1
|
Corderfeldt Keiller A, Axelsson M, Bragadottir G, Blennow K, Zetterberg H, Olofsson Bagge R. A prospective feasibility trial exploring novel biomarkers for neurotoxicity after isolated limb perfusion. Perfusion 2023:2676591231213506. [PMID: 37933726 DOI: 10.1177/02676591231213506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a regional cancer treatment in which high-dose chemotherapy is administered in an isolated extremity. The main side effect is regional toxicity, which occasionally leads to nerve damage. Measuring neuroaxonal biomarkers, might be a method predicting such complications. Therefore, the primary aim of the study is to investigate if neuronal biomarkers are measurable and alters in an isolated extremity during ILP. Secondly, if postoperative regional toxicity, alterations in sensitivity, and/or muscle strength are correlated to the biomarker levels. METHODS Eighteen scheduled ILP-patients were included in the study. Glial fibrillary acidic protein (GFAP), neurofilament light (NfL), and tau concentrations were measured in plasma sampled preoperatively, at the start and end of the ILP, on days 3 and 30, using ultrasensitive Single molecule array (Simoa) technology. The patients were assessed by a physiotherapist pre- and postoperatively. RESULTS At ILP end, significantly higher NfL and tau levels were measured in the extremity than in the corresponding systemic circulation (NfL; 17 vs 6 ng/L, p < .01, tau; 1.8 vs 0.6 ng/L, p < .01), and the extremity levels were significantly increased at ILP end (NfL; 66 ± 37%, p < .001, tau; 75 ± 45%, p = .001). On days 3 and 30, significantly increased NfL and GFAP levels were measured systemically (NfL day 3: 69 ± 30%, p < .001; day 30: 76 ± 26%, p < .001; GFAP day 3: 33 ± 22%, p < .002; day 30: 33 ± 23%, p ≤ .004). Finally, no significant correlations were found between regional toxicity or between postoperative muscle or sensitivity decrease and biomarker release. CONCLUSION During ILP, NfL and tau levels increased significantly. No obvious correlations were observed between biomarker release and regional toxicity or decreased muscle strength or sensitivity, although large-scale studies are warranted.
Collapse
Affiliation(s)
- Anna Corderfeldt Keiller
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudrun Bragadottir
- Department of thoracic anesthesia and intensive care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
2
|
Niethard M, Fischer H, Gaßmann B, Haralambiev L, Tipp A, Tunn PU. The Use of Regional Anesthesia to Reduce Blood Loss in Isolated Limb Perfusion (ILP)-A Novel Approach. J Clin Med 2023; 12:6542. [PMID: 37892681 PMCID: PMC10607281 DOI: 10.3390/jcm12206542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) for soft tissue sarcomas (STS) is usually performed with tumor necrosis factor alpha (TNF-α) and melphalan. ILP regularly leads to a total blood loss (BLt) of 1.5-2 L/patient. Blood inflow from the central blood circulation to the limb is influenced by unstable pressure gradients and pain reactions after the administration of melphalan. With perioperative regional anesthesia (RA), pain levels can be reduced, and the pressure gradient stabilized resulting in a reduced BLt. The aim of this study was to compare the BLt with and without RA in patients with ILP during circulation of drugs. METHODS Patients were treated according to the following protocol: After the establishment of limb circulation, ILP was started with the administration of TNF-α. Half the dose of melphalan was given as a bolus after 30 min, and the remaining dose was continuously administered in the following 30 min. The extremity was washed out after 90 min. ILP with perioperative RA (supraclavicular plexus block/peridural catheter) was performed prospectively in 17 patients and compared to a matched retrospective control group of 17 patients without RA. BLt was documented and perioperative anesthesiological data were analyzed for response rates after the application of melphalan (RaM). RESULTS BLt and RaM tended to be lower for the intervention group with RA if compared to the control group without RA in all analyses. The trend of lower BLt and RaM in ILP with RA was more pronounced for the upper extremity compared to the lower extremity. Results were not statistically significant. CONCLUSION These findings indicate that the use of RA can help to stabilize hemodynamic anesthetic management and reduce the BLt in ILP, especially during perfusion of the upper extremities.
