James H. Muchmore

Prognostic evaluation of intracranial metastasis in malignant melanoma.

AbstractBackground: Malignant melanoma (MM) is often reported as the third most common cause of intracranial metastasis (IM) after carcinoma of the breast and lung. Most patients with advanced MM will have widespread extracranial disease, but the majority will die from intracerebral spread. Methods: A retrospective review of 117 patients with documented IM from MM over the past 25 years was undertaken. Various factors (including age, race, sex distribution, primary lesions with Clarks level, Breslows thickness, primary sites and staging at initial presentation, diagnosis of IM and its various treatment methods, survival data, and autopsy findings) were analyzed. Prognostic indicators were clarified from this analysis as a predictor of central nervous system (CNS) metastasis. An ideal treatment plan was also analyzed in order to predict a better survival. Results: Fifty-eight percent of patients were male; 42% were female. Seventy-one percent of the primary lesions were of Clarks level IV and V, with mean Breslows thickness of 3.5 mm. Median time interval between the initial diagnosis and development of IM was 3.5 years. Complete surgical resection of the intracranial lesion in the brain resulted in the longest mean survival of 10.3 months, whereas mean survival for the group with no treatment was only 3 weeks. Patients with primary lesions of the head and neck had the lowest mean survival of 3.3 months, whereas those whose primary sites were unknown had the longest mean survival of 7.5 months. One- and 2-year survival were 9% and 3%, respectively. All but one of the 30 patients at autopsy were found to have visceral metastasis, namely of the lung, liver, and bone. Conclusion: An aggressive search for metastasis should be undertaken in patients at high risk of developing CNS metastasis, e.g., male, head and neck primary, Clarks level IV and V, Breslows thickness of >3 mm, and presence of visceral metastases, mainly lung. A complete surgical resection should be attempted whenever possible, with adjunctive use of whole-brain irradiation, along with systemic chemotherapy for further control of recurrence and to prolong survival.

Acral lentiginous melanoma

Between 1958 and 1990, 82 patients with acral lentiginous melanoma were treated by the Tulane Surgical Service with regional perfusion, excision of lesion, and lymph node dissection. The patient group comprised 27 white men, 29 white women, 18 black men, and 8 black women, with an average age of 61 years. More foot lesions than hand lesions were reported, and all the lack men had foot lesions. In stage I patients, overall 5-year survival rates were 65% at 5 years and 44% at 10 years, with differences by race and gender. The black men did poorest, with a 13% 10-year survival rate. Survival rates were worse with increasing disease stage when calculated using univariate analysis. The 5-year survival rate of all patients with stage III and stage IV disease was 26%. A multivariate analysis was performed in 78 of 82 patients in whom all variables of Clarks level, age, race, stage, and sex were known. A strong relationship was observed between decreasing survival time and increasing Clarks level, with stage of marginal significance. In a multivariate analysis of patients with stage I disease, an increasing level of invasion was found to be significant, with a trend for a relationship to thickness. A trend toward decreased survival time was observed in men and blacks.

Clinical Science Review: Regional Perfusion for Malignant Melanoma and Soft Tissue Sarcoma: A Review

(1985). Clinical Science Review: Regional Perfusion for Malignant Melanoma and Soft Tissue Sarcoma: A Review. Cancer Investigation: Vol. 3, No. 2, pp. 129-143.

Isolated hyperthermia chemotherapy perfusion for limb melanoma.

Safe techniques for regional chemotherapy of the limbs by perfusion are now available. The method is effective in obtaining regionally confined high levels of toxic drugs or chemotherapeutic agents in the isolated areas. The best responses have been observed in limb melanoma with recurrent or intransit disease. Chemotherapy by perfusion as an adjunct to surgical excision reduces the local recurrence and the regional and lymph node metastases. Our survivals for adjunctive perfusion for Stage I melanomas with Level V and lesions 5 mm thick and thicker are better than usually reported. Regional chemotherapy has had an important role in reduction of major amputations for the control of limb melanoma. Multiple chemotherapeutic limb perfusions can further extent survival in patients with recurring melanoma.

