1990;3:90–97.

2. Lazzerini S, Millanta L, Olmi R, et al.: An analysis of heatsupply and temperature distribution in isolated hyperthermicperfusion of the limbs. Phys Med 1991;7:135–143.

3. Pace M, Millanta L, Bellacci M, et al.: Heat administrationtemperature monitoring and control in hyperthermic - antibalsticperfusion of the limbs. Reg Cancer Treat 1992;4:207–212.

4. Pace M, Millanta L, Gattai R, et al.: Optimal procedure for ther-mal delivery in hyperthermic/chemotherapeutic treatments inthe isolated perfusion of the limbs. J Exp Clin Cancer Res2005;24:35–42.

5. Pace M, Millanta L, Gattai R, et al.: Key factors for best controlof the systemic leakage during hyperthermic isolated limbperfusion (HILP) in ECC. A critical synthesis of our experience.J Exp Clin Cancer Res 2007;26:433–442.

6. Pace M, Gattai R, Matteini M, et al.: Toxicity and morbilityafter isolated lower limb perfusion in 242 chemo-hyperthermaltreatments for cutaneous melanoma: The experience of theTuscan Reference Centre. J Exp Clin Cancer Res 2008;27:67.

7. Schraffordt Koops H: Prevention of neural and muscular lesionsduring hyperthermic regional perfusion. Surg Gynecol Obstet1972;135:401–403.

Fig. 2. X-axis: time after ILP; Y-axis: overall survival—(a) cumu-lative stage III survival, (b) IIIA stage, (c) IIIAB stage, (d) IIIB stagedisease.

722 Pace et al.

Journal of Surgical Oncology

8. Kroon BBR, Klase JM, van Geel AN, et al.: Application ofhyperthermia in regional isolated perfusion for melanoma of thelimbs. Reg Cancer Treat 1992;4:223–226.

9. Vrouenraets BC, Eggermont AM, Klaase JM, et al.: Long-termneuropathy after regional isolated perfusion with melphalanfor melanoma of the limbs. Eur J Surg Oncol 1994;20:681–685.

10. Pace M, Galli A, Bellacci A: True hyperthermia plus doublemelphalan bolus in the isolated perfusion for stage IIIlower limb melanoma. A pilot study. Reg Cancer Treat 1996;9:1–7.

11. World Health Organization. WHO handbook for reportingresults of cancer treatment. Geneva: World Health Organization;1979.

12. Kaplan EL, Meier P: Nonparametric estimation from incompleteobservations. J Am Statist Assoc 1958;53:457–481.

13. Wieberdink J, Benckhuijsen C, Braat RP, et al.: Dosimetry inisolated perfusion of the limbs by assessment of perfused tissuevolume and grading of toxic tissue reactions. Eur J CancerClinic Oncol 1982;18:905–910.

14. Miller AB, Hoogstratem B, Staquet M: Reporting results of can-cer treatment. Cancer 1981;47:207–214.

15. Klaase JM, Kroon BB, van Geel BN, et al.: Patient- andtreatment-related factors associated with acute regional toxicityafter isolated perfusion for melanoma of the extremities. Am JSurg 1994;167:618–620.

16. Thompson JF, Lai DT, Ingvar C, et al.: Maximizing efficacy andminimizing toxicity in isolated limb perfusion for melanoma.Melanoma Res 1994;1:45–50.

17. Vrouenraets BC, Klaase JM, Kroon BB, et al.: Long-term mor-bidity after regional isolated perfusion with melphalan for mela-noma of the limbs. The influence of acute regional toxicreactions. Arch Surg 1995;130:43–47.

18. Noorda EM, Vrouenraets BC, Nieweg OE, et al.: Long-termresults of a double perfusion schedule using high dose hyper-thermia and melphalan sequentially in extensive melanoma ofthe lower limb. Melanoma Res 2003;13:395–399.

19. Noorda EM, Vrouenraets BC, Nieweg OE, et al.: Prognosticfactors for survival after isolated limb perfusion for malignantmelanoma. Eur J Surg Oncol 2003;29:916–921.

20. Knorr C, Meyer T, Janssen T, et al.: Hyperthermic isolated limbperfusion (HILP) in malignant melanoma. Experience with 101patients. Eur J Surg Oncol 2006;32:224–227.

21. Storm FK, Morton DL: Value of therapeutic hyperthermic limbperfusion in advanced recurrent melanoma of the lower extrem-ity. Am J Surg 1985;150:32–35.

22. Di Filippo F, Calabro A, Giannarelli D, et al.: Prognostic vari-ables in recurrent limb melanoma treated with hyperthermicantiblastic perfusion. Cancer 1989;63:2551–2561.

23. Skene AI, Bulman AS, Williams TR, et al.: Hyperthermic iso-lated perfusion with melphalan in the treatment of advancedmalignant melanoma of the lower limb. Br J Surg 1990;77:765–767.

24. Kroon BBR, Klasse JM, van Geel BN, et al.: Application ofhyperthermia in regional isolated perfusion for melanoma of thelimbs. Reg Cancer Treat 1992;4:223–226.

25. Vrouenraets BC, Nieweg OE, Kroon BB: Thirty-five years ofisolated limb perfusion for melanoma: indications and results.Br J Surg 1996;83:1319–1328.

