Case C (Status: died in April 2011; survival: 3 years)

A 57-year-old male presented in May 2005 for amputation of his right middle finger for advanced subungual acral lentiginous melanoma, Clark level IV, Breslow depth 2.5 mm. In January 2008, he was found to have bilateral pulmonary metastases and he was commenced on six cycles of DTIC, which successfully reduced the size of these tumors by November 2008. In June 2009, CT scans showed progression of a right hilar mass and the patient was commenced on fotemustine, which was not effective. In February 2010, he began a trial of timed administration of the VMCL vaccine with oral cyclophosphamide (2×50 mg doses per day intermittently) with immune monitoring based on high-sensitivity C-reactive protein levels. Stability of disease was observed for 2 months. In April 2010, a left ischiorectal fossa melanoma metastasis was surgically resected. In August 2010, a CT scan revealed further pulmonary, hepatic, and bony metastases. Radiotherapy was given to the right hilar metastatic deposit and mediastinum, with some success. In September 2010, he developed a metastasis to his left buttock, which was completely excised, and in October he went on to develop multiple subcutaneous metastases to his scalp, neck, and jaw. He recommenced palliative treatment with DTIC chemotherapy in November, but failed to respond. In January 2011, he was noted to have an increasingly severe cough and had developed subsequent pneumonia with pleural effusions. The pleural effusions were drained but he recovered incompletely and died.

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Case D (Status: alive and disease-free; survival: 13 years)

A 58-year-old male presented in 2000 with malignant melanoma in the liver, with no identified primary tumor. This was completely resected, and he went on to develop metastases to his scalp in 2001, which were also completely excised. Chemotherapy was declined. He has remained well since. No other treatment apart from self-termed “positive thinking” was instituted.

Case E (Status: died in March 2010; survival: 8 years)

A 45-year-old male presented in late 2000 for WLE of a melanoma of his right ear, Clark level III, and Breslow depth 0.45 mm. In 2002, he re-presented for excision of a metastasis to his right eye and adjuvant chemotherapy. In early 2007, he developed a subcutaneous metastasis to his left buttock, as well as pulmonary and renal secondaries. He commenced VMCL vaccine therapy, which was initially effective, but he went on to develop a metastasis to a left groin lymph node later that year, for which he received radiotherapy. In 2009, he underwent several cycles of fotemustine chemotherapy with some decrease in the size of his pulmonary metastases. However, in early 2010, the patient deteriorated quickly, developing multiple brain metastases that were not responsive to whole-brain radiotherapy. In addition, he required sigmoid colon resection and stoma formation after mesenteric metastases caused colonic obstruction. Imaging in February 2010 revealed progression with pulmonary, hepatic, gastrointestinal, and lymphatic metastases.

Case F (Status: died in October 2009; survival: 6 years)

A 60-year-old male presented in 2003 with two primary melanomas: left flank Clark level IV, Breslow depth 2.91 mm; and lower back Clark level IV, Breslow depth 1.01 mm. Metastatic disease was diagnosed on sentinel node biopsy in 2003, with radical axillary dissection, then multiple subcutaneous in-transit metastases to his anterior chest wall occurred over 5 years, all of which were completely excised. Pulmonary/pleural metastases were noted in March 2008, prompting the commencement of the VMCL vaccine in April 2008. A further subcutaneous metastasis to his left thigh was noted in July, but it was not excised. He commenced concurrent DTIC chemotherapy in January 2009. In August 2009, a cerebellar metastasis was excised, and radiotherapy was commenced for leptomeningeal seeding. Later CT scans revealed disseminated disease of the lungs, gallbladder, left adrenal gland, peritoneum, epicardium, muscle, bone, and spine. The patient recommenced the VMCL vaccine trial and chemotherapy with fotemustine with some initial stabilization of disease, but he died later that year.

Case G (Status: alive and disease-free; survival: 12 years)

A 59-year-old male presented in 1999 for WLE of a primary Clark IV, Breslow 4.5 mm melanoma of his central back. In 2001, recurrences in the right neck and right lung were surgically excised and radiotherapy was delivered to those areas. In 2005, further metastases to the left buttock and back were fully excised and targeted radiotherapy was delivered to the buttock. Further to this, resection of a malignant right retrocrural mass encircling the esophagus was performed, but residual melanoma was documented on the pathology report. In 2006, the patient underwent a sigmoid colectomy for metastatic bowel deposits, and later that same year, underwent resection of cutaneous metastasis of the scalp and a radical right axillary dissection. In November of 2006, the patient commenced VMCL vaccine trial therapy, and he has remained disease-free since.

Case H (Status: alive and disease-free; survival: 14 years)

A 41-year-old female presented in 1987 for excision of what was reported to be a benign Spitz nevus of her left calf. In 1999, excision of a nodule adjacent to the scar revealed melanoma. A WLE and sentinel node dissection was then performed. Review of the previous pathology revealed the initial lesion to be a malignant Spitzoid melanoma. Over the following 2 years, the patient required multiple excisions for in-transit recurrences near the original site, and in August of 2000, she required a radical left inguinal and pelvic lymph node dissection and was commenced on the C-Vax vaccine from October 2000 to February 2001, when further local subcutaneous recurrences occurred and were excised. She was commenced on VMCL vaccine in March 2001. CT scans in early 2001 showed multiple pulmonary deposits, and in November 2001, hepatic metastases. In late 2002, CT scans demonstrated disseminated disease involving the mediastinum, lungs, liver, and spleen. In September 2002, DTIC chemotherapy was commenced. Further CT scans in April 2003 demonstrated a marked reduction in the size of her pulmonary nodules and no evidence of metastatic disease elsewhere. The patient remained well until 2006, when she was diagnosed with a deep, lobulated, large, soft tissue calf metastasis involving the left tibia for which she underwent isolated limb infusion chemotherapy with melphalan and actinomycin-C, and radiotherapy. The mass stabilized then gradually regressed, and medullary reamings from orthopedic stabilization for a pathological fracture revealed no malignancy. In August 2007, right sacroiliac joint metastases were treated with radiotherapy, and she recommenced the VMCL vaccine in February 2008, after a PET scan showed persistent bony metastases. CT and PET imaging demonstrated a renal metastasis in June 2008. The VMCL vaccine was ceased in September 2008, as the renal metastasis was regressing. The initial partial responses developed into a CR by late 2009. CT scans to date have shown no metastatic disease.