Eur J Cardiothorac Surg 2006;30:408-410
© 2006 Elsevier Science NL
Isolated limb perfusion for an irresectable melanoma recurrence in a Jehovah's witness
Alexander C.J. van Akkooia,
Hannah D. Golab-Schwarzb,
Alexander M.M. Eggermonta,*,
Albertus N. van Geela
a Erasmus University Medical Center—Daniel den Hoed Cancer Center, Department of Surgical Oncology, Rotterdam, The Netherlands
b Erasmus University Medical Center, Department of Thoracic Surgery—Extracorporeal Circulation, Rotterdam, The Netherlands
Received 8 March 2006;
received in revised form 11 April 2006;
accepted 11 April 2006.
* Corresponding author. Address: Department of Surgical Oncology, Erasmus University Medical Center—Daniel den Hoed Cancer Center, 301 Groene Hilledijk, 3075 EA, Rotterdam, The Netherlands. Tel.: +31 10 4391506; fax: +31 10 4391011. (Email: a.m.m.eggermont{at}erasmusmc.nl).
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Abstract
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Isolated limb perfusion (ILP) is a treatment option for irresectable melanoma lesions, because with ILP 20-fold higher concentrations of chemotherapy can be achieved locally than is systemically possible and high response rates are subsequently achieved. Jehovah's witnesses do not accept any form of blood transfusion, either autologous or homologous blood or only blood products. The use of an extracorporeal circuit, without the use of any blood products is acceptable for Jehovah's witnesses. The case of a 59-year-old Jehovah's witness with an irresectable melanoma recurrence for which an ILP. Because of adequate blood flow through the perfused limb, the limb did not become acidotic, even though there was a significant drop in the Hb concentration in the limb during the ILP. Isolated limb perfusions without the use of any blood transfusion products are technically possible, but an adequate preoperative hemoglobin concentration is a prerequisite.
Key Words: Extracorporeal circulation • Melanoma • Isolated limb perfusion • Surgery • Jehovah's witness
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1. Introduction
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Approximately 33–66% of primary melanomas are located on an extremity and 5–9% of these patients will develop locoregional recurrences [1]. Radical excision of these recurrences is the first choice of treatment, but when this is no longer possible the isolated limb perfusion (ILP) is a treatment option for localized melanoma. The ILP was developed in 1958 by Creech et al. [2]. The ILP is very effective, because 20-fold higher concentrations of chemotherapy can be achieved in the limb than can be achieved systemically, due to the toxicity [3–5]. A schematic illustration of the ILP is depicted in Fig. 1A.
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Fig. 1. Schematic illustration of an isolated limb perfusion (A); preoperative illustration of the lesion (B); perioperative illustration of the ILP (C); and postoperative illustration of the result of the treatment (D).
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The religious community of the Jehovah's witnesses was founded in 1870. Jehovah's witnesses believe that it is against God's will to have blood transfusions and therefore they refuse to receive any blood or blood products, even their own. However, because of improved operating techniques and due to the use of erythropoietin (EPO), which raises the hemoglobin (Hb) concentration in the blood of patients, more Jehovah's witnesses can undergo surgery safely.
In this case report, we report that ILP, without the use of any blood or blood products in the perfusion circuit, which is usual in the standard practice of an ILP, can be a treatment option for patients who, because of religious or other reasons, refuse blood transfusions [6–8].
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2. Case report
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A 59-year-old woman presented at our clinic in 2001 with a superficial spreading melanoma of the left tibia. Breslow thickness 2.3 mm, Clark level IV. There were no signs of ulceration or satellites. After wide local excision there was no residual tumor left. One (negative) sentinel node was harvested from the left groin.
After more than 3 years, the patient presented again with a local recurrence of melanoma. However, physical examination revealed multiple satellite lesions. There were no signs of lymphogenous metastases and a CT scan of the thorax/abdomen showed no signs of distant metastases. Resection was considered, but the chance of an irradical resection was thought to be too large, because of the location of the recurrence and the fixation on the tibia, which would require the defect to be closed with the use of a transplant flap. The chance of a successful transplant flap was thought to be low in this adipose, severely diabetic patient and the risk of an amputation too high. An ILP was considered as an alternative for a lower leg amputation. An ILP, without use of blood or blood products in the perfusion circuit, was possible, on condition that the patient had a sufficient preoperative Hb concentration and therefore the patient received EPO preoperatively to achieve this. The patient received the information about the use of an extracorporeal circuit in the presence of another member of the Jehovah's witnesses’ community and agreed to undergo the procedure.
