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INVITED SPEAKERS ABSTRACTS

Management of in-transit limb metastases in melanoma: state of the art

Marsden, J.

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doi: 10.1097/01.cmr.0000382767.08743.d0
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In transit melanoma metastases in a limb occur in about 5% of patients. Five and 10-year survival for stage group N2c are 61% and 45% respectively. An effective strategy for long-term palliation is therefore required to minimize risk of local progression with consequent pain, ulceration, infection, smell, reduced mobility and social isolation. Treatment type is determined by size, depth, number, site, and rate of progression of metastases. For single or multiple dermal or superficial subcutaneous metastases <10 mm diameter, local destruction by CO2 laser or electosurgery gives response rates (RR) >90%, with healing by second intention. If lesions are >10 mm diameter, subcutaneous or deeper, confluent, or threatening limb viability, then surgical excision is required if this is feasible; response rates are >90% if margins are clinically and histologically clear. Repair will normally be simple, either by direct closure, second intention, or graft. For laser, electrosurgery, and excisional surgery, response duration is unpredictable but may be prolonged. For metastases which are unlikely to be completely resectable or are inoperable, rapidly recurrent, rapidly progressive, or confluent, regional chemotherapy is likely to be the most effective treatment. Isolated limb infusion (ILI) with melphalan and actinomycin gives RR of 70% (25% CR, 45% PR); isolated limb perfusion (ILP) with melphalan is probably more effective with RR of 80% (40% CR, 40% PR). ILI is less complex, less invasive, better tolerated, cheaper, and easier to repeat. For metastases >5 cm diameter, ILP with melphalan and tumour necrosis factor is likely to be more effective than ILP with melphalan alone, or ILI, though this has not been confirmed. Median response duration is >12 months for both ILI and ILP. Adjuvant ILI or ILP has not been shown to be effective in preventing recurrence of in-transit metastases. However, neo-adjuvant ILI or ILP can facilitate surgical limb salvage. Radiotherapy can be effective, but responses are unpredictable and rarely complete, and so it should only be used if surgery or regional chemotherapy are not feasible. Such a situation is rare. Systemic chemotherapy is much less effective than regional chemotherapy, with RR <10%, and should not be used unless all other loco-regional treatments have failed.

© 2010 Lippincott Williams & Wilkins, Inc.