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NEW TREATMENT FOR RECURRENT MELANOMA IN THE EXTREMITIES

From Washington University Physicians, written by Mary Jo Blackwood, RN, MPH, posted April 8. 2013

Although melanoma accounts for only 4 percent of skin cancers, it is responsible for 80 percent of skin cancer deaths. There will be an estimated 70,000 new cases in of melanoma diagnosed in the United States in 2013.

It is especially lethal because it often recurs after initial surgical resection; it can metastasize to other areas of the body; and it is resistant to chemotherapy. Approximately half of newly diagnosed cases of melanoma are isolated to the extremities - the arms and legs - , and in about ten percent of these, after surgery, lesions recur within the same extremity.

A new treatment, only offered in this area at Washington University, provides a way of treating advanced, recurrent melanoma of the extremity. Called ILI (isolated limb infusion), it provides high-dose chemotherapy to the affected limb, while sparing the rest of the body from its effects.

Only a few centers around the country offer ILI for treatment of melanoma and other skin or soft tissue malignancies of the extremities.

Treatment for melanoma starts with surgery to excise lesions, but may include radiation therapy, systemic chemotherapy, interferon, immunotherapy, and now ILI.

Ryan Fields, MD, a Washington University cancer surgeon, explains how some melanomas recur: “A patient with a melanoma on the calf of the leg, for example, has it removed and he does well. Then perhaps a few years later, he develops another one or two recurrences on the same leg, higher up, because the melanoma is following the lymphatic system.

We remove those and then a short time later, he develops more lesions on the same leg, often too many to remove. We do a PET-CT scan of the body to make sure the melanomas are confined to that extremity, and then we can use ILI.”

Fields says by isolating the blood supply in that leg, he can treat it with much higher doses of chemotherapy than the entire body could tolerate.  ILI is the best alternative for multiple melanomas confined to one limb that can’t be surgically removed. Having ILI as an option helps avoid amputation of the cancerous limb and offers a reasonable chance of controlling the disease.

How ILI Works

Under general anesthesia in the operating room, catheters are inserted into the femoral artery and vein. A pneumatic tourniquet is tightened at the thigh to prevent blood flowing in and out of the leg.

Then a powerful chemotherapy is circulated through the vessels for 30 minutes. After that, the chemotherapy is flushed out of the leg and the tourniquet removed.

The patient stays in the hospital for 3 to 5 days until the inflammation in the leg resolves.

Says Fields: “There is widespread inflammation and swelling that have to abate before the patient can be discharged. The leg doesn’t like the treatment, but the tumors like it even less.”

Three months after the procedure, he repeats the PET-CT scan to check response to the treatment. Two-thirds of patients will have significant shrinkage or eradication of the tumors, and half of these patients will have a complete response, meaning all tumors disappear completely. How long it lasts varies from patient to patient, but the average duration of response is 18 months. In many patients, the tumors will start growing again.

ILI has the advantage of being minimally invasive and repeatable when needed. Because the treatment is isolated to the extremity, the patient can still have other systemic therapies as needed. It is a good option for managing patients with multiple recurrent tumors where surgical excision is not an option.

Patient Education Handout on ILI procedure
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Copyright 2014 Washington University School of Medicine