BALTIMORE, MD (Ivanhoe Newswire) - May is melanoma awareness month, and as summer creeps closer, it's important to protect your skin. People diagnosed with metastatic melanoma in their arms or legs can't always protect their limbs from the cancer and risk losing them. But, now there's a way to help save patients' lives and limbs from the disease.
Eileen Zbignewich has tender memories of her late husband Ziggy. Together 62 years, the couple met when Ziggy returned home from World War II. Eileen was his nurse.
"I was working on the amputee ward and I took care of him at that time when he lost his leg," Ellen Zbignewich, diagnosed with melanoma, told Ivanhoe.
Ten years after her husband died, Eileen was in jeopardy of losing her leg because of melanoma.
"That part of it with my husband, being the right leg and mine being the right leg it's just unbelievable," Eileen said.
The condition often leads to amputation but a new minimally invasive procedure known as isolated limb infusion or ILI is changing that.
"The new idea is to put small catheters into the vessel instead of making incisions," Dr. Vadim Gushchin, director of the gastrointestinal oncology atMercy Medical Center, said.
First doctors isolate the affected limb with a tourniquet. Then a catheter delivers high doses of chemotherapy directly to the limb, targeting the cancer. By isolating the limb, the drug does not enter the systemic circulation.
"It does not kill the patient," Dr. Gushchin said.
The survival rate for mestatic melanoma in the limbs used to be one in ten. ILI has tripled that. Another third of patients experience a slowdown of the disease. Eileen is one of them. She had ILI two years ago but now the cancer has come back.
"Fortunately my melanoma has been isolated to just this leg," Eileen said.
She's a candidate for another ILI procedure and is focusing on keeping her leg. The outpatient procedure takes about two hours to complete. At the end of the procedure, the chemo drugs are flushed out of the limbs and circulation is returned to normal. Just like in Eileen's case, it can be repeated if necessary.
BACKGROUND: Isolated limb infusion (ILI) is a procedure used to deliver anticancer drugs directly to an arm or leg but not to the rest of the body. The flow of blood to and from the limb is temporarily stopped with a tourniquet (a tight band around the limb). This allows for large doses of chemotherapy medications to be administered without poisoning the rest of the body.
Catheters (small, flexible tubes) attached to a pump are put into an artery and a vein in the limb so that blood can be circulated through the pump into the limb. High doses of anticancer drugs are then injected into the catheters.
The procedure is used to control advanced melanoma or soft tissue sarcoma of the extremity. (Source: The Institute for Cancer Care at Mercy Hospital)
TREATMENT OPTIONS: ILI is preferred to other methods of treatment because it helps avoid amputation of the cancerous arm or leg. There is no other effective chemotherapy that can prevent this tumor from growing. Without treatment it will eventually become large, non-healing wounds with bleeding craters and repeated infections.
In the past, one of the most effective strategies for treatment involved surgically inserting large catheters in the main vessel of the leg and perfusing high dose chemotherapy using a heart-lung machine. Today, Isolated Limb Infusion, a minimally invasive technique that uses the same principle of regional high dose chemotherapy but through smaller catheters (cardiologists use similar catheters to study vessels of the heart) is the state of the art treatment for patients with locally recurrent melanoma and some other malignances.
A majority of patients have a durable response. ILI requires cooperation between multiple services: surgical oncology, interventional radiology, operating room, anesthesia, pharmacy and others to administer this treatment safely and effectively.
The Institute for Cancer Care at Mercy is one of the few oncology centers in the country to offer this sophisticated treatment for patients with advanced melanoma, sarcoma and some other tumors of the extremities.
Tumor shrinkage can be seen in as little as 90-120 days and can be repeated if necessary.
Dr. Vadim Gushchin, Director of Gastrointestinal Oncology at Mercy Medical Center in Baltimore, MD, talks about saving cancer patients from amputation.
Can you tell me about this elite procedure?
Dr. Gushchim: It has been around for several years now. It was pioneered in Australia where there is the highest rate of melanoma incidence in the world. The idea was taken after an older procedure where we used to deliver chemotherapy through big vessels in the arm or leg when we actually cut the vessels, put big cannulas inside the vessels and deliver chemotherapy this way. The new idea is to put small catheters like we use for cardiac catheterization. We put the small catheters in the vessels instead of making incisions and deliver chemotherapy this way. The idea is the same. We use the same chemotherapy agents, but patients tolerate this procedure better and you can repeat the procedure several times which was not possible before.
