Isolated Limb Perfusion: a LimbSparing Palliative Treatment

1
Isolated Limb Perfusion a Limb-Sparing
Palliative Treatment

• Eric Dy
• Laszlo Romics
• Prof. H.P. Redmond
• Department of Surgery, Cork University Hospital

2
Benefit of Isolated Limb Perfusion

• Provides an alternative to amputation by
  decreasing or eradicating local tumour burden
• Preserves Quality of Life by avoiding amputation
  (of particular importance in the elderly)

3
Isolated Limb Perfusion (ILP)

• Creech and Krementz developed ILP at Tulane
  University in 1958
• Method for delivering local doses of chemotherapy
  approximately 20 times the concentration than
  would be tolerable systemically
• ILP does not prolong overall survival

4
Indications for Isolated Limb Perfusion (ILP)

• Unresectable metastatic melanoma or sarcoma
  lesions of the limbs
• Melanoma stage III disease with widespread IT
  metastases
• Sarcoma bulky invasive lesions (TNF)
• Krementz ET Carter RD Sutherland CM Muchmore
  JH Ryan RF Creech O Jr. Regional chemotherapy
  for melanoma. A 35-year experience. Ann Surg 1994
  Oct220(4)520-34 discussion 534-5.
• Brobeil A Berman C Cruse CW De Conti R
  Cantor A Lyman GH Joseph E Rapaport D Wells
  K Reintgen DS. Efficacy of hyperthermic isolated
  limb perfusion for extremity-confined recurrent
  melanoma. Ann Surg Oncol 1998 Jun5(4)376-83.

5

• Perfusion can be performed
• iliac level (for tumours in the upper 2/3 of the
  thigh)
• femoral level
• popliteal level
• axillary level (for upper extremity tumours)

Cannulated femoral vein
Cannulated femoral artery
6
Cork University Hospital Isolated Limb Perfusion
Study
A retrospective review of the experience of ILP
at Cork University Hospital No exclusion
criteria 2001 through 2005
7
Methods

• Determinants
• Survival
• Tumour response
• Recurrence
• Side effects (local and systemic)

8
Outcome after ILPCork University Hospital
Median time to recurrence 40weeks
Actuarial Survival Curve 83 survived 1year 63
survived 1.5years
47 were still alive at 3.5 years
9
Outcome after ILPCork University Hospital
10
Main Adverse Effects Cork University Hospital

• Local Effects
• Most patients had slight or moderate erythema and
  oedema with slightly reduced mobility that
  resolved before discharge (Grade II)
• Systemic Effects
• Anaemia 92
• Hypoalbuminaemia 92
• Blood transfusion required in 66

11
Outcome after ILP(from large International
studies)

• ILP with melphalan for melanoma with IT
  metastases overall response (OR) 75-80 and
  complete response (CR) 40-50 partial response
  (PR) 20-30
• ILP with TNF alpha and melphalan OR 95 and CR
  69 and (PR) 26
• Survival after 5yrs 50 of those with CR are
  alive
• Recurrence median recurrence free interval
  1.4yrs
• Grunhagen DJ, Brunstein F, Graveland WJ, van
  Geel AN, de Wilt JHW, Eggermont AMM. One hundred
  consecutive isolated limb perfusions with
  TNF-alpha and melphalan in melanoma patients with
  multiple in-transit metastases. Ann Surg
  2004240 939-948.
• Eggermont AM. Treatment of melanoma in-transit
  metastases confined to the limb. Cancer Surv.
  1996 26 335-349.
• Zogakis TG, Bartlett DL, Libutti SK, Liewehr DJ,
  Steinberg SM, Fraker DL, Alexander HR. Factors
  affecting survival after complete response to
  isolated limb perfusion in patients with
  in-transit melanoma. Ann Surg Oncol. 2001
  8(10)771-778.

12
To Compare(with European and American data)

• Overall response CUH 91 vs 75-95
• Complete response CUH 66 vs 40-70
• Partial response CUH 25 vs 20-30

13
In Conclusion

• ILP is highly effective adjuvant treatment for
  unresectable melanoma and sarcoma of the limb
• It is generally well tolerated, it has low local
  and systemic toxicity rate.
• The response rates and complications of this
  group are consistent with the findings of larger
  multi-centre studies in Europe.
• Special Thanks to
• Alkesh Patel
• Catriona Fogarty

14
ILP VideoStage 1

• Preparation (with excision of lesion above the
  level of the ILP)

Surgeons Laszlo Romics, Prof. Redmond, Mr.
Aonghus ODonnell
15
ILP VideoStage 2

• Cannulation, Perfusion, Tourniquet Tight

16
ILP VideoStage 3

• Infusion of Melphalan, Circulation (60 min.), and
  Washout of the limb