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Hayes AJ, Coker DJ, Been L, Boecxstaens VW, Bonvalot S, De Cian F, de la Cruz-Merino L, Duarte C, Eggermont A, Farricha V, Fiore M, Grünhagen D, Grützmann R, Honoré C, Jakob J, Hocevar M, van Houdt W, Klauzner J, Kettelhack C, Märten A, Martinez-Said H, Matter M, Michot A, Niethard M, Pennacchioli E, Podleska LE, Rabago G, Rastrelli M, Reijers S, Ribeiro M, Schwarzbach M, Snow HA, Spacek M, Stoldt S, Testori A, Zoras O, Olofsson Bagge R. Technical considerations for isolated limb perfusion: A consensus paper. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108050. [PMID: 38498966 DOI: 10.1016/j.ejso.2024.108050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique. METHODS Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations. RESULTS The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training. CONCLUSION We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.
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Affiliation(s)
- Andrew J Hayes
- Department of Academic Surgery, Royal Marsden Hospital, London, UK; Institute of Cancer Research, London, UK.
| | - David J Coker
- Department of Academic Surgery, Royal Marsden Hospital, London, UK; Department of Surgery, Royal Prince Alfred Hospital, Sydney, Australia; The University of Sydney, Sydney, Australia.
| | - Lukas Been
- Department of Surgical Oncology University Medical Center Groningen, University of Groningen, the Netherlands
| | | | | | - Franco De Cian
- Policlinico San Martino, University of Genoa, Genoa, Italy Clinical Oncology Department; Italy Clinical Oncology Department, Italy
| | | | - Carlos Duarte
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | - Alexander Eggermont
- University Medical Center Utrecht and Princess Maxima Center, Utrecht, the Netherlands; Comprehensive Cancer Center München, Technical University München & Ludwig Maximilian University, Munich, Germany
| | - Victor Farricha
- Melanoma and Sarcoma Unit, Department of Surgery, Portuguese Institute of Oncology, Lisbon, Portugal
| | - Marco Fiore
- Sarcoma Service, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dirk Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Charles Honoré
- Sarcoma Unit, Department of Cancer Medicine, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, Villejuif, France
| | - Jens Jakob
- Sarcoma Unit, Interdisciplinary Tumor Center, Mannheim University Medical Center University of Heidelberg, Mannheim, Germany
| | | | - Winan van Houdt
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, the Netherlands
| | - Joseph Klauzner
- Surgical Oncology- Melanoma, Division of Surgery, Sourasky Tel Aviv Medical Center (Ichilov Hospital), Tel Aviv University, Israel
| | - Christoph Kettelhack
- Clarunis, University Center for Gastrointestinal and Liver Disease Basel, Basel, Switzerland
| | | | - Hector Martinez-Said
- Deputy Direction of Surgical Oncology, Instituto Nacional de Cancerología, Mexico
| | - Maurice Matter
- Institut Bergonié Sarcoma Unit, '229 cours de l'Argonne, 33000, Bordeaux, France
| | - Audrey Michot
- Lausanne University Hospital and University of Lausanne Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011, Lausanne CHUV, Switzerland
| | - Maya Niethard
- Department of Orthopedic Oncology, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | | | - Lars E Podleska
- Department of Orthopaedic Oncology and Soft Tissue Sarcoma, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Gregorio Rabago
- Department of Cardiovascular Surgery Clinica University of Navarra, Pamplona, Spain
| | - Marco Rastrelli
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padua, Padua, Italy; Department of Surgery, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Sophie Reijers
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital (NCI-AVL), Amsterdam, the Netherlands
| | - Matilde Ribeiro
- Instituto Português De Oncologia De Porto, 4200 Porto, Portugal
| | | | - Hayden A Snow
- Peter MacCallum Cancer Centre, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Victoria, Australia
| | - Miroslav Spacek
- Second Department of Surgery-Department of Cardiovascular Surgery, General University Hospital in Prague and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stephan Stoldt
- Department of Abdominal and Paediatric Surgery, Oslo University Hospital, Norwegian Radium Hospital, Oslo, Norway
| | - Alessandro Testori
- Chairman surgical subgroup EORTC Melanoma Group, Brussels, Belgium; Direttore divisione dermatologia Oncologica, Image Institute, Milan, Italy
| | - Odysseas Zoras
- Emeritus Professor of Surgical Oncology, University of Crete, Greece
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Martin-Tellez KS, van Houdt WJ, van Coevorden F, Colombo C, Fiore M. Isolated limb perfusion for soft tissue sarcoma: Current practices and future directions. A survey of experts and a review of literature. Cancer Treat Rev 2020; 88:102058. [PMID: 32619864 DOI: 10.1016/j.ctrv.2020.102058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
Abstract
Soft tissue sarcomas constitute 1% of adult malignant tumors. They are a heterogeneous group of more than 50 different histologic types. Isolated limb perfusion is an established treatment strategy for locally advanced sarcomas. Since its adoption for sarcomas in 1992, after the addition of TNFα, few modifications have been done and although indications for the procedure are essentially the same across centers, technical details vary widely. The procedures mainly involves a 60 min perfusion with melphalan and TNFα under mild hyperthermia, achieving a limb preservation rate of 72-96%; with an overall response rates from 72 to 82.5% and an acceptable toxicity according to the Wieberdink scale. The local failure rate is 27% after a median follow up of 14-31 months compared to 40% of distant recurrences after a follow up of 12-22 months. Currently there is no consensus regarding the benefit of ILP per histotype, and the value of addition of radiotherapy or systemic treatment. Further developments towards individualized treatments will provide a better understanding of the population that can derive maximum benefit of ILP with the least morbidity.
