Twenty-seven patients with locally recurrent melanoma of the lower extremity were treated during a six year period. Recurrences were noted with primary lesions, at Clark's level II, III, IV or V, greater than 1.7 millimeters in depth of invasion and included intransit metastases, satellitosis, subcutaneous metastases and combinations of the three. Median time to recurrence was 12 to 14 months whether or not lymphadenectomy had been performed or lymph node metastases were present. Local recurrence was treated initially with intratumor bacille Calmette Guérin; 20 of 27 patients had complete or transient disease control and 14 patients were alive at 1.5 to 55.0 months. More responders reacted to dinitrochlorobenzene and purified protein derivative skin tests, although these parameters did not predict response to therapy. If intratumor bacille Calmette Guérin therapy did not control local disease or if the disease progressed toward the upper third of the thigh, patients underwent hyperthermic perfusion with L-phenylalanine mustard. Nine patients underwent ten therapeutic perfusions with objective response in seven of nine, with five being alive at two to 65 months. Intratumor bacille Calmette Guérin therapy and subsequent hyperthermic perfusion in bacille Calmette Guérin failures are rational treatment alternatives for locally recurrent melanomas of the extremity.