Regional therapies for in-transit disease

Abstract

In-transit melanoma is an uncommon pattern of recurrence, but presents unique management challenges and opportunities for treatment. The clinical presentation usually involves from 1 to more than 100 small subcutaneous or cutaneous nodules, ranging from submillimeter to multiple centimeters in diameter. Regional chemotherapy techniques are a mainstay of treatment of patients without systemic disease spread. Future applications of regional therapy are likely to involve combination therapy with cytotoxic agents and novel immune modulators. Regional therapy provides distinct opportunities for the treatment of unresectable disease, and offers a unique platform for investigation of novel therapeutics in early-stage clinical trials.

Keywords: In-transit melanoma; Isolated limb infusion; Isolated limb perfusion; Regional therapy.

FIGURE 1

The spectrum of clinical presentation for patients with in-transit melanoma of the extremity. Disease can manifest as (A) low-volume disease or solitary nodules, (B) multifocal unpigmented lesions, (C) multifocal disease with diffuse dermal spread, or (D) traditional multifocal dark pigmented lesions.

FIGURE 2

HILP. (From Coleman A, Augustine CK, Beasley G, et al. Optimizing regional infusion treatment strategies for melanoma of the extremities. Expert Rev Anticancer Ther 2009;9(11):1600; with permission.)

FIGURE 3

ILI. (From Coleman A, Augustine CK, Beasley G, et al. Optimizing regional infusion treatment strategies for melanoma of the extremities. Expert Rev Anticancer Ther 2009;9(11):1602; with permission.)

FIGURE 4

A complete durable response following temozolomide ILI in a patient who previously progressed after melphalan ILI. (A) Progressive disease within 3 months following initial treatment with melphalan ILI. (B) The same patient showing complete pathologic response following a subsequent temozolomide ILI, with evidence of residual nonmalignant pigmentation out to 12 months after infusion.

FIGURE 5

Typical time course of a complete response following regional therapy, showing steady resolution of in-transit melanoma lesions over a 12-week postoperative period.

FIGURE 6

Patterns of tumor regression in 2 patients who experienced complete responses following regional therapy. Nonpigmented lesions (A) typically resolve visually, whereas pigmented lesions (B) following complete response often leave a tattooed-appearing area consisting of pigment-laden macrophages with no viable tumor on biopsy.