August 17, 2012
Dear Mayo Clinic:
A year ago I had a melanoma removed from my lower leg. I did not need additional treatment at the time, but unfortunately the cancer has returned in my leg. My doctor recommends limb perfusion. What can you tell me about this treatment? Is it just as successful as traditional chemotherapy?
This procedure, known formally as hyperthermic isolated limb perfusion, is a way of delivering chemotherapy directly to one arm or leg without affecting the rest of the body. Limb perfusion is used mainly for melanoma, but some other kinds of cancer that are isolated to a single limb can also be treated using this method.
Limb perfusion is a surgical procedure that was developed in the 1950s. But only in recent years has it been used frequently, as technological advances made it safer. Even now, limb perfusion is done at just a few specialized medical centers because of the procedure's complexity.
The process involves putting the arm or leg affected by cancer on a bypass machine, similar to those used in heart surgery, to isolate the blood flow in the affected limb from the rest of the body. That way, high doses of chemotherapy can be delivered where needed without exposing the rest of the body to the chemotherapy. Typically, the doses of chemotherapy delivered during limb perfusion are six to 10 times higher than would be possible to give to a person's entire body. This makes limb perfusion more effective at targeting chemotherapy to the cancer, and it's safer for the patient.
In addition to melanoma, certain kinds of soft tissue sarcomas and other rare cancers such as Merkel cell carcinoma can be treated with limb perfusion. Even in people who have melanoma, only about 2 percent are good candidates for limb perfusion.
Melanoma is the most common type of cancer treated with limb perfusion for two reasons. First, the chemotherapy agents given during the procedure have been shown to be effective against melanoma, but they are toxic if given to the whole body in the doses used for limb perfusion. Second, melanoma is the most common form of cancer to affect only an arm or leg. Cancer that is confined to a single spot can usually be effectively removed with surgery. But in some patients, melanoma returns in multiple spots throughout an arm or leg, and simple surgical removal is not feasible. In these cases, limb perfusion is a viable alternative.
People treated with limb perfusion for melanoma confined to one arm or leg respond quite well. More than 85 percent see a reduction in the cancer and, in more than 70 percent, the melanoma goes away completely, though significant risk remains that the cancer will return.
The risks of limb perfusion treatment are mainly related to the effects of the chemotherapy drugs and, rarely, damage to the blood vessels that are used to connect the arm or leg to the bypass machine. Most people get redness of the skin and have swelling of the tissues where the chemotherapy is delivered. If chemotherapy medication escapes into the rest of the body, it can cause damage such as bone marrow suppression or kidney injury. Other risks are the development of blot clots and damage to blood vessels used in the treatment. Because the chemotherapy does not usually affect a person's entire system, side effects such as hair loss and nausea, which are commonly associated with chemotherapy, do not affect people who undergo limb perfusion.
Among appropriate candidates for the procedure, limb perfusion can be an effective treatment option that targets therapy directly at the cancer while minimizing side effects. It can help almost all those patients avoid amputation of the limb and preserve quality of life.
— Richard Gray, M.D., Surgical Oncology, Mayo Clinic, Scottsdale, Ariz.