Collapse
Affiliation(s)
- Maya Niethard
- Department of Orthopedic Oncology, Sarcoma Center, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany;
- Center for Orthopedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany;
| | - Heilwig Fischer
- Department of Oral and Maxillofacial Surgery, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany;
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
- BIH Charité Clinician Scientist Program, Charité–Universitätsmedizin Berlin and Berlin Institute of Health, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Lyubomir Haralambiev
- Center for Orthopedics, Trauma Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475 Greifswald, Germany;
| | - Alexander Tipp
- Department of Anesthesiology, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany;
| | - Per-Ulf Tunn
- Department of Orthopedic Oncology, Sarcoma Center, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany;
| |
Collapse
|
3
|
Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature. Cancers (Basel) 2021; 13:cancers13215485. [PMID: 34771649 PMCID: PMC8583108 DOI: 10.3390/cancers13215485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. METHODS PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000-2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. RESULTS Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. DISCUSSION ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. CONCLUSIONS ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies.
Collapse
|
4
|
Ekenberg M, Wesslau H, Olofsson Bagge R, Engström M. Patient experiences with isolated limb perfusion for malignant melanoma - A qualitative study. Eur J Oncol Nurs 2019; 43:101672. [PMID: 31614318 DOI: 10.1016/j.ejon.2019.101672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 08/26/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE In recent years, the incidence of malignant melanoma has rapidly increased worldwide. Among patients with recurrences, approximately 5% develop in-transit metastases, which can potentially be treated with isolated limb perfusion (ILP). However, little is known about patient experiences with this treatment. A more thorough understanding might guide future research and clinical care. In this study, we aimed to describe patients' experiences of ILP treatment. METHODS This study included eight patients who participated in a semi-structed interviewed, conducted at one occasion between 3 and 11 months after their ILP treatment. The mean interview duration was 26 min. Data were analyzed using qualitative inductive content analysis according to the methods of Elo-Kyngäs and Graneheim and Lundman. RESULTS Our analysis yielded three categories, each built on two subcategories: positive experiences after ILP treatment emerged from the sub-categories reduced tumor burden and living a less restricted life; negative experiences after ILP was built on the subcategories fear of relapse and complications and side effects; and experiences of healthcare was founded on the subcategories need for correct information and being viewed as sicker then experienced. CONCLUSION Participants showed greater focus on the healthy parts of their lives, even when negative symptoms occurred after ILP treatment. They also described how healthcare workers focused on their illness. Based on these findings, we suggest the following means of providing good nursing care to ILP patients: give correct information, strive to reduce patients' negative symptoms, support their daily living needs, and provide emotional support to reduce fear of recurrence.
Collapse
Affiliation(s)
- Monica Ekenberg
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Wesslau
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - My Engström
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Care Science, Sahlgrenska Academy at the University of Gothenburg, Sweden; Department of Gastrosurgical research and education, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg, Sweden.
| |
Collapse
|
5
|
Corderfeldt A, Nielsen S, Katsarelias D, Hjärpe A, Mattsson J, Olofsson Bagge R. Is blood a necessary component of the perfusate during isolated limb perfusion - a randomized controlled trial. Int J Hyperthermia 2019; 36:794-800. [PMID: 31450986 DOI: 10.1080/02656736.2019.1640900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Background: Isolated limb perfusion (ILP) is a treatment option for malignancies localized to an extremity and is performed by surgical isolation of the limb which is connected to an extracorporeal circulation system. A high concentration of a chemotherapeutic agent is perfused through the limb, while systemic toxicity is avoided. Currently, the use of packed red blood cells in the priming solution is the norm during ILP. The aim of this study was to investigate the possibility to replace an erythrocyte-based prime solution with a crystalloid-based prime solution while maintaining the regional metabolic oxygen demand during ILP. Methods: In a single-center, randomized controlled, non-blinded, non-inferiority clinical trial, 21 patients scheduled for treatment with ILP were included and randomized 1:1 to either an erythrocyte-based prime solution (control) or a crystalloid-based prime solution (intervention). Results: There was a significant difference in lactate level (mmol/L) during the perfusion between the intervention group and the control group (1.6 ± 0.4 vs. 3.6 ± 0.7, p = .001). No significant differences in oxygen extraction (%) (22 ± 11 vs. 14 ± 4, p = .06), oxygen delivery (ml/min) (90 ± 49 vs. 108 ± 38, p = .39), oxygen consumption (ml/min) (14 ± 2 vs. 14 ± 5, p = .85), regional central venous saturation (%) (83 ± 10 vs. 91 ± 4, p = .07) or INVOS (%) (76 ± 14 vs. 81 ± 11, p = .42) were found between the intervention group and the control group. Conclusion: This study showed no significant improvement with the addition of packed red blood cells into the prime solution in ensuring the metabolic oxygen demand in the treated extremity during ILP, and we, therefore, recommend that a crystalloid-based prime solution should be used.
