Isolated Limb Perfusion in the Management of Patients With Recurrent Limb Melanoma: An Important but Limited Role

Abstract

Isolated limb perfusion (ILP) was introduced into clinical practice in the mid-1950s, based on the same principles that had been applied to develop extracorporeal cardiopulmonary bypass a few years earlier. The concept was simple. By temporarily isolating the vasculature of a limb, high cytotoxic drug concentrations could be achieved without producing serious systemic side effects. Early studies using hyperthermic ILP with melphalan for limb melanoma produced impressive results, with overall response (OR) rates of around 80% and complete response (CR) rates for measurable limb disease of 30%-50%. 1 More recent reports indicate that CR rates exceeding 50% are now obtained in most melanoma treatment centers where ILP is undertaken. 2 Even higher CR rates have been reported when tumor necrosis factor (TNF) has been used with melphalan. 3 Apart from the generally unacceptable option of amputation, no other form of treatment (systemic, regional, or local) achieves response rates that are consistently as high as those able to be obtained by ILP. It provides results far superior to those able to be achieved by any form of systemic chemotherapy, for example, where OR rates exceeding 20% are uncommon and CR rates rarely exceed 1%-2%.However, despite the clearly demonstrated effectiveness of ILP for limb melanoma, it is a technique still used in only a small number of centers worldwide. The principal reason for this paradoxical situation is that, although the procedure is elegantly simple in concept, in practice it is a surgical tour-de-force -technically complex and demanding, labor intensive, time consuming, and costly. It has become clear that if ILP is to be effective and safe, meticulous attention to every aspect of the procedure is essential, with comprehensive monitor

Efficacy of repeat isolated limb infusion with melphalan and actinomycin D for recurrent melanoma

“…Also, the risk of complications is increased, and this may discourage surgeons from repeating the procedure. 1,35 These technical difficulties are avoided with repeat ILI, because the catheters used in ILI are introduced percutaneously without open surgical access to the vessels.…”

Isolated limb infusion for melanoma: A simple but effective alternative to isolated limb perfusion

“…Conventional ILP induces a CR in 7-90% (median 46%) of limbs, and a partial response (PR) in 0-44% (median 34%), with a median response duration of 9-19 months in patients who have achieved a CR [1,4]. However, ILP is a complex and invasive procedure that is available only in specialized centers, and is generally considered inappropriate in patients who are elderly or who have serious co-morbidities [7].…”

Isolated limb infusion: A review

“…Despite recent publications suggesting that ILP can be safely administered in elderly patients [69,70] its use in this patient group is still a topic of discussion and is often denied for fear of high associated morbidity [71,72].…”