Minimally Invasive Isolated Limb Perfusion (MI-ILP) for Locally Advanced Melanomas and Sarcomas of the Extremity

Summary

This protocol presents a step-by-step guide for performing minimally invasive isolated limb perfusion (MI-ILP), a treatment option for patients with locally advanced melanomas and sarcomas of the extremities.

Abstract

Minimally invasive isolated limb perfusion (MI-ILP) is a treatment option for patients with locally advanced melanomas and sarcomas of the extremities. Briefly, the procedure starts with percutaneous access of the femoral or brachial vessels in the diseased extremity. It is then isolated from the rest of the body with a tourniquet. The catheters are connected to a heart-lung machine, and the extremity is perfused with a high dose of melphalan. In the literature, the reported overall and complete response rates for ILP are approximately 80% and 60%, respectively. Our previously reported results using MI-ILP, showed similar response rates. The objective of this manuscript is to provide a step-by-step guide on how to perform an MI-ILP. The purpose of this protocol is to enable local perfusion of the extremities with a high dose of chemotherapy without systemic leakage in a minimally invasive manner.

Introduction

The global incidence of melanoma is increasing and is particularly pronounced in the Western population, where one out of every 50 individuals will develop melanoma¹. Patients with cutaneous melanoma can develop in-transit metastasis (ITM), most often localized to the limb². These metastatic deposits appear as discrete tumor nodules within the subcutaneous or cutaneous tissue and arise between the primary melanoma site and the nearest regional lymph node basin. A compelling hypothesis implies that ITM develops after the entrapment and subsequent proliferation of tumor cell emboli in dermal lymphatic vessels between the p....

Protocol

The protocol adheres to the guidelines established by our Institution's Human Research Ethics Committee.

1. Anesthesia

1. Induce anesthesia according to the Institute's local protocol.

2. Set up

1. Calculate the leg volume of the patient (1 day preoperative):
   1. Lay the patient supine and draw a circular baseline starting in the groin. With 5 cm intervals, mark the patient's leg down to the ankle.
   2. If there is evidence of tumor load in the foot, include foot measurements by adding the length from the heel of the patient to t....

Results

We have previously published the results of the first six patients treated with MI-ILP (five femoral and one brachial) between June 2016 and March 2017 at Sahlgrenska University Hospital¹¹. Patients who were 18 years or older with a locally advanced tumor of the extremity that had an indication for ILP were included in the study. Patients were excluded if they had a previous lymph node dissection, current lymph node disease, or severe atherosclerosis, as this could potentially complicate percutane.......

Discussion

Patients with ITM have a poor prognosis and their treatment remains challenging. A key factor in treating these patients is aiming for local control. In a minority of these patients, surgical excision can be used when the tumor load is limited. When patients have more extensive disease or when ITMs are rapidly recurring, surgical resection is not possible. In these patients, isolated limb perfusion is an effective treatment option, with a high overall response rate of around 80%¹⁰. Despite its hig.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0.018” introducer guidewire
0.035” exchange guidewire
10-12Fr BioMedicus Nextgen Pediatric Arterial cannulae.	Medtronic, Minneapolis, MN, USA	96820-110 (10Fr); 96820-112 (12Fr)
12-14 Fr BioMedicus  NextGen Pediatric Venous Cannulae	Medtronic, Minneapolis, MN, USA	96830-112 (12Fr); 96830-114 (14Fr)
Esmarch tourniquets	McKesson	16-50409
Micro-introducer, 4 Fr, 10 cm	MAK, Merit Medical, USA	MAK401	Includes: (1) Co-axial introducer/dilator pair; (2) 21G Needle; (3) Guide wire
PerClose ProGlide closure devices	Abbott	12773-02	Includes:  (1)Perclose Suture-Mediated Closure and repair device; (2) suture trimmer; (3) snared knot pusher
Special Needle (20G, 12 cm)	Mediplast AB, Sweden	662620091