Regional Chemotherapy: Overview

Regional chemotherapy was developed in the 1950s and continues to play an integral part in the development of newer therapies for advanced solid malignancies. Regional therapies have evolved in complexity but are still based on the pharmacokinetics of drug delivery to solid malignancies. Newer techniques demonstrate that the combination of regional therapies, hyperthermia, and surgery is essential in promoting improved patient outcomes.

Computed tomography of infiltrating benign lipoma

Lipomas are frequently encountered benign tumors of adipose tissue origin. A lipoma generally develops in the superficial subcutaneous tissues but may occasionally be deep seated, growing between or within muscles. Deep-seated lipomas (excluding body cavities and viscera) have been termed infiltrating benign lipomas, of which there are two varieties--lipoma and angiolipoma. We wish to report three cases of infiltrating benign lipomas. Computed tomography scanning is the diagnostic modality of choice in the evaluation of these tumors.

Pre- and Perioperative Perfusion Chemotherapy for Soft Tissue Sarcoma of the Limbs

Soft tissue sarcomas are relatively rare tumors. Each year in the U.S., there are approximately 5,500 new cases and 2,900 deaths attributed to these tumors [1,2]. Approximately 60% of these tumors develop in the extremities.

Wirkstoffeliminationssysteme und Induktionschemotherapie

Seit Beginn der chemotherapeutischen Behandlung von Krebs Anfang der 1940er Jahre [1–3] wurden zahlreiche Wirkstoffe, Vorrichtungen und Methoden zur Behandlung fortgeschrittener solider Tumore entwickelt. Diese hatten eine Verbesserung der Wirkstoffzufuhr zum Ziel, wobei gleichzeitig sowohl die lokale/regionale als auch die systemische Toxizitat in vertretbaren Grenzen gehalten werden sollte. Die Toxizitat als dosisbeschrankender Faktor bei den meisten Chemotherapeutika ist nicht das einzige Hindernis fur bessere Tumoransprechraten und klinische Ergebnisse. Die Wirkstoffzufuhr in die Tumorzellen stellt jedoch weiterhin einen der Hauptfaktoren dar, der eine komplette Remission bei fortgeschrittenen malignen Erkrankungen verhindert.

Drug Removal Systems and Induction Chemotherapy

Regional chemotherapy developed in the 1950s continues to play an integral part in the development of newer therapies for advanced solid malignancies. Regional therapies have evolved in complexity, but are still based on the pharmacokinetics of drug delivery to solid malignancies. The quest remains on how to get more antineoplastic agent to the tumor-bearing region with less side effects and toxicity. Hemodialysis, hemofiltration, and hemoperfusion are used to improve systemic and regional drug clearance. These newer techniques using drug removal systems demonstrate that the combination of regional therapies plus surgery can be essential in promoting improved patient outcomes.

Randomized trials of heated perfusion of extremity melanoma

Regional isolation perfusion has been performed at Tulane Medical Center for a variety of diseases and anatomic locations since 1957. These data were gathered from 897 patients with limb involvement of melanoma treated from 1957 to 1983. Melphalan (1-PAM) has been the drug used most commonly, alone in 69% of the patients and in combination with other drugs in 22%. No emphasis was placed on temperature until the mid-1960s, when temperatures were elevated to 40°C in the limb. Higher temperatures have been related to excessive toxicity; therefore, limb temperatures have been maintained at 39°C to 40°C. Only one death, which was secondary to pulmonary embolism, has occurred since 1967. Locoregional complications with infection, edema, nerve or muscle damage, thrombosis, and amputation have occurred, but have been infrequent since drug dose and temperature were standardized (e.g., only two amputations occurred in the last ten years, both as calculated risks in high-risk patients with vascular disease and extensive metastases). In 381 Stage I patients (primary melanoma), the ten-year survival rate has been 79%; in 39 Stage II patients (local metastases within 3 cm of the primary), 60%; in 333 Stage III patients (regional lymph node or soft tissue metastases, or both), 42%; and in 144 Stage IV patients (positive iliac or supraclavicular nodes, trunk primary with limb metastases, or limb primary with systemic metastases), 8% [1].