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Case Discussion

Shiva Sharma. Case Discussion. KM. 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

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Case Discussion

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  1. Shiva Sharma Case Discussion

  2. KM • PMHx – HTN, Cholecystectomy, hysterectomy, C-Section • PC • Rash on left leg • Found to be erythematous

  3. Plan? • Biopsy • Showed melanoma • Now what? • Surgery? • Scan? • Chemotherapy? • Radiotherapy? • Palliative measures?

  4. CT – scan • No evidence of metastatic disease • WLE of satellite lesion • Consideration for electrochemotherapy • Patient not keen for this

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

  6. 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

  7. 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

  8. 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

  9. Risk Factors

  10. Clinical

  11. Melanoma • 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

  12. Options ? • Surgery • Radiotherapy • Chemotherapy • Systemic vs Isolated chemotherapy • Advantages • Disadvantages

  13. Targeted Chemotherapy • 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. 1998 • Alternative method to ILP

  14. Pre-Op

  15. Procedure • Prophylactic LMWH • Pre-op limb measurements done by OT • Under radiological guidance 2 catheters placed • Contra-lateral groin access site to the femoral artery and vein (8Fr and 6Fr) • Leg kept warm to induce hyperthermia • Transferred to theatre

  16. General anaesthetic • 30ml of Papaverine • Tourniquet placed • Melphalan and Dactinomycin in 400ml Normal Saline infused over 25min • Circulated over 20min • Flushed with 1L Hartmans’

  17. 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

  18. Post-Op

  19. Weiberdink Limb Toxicity Assessment • 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

  20. Pre ILI

  21. 30days Post ILI

  22. Results • 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

  23. References • 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

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