Isolated limb perfusion (ILP) for melanoma that has come back in the same area
You may be given chemotherapy directly into a limb (leg or arm) to treat clusters of melanomas that have come back in the same limb.
These clusters of melanomas are called satellite lesions or in-transit lesions. This treatment is only given if the melanoma hasn’t spread anywhere else in the body.
ILP can also be used to treat another type of cancer called a sarcoma. The information in this section is only about ILP to treat melanoma. It describes the treatment, how it’s given and some of the possible side effects.
We hope this information answers your questions. If you have any further questions, you can ask your doctor or nurse at the hospital where you’re having your treatment.
Isolated limb perfusion
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ILP is a way of giving high doses of anti-cancer drugs, such as chemotherapy, directly into a leg or an arm to control melanoma that’s confined to that area. This is known as regional treatment.
The drugs are given directly into the affected limb, which is isolated using a tight band (tourniquet). This prevents the treatment from going to other areas of your body. This means you’re unlikely to get the common side effects of having chemotherapy, such as feeling sick, being at more risk of getting an infection, and losing the hair from your head.
ILP is a specialised treatment that's only carried out in a few centres in the UK. You may have to travel to another hospital if your specialist advises you to have this treatment.
Isolated limb infusion
There is another treatment called isolated limb infusion. It’s similar to ILP, but uses lower doses of chemotherapy. It may be used as an alternative to ILP. It’s offered in some hospitals in the UK.
With this treatment, the blood from the limb doesn’t need to go through a pump. This makes it a simpler procedure than isolated limb perfusion. Your doctors will be able to tell you more about isolated limb infusion if this is a suitable treatment for you.
Sometimes melanoma comes back (recurs) in the skin, very close to where the original melanoma was. This is called a local recurrence. If you have a recurrence, it’s usually treated with an operation to remove it. Surgery can be used even if you have more than one local recurrence.
Sometimes clusters of melanomas come back in the same limb, but further away from the original melanoma. Doctors call these satellite lesions or in transit metastases. Because there are lots of them, it can be difficult to remove them all with surgery. In this situation a specialist may advise that you have ILP.
ILP is given under a general anaesthetic and usually involves staying in hospital for 7–10 days. The procedure is carried out by a surgeon who specialises in operations involving blood vessels (vascular surgeon) and who has experience in ILP.
Below is the usual procedure:
First the surgeon makes a small cut in your thigh or groin if the melanoma is in your leg, or in your armpit if the melanoma is in your arm.
The surgeon temporarily disconnects the blood flow (circulation) between the affected limb and the rest of your body.
Fine tubes are placed into your blood vessels. This is to transfer the blood flow from your limb to a pump. Your blood is circulated through the pump, and then goes back into your limb.
A tourniquet is then applied to the top of your limb. This is to make sure the blood and circulating drugs stay in your limb.
Oxygen is added to the blood going to your limb by a machine called an oxygenator. This is because your limb still needs to get oxygen during the treatment. After the treatment, your limb will get oxygen in the usual way from the blood flowing through your lungs.
The blood to your limb may also be heated, as some research shows that this improves the results of the treatment.
High doses of anti-cancer drugs are given into the blood circulating through the pump, which then go into your limb. The drugs circulate in your limb for about an hour.
After the procedure is finished, the blood flow from your limb is reconnected to the rest of your body and the tourniquet is removed. The blood supply to your limb goes back to normal.
Because the blood flow to your limb is disconnected from the rest of your circulation during treatment, the drugs won’t travel anywhere else in your body.
The drugs used
A chemotherapy drug called melphalan is usually used. It can be given on its own, or sometimes with an immunotherapy drug called tumour necrosis factor (TNF). Another chemotherapy drug that may be used is actinomycin D.
The nurses and doctors will monitor you closely. You’ll have to rest and raise (elevate) your limb. This improves the blood circulation and allows time for the tissues in your limb to heal. You may need to do this for several weeks after you go home too. Your surgeon will advise you on this. You will also be monitored after the operation to make sure you don’t have any complications. If anything does happen, it will usually be picked up early.
The nurses will take the pulse in your limb regularly to make sure the blood flow is good. There’s a small risk of developing a blood clot, which would cause symptoms such as pain, redness and swelling in the limb, or breathlessness and chest pain. Blood clots can be very serious, so it’s important to tell your doctor straight away if you have any of these symptoms. Most clots can be treated with drugs that thin the blood. Your doctor or nurse can tell you more about this.