26. Lienard D, Eggermont AM, Koops HS, et al.: Isolated limb per-fusion with tumor necrosis factor-alpha and melphalan with orwithout interferon-gamma for the treatment of in-transitmelanoma metastases: a multicentre randomized phase II study.Melanoma Res 1999;9:491–502.

27. Noorda EM, Takkenberg B, Vrouenraets BC, et al.: Isolatedlimb perfusion prolongs the limb recurrence-free interval afterseveral episodes of excisional surgery for locoregional recurrentmelanoma. Ann Surg Oncol 2004;11:491–499.

28. Hafstrom L, Jonsson PE: Hyperthermic perfusion of recurrentmalignant melanoma on the extremities. Acta Chir Scand 1980;146:313–318.

29. Abdel-Wahab OI, Grubbs E, Viglianti BL, et al.: The role ofhyperthermia in regional alkylating agent chemotherapy. ClinCancer Res 2004;10:5919–5929.

30. Aloia TA, Grubbs E, Onaitis M, et al.: Predictors of outcomeafter hyperthermic isolated limb perfusion: role of tumorresponse. Arch Surg 2005;140:1115–1120.

31. Vaglini M, Santinami M, Manzi R, et al.: Treatment of in-transitmetastases from cutaneous melanoma by isolation perfusionwith tumour necrosis factor-alpha (TNF-alpha), melphalan andinterferon-gamma (IFN-gamma). Dose-finding experience at theNational Cancer Institute of Milan. Melanoma Res 1994;4:35–38.

32. Klop WM, Vrouenraets BC, van Geel BN, et al.: Repeatisolated limb perfusion with melphalan for recurrent melanomaof the limbs. J Am Coll Surg 1996;182:467–472.

33. Eggermont AMM: Treatment of melanoma in transit metastasisconfined to limb. Cancer Surv 1996;26:335–349.

34. Fraker D, Alexander H, Ross M, et al.: A phase III trial ofisolated limb perfusion for extremity melanoma comparing mel-phalan alone versus melphalan plus tumor necrosis factor (TNF)plus interferon gamma. Ann Surg Oncol 2002;9:S8.

35. Eggermont AMM, Brunstein F, Grunhagen D, et al.: Regionaltreatment of metastasis: role of regional perfusion. State of theart isolated limb perfusion for limb salvage. Ann Oncol 2004;15:iv107–iv112.

36. Noorda EM, Vrouenraets BC, Nieweg OE, et al.: Repeatisolated limb perfusion with TNF-alpha and melphalan forrecurrent limb melanoma after failure of previous perfusion. EurJ Surg Oncol 2006;32:318–324.

37. Di Filippo F, Giacomini P, Rossi CR, et al.: Prognostic factorsinfluencing tumor response, locoregional control and survival,in melanoma patients with multiple limb in-transit metastasestreated with TNFalpha-based isolated limb perfusion. In Vivo2009;23:347–352.

38. Cornett WR, McCall LM, Petersen RP, et al.: Randomizedmulticenter trial of hyperthermic isolated limb perfusion withmelphalan alone compared with melphalan plus tumor necrosisfactor: American College of Surgeons Oncology Group TrialZ0020. J Clin Oncol 2006;24:4196–4201.

39. Moreno-Ramırez D, de la Cruz L, Ferrandiz L, et al.: Study andtreatment of locally advanced melanoma. Actas Dermosifiliogr2009;100:767–779.

40. Padsis J, Turley R, Tyler D: Pharmacotherapy of regionalmelanoma therapy. Expert Opin Pharmacother 2010;11:79–93.

41. Hafstrom L, Rudenstam CM, Blomquist E, et al.: Regionalhyperthermic perfusion with melphalan after surgery forrecurrence malignant melanoma of the extremities. SwedishMelanoma Study Group. J Clin Oncol 1991;9:2091–2094.

42. Feldman AL, Alexander HR Jr, Bartlett DL, et al.: Managementof extremity recurrences after complete responses to isolatedlimb perfusion in patients with melanoma. Ann Surg Oncol1999;6:562–567.

43. Rossi CR, Foletto M, Pilati P, et al.: Isolated limb perfusion inlocally advanced cutaneous melanoma. Semin Oncol 2002;29:400–409.

44. Klaase JM, Kroon BB, van Geel AN, et al.: Prognostic factorsfor tumor response and limb recurrence-free interval inpatients with advanced melanoma of the limbs treated withregional isolated perfusion with melphalan. Surgery 1994;115:39–45.

45. Thompson JF, Hunt JA, Shannon KF, et al.: Frequency andduration of remission after isolated limb perfusion for mela-noma. Arch Surg 1997;132:903–907.

46. Krementz ET, Sutherland CM, Muchmore JH: Isolated hyper-thermia chemotherapy perfusion for limb melanoma. Surg ClinNorth Am 1996;76:1313–1330.

47. Balch CM, Buzaid AC, Soong SJ, et al.: Final version of theAmerican Joint Committee on Cancer staging systemfor cutaneous melanoma. J Clin Oncol 2001;19:3635–3648.

Results of Isolated Lower Limb Perfusion 723

Journal of Surgical Oncology