Luigi Mascheroni

Results obtained by using a computerized image analysis system designed as an aid to diagnosis of cutaneous melanoma

Results obtained using a computerized image analysis system as an aid to clinical diagnosis of melanoma are reported. The system comprises a colour television camera connected through a digitizing board to a 386 personal computer. By means of original algorithms able to measure the shape, the colours and texture of a pigmented lesion of the skin, the system provides eight on/off indicators that are matched with the histological diagnosis to identify benign and malignant pigmented lesions. The chances that a given lesion is malignant increase with the increasing number of positive indicators. The training field of the system was constituted of images and data of 169 cutaneous lesions in 165 patients. Taking two positive indicators as the threshold between pigmented benign and malignant lesions, the efficiency of the system is 0.98, the positive predictive value is 0.45 and the negative predictive value is 0.95. These values were confirmed in a series of 44 pigmented lesions, 10 of which were melanoma, that constitute the present test series. The authors conclude that this computerized image analysis system should be regarded as a useful aid to diagnosis for a non-expert clinician. The system limit is transformation within a naevus.

Neurotoxicity of interferon-α in melanoma therapy: Results from a randomized controlled trial

The objective of this study was to evaluate the neurologic and quality of life impact of low dose adjuvant interferon (IFN)‐α immunotherapy in patients with malignant melanoma metastatic to regional lymph nodes after radical surgery.

Active immunization of metastatic melanoma patients with interleukin-2-transduced allogeneic melanoma cells: evaluation of efficacy and tolerability.

Abstract From January 1994 to July 1996 we immunized metastatic melanoma patients with HLA-A2-compatible, interleukin-2 (IL-2)-secreting, immunogenic melanoma lines in an attempt to induce a systemic reaction that might also affect distant melanoma lesions. Twelve patients (6 male and 6 female) aged from 28 to 72 years, affected with visceral and/or subcutaneous (s.c.) melanoma metastases, were treated. Two different HLA-A2+ melanoma lines were transduced with the human IL-2 gene (14932/IL-2 and 1B6/IL-2) and used as vaccine. Two groups of 4 patients each were injected s.c. with 5×107 and 15×107 irradiated 14932/IL-2 melanoma cells respectively, whereas a third group received 5×107 cells of the second line (1B6/IL-2). All patients received the vaccine on days 1, 13, 26; if no progression was evident, further immunizations were administered at monthly intervals. All patients were assessable for clinical response after at least three injections of the vaccine. In 4 cases a stabilization of disease lasting from 2 to 6 months was observed; in 2 of them a mixed type of response to treatment was noted with simultaneous evidence of regressing and non-responding lesions in the same patients. No signs of clinical response were found in the remaining patients. Nine patients died of disease between 3 and 24 months after the onset of therapy, whereas 3 were alive 3 months after the end of therapy. The local and systemic side-effects of treatment were mild. These results indicate that vaccination with cells bearing the appropriate antigens and releasing IL-2 locally can produce weak clinical responses, but also indicate that better results may be achieved through modifications of the vaccine, the schedule of immunization and/or a more appropriate selection of patients.

Adoptive immunotherapy of advanced melanoma patients with interleukin-2 (IL-2) and tumor-infiltrating lymphocytes selected in vitro with low doses of IL-2

Freshly isolated tumor-infiltrating lymphocytes (TIL) from stage IV melanoma patients were cultured for 2 weeks with low doses of interleukin-2 (IL-2; 120 IU/ml), to select potentially for tumor-specific lymphocytes present in the neoplastic lesion, followed by high doses (6000 IU/ml) to achieve lymphocyte expansion. TIL were serially analyzed for their expansion, phenotype and cytotoxic activity against autologous and allogeneic tumor cells. A preferential lysis of autologous melanoma cells was obtained in long-term cultures of 7/13 cases (54%), while the remaining ones showed a major-histocompatibility-complex-unrestricted, lymphokine-activated-killer(LAK)-like activity at the time of in vivo injection. Sixteen patients with metastatic melanoma were infused with TIL (mean number: 6.8×109, range: 0.35 × 109−20 × 109) and IL-2 (mean dose: 130 × 106 IU, range: 28.8 × 106−231 × 106 IU); 1 complete and 3 partial responses were observed in 12 evaluable patients (response rate 33%). In all responding patients, injected TIL showed an in vitro preferential lysis of autologous tumor cells, while in no cases were TIL with LAK-like activity associated with a clinical response. The mean autologous tumor cytotoxic activity of TIL at the time of in vivo injection was significantly higher in responding patients in comparison to nonresponding ones, suggesting that a marked and preferential cytolysis of autologous tumor cells is associated with the therapeutic efficacy of TIL.