The patient underwent a femoral ILP with TNF alpha and Melphalan without any complications. The patient was discharged from the hospital in good condition 6 days after surgery. At least a partial, nearly a complete, response was seen, 4 months postoperatively. Fig. 1B–D show respective pre-, peri-, and postoperative pictures of the procedure and lesion.
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3. The technique of an ILP
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First, the patient received heparin in the amount of 200 I.E./kg b.w. (Leo Pharma BV, the Netherlands). Then 18 and 20 Fr. Catheters (Bardic Nr. 1855 straight) were placed in the lumen of the femoral artery and vein, which connected the limb circulatory system to the extracorporeal system. The extracorporeal circuit utilized was the Polystan Safe Mini Pediatric Oxygenating System (Maquet Cardiopulmonary AG, Germany) and a PVC tubing set of 1/4 in. in diameter. The CAPS roller pump (Stockert Gmbh, Germany) was used as a flow-regulating element of the system. This circuit required 400 ml priming, which consisted of Gelofusine colloidal solution (Braun AG, Germany) and 5 ml of natriumbicarbonat 8.4% (Fresenius Kabi BV, the Netherlands) and 2500 I.E. heparin.
Isolation of the extremity was achieved by compression of the proximal upper leg with an inflatable band and subsequently the extracorporeal circulation was started. The blood flow (280 ml/min) was calculated based upon the volume of the extremity. In reality we were able to give a blood flow of 350 ml/min during the procedure. Systemic leakage was checked with the use of radiolabeled human serum albumin. Once the absence of systemic leakage was confirmed and target tissue temperatures of 38 °C were reached, the chemotherapy agents were given directly in the arterial line of the extracorporeal circuit. First, a dose of 2 mg TNF alpha was administrated. After 10 min, 70 mg Melphalan was infused during 20 min. Then the extremity was circulated for 40 min and the tissues were warmed up to 39.0 °C. Afterwards, the extremity was washed out with 3000 ml Haes 10% solution (Fresenius Kabi BV).
During the procedure, arterial and venous blood gas and hematology samples were taken to control perfusion parameters (Table 1
). During the procedure a stable, very low level of hematocrite and a stable, adequate level of pO2 was measured in the blood of the extremity. There were no signs of acidosis and there was no leakage from the extremity to the systemic circulation. Total perfusion time was 124 min, first and second anoxic periods were 10 and 21 min, respectively. Postperfusion 120 mg of protamine was administrated to neutralize the heparin. The patient's systemic Hb was 7.3 mmol/L and 7.0 mmol/L, pre- and post-ILP, respectively.
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4. Discussion
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Not much is written about the use of an extracorporeal circuit for Jehovah's witnesses during cardiothoracic surgery [9,10]. To our knowledge, there are no publications on the use of an extracorporeal circuit during an ILP of a Jehovah's witness.
Despite the significant decrease in the hematocrite and Hb concentrations within the perfusion tract during the treatment, the other parameters remained within acceptable ranges. The large oxygenation capacity of the system and the adequate blood flow through the limb during the procedure made sure that the limb did not become acidotic and that the measured arterial and venous oxygen saturation remained at the correct levels. After the ILP the systemic Hb concentration had dropped with 0.3 compared to the preoperative measured concentration.
‘Bloodless’ ILP is technically possible, when the patient has an adequately preoperative Hb concentration. There are no indications for a decreased response rate. Patients, who refuse blood transfusions, should not be excluded for treatment with an ILP.
The patient gave written consent for this article and the use of photographs.
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References
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- de Wilt JH, ten Hagen TL, de Boeck G, van Tiel ST, de Bruijn EA, Eggermont AM. Tumour necrosis factor alpha increases melphalan concentration in tumour tissue after isolated limb perfusion. Br J Cancer 2000;82:1000-1003.[CrossRef][Medline]
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Abstract
1. Introduction