Collapse
Affiliation(s)
- Anna Corderfeldt
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital , Gothenburg , Sweden.,Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Susanne Nielsen
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University , Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden.,Department of Surgery, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Anders Hjärpe
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Jan Mattsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden.,Department of Surgery, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden.,Department of Surgery, Sahlgrenska University Hospital , Gothenburg , Sweden.,Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg , Gothenburg , Sweden
| |
Collapse
|
6
|
Turaga KK, Gamblin TC, Edwards R, Alexander HR, Bartlett D. It Is Time. Ann Surg Oncol 2019; 26:1963-1966. [PMID: 31037435 DOI: 10.1245/s10434-019-07207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Kiran K Turaga
- Department of Surgery, University of Chicago, Chicago, IL, USA.
| | - T Clark Gamblin
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert Edwards
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA, USA
| | - H Richard Alexander
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - David Bartlett
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Belgrano V, Pettersson J, Nilsson JA, Mattsson J, Katsarelias D, Olofsson Bagge R. Response and Toxicity of Repeated Isolated Limb Perfusion (re-ILP) for Patients With In-Transit Metastases of Malignant Melanoma. Ann Surg Oncol 2019; 26:1055-1062. [PMID: 30617871 PMCID: PMC6399180 DOI: 10.1245/s10434-018-07143-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) is a safe and well-established treatment for in-transit metastases of melanoma. In case of relapse or disease progression, ILP can be repeated (re-ILP). This study aimed retrospectively to analyze a large consecutive series of re-ILP and compare clinical outcomes with first-time ILP. METHOD Between 2001 and 2015, 290 consecutive patients underwent 380 ILPs. Of these, 90 were re-ILPs including 68 second ILPs, 16 third ILPs, 4 fourth ILPs, and two fifth ILPs. The study evaluated response (using World Health Organization [WHO] criteria), local toxicity (using the Wieberdink scale), and complications (using Clavien-Dindo). RESULTS The results were compared between the first ILP, the second ILP, and the third to fifth ILP. The overall response rate was respectively 83%, 80% and 68%, with a complete response (CR) rate of 60%, 41%, and 59%. In the re-ILP group, the patients with a CR after the first ILP had a 65% CR rate after the second ILP compared with 8% for the patients without a CR (p = 0.001). The risk for local toxicity or complications was not increased after re-ILP. The median overall survival periods were respectively 34, 41, and 93 months (p = 0.02). CONCLUSION As a therapeutic option, ILP can be repeated safely for in-transit metastases of melanoma, achieving similar high response rates without increasing complications or toxicity. Re-ILP is mainly indicated for patients who already had a CR after the first ILP, whereas other treatment options should be considered for primary non-responders.
Collapse
Affiliation(s)
- Valerio Belgrano
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Sahlgrenska Cancer Center, University of Gothenburg, 405 30, Gothenburg, Sweden
| | - Jessica Pettersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Jonas A Nilsson
- Sahlgrenska Cancer Center, University of Gothenburg, 405 30, Gothenburg, Sweden
| | - Jan Mattsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| |
Collapse
|
8
|
Katsarelias D, Olofsson Bagge R. ASO Author Reflections: The Future of Isolated Limb Perfusion. Ann Surg Oncol 2018; 25:914-915. [PMID: 30411268 DOI: 10.1245/s10434-018-6968-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Dimitrios Katsarelias
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|