New perspective in the treatment of low rectal cancer: Total rectal resection and coloendoanal anastomosis

PURPOSE: Presently abdominoperineal resection still remains the most diffuse modality of treatment of low rectal cancer. However, a new surgical approach is now available to avoid such a demolitive surgery and a definitive colostomy. METHODS: From March 1990 to March 1993, 58 total rectal resections were performed in 55 patients affected with primary or recurring cancers of the low rectum. As a restorative procedure, a colic J-shaped pouch and a handsewn pouch-endoanal anastomosis was adopted. All of the primary lesions were within 7 cm of the anal verge; in 74 percent the distal tumor margin was located less than 6 cm from the cutaneous edge. RESULTS: Histologic clearance of the rectum cut edge was documented in all cases. Seven patients relapsed locally from 7 to 14 months after surgery and in 3 more cases distant metastases were documented. Postoperative morbidity is low. After colostomy closure in 78 percent of patients, perfect continence was achieved and in 74 percent less than two bowel movements a day were recorded. Fifty patients are presently alive, 46 without evidence of disease. The follow-up ranged from 2 to 37 (median, 13) months. CONCLUSION: This experience, along with data obtained from last years literature, indicates that a conservative surgical procedure, such as total rectal resection and coloendoanal anastomosis, can be considered a feasible and radical option for treatment of low rectal cancer.

SENTINEL NODE BIOPSY AND SELECTIVE DISSECTION FOR MELANOMA NODAL METASTASES

Background Early detection of nodal metastases still represents an important goal in the management of melanoma patients. A sentinel node is defined as the first colored node in the regional lymphatic basin following injection of blue dye in the site of the primary melanoma. Sentinel node biopsy may represent a feasible technique for early identification of occult disease. A therapeutic dissection is then performed only in patients with proven nodal disease, thus introducing the concept of selective dissection. Methods At the National Cancer Institute of Milan from February 1994 to October 1996, 74 patients with a melanoma of the trunk or limbs and without clinically detectable node metastases were submitted to sentinel node biopsy and eventual selective dissection. Results The sentinel node was identified in 67 patients (90%). Nodal metastases were detected in 11 patients (16%); 5 of these were identified by an intraoperative frozen section examination. In all but one case, only the sentinel node was affected at radical dissection. Incidence of positive sentinel nodes was correlated with depth of infiltration of the primary lesion. Mapped nodal basin failures were observed in 3 patients with negative sentinel node biopsy. All patients but one, presenting distant metastases, are alive at this writing and free of disease with a follow-up ranging from 2 to 34 months. Conclusions Our study adds to accumulating evidence supporting the efficacy of sentinel node biopsy in detecting occult localizations and the potential of the technique to better select the group of patients that may benefit from nodal dissection.

Evaluation of clinical efficacy and tolerability of intravenous high dose thymopentin in advanced melanoma patients.

Thymopentin (TP5) has been recently evaluated as an immunotherapeutic agent for the treatment of cancer. Melanoma is a highly immunogenic malignancy, and in our previous studies the treatment of metastatic melanoma with TP5 showed encouraging results. In the present study, we evaluated the clinical efficacy and tolerability of high dose intravenous TP5 in 16 patients with melanoma which had metastasized to cutaneous and subcutaneous tissue. All patients were given 1 g intravenous TP5 every second day for 7 weeks and were then evaluated; responders were given a subsequent course of 2g intravenous TP5 every second day for 5 weeks. Six patients showed a partial response after the first course and were given the second course: one patient achieved a complete response, while the other five remained in partial response at the end of the treatment. The mean duration of response was 7.5 months. No drug side effects were observed. Histopathological and immunohistochemical evaluation of regressing metastatic nodules showed the presence of tumour-infiltrating lymphocytes, necrosis, sclerosis, intratumoral vascular proliferation and microthrombosis. Immunophenotyping of lymphoid infiltrates demonstrated the prevalence of CD4+ and CD45RO+ T-lymphocytes in one patient. We conclude that high dose intravenous TP5 three times a week may induce a clinical response in patients with cutaneous and subcutaneous metastases of melanoma without relevant side effects.

