Radionuclide leakage monitoring during hyperthermic isolated limb perfusion for treatment of local melanoma metastasis in an extremity

Paulsen, Ida Felbo; Chakera, Annette Hougaard; Schmidt, Garbi; Drejøe, Jennifer Berg; Klyver, Helle; Oturai, Peter; Hesse, Birger; Drzewiecki, Krystztof; Mortensen, Jann

doi:10.1111/cpf.12164

Cited by 6 publications

(5 citation statements)

References 25 publications

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“…In contrast to prior studies, the current study did not report the volume of drug leakage from the limb to the systemic circulation, which is reportedly correlated with the degree of systemic toxicity ( 8 , 15 ). It is notable that isolated limb perfusion is stopped when the leakage from the limb to the systemic circulation reaches 5% when using TNFα, or 10% when using melphalan in the Instituto Nacional de Cancerología.…”

Section: Discussioncontrasting

confidence: 80%

“…Nevertheless, it is also involved in sepsis-induced cardiovascular dysfunction ( 6 , 7 ). Systemic toxicity appears to be associated with the amount of leakage of these cytotoxic agents into the systemic circulation, and it is recommended that the procedure be stopped when this amount exceeds 10% ( 8 ). When it appears, systemic toxicity is usually limited, consisting of nausea and post-operative emesis, as well as transitory myelosuppression ( 4 ).…”

Section: Introductionmentioning

confidence: 99%

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Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion

Ñamendys‐Silva

Ruiz-Beltrán

Barragán-Dessavre

et al. 2017

Molecular and Clinical Oncology

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The aim of the present study was to investigate the incidence of organ dysfunction, and to describe the clinical characteristics and intensive care unit (ICU) outcomes of critically ill cancer patients who were admitted to an oncological ICU during the isolated limb perfusion post-operative period. The present study was an observational investigation of 42 critically ill cancer patients who were admitted to the ICU of the Instituto Nacional de Cancerología, during the isolated limb perfusion post-operative period, between July 2010 and February 2016. The mean age of the patients was 45.7±16.9 years, and 45.2% (19 cases) were female. Soft tissue sarcoma was the most common pre-operative diagnosis (38.1%), and the mean duration of surgery was 267.6±50.1 min. Furthermore, a mean blood loss volume of 732.3±526.1 ml during the procedure was recorded, and the patients received a mean volume of 3.88±1.28 l crystalloid fluid during the surgical procedure, subsequently requiring an additional 2.95±6.28 l on the first post-operative day. The incidence of organ dysfunction was 90.5% and was most frequently noted in the respiratory (81%), hepatic (33%), hematologic (31%) and renal (11.9%) systems. No patients succumbed to the disease during the ICU and hospital stay. Nevertheless, <10% of the patients required vasopressors. Additionally, <5% of the patients required invasive mechanical ventilation. Therefore, ICU admission directly following isolated limb perfusion should not be standardized.

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Section: Discussioncontrasting

confidence: 80%

Section: Introductionmentioning

confidence: 99%

Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion

Ñamendys‐Silva

Ruiz-Beltrán

Barragán-Dessavre

et al. 2017

Molecular and Clinical Oncology

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“…Yet, critical to the safe use of these concentrated agents is effective leakage control. Traditionally, radionuclide tracer addition to the perfusion solution has been a method for ensuring adequate leakage control [10], but this approach involves radiation exposure and requires specialized equipment and personnel [11].…”

Section: Discussionmentioning

confidence: 99%

Feasibility and efficacy of indocyanine green in monitoring systemic drug leakage during isolated limb perfusion for recurrent melanoma of extremity

