Case Discussion

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Case Discussion

• Shiva Sharma

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KM

• PMHx HTN, Cholecystectomy, hysterectomy,
  C-Section
• PC
• Rash on left leg
• Found to be erythematous

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• Plan?
• Biopsy
• Showed melanoma
• Now what?
• Surgery?
• Scan?
• Chemotherapy?
• Radiotherapy?
• Palliative measures?

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• CT scan
• No evidence of metastatic disease
• WLE of satellite lesion
• Consideration for electrochemotherapy
• Patient not keen for this

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• What options are left?
• Patient discussed at Melanoma MDM
• Decided she may benefit from ILI vs ILP

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• 160,000 new cases of melanoma diagnosed each year
  
• More common in women and Caucasians living in
  sunny climates
• Highest rates of incidence in Australia, New
  Zealand, North America, and northern Europe
• 48,000 melanoma related deaths world wide

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• 1. Superficial spreading melanoma
• Most common begins initial radial growth phase
  then invasion
• 2. Lentigo maligna melanoma
• Long radial growth phase,
• Most common in elderly and in sun-exposed areas

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• 3. Acral lentiginous
• Most common form in darkly pigmented patients
• Occurs on palms and soles, mucosal surfaces, in
  nail beds and mucocutaneous junctions
• More aggressive
• 4. Nodular
• Invasive growth from onset
• Poor prognosis

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Risk Factors
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Clinical
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Melanoma

• Problem
• How to treat advanced and recurrent melanoma
• 10 of patients will develop in-transit
  metastases
• defined by tumour recurrence occurring between
  the primary tumour and the regional lymph node.
• 5ysr 12
• Median survival is 19months

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• Options ?
• Surgery
• Radiotherapy
• Chemotherapy
• Systemic vs Isolated chemotherapy
• Advantages
• Disadvantages

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Targeted Chemotherapy

• ILP
• First described in 1957
• Requires surgical placement of catheters to the
  femoral artery and vein
• Patient on extracorporeal bypass for procedure
• High dose chemotherapeutic agent given
• More invasive
• Longer recovery time
• ILI
• First described by Thomson etal. 1998
• Alternative method to ILP

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Pre-Op
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Procedure

• Prophylactic LMWH
• Pre-op limb measurements done by OT
• Under radiological guidance 2 catheters placed
• Contra-lateral groin access site to the femoral
  artery and vein (8Fr and 6Fr)
• Leg kept warm to induce hyperthermia
• Transferred to theatre

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• General anaesthetic
• 30ml of Papaverine
• Tourniquet placed
• Melphalan and Dactinomycin in 400ml Normal Saline
  infused over 25min
• Circulated over 20min
• Flushed with 1L Hartmans

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• Tourniquet removed
• Catheters withdrawn
• Direct pressure applied for 20min
• Post-Op care
• Leg elevated
• Regular peripheral pulse checks
• CK levels
• Look for signs of Compartment Syndrome
• Thrombosis

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Post-Op
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Weiberdink Limb Toxicity Assessment

• Grade I no visible effect
• Grade II slight erythema and/or oedema
• Grade III considerable erythema and/or oedema
• Grade IV extensive epidermolysis and/or obvious
  damage to deep tissues with a threatened or
  actual compartment syndrome
• Grade V severe tissue damage necessitating
  amputation

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Pre ILI
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30days Post ILI
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Results

• ILP and ILI overall response rates approximating
  80
• complete response rate 3050
• Systemic chemotherapy/immunotherapy overall
  response rates rarely gt20
• complete response rates rarely gt12
• Not a cure for disease
• Palliative measure to reduce morbidity and avoid
  amputation

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References

• Isolated Limb Infusion Technique Description and
  Clinical Application Cronin C. etal.
• J Vasc Interv Radiol 2009 20837841
• Isolated limb infusion with cytotoxic agents a
  simple alternative to isolated limb perfusion
  Thompson JF, etal.
• Semin Surg Oncol 1998 14238 247.
• Isolated limb infusion for melanoma, Z. Al-Hilli
  etal
• Surgeon, 1 October 2007 310-12
• Harrisons Manual of Internal Medicine 17th Ed
• Pp 364-365
• Mayo Clinic Internal Medicine Review 8th Ed
• Pp 173-174