Total rectal resection, mesorectum excision, and coloendoanal anastomosis: a therapeutic option for the treatment of low rectal cancer.

AbstractBackground: There is recent and sporadic evidence indicating that patients with very low rectal cancer may be treated via a sphincter-saving procedure, obviating the need for abdominoperineal resection and definitive colostomy. This study confirms these findings. Methods: From March 1990 to October 1994, 79 patients affected with primary low rectal cancers were submitted for total rectal resection, mesorectum excision, and coloendoanal anastomosis. All lesions were located within 8 cm of the anal verge (within 6 cm in 64 cases). Results: Eight patients relapsed at the pelvic level, and one patient only at the paraanastomotic site. Postoperative morbidity attributable to the procedure was low. A perfect continence was documented in 66% of cases after colostomy closure, and many patients (63%) had one or two bowel movements a day. Sixty-two patients of this series are alive, 49 without actual evidence of disease. Follow-up ranged from 2 to 56 months (median 23). Conclusions: The clinical and pathological data derived from this study suggest that radical mesorectum excision more than a large clearance margin of resection remains the most important factor in reducing the incidence of local relapse after low rectal cancer surgery and that total rectal resection and coloendoanal anastomosis is a suitable and safe option to traditional, demolitive surgical techniques.

Perinodular injection of thymopentin (TP5) in cutaneous and subcutaneous metastases of melanoma.

The potential therapeutic efficacy of TP5 in patients with cutaneous and subcutaneous metastases of melanoma was tested in a double-blind study comparing the drug and placebo injected perinodularly. Of the 47 nodules present in the 16 patients treated with TP5, 24 showed a measurable response, whereas only one out of 15 nodules in patients treated with a placebo showed a minor response (P = 0.02). In two patients treated with TP5 a response of two nodules not perinodularly injected was also observed. Sclerosis, CD45RO+ cells and MIB 1− cells were more frequently observed in nodules treated with TP5 than with placebo. (P = 8 ± 10−4; 0.03 and 0.01, respectively). Evaluating the trends of these findings in nodules treated with placebo; with TP5-treated, non-responding nodules; or with TP5-treated, responding, a positive trend was observed for sclerosis and CD45RO+ cells (P = 5 ± 10−4 and 2 ± 10−3, respectively) and a negative one for MIB 1 cells (P = 2 ± 10−3). These preliminary data suggest that lymphoid cells associated with nodules regression are activated large lymphocytes (CD45RO+ and CD3−). Sclerosis might be Interpreted as the final morphologic event, and reduction of proliferative activity (MIB 1- cells) as the conseqence of cytolytic action.

Treatment of recurrent in transit metastases from cutaneous melanoma by isolation perfusion in extracorporeal circulation with interleukin-2 and lymphokine activated killer cells. A pilot study.

Chemoresistant melanoma cells are known to be susceptible in vitro to lymphokine activated killer (LAK) cells. To obtain a high LAK/tumour cell ratio in vivo and avoid systemic toxicity due to interleukin-2 (IL-2), we used IL-2 plus LAK cells in the treatment of in transit melanoma metastases of the limbs by isolation perfusion (IP). In vivo immunological modifications induced by this immunotherapeutic approach were also analysed. Six patients previously treated with IP in extracorporeal circulation with tumour cytotoxic drugs and presently relapsing or not responding, were submitted to locoregional adoptive therapy consisting of 5 days systemic administration of IL-2 (Proleukin, EuroCetus) (9–12x106 IU/m2/day c.i.). Autologous LAK cells were derived from leuka-pheresis and subsequent in vitro stimulation with IL-2; LAK cells were then given along with IL-2 (120–2400 IU/ml of perfusion priming) to the affected limb by IP. In addition, 7–16x109 LAK cells were administered by systemic infusion the day after together with IL-2 (9–12x106 IU/m2/day) c.i. for 5 days. All patients concluded the treatment without major toxicity. The analysis of circulating lymphocytes obtained from extracorporeal circuit at different times revealed rapid disappearance of LAK cells, suggesting their extravasation and/or endothelial adhesion in perfused tissues. Clinical responses included four partial and one complete response; another patient had stable disease. All patients are presently alive. Follow-up after IP ranges from 8 to 22 months.