Nekkanti,

Nusrath,

Jarang

et al. 2024

Melanoma Research

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Melanoma is known for its high metastatic potential and aggressive growth. Recurrence is common post-surgery, sometimes leading to unresectable disease. Locally recurrent unresectable melanoma of extremity has been treated with high-dose anticancer chemotherapy via isolated limb perfusion (ILP) to improve local efficacy of drug and salvage limbs. Standard ILP monitoring uses radiolabeled dyes, requiring specialized personnel and involving radiation exposure. In this case, we used indocyanine green (ICG) to track systemic drug leakage during ILP. A 47-year-old gentleman with recurrent malignant melanoma of the left foot, operated twice earlier and treated with adjuvant pembrolizumab, presented with multiple in-transit metastases in the limb. ILP was planned, with 5 mg ICG administered in the perfusion solution along with high-dose melphalan. Stryker’s SPI PHI handheld device was employed to visualize ICG during ILP. Absence of fluorescence beyond the involved extremity, such as fingers, ears, and the abdominal wall, indicated no systemic drug dispersion. For control, technetium radiocolloid dye was co-administered, monitored by a precordial gamma probe, confirming no systemic leakage, and validating effectiveness of ICG in leakage monitoring. ICG proves to be a safe, reliable, cost-effective, radiation-free approach for precise systemic drug leakage monitoring during ILP for recurrent melanoma of extremity.

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“…However, for safe application of these highly concentrated cytostatic agents, leakage control is of utmost importance. In this regard, the addition of radionuclides to the perfusion solution has already been described as a method for sufficient leakage control [16,17], but this causes a certain amount of radiation and requires specialized personnel [19,20]. Although doxorubicin has been used for decades, it was recently replaced by TNFα + melphalan, which is now the standard therapy in ILP for sarcomas.…”

Section: Discussionmentioning

confidence: 99%

“…Radionuclide-labeled cytostatic drugs or perfusion solutions have been used for adequate leakage control at the cannulation site and for the control of the correct application of such procedures [16,17]. After the correct cannulation is confirmed, high-dose cytostatic drugs, such as TNFα + melphalan [9,18] are added to the solution, which is subsequently injected into the chosen region.…”

Section: Introductionmentioning

confidence: 99%

Indocyanine Green for Leakage Control in Isolated Limb Perfusion

Zucal

Geis

Prantl

et al. 2021

JPM

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Sarcomas are characterized by a high metastatic potential and aggressive growth. Despite surgery, chemotherapy plays an important role in the treatment of these tumors. Optimal anti-cancer therapy with maximized local efficacy and minimized systemic side effects has been the object of many studies for a long time. To improve the local efficacy of anti-tumor therapy, isolated limb perfusion with high-dose cytostatic agents has been introduced in surgical oncology. In order to control the local distribution of substances, radiolabeled cytostatic drugs or perfusion solutions have been applied but often require the presence of specialized personnel and result in a certain exposure to radiation. In this study, we present a novel strategy using indocyanine green to track tumor perfusion with high-dose cytostatic therapy. In a rat cadaver model, the femoral vessels were cannulated and connected to a peristaltic pump to provide circulation within the selected limb. The perfusion solution contained indocyanine green and high-dose doxorubicin. An infrared camera enabled the visualization of indocyanine green during limb perfusion, and subsequent leakage control was successfully performed. Histologic analysis of sections derived proximally from the injection site excluded systemic drug dispersion. In this study, the application of indocyanine green was proven to be a safe and cost- and time-efficient method for precise leakage control in isolated limb perfusion with a high-dose cytostatic agent.

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Radionuclide leakage monitoring during hyperthermic isolated limb perfusion for treatment of local melanoma metastasis in an extremity

Abstract: Leakage monitoring using a threshold of 10% during ILP saves the patients from systemic toxicity, however, at the expense of early termination or cancellation of ILP treatment in a few patients and repeated ILP procedures in some.

Cited by 6 publications

References 25 publications

Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion

Clinical characteristics of critically ill cancer patients who are undergoing isolated limb perfusion

Feasibility and efficacy of indocyanine green in monitoring systemic drug leakage during isolated limb perfusion for recurrent melanoma of extremity

Indocyanine Green for Leakage Control in Isolated Limb Perfusion

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