Generic: Melphalan

Trade name: Alkeran ^®
Other names: L-PAM, Phenylalanine Mustard

Drug type: L-Sarcolysin is an anti-cancer ("antineoplastic" or "cytotoxic") chemotherapy drug.  L-Sarcolysin is classified as an "alkylating agent."  (For more detail, see "How this drug works" section below).

What L-Sarcolysin Is Used For:

• Multiple myeloma
• Ovarian cancer
• Neuroblastoma
• Rhabdomyosarcoma 
• Breast cancer
• Used in some conditioning regimens prior to bone marrow transplant

Note:  If a drug has been approved for one use, physicians may elect to use this same drug for other problems if they believe it may be helpful.

How L-Sarcolysin Is Given:

• As a pill by mouth.  Tablets come in a 2mg size.
• Take medication on an empty stomach (1 hour before to 2 hours after meals).
• As an injection or infusion into the vein (intravenous, IV).
• The amount of L-Sarcolysin that you will receive depends on many factors, including your height and weight, your general health or other health problems, and the type of cancer or condition being treated.  Your doctor will determine your dose and schedule.

Side Effects:

Important things to remember about the side effects of L-Sarcolysin:

• Most people do not experience all of the side effects listed.
• Side effects are often predictable in terms of their onset and duration. 
• Side effects are almost always reversible and will go away after treatment is complete.
• There are many options to help minimize or prevent side effects.
• There is no relationship between the presence or severity of side effects and the effectiveness of the medication.
• The side effects of L-Sarcolysin and their severity depend on how much of the drug is given.  In other words, high doses may produce more severe side effects).

The following side effects are common (occurring in greater than 30%) for patients taking L-Sarcolysin:

• Low blood counts.  Your white and red blood cells and platelets may temporarily decrease.  This can put you at increased risk for infection, anemia and/or bleeding.  This effect may be prolonged and cumulative.
• Nausea and vomiting. (mild with regular dosing, can be severe with high-dose therapy)

These side effects are less common side effects (occurring in about 10-29%) of patients receiving L-Sarcolysin:

• Allergic reaction (rare with pill form, happen in about 10% of patients treated with IV form).
• Mouth sores (mild with regular dosing, can be severe with high-dose therapy).
• Diarrhea (mild with regular dosing, can be severe with high-dose therapy).
• Loss of fertility. Meaning, your ability to conceive or father a child may be affected by L-Sarcolysin. Discuss this issue with your health care provider.
• Hair loss (rare with regular dosing, common with high-dose used for bone marrow transplant).
• Nephrotoxicity (see kidney problems): Uncommon with regular doses, seen when L-Sarcolysin is given in high-doses used for bone marrow transplant.
• Arrythmias (see heart problems): Uncommon with regular doses, seen when L-Sarcolysin is given in high-doses used for bone marrow transplant.

Delayed effects:

• There is a slight risk of developing a blood cancer such as leukemia or myelodysplasia after taking L-Sarcolysin.  Talk to your doctor about this risk.

Nadir:  Meaning low point, nadir is the point in time between chemotherapy cycles in which you experience low blood counts.

Onset:  7 days
Nadir:  8-10 days (white blood cells), 27-32 days (platelets).
Recovery:  42-50 days

Not all side effects are listed above. Some that are rare (occurring in less than 10% of patients) are not listed here.  However, you should always inform your health care provider if you experience any unusual symptoms.

When to contact your doctor or health care provider:

Seek emergency help immediately and notify your health care provider, it you experience the following symptoms:

• Shortness of breath, wheezing, difficulty breathing, closing up of the throat, swelling of facial features, hives (possible allergic reaction).

Contact your health care provider immediately, day or night, if you should experience any of the following symptoms:

• Fever of 100.4° F (38° C) or higher, chills (possible signs of infection)

The following symptoms require medical attention, but are not an emergency.  Contact your health care provider within 24 hours of noticing any of the following:

• Nausea (interferes with ability to eat and unrelieved with prescribed medication)
• Vomiting (vomiting more than 4-5 times in a 24 hour period)
• Diarrhea (4-6 episodes in a 24-hour period)
• Unusual bleeding or bruising
• Black or tarry stools, or blood in your stools or urine
• Extreme fatigue (unable to carry on self-care activities)
• Mouth sores (painful redness, swelling or ulcers)
• Yellowing of the skin or eyes. Signs of infection such as redness or swelling, pain on swallowing, coughing up mucous, or painful urination.

Always inform your health care provider if you experience any unusual symptoms.

