Shiva Sharma

PMHx – HTN, Cholecystectomy, hysterectomy, C-Section

PC Rash on left leg Found to be erythematous

Plan? Biopsy Showed melanoma

Now what? Surgery? Scan? Chemotherapy? Radiotherapy? Palliative measures?

CT – scan No evidence of metastatic disease

WLE of satellite lesionConsideration for

electrochemotherapy Patient not keen for this

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

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

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

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

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

Options ? Surgery Radiotherapy Chemotherapy

Systemic vs Isolated chemotherapy Advantages Disadvantages

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. 1998Alternative method to ILP

Prophylactic LMWHPre-op limb measurements done by OTUnder radiological guidance 2 catheters

placedContra-lateral groin access site to the

femoral artery and vein (8Fr and 6Fr)Leg kept warm to induce hyperthermiaTransferred to theatre

General anaesthetic30ml of PapaverineTourniquet placedMelphalan and Dactinomycin in

400ml Normal Saline infused over 25min

Circulated over 20minFlushed with 1L Hartmans’

Tourniquet removed Catheters withdrawn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

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

ILP and ILI overall response rates approximating 80% complete response rate 30%–50%

Systemic chemotherapy/immunotherapy overall response rates rarely >20% complete response rates rarely >1%–2%

Not a cure for disease Palliative measure to reduce morbidity and

avoid amputation

Isolated Limb Infusion: Technique Description and Clinical Application; Cronin C. etal. J Vasc Interv Radiol 2009; 20:837–841

Isolated limb infusion with cytotoxic agents: a simple alternative to isolated limb perfusion: Thompson JF, etal. Semin Surg Oncol 1998; 14:238 –247.

Isolated limb infusion for melanoma, Z. Al-Hilli etal Surgeon, 1 October 2007 310-12

Harrison’s Manual of Internal Medicine 17th Ed Pp 364-365

Mayo Clinic Internal Medicine Review 8th Ed Pp 173-174