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Affiliation(s)
- K S Martin-Tellez
- Fellow of the European School of Soft Tissue Sarcoma, Department of Surgical Oncology, The American British Cowdray Medical Center ABC, Mexico city, Mexico.
| | - W J van Houdt
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F van Coevorden
- Sarcoma Unit, Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - C Colombo
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - M Fiore
- Sarcoma Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
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Neuwirth MG, Song Y, Sinnamon AJ, Fraker DL, Zager JS, Karakousis GC. Isolated Limb Perfusion and Infusion for Extremity Soft Tissue Sarcoma: A Contemporary Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3803-3810. [PMID: 29022281 DOI: 10.1245/s10434-017-6109-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) and isolated limb infusion (ILI) have been variably used in recent years for the treatment of locally advanced or marginally resectable extremity soft tissue sarcomas (STSs). We performed a systematic review and meta-analysis of contemporary studies to further characterize treatment patterns and outcomes. METHODS PubMed was queried for articles published in or after the year 2000, in the English language, with > 10 patients, and with adequate outcome data following ILP/ILI. Descriptive aggregate statistics were performed. RESULTS Nineteen studies that met the inclusion criteria were identified, with a total of 1288 patients. Weighted mean patient age was 55.9 years and 52% were male. The majority underwent ILP (88%) versus 12% for ILI, and chemotherapeutic regimens used were as follows: (1) melphalan with tumor necrosis factor (TNF)-α (78%), (2) melphalan ± actinomycin (10%), and (3) other regimens (12%). Most common histologies treated were malignant fibrous histiocytoma (21%), liposarcoma (16%), synovial (11%) and leiomyosarcoma (7%). Aggregate overall response rate (ORR) post-procedure was 73.3%, with 25.8% demonstrating a complete response (CR). Similar unadjusted ORRs were noted in the melphalan treatment groups with and without TNFα (72.0 and 67.0%, respectively; p = 0.27). Grade III toxicity was observed in 15.4% of patients, and grade IV/V toxicity was observed in 6.0% of patients. Overall limb salvage rate was 73.8% and median time to local (in-field) progression ranged from 4 to 28 months (weighted median 22.1 months). CONCLUSION ILP and ILI for extremity STS can be safely performed with appreciable response rates and significant limb salvage rates. Further study is needed to identify optimal treatment regimens by histology.
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Affiliation(s)
- Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Jakob J, Tunn PU, Hayes AJ, Pilz LR, Nowak K, Hohenberger P. Oncological outcome of primary non-metastatic soft tissue sarcoma treated by neoadjuvant isolated limb perfusion and tumor resection. J Surg Oncol 2014; 109:786-90. [PMID: 24619722 DOI: 10.1002/jso.23591] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 02/11/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is an effective limb salvage strategy in patients with advanced soft tissue sarcoma (STS) where surgery alone would result in significant functional morbidity or mandate an amputation. Most previous reports of patients undergoing ILP focus on limb salvage rates rather than local and distant relapse rates. Here, we report the oncological outcome of sarcoma patients treated by ILP and surgery. METHODS Data were retrieved from prospective ILP databases from two ILP centers following similar ILP techniques and surgical approaches. Only patients with primary, intermediate, or high grade non-metastatic STS were included. RESULTS The cohort comprised 90 patients. Median follow-up was 39 months (range 3-165 months). Median tumor size was 11 cm (range 5-34). Twenty of 90 (22%) patients underwent prior debulking surgery outside the centers. Twenty-nine of 90 (32%) had postoperative irradiation. Four of 90 underwent amputation either related to local recurrence or irresectability, 4 of 90 underwent amputation for treatment-related complications. Fifteen of 83 (18%) patients had local recurrences after ILP and limb sparing surgery, 39 of 90 (43%) developed metastatic disease. Twenty-two of 90 (24%) died of disease. CONCLUSION Preoperative ILP and tumor resection resulted in good local control in a cohort of high-risk STS patients.
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Affiliation(s)
- Jens Jakob
- Division of Surgical Oncology and Thoracic Surgery, Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Bhangu A, Broom L, Nepogodiev D, Gourevitch D, Desai A. Outcomes of isolated limb perfusion in the treatment of extremity soft tissue sarcoma: a systematic review. Eur J Surg Oncol 2013; 39:311-9. [PMID: 23351681 DOI: 10.1016/j.ejso.2012.12.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/25/2012] [Accepted: 12/17/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) may provide a limb salvage option for locally advanced soft tissue sarcoma (STS) not amenable to local resection. METHODS A systematic review was performed for studies reporting outcome of ILP for locally advanced STS performed after 1980 in patients aged ≥ 12 years old. The main endpoints were tumour response and limb salvage rates. Complication and recurrence rates were secondary endpoints. RESULTS Eighteen studies were included, providing outcomes for 1030 patients. Tumour necrosis factor-alpha with melphalan was the commonest chemotherapy regime. When reported, 22% of cases achieved a complete tumour response (216/964, 15 studies) with an overall response rate of 72% (660/911, 15 studies). At median follow-up times ranging between 11 and 125 months, the limb salvage rate was 81% in patients who otherwise would have been subjected to amputation. However, 27% of patients suffered local recurrence and 40% suffered distant failure. ILP was associated with severe locoregional reactions in 4% (22/603) of patients. Amputation due to complications within 30 days was necessary in 1.2% of cases (7/586, nine studies). There was insufficient evidence to determine the effect of ILP on survival. CONCLUSION ILP induces a high tumour response rate, leads to a high limb salvage rate but is associated with a high recurrence rate. It provides a limb salvage alternative to amputation when local control is necessary.
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Affiliation(s)
- A Bhangu
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
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