Isolated limb infusion for melanoma: a simple alternative to isolated limb perfusion.

OBJECTIVE: To describe initial experience with the new technique of isolated limb infusion (ILI) for in-transit melanoma. DESIGN: A prospective case series. SETTING: The major tertiary care oncology centre for the state of Victoria, Australia. PATIENTS: Nine patients having for extensive in-transit limb melanoma INTERVENTIONS: All patients received ILI (13 treatments). OUTCOME MEASURES: Patient survival, response to treatment and complications of treatment. RESULTS: There were no perioperative deaths and morbidity was limited to deep venous thrombosis and pulmonary embolism in 1 patient. Control of the in-transit metastases was achieved to some degree in all patients and was complete in 4. CONCLUSIONS: ILI is an alternative treatment modality for patients suffering from multiple, advanced in-transit melanoma metastases. It provides effective palliation with limited morbidity and offers a safe, quick, inexpensive alternative to isolated limb perfusion with comparable results.     

Isolated limb perfusion for recurrent melanoma of the extremity.

Recent reports in the literature suggest that hyperthermic isolated limb perfusion (HILP) may be effective in preventing local recurrence in patients with deeply invasive melanoma or in patients with recurrent disease confined to the extremity. It has been used in the past as an adjuvant treatment after resection of the primary melanoma or recurrence, or as a therapeutic measure if all the disease on the extremity cannot be resected. A prospective, nonrandomized trial of 16 patients with melanoma with recurrent disease confined to the extremity underwent HILP. The protocol involved the wide local excision of all recurrent disease when possible, elective or therapeutic node dissection when indicated, and HILP using cisplatin. In 11 patients in whom all recurrent disease could be resected and the HILP was considered prophylactic, only 1 patient's disease has recurred in the perfusion circuit. Before the perfusion, the 11 patients had a total of 19 local or intransit recurrences. Of the 5 patients in whom all recurrent disease could not be resected, disease persisted in 4 patients. When compared with a concurrent control population of patients with extremity melanoma who had a local recurrence and were not perfused, the patients with melanoma who underwent HILP had a significant prolongation of disease-free survival (p less than 0.05), but a similar actuarial survival. In this study, we demonstrate that HILP can prevent local regional recurrences in patients with metastatic melanoma who are at high risk for further recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated limb perfusion for unresectable melanoma of the extremities

HYPOTHESIS: In patients with truly unresectable melanoma of the extremities, results after isolated limb perfusion (ILP) are absent in the literature. Complete response rates are probably lower than the reported 54% for locoregional recurrent melanoma. In these patients, ILP with melphalan and tumor necrosis factor alpha (TNF-alpha) could be superior to ILP with melphalan alone. DESIGN: Retrospective analysis with a median follow-up period of 21 months (interquartile range, 9-40 months). SETTING: Two tertiary care cancer centers in the Netherlands. PATIENTS: We assessed all 130 consecutive patients who underwent ILP for unresectable melanoma of the extremities, performed between 1978 and 2001. Of these patients, 38% had stage IIIA melanoma and 45% had stage IIIAB melanoma according to criteria of the MD Anderson Cancer Center. Lesions were considered unresectable on the basis of their size, number, or localization. INTERVENTIONS: Forty ILPs were performed with melphalan, and 90 were done with TNF-alpha and melphalan. MAIN OUTCOME MEASURES: Response rate, disease-free survival, limb salvage rate, and overall survival. RESULTS: In 45% of the patients, a complete response was attained after ILP with melphalan (95% confidence interval, 29%-61%) compared with 59% after ILP with TNF-alpha and melphalan (95% confidence interval, 49%-69%; P = .14). The time to complete response was 3 months (interquartile range, 2-6 months) vs 2 months (interquartile range, 1-3 months; P = .01), respectively. The recurrence rate and median limb recurrence-free survival were not significantly different for both ILP types. The overall limb salvage rate was 96%. Overall 5-year survival was 29% (95% confidence interval, 20%-38%). The ILP type was not an independent prognostic factor for complete response, nor was limb recurrence-free survival, whereas stage IIIA was a favorable prognostic factor (P = .01 and P = .02, respectively). Favorable prognostic factors for improved survival were complete response (P<.001) and a tumor size of 3 cm or less (P = .01). CONCLUSIONS: In more than half of the patients with truly unresectable melanoma of the extremities, a complete response was obtained after ILP with melphalan with or without TNF-alpha. The ILP type was not an independent prognostic factor for complete response, limb recurrence-free survival, or overall survival.     