What is the success rate?
Dr. Gushchim: The success rate of this procedure is about 1 in 3 patients have complete disappearance of melanoma implants in the extremity. One-third would have partial regress of the tumor and another 1/3 has no effect or progression of the disease. To put it into perspective, the best hope for other methods to work is about 1 in 10. It is clearly more effective than anything we have currently.
Is melanoma an absolutely deadly disease?
Dr. Gushchim: Yes, especially when it comes back or presents with multiple implants in the extremity.
How is this procedure helping patients save their limbs?
Dr. Gushchim: When patients have melanoma recurrence in the extremity, they lose the function of the leg. It is commonly a big fungating mass that prevents them from using the arm or the leg. It commonly leads to amputation if you do not have any means to stop the growth of the tumor.
What is the response rate with chemotherapy?
Dr. Gushchim: The response rate for chemotherapy is about 8% to 10%. With the newer drugs, it is up to 15%, but again, for very rarely patients respond to chemotherapy.
How common is this form of melanoma?
Dr. Gushchim: Fortunately, only a minority of the patients who are diagnosed with melanoma progress to this stage of the disease. But, when they do, we do not have any effective means to treat it. It is important to remember about this option and use it in patients with this progressive melanoma. There are 3 or 4 hospitals in this mid-Atlantic region which uses it.
How long have you been using this new procedure?
Dr. Gushchim: I have been using it for 5 years only in this institution and I have about 20 to 25 procedures done and 3 out of 10 patients will never have recurrence of the disease and will also help another 3 to 4 out of 10 patients with slowing down of the disease.
Why should doctors use this procedure?
Dr. Gushchim: It is important to treating oncologists and dermatologists to think about this procedure and to think about it as not only curative procedure, but also as a palliative procedure to improve the patient's quality of life and to help with comfortable life.
Is it giving people a better quality of life?
Dr. Gushchim: Correct. It will make me very happy if we make progress with newer drugs, and we have pretty serious leads on using this procedure together with newer drugs that have become available in the last year or so.
What is the main method to treat melanoma?
Dr. Gushchim: The main method to treat melanoma is to excise it when it is at the early stages. Addition of Interferon in stage III disease could be effective.
As for the ILI we have unique experience with performing this procedure 4 times in one patient and in a span of 2 years, he was able to keep the leg and keep it functional. When this patient first presented to us, he was not able to walk because and no drugs were available. Later, when they become available, they did not work. He died of melanoma. However, he was able to use the leg. He was able to travel. He was able to go his daughter's wedding, to take her down the aisle and I do not think that without the ILI, he would be able to do all this.
What does the future hold as far as new research?
It should be clear that this part of the conversation was about the article on vitamin A and melanoma incidence.
Dr. Gushchim: The idea is to see if any commonly used drugs like vitamins could be used a chemo prophylaxis as we say for melanoma. It is not a new idea and it has been tried with different vitamins for different cancers. However, the results of such studies could be quite puzzling. For example, there are several studies with other vitamins that unexpectedly show increased risk for other cancers. Fortunately, this study showed decreased risk for melanoma in normal subjects who take supplemental vitamin A. It is a very exciting piece of information for future research. However, I should caution that it should not be taken by general public as a kind of way out of precautions from excessive sun exposure. For example, I have sunburn today. I can take a pill for the next year or so and I will be fine. That is not how this information should be used by general public.
It has more use for future patients with hereditary melanoma. In these patients the risk of melanoma is quite high and it is not related to sun exposure. In these types of patients, chemo prevention is the way to go. The major risk for melanoma occurs before men and women reach age of 15. It is important to watch the kids so they don't have sunburns or excessive sun exposure. Whatever happens after that, you can't modify so much with vitamin A, especially if the sun damage has been created and it has been quite extensive. It's probably not going to make too much difference. Again, this research is quite interesting, exciting, but it should be used very cautiously in general population. It also could show us natural mechanisms of how the organism keeps melanoma in check. That is another venue of how you can interpret this data. There is nothing more natural than preventing yourself from excessive sun exposure. I think that is the key thing to remember.
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