Precautions:

• Before starting L-Sarcolysin treatment, make sure you tell your doctor about any other medications you are taking (including prescription, over-the-counter, vitamins, herbal remedies, etc.). Do not take aspirin, or products containing aspirin unless your doctor specifically permits this.
• Do not receive any kind of immunization or vaccination without your doctor's approval while taking L-Sarcolysin.
• Inform your health care professional if you are pregnant or may be pregnant prior to starting this treatment.  Pregnancy category D (melphalan may be hazardous to the fetus.  Women who are pregnant or become pregnant must be advised of the potential hazard to the fetus).
• For both men and women: Do not conceive a child (get pregnant) while taking L-Sarcolysin. Barrier methods of contraception, such as condoms, are recommended. Discuss with your doctor when you may safely become pregnant or conceive a child after therapy.
• Do not breast feed while taking this medication.

Self-Care Tips:

• If taking L-Sarcolysin pills take on an empty stomach 1 hour before or 2 hours after meals.
• Drink at least two to three quarts of fluid every 24 hours, unless you are instructed otherwise.
• You may be at risk of infection so try to avoid crowds or people with colds and those not feeling well, and report fever or any other signs of infection immediately to your health care provider.
• Wash your hands often.
• To help treat/prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda and/or 1/2 to 1 teaspoon of salt mixed with 8 ounces of water.
• Use an electric razor and a soft toothbrush to minimize bleeding.
• Avoid contact sports or activities that could cause injury.
• This medication when taken as pills causes little nausea.  But if you should experience nausea, take anti-nausea medications as prescribed by your doctor, and eat small frequent meals.  Sucking on lozenges and chewing gum may also help. 
• Avoid sun exposure.  Wear SPF 15 (or higher) sunblock and protective clothing.
• In general, drinking alcoholic beverages should be kept to a minimum or avoided completely.  You should discuss this with your doctor.
• Get plenty of rest. 
• Maintain good nutrition.
• If you experience symptoms or side effects, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.

Monitoring and Testing:

You will be checked regularly by your health care professional while you are taking L-Sarcolysin, to monitor side effects and check your response to therapy.  Periodic blood work to monitor your complete blood count (CBC) as well as the function of other organs (such as your kidneys and liver) will also be ordered by your doctor.   

How L-Sarcolysin Works:

Cancerous tumors are characterized by cell division, which is no longer controlled as it is in normal tissue.   "Normal" cells stop dividing when they come into contact with like cells, a mechanism known as contact inhibition.  Cancerous cells lose this ability.  Cancer cells no longer have the normal checks and balances in place that control and limit cell division.  The process of cell division, whether normal or cancerous cells, is through the cell cycle.  The cell cycle goes from the resting phase, through active growing phases, and then to mitosis (division).

The ability of chemotherapy to kill cancer cells depends on its ability to halt cell division.  Usually, the drugs work by damaging the RNA or DNA that tells the cell how to copy itself in division.  If the cells are unable to divide, they die.  The faster the cells are dividing, the more likely it is that chemotherapy will kill the cells, causing the tumor to shrink.  They also induce cell suicide (self-death or apoptosis).

Chemotherapy drugs that affect cells only when they are dividing are called cell-cycle specific.  Chemotherapy drugs that affect cells when they are at rest are called cell-cycle non-specific.  The scheduling of chemotherapy is set based on the type of cells, rate at which they divide, and the time at which a given drug is likely to be effective.  This is why chemotherapy is typically given in cycles.

Chemotherapy is most effective at killing cells that are rapidly dividing.  Unfortunately, chemotherapy does not know the difference between the cancerous cells and the normal cells. The "normal" cells will grow back and be healthy but in the meantime, side effects occur.  The "normal" cells most commonly affected by chemotherapy are the blood cells, the cells in the mouth, stomach and bowel, and the hair follicles; resulting in low blood counts, mouth sores, nausea, diarrhea, and/or hair loss.  Different drugs may affect different parts of the body.

L-Sarcolysin is classified as an alkylating agent.  Alkylating agents are most active in the resting phase of the cell.  These drugs are cell cycle non-specific.  There are several types of alkylating agents:

• Mustard gas derivatives:  Mechlorethamine, Cyclophosphamide, Chlorambucil, L-Sarcolysin, and Ifosfamide. 
• Ethylenimines:  Thiotepa and Hexamethylmelamine.
• Alkylsulfonates:  Busulfan.
• Hydrazines and Triazines: Altretamine, Procarbazine, Dacarbazine and Temozolomide. 
• Nitrosureas:  Carmustine, Lomustine and Streptozocin.  Nitrosureas are unique because, unlike most chemotherapy, they can cross the blood-brain barrier.  They can be useful in treating brain tumors.
• Metal salts:  Carboplatin, Cisplatin, and Oxaliplatin.

Note:  We strongly encourage you to talk with your health care professional about your specific medical condition and treatments. The information contained in this website is meant to be helpful and educational, but is not a substitute for medical advice.

Chemocare.com is designed to provide the latest information about chemotherapy to patients and their families, caregivers and friends. For information about the 4th Angel Mentoring Program visit www.4thangel.org