Surgical treatment of malignant melanoma of the limbs combined with thermochemotherapy under extracorporeal circulation

In spite of the better results observed during the last decades and particularly due to earlier diagnosis and earlier surgical excision, malignant melanoma remains a tumour with a disconcerting course. This relative therapeutic impotence explains the variety of treatments used, including chemotherapy, radiotherapy, immunotherapy, etc. Surgical excision after chemotherapy under hyperthermic regional perfusion with extracorporeal circulation is an original method which has been applied for more than 3 decades with conflicting results but which may prove useful in several circumstances. The principle of regional perfusion using cytostatic drugs injected into the regional arterial blood flow resulted from a study by Klopp et al. in 1950. This technique was developed in practice by Creech et al. in 1957, and it was improved about 10 years later by additional hyperthermia, an idea suggested by Cavaliere et al. and by Stehlin. In Strasbourg, we have been using this method since January, 1982. Indications for perfusion are melanoma of the limbs with Breslow thickness greater than or equal to 0.85 mm, but from 1984 onwards these indications have been limited to patients with high-risk tumours such as melanoma with a Breslow thickness greater than or equal to 1.5 mm. Such melanomas are situated on the upper limb below the brachial insertion of the deltoid muscle, and on the lower limb below the upper third portion of the thigh. The technique consists of regional chemotherapy of the limb using extracorporeal circulation with hyperthermic perfusion. Melphalan is the drug used, and its dosage is based on body-weight: 1.4 mg/kg for the lower limb, and 0.9 mg/kg for the lower limb. Melphalan is introduced in the perfusion when the subcutaneous temperature near the tumour reaches 38 degrees C. The temperature of the limb is maintained at 40-42 degrees C for 45 minutes. At completion of the perfusion a wash-out is performed, and the tumour is excised with a 3 cm margin. From January, 1982 to January, 1987, 68 patients with malignant melanoma were treated by this method. Perfusion could not be performed in 5 patients because the small caliber of the vessel did not allow sufficient perfusion flow rate. No lethal complication occurred, and morbidity was very low.(ABSTRACT TRUNCATED AT 400 WORDS)