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Isolated Limb Perfusion With Melphalan Triggers Immune Activation in Melanoma Patients

Journal article
Authors Junko Johansson
Roberta Kiffin
Annica Andersson
Per Lindnér
Peter Naredi
Roger Olofsson Bagge
Anna Martner
Published in Frontiers in Oncology
Volume 8
ISSN 2234-943X
Publication year 2018
Published at Institute of Clinical Sciences, Department of Surgery
Sahlgrenska Cancer Center
Institute of Biomedicine, Department of Infectious Medicine
Language en
Keywords melanoma, isolated limb perfusion, melphalan, monocytes, cytotoxic T cells, in-transit melanoma, t-cells, calreticulin, chemotherapy, lymphocytes, metastases, monocytes, antigens
Subject categories Cancer and Oncology


Hyperthermic isolated limb perfusion with melphalan (M-ILP) is a treatment option for melanoma patients with metastases confined to the limbs. This study aimed at defining the role of cellular immunity for the clinical response to M-ILP in melanoma patients. It was observed that patients with enhanced cytotoxic CD8(+) T cell reactivity to common antigens (HCMV/EBV/influenza virus) prior to M-ILP were more likely to achieve a complete disappearance of macroscopic tumors (complete response). Following M-ILP treatment, the proportions of CD16(+) intermediate and non-classical monocytes in peripheral blood were significantly enhanced along with induction of HLA-DR on CD4(+) and CD8(+) T cells. For further studies of the mechanism behind melphalan-induced immune activation an in vitro model, aiming at mimicking the clinical M-ILP protocol, was established, where PBMCs were co-cultured with melanoma cells, which had been pre-exposed to melphalan under mild hyperthermia. Upon exposure to melphalan, melanoma cells showed increased expression of immune-related markers including MHC class I and Hsp70. Moreover, when the melphalan-treated melanoma cells were co-cultured with PBMCs, this triggered an increased proportion of CD33(+)CD14(+)CD16(++) non-classical monocytes among the PBMCs. Furthermore, the melphalan-treated melanoma cells stimulated the expansion of CD8(+) T cells in the co-cultured PBMCs. These cells produced enhanced levels of IFN-gamma and granzyme B and were capable of killing melanoma cells. To further verify an immunogenic role of melphalan, mice were vaccinated with melphalan-exposed murine melanoma cells. When challenged with live melanoma cells, vaccinated mice showed reduced tumor growth and enhanced infiltration of tumor-specific T cells into tumors. We conclude that melphalan-exposed melanoma cells trigger expansion of CD16(+) monocytes and activate cytotoxic T cells and that these events may contribute to the antitumoral efficacy of M-ILP.

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