Therapeutic isolated limb perfusion (ILP) in the management of patients with advanced or recurrent limb melanoma

Abstract

Dear Sir,Isolated limb perfusion (ILP) was introduced in clinicalpractice in the 1950s and earlier studies using hyperthermicILP with melphalan for limb melanoma reported impressiveresultswithoverallresponse(OR)ratesof80%andcompleteresponse (CR) rates of 30 and-50% [1]. More recent reportsindicate that CR rates exceeding 50% are now obtained inmost melanoma treatment centres where ILP is undertaken[2]andevenhigherCRrateshavebeenreportedwhentumournecrosis factor (TNF) has been used with melphalan [3].We read with interest the paper by Romics in your June2011 issue utilising melphalan ± TNF alpha in patientswith unresectable melanoma of the limb and reporting anOR rate of 93% and CR rate of 67%. ILP is also undertakenin our unit and we recently audited our results which aresummarised below.From 1980 to 2001, 378 patients with limb malignantmelanoma underwent therapeutic ILPs at St Mary’s Hos-pital, London. 41 patients had ILP of the upper limb while337 had ILP of the lower limb (236 iliac ILP/101 femoralILP). We employed the melphalan and mitomycin C drugregimen. 284/378 patients had complete follow-up and ofthese 32% had a CR, 38% had [50% response, 25% had\50% response and 6% had no response. There was a 13%leak rate in responders and 21% in non-responders. Therewas no postoperative mortality, while perioperative mor-bidity was seen in 50/284 patients (18%) and included limboedema (34), deep venous thrombosis (8), vascular damage(4) and transient nerve/muscle damage (2). 60% of ourpatients survived more than a year on 5-year follow-up.ILP is a technically demanding, costly and time-con-suming technique which should be undertaken in tertiaryreferral centres by experts. Limb amputation for nonresec-table disease can lead to stump recurrences which are diffi-cult to control and make the fitting of a prosthesischallenging. However, with good patient selection, ILP is avaluable therapeutic option and in our experience it is pref-erable to amputation as an effective therapeutic modality fornonresectable limb melanoma despite the significant risk ofregional and systemic complications and lack of an effect onsurvival.We, the undersigned, are pleased for an opportunity toreport our results to augment the ever-increasing pool ofknowledge relevant to this technique.References