Damage to the blood vessels
There may be a risk of damage to the main blood vessels supplying the limb. Usually when this happens, the surgeon recognises it during the procedure and can repair any damage there and then.
Possible side effects of ILP
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The side effects of ILP usually only affect the treated limb. Your specialist will explain them to you and tell you what you can expect. The side effects of ILP usually get better after 6-8 weeks, but in some
people they may last longer. Let your doctor or nurse know about any side effects or problems you’re having. There’s usually something they can do to make things easier.
These are the main side effects that can occur:
Pain and stiffness
After the operation you’re likely to have some pain in the limb, and your muscles and joints might be inflamed. This means you’ll feel stiff and uncomfortable when you’re moving about. You will be given painkillers to take regularly to control the pain. You’ll probably need to take them for several weeks. Let your doctor or nurse know if you’re still in pain so that they can prescribe a stronger painkiller.
Swelling and redness
Your limb may become red and swollen. This usually starts about 48 hours after your treatment and is most noticeable after a week. The swelling gradually reduces over 2–3 months. The redness will gradually fade to brown and become lighter over the next few months. Your skin colour should go back to normal after about six months, but some people are permanently left with a slight darkening of the skin.
Blisters and peeling skin
You may get blisters or peeling skin after treatment. This can be on the sole of your foot if you have ILP on your leg, or on the palm of your hand if you have ILP on your arm. This usually happens in the first two weeks after treatment but it will gradually heal.
Risk of infection
During ILP, small amounts of the chemotherapy drug may get into the rest of your body. This can temporarily reduce the number of infection-fighting cells (white blood cells) in your blood and increase your risk of infection. Your white blood cells will gradually recover, but you may have to stay in hospital for a bit longer until they do. You’ll have regular blood tests to check this.
You’ll lose the hair on the leg or arm that’s been treated, but this will grow back again. Very occasionally, people also have a little thinning of the hair on their head but this is not usually noticeable.
A few weeks after treatment, you may notice changes to your nails on the treated limb. They may develop lines or sometimes a nail may come off. If this happens a new nail will grow in its place.
Numbness or tingling
You may get numbness or tingling after treatment. This will be in your foot if you have ILP on your leg, or in your hand if you have ILP on your arm. It is due to the effect of the chemotherapy drugs on your nerves and is called peripheral neuropathy. Tell your doctor if this happens. It usually improves slowly over a few months but is sometimes permanent.
A possible long-term side effect of ILP is a permanent swelling of the treated limb, known as lymphoedema. We have more information in our section on lymphoedema.
You’ll be seen at the surgical outpatient clinic, usually about six weeks after the procedure. After this you’ll be seen every few months, unless you live far from the hospital where you had ILP. In this situation you’ll be seen by your own cancer specialist or dermatologist, so that you don’t have to travel far.
It can take time for ILP to shrink the melanomas, and you may still notice them getting smaller months after the procedure. Even if ILP has been successful, the melanoma sometimes leaves a discoloured mark on your skin.
When melanoma has come back, it’s usual to have times when you find your emotions difficult to cope with. Coping with any physical changes caused by the melanoma or its treatment can also be hard. Everyone copes differently with their emotions, and there’s no right or wrong way. It’s important to get the support you need. Talking to family and friends about how you’re feeling often helps. You can also talk to your doctor or nurse for support. Some people may prefer to talk to a counsellor. Your doctor or nurse can give you more advice about this.
This information has been compiled using a number of reliable sources, including:
Kroon, et al. Isolated limb perfusion for melanoma. Surgical oncology clinics of North America. 2008. 17: 785–794.
Marsden, et al. Revised UK guidelines for the management of cutaneous melanoma 2010. British Journal of Dermatology. 2010.
Sanki, et al. Isolated limb perfusion and isolated limb infusion for malignant lesions of the extremities. Current Problems in Surgery. 2011. 48: 371–430.
Thanks to Mr Dominique Byrne, Consultant General & Vascular Surgeon, and the people affected by cancer who reviewed this edition. Reviewing information is just one of the ways you could help when you join our Cancer Voices network.