Isolated limb infusion for melanoma.

Isolated limb infusion involves administrating cytotoxic drugs in a patient with malignant melanoma confined to one limb, and which is not surgically resectable. It provides palliation in cases where cutaneous disease is extensive.     

Isolated regional perfusion for treatment of limb melanoma in the American black

Since 1957, 961 patients with invasive malignant melanoma of the limbs were treated by regional perfusion. Forty-eight patients were black, representing 5 per cent of all patients with regional melanoma treated during this period. Thirty-one of the 48 patients were men, and 17 were women. Only 21 of the 48 patients had stage I lesions (M.D. Anderson classification), of whom 63 per cent had level IV or greater invasion. The average depth of invasion was 3.70 mm. Of 21 patients with stage III disease, 15 came to diagnosis with an intact primary lesion in addition to regional disease, and the majority of lesions arose on a plantar site with level V invasion. Eighty per cent of the patients had acral lentiginous melanoma. All melanoma patients were treated by isolated regional perfusion with wide excision of the primary plus regional lymph node dissection for biopsy-proven regional disease. At 10 years, survival rates were 71 per cent for stage I patients and 12.5 per cent for those with stage III disease. When black patients having had acral melanoma on a plantar or palmar site were compared with white patients of a similar stage of disease, however, it was found that black patients had equivalent long-term survival rates.     

Recurrent bronchogenic cyst in a Jehovah's witness

A 26-year-old female practising Jehovah's witness presented with a history of recurrent respiratory infections since childhood and more recently, recurrent cardiac dysrhythmias. A large bronchogenic cyst arising beneath the carina and compressing the bronchi was felt to be responsible. The cyst was adherent to the roof of the left atrium. She initially underwent a partial excision through the standard approach of left thoracotomy. Complete resection via this route was hazardous with real danger of laceration of the atrial wall. Repeat surgery was performed on cardiopulmonary bypass 3 years later for recurrence of symptoms. Complete excision was achieved.     

Isolated limb perfusion: a literature review

Through patient education, biological research, and technological advances, the rate of many cancers in the United States of America is declining. However, the incidence of melanoma is rising steadily, as are the efforts and resources allocated to its treatment. Isolated limb perfusion, ILP, is a standard of care for treating recurrent malignant melanoma confined to a limb. Although an extracorporeal procedure, only a small percentage of perfusionists are experienced regarding ILP's indications and performance techniques. Use of ILP may increase as the incidence of melanoma increases. This two-part review is designed to familiarize the perfusionist with the procedure and the disease it treats. Part I reviews the history of isolated limb perfusion, the diagnosis and classification of malignant melanoma, and the applicability of ILP in its treatment. Part II details a procedural overview and technical considerations of the therapy from the perfusionist perspective. The review concludes with patient selection, outcomes, and the future of ILP as well as other applications for the hyperthermic regional delivery of chemotherapy using extracorporeal technology.     

Chemotherapy by regional perfusion for limb melanoma

The administration of chemotherapy by isolated regional perfusion was developed in 1957 at Tulane University and was found to be of greatest benefit for patient with melanoma of the limbs. From 1957 to 1984, 897 patients were treated by this method. The 10-year survival rate for 831 patients with primary melanoma was 77 per cent. Women survived longer than men, with 10-year rates of 81 per cent and 65 per cent, respectively. Prophylactic lymph node dissection was of benefit for males with poor prognosis distal lower limb lesions, but other groups did not benefit. Primary lesions on the arm and thigh did better than lesions of the hand or foot, with plantar and subungual lesions having the least favorable results. Thickness, level, and histologic type were also significant prognostic indicators. Thirty-three patients with locally recurrent melanoma (stage II) treated by perfusion and excision had a 10-year survival rate of 59 per cent. For 129 patients with metastases to the regional lymph nodes (IIIB), perfusion plus RLND produced a 10-year rate of 51 per cent; survival rates for those with a single positive node was 64 per cent. Seventy patients with satellitosis or intransit metastases (IIIA) had a 10-year survival rate of 23 per cent. Thirty-eight patients with metastases to limbs from unknown primaries had a 10-year survival rate of 52 per cent. The overall 10-year rate for all stage III patients was 41 per cent. Perfusion produced useful palliation in 144 patients with limb melanoma in the presence of systemic metastases.     

