Is there an indication for a double perfusion schedule with melphalan for patients with recurrent melanoma of the limbs?

It has been reported that a double perfusion schedule shows a better complete remission rate than does the single procedure for recurrent melanoma of the limb. As more perfusion strategies approach the ideal of a 100% complete remission rate, the main issue now is to prolong the period of disease control in the limb, ie to reduce the limb recurrence rate. The follow up of 42 patients treated with a double perfusion schedule and of 45 patients treated with a single perfusion procedure was updated to compare the duration of limb disease control. Both treatment groups were well balanced with respect to patient and tumour characteristics. For patients treated with a double schedule, the dose of melphalan given in the first perfusion was low (6 mg/l limb volume; 1 h; normothermic) in order to make it possible to carry out a second perfusion (9 mg/l; 1 h; normothermic) with a planned short interval of 3-4 weeks. In the single perfusion group a normothermic perfusion with 10 mg melphalan/l was carried out. The acute tissue reactions and long-term side effects did not differ between the two treatment modalities. The response rate was significantly higher in the double perfusion group owing to a higher complete remission rate (76% vs 48%; P=0.006). However, no significant difference was seen in limb disease control rates 3 years after perfusion (double schedule, 36%; single schedule, 30%), nor in overall 3-year survival (double schedule, 52%; single schedule, 45%). When evaluating perfusion regimens with equally high complete remission rates, attention should be focused on the duration of limb disease control.