Isolated limb perfusion for advanced melanoma

What is isolated limb perfusion?

Isolated limb perfusion is a treatment method usually used in advanced cases of melanoma. It is also sometimes used for sarcoma and other cancers. It was developed in the 1950s as an alternative to amputation, which was often the standard of care when cutaneous melanoma metastases (secondaries) arose in one limb. Isolated limb perfusion with cytotoxic medications is intended to get rid of the metastases.

In this procedure:

1. The femoral artery and vein (if treating a leg) or the axillary artery and vein (if treating the arm) are clamped. Subclavian or iliac approaches in this procedure are also possible but less common. A tourniquet is applied to produce pressure on the smaller vessels, thus isolating the limb from the rest of the body.
2. Tubes are inserted into the affected limb and attached to a machine to circulate heated chemotherapy medications (cytotoxic drugs). A combination of phenylalanine mustard and actinomycin D is often used.
3. The cytotoxic drugs are allowed to circulate for 60–90 minutes; the limb is then allowed to cool and then is flushed to remove any residual medication.
4. The tubes are removed and the vessels reattached before the closure of the incision. The patient can then be sent to recovery.

Isolated limb perfusion

When should isolated limb perfusion be considered?

Patients should be carefully selected for isolated limb perfusion. Indications for isolated limb perfusion may include the following criteria:

• Melanoma metastases that are confined to a single limb
• A primary lesion with a poor prognosis
• Thick or ulcerated tumours
• Palpable regional nodal metastases.

Isolated limb perfusion can be a stand-alone therapy or can be used in combination with surgical resection or other treatments.

What is the appearance of the limb after isolated limb perfusion?

After this procedure, there can be distinct physical changes in the affected limb. These include:

• Redness. This redness usually begins within 48 hours of surgery but eventually fades to brown and normal skin colour can return within 6 months. Sometimes, however, discolouration is permanent.
• Blistered or peeling skin.
• Swelling and lymphoedema of the affected limb. For some patients, oedema can also be permanent after isolated limb perfusion.
• Changes in the nails.

How well does isolated limb perfusion work?

Reports about isolated limb perfusion procedure for melanoma indicate:

• A 75% response rate to the procedure
• Achievement of local disease control
• An enhanced patient survival rate compared to no treatment
• The death rate from the procedure is 0.6% and limb loss rate of 0.8%.

Patients with poor prognosis receive the greatest benefit from this procedure.

What are the benefits and drawbacks of isolated limb perfusion?

The benefits of isolated limb perfusion for advanced localised melanoma include:

• Its efficacy (see above)
• It avoids systemic treatment, which may not be as effective as isolated limb perfusion.

The drawbacks of isolated limb perfusion include:

• It is invasive and carries the risk of infection
• It is a highly specialised, expensive procedure and requires a perfusionist and surgeon as well as an extensive support staff
• It has unpleasant side effects (mostly confined to the affected limb), which include discomfort, irritation, pain or stiffness, loss of body hair, tingling or numbness, nail deformity, and swelling.