Isolated limb perfusion for localized melanoma of the extremity. A matched comparison of wide local excision with isolated limb perfusion and wide local excision alone

The therapeutic efficacy of isolated limb perfusion in patients with localized melanoma of the extremity remains controversial. We compared patients treated at the University of Texas M.D. Anderson Cancer Center, Houston, with wide local excision and isolated limb perfusion using either melphalan or imidazole carboxamide with a group matched for prognostic factors from the University of Alabama at Birmingham and the University of Sydney (Australia) who were treated with wide local excision alone. No significant difference in disease-free or overall survival rates was found between patients treated with wide local excision with adjuvant isolated limb perfusion or wide local excision alone. However, a subset of patients with thicker lesions (greater than 2.0 mm) treated with wide local excision and isolated limb perfusion using melphalan had a significant improvement in both disease-free and overall survival rates. These data suggest that isolated limb perfusion using melphalan may improve survival rates in selected patients with localized melanoma of the extremity who are at increased risk for local and regional micrometastases, and justifies the continued study of this treatment approach in prospective clinical trials.     

Lung transplantation in a Jehovah's witness. Case report in a twinning procedure

Jehovah's Witnesses, patients who refuse blood transfusions, are generally not considered as candidates for lung transplantation owing to the frequent requirement for transfusions. A successful procedure in a Jehovah's Witness is presented and to our knowledge this is the 2(nd) reported case. The patient, a 38-year-old female, type I diabetes, affected by idiopatic pulmonary fibrosis underwent left lung transplantation. From the same pulmonary bloc a twinning procedure was obtained by means of right lung transplantation in a 58-year-old man affected by the same pathology. Surgical strategies employed in achieving a successful outcome, ethical and moral aspects are discussed.     

Use of erythropoietin for bloodless surgery in a Jehovah's witness infant

We present a case of surgery in a 2-month-old infant of the Jehovah's Witness (JW) faith weighing 2.8 kg scheduled for left upper lobectomy because of congenital lobar emphysema. He presented with physiological anaemia (haematocrit 33.8%) in accordance with his age. Because of the relative emergency of surgery, a short erythropoietin course was instituted. Recombinant human erythropoietin (rHuEPO) at a dosage of 180 U x kg-1x day-1 was administered for 10 days preoperatively and for 4 days postoperatively. Iron was administered orally and intravenously over the entire perioperative period. No side-effects from either erythropoietin or intravenously administered iron were observed. To our knowledge, this is the first case published of a short perioperative rHuEPO course in an infant.     

Isolated hyperthermic limb perfusion for soft tissue sarcoma

Background By combining different treatment modalities, function sparing resection of soft tissue sarcoma of the extremities has become possible for the majority of patients. To evaluate the role of isolated hyperthermic limb perfusion in this concept, the patients treated with this method in our institution were reviewed. Methods From January 1982 to December 1991 18 patients with extremity soft tissue sarcoma were treated by isolated hyperthermic limb perfusion. 41% of the patients presented with local recurrence, 67% with high grade malignancy and 61% after incomplete tumor resection. If present, residual tumors were resected several weeks after perfusion. Results The 5-year survival rate is 94% (mean follow-up 30 months). 38.6% of the patients developed local tumor recurrence, but limb sparing treatment had been carried out only after refusal of amputation in 4 of the 7 patients with local failure. Complications of therapy were moderate. Systemic toxicity was not observed. Conclusions We conclude that isolation perfusion is a valuable addition to combined modality treatment of soft tissue sarcomas of the extremities. With the aid of this method limb salvage can be achieved for the majority of patients.     

Surgery and transfusion in Jehovah's witness patient. Medical legal review

The religious convictions of the witnesses of Jehovah leads them to refuse transfusion of blood, of its major components and of blood sparing procedures breaking the physical contact between the patient and his blood. We recall the rules of good practice in case of elective surgery concerning exhaustive information of the patient within multidisciplinary team associating anesthetist and surgeon advised by the forensic pathologist. This consultation must, to our point of view, be concluded by a report which summarizes what is accepted or not by the patient. This report will be initialed by the patient. This consultation can never lead the physician to swear to never use a transfusion whatever the circumstances. In case of emergency if and only some conditions are met (everything was made to convince the patient, vital emergency, no therapeutic choice, therapeutic care adapted to the patient heath status), the physician can be brought to overpass the patient's will to not receive blood transfusion. Current jurisprudence has, to date, never recognized as faulty the physicians having practiced such transfusions whenever they took place within a precise framework.