Chemotherapy into a limb
Chemotherapy can be given directly into a limb (leg or arm) to help control cancer that has come back in one area. This is also called regional chemotherapy.
Giving the drugs directly into the affected limb means that very high doses can be given. The affected limb is isolated using a tight band (tourniquet), which prevents the chemotherapy drugs from going to other areas of your body.
This means you are unlikely to get the common side effects of chemotherapy, such as feeling sick, being at more risk of getting an infection or losing the hair from your head.
Regional chemotherapy is only done once.
There are two ways of giving chemotherapy into a limb:
- isolated limb perfusion (ILP)
- isolated limb infusion (ILI).
These treatments are only carried out in some specialist centres in the UK. You may have to travel to another hospital if your specialist advises you to have this treatment.
Regional chemotherapy for melanoma
Most melanomas can be successfully treated with surgery. Sometimes melanoma comes back (recurs) in the skin, very close to where the original melanoma was. This is called a local recurrence. If you have a recurrence, it is usually treated with an operation to remove it. You can have surgery even if you have more than one local recurrence.
Sometimes, clusters of melanomas come back in the same limb, but further away from the original melanoma. Doctors call these satellite lesions or in-transit metastases. Because there are lots of them, it can be difficult to remove them all with surgery. In this situation, a specialist may advise that you have either ILP or ILI.
These treatments are only given if the melanoma has not spread anywhere else in the body.
Regional chemotherapy for sarcoma
Soft tissue sarcomas are cancers that develop from cells in the soft, supporting tissues of the body, for example in fat, muscle, nerves or blood vessels.
Sarcoma in a limb can often be treated successfully using surgery and radiotherapy. You may also have chemotherapy. Sometimes, the sarcoma is too large to be removed with an operation (locally advanced). Or it may come back in the same area after treatment (local recurrence).
In these situations, you can often have further treatment to help control the cancer. One of the treatment options is regional chemotherapy with either ILP or ILI.
ILP is a surgical procedure given under a general anaesthetic. It usually involves staying in hospital for 3 to 7 days.
During ILP, the surgeon temporarily disconnects the blood flow between your affected limb and the rest of your body. The blood from your limb is circulated through an external pump and back into your limb. The chemotherapy drugs are given into the blood that circulates through your limb.
The usual way to have ILP is:
- You have a general anaesthetic.
- If the cancer is in the leg, the surgeon makes a small cut in the thigh, or occasionally in the lower abdomen or groin. If the cancer is in the arm, the surgeon makes a small cut in the armpit or arm.
- The surgeon temporarily disconnects the blood-flow (circulation) between the affected limb and the rest of the body. They then put 2 small tubes (catheters) into the main blood vessels in the limb. The first tube allows the blood to flow from the limb to a pump. Your blood is circulated through the pump, and then goes back into the limb through the second tube.
- A tourniquet is applied to the top of the limb. This is to stop the chemotherapy drugs circulating into the rest of the body. Oxygen is added to the blood going to the limb. This is done by a machine called an oxygenator. This is because the limb still needs oxygen during the treatment. After the treatment, the limb will get oxygen in the usual way – from the blood flowing through the lungs. The blood to the limb may also be heated, as some research shows this improves the results of the treatment.
- High doses of anti-cancer drugs are given into the blood that is circulating through the pump into the limb. The drugs circulate in the limb for up to 90 minutes.
- Once the treatment is finished, the drugs are flushed out of the limb using salt water (saline).
- The surgeon reconnects the blood-flow from the limb to the rest of your body. They remove the tourniquet, and the blood-flow goes back to normal. They then remove the catheters and seal the blood vessels to prevent any bleeding.
Because the blood-flow to the limb is disconnected from the rest of your circulation during treatment, the drugs will not travel anywhere else in your body.
The drugs used
A chemotherapy drug called melphalan is usually used. It can be given on its own, or sometimes with an immunotherapy drug called tumour necrosis factor (TNF). Immunotherapy is the name given to cancer treatments that use the body’s immune system to attack cancer cells.
Another chemotherapy drug you may have is dactinomycin.
This is a similar treatment to isolated limb perfusion and may sometimes be used instead. With ILI, the blood does not circulate through a pump and no oxygen is added. Because of this, the length of time that the tourniquet can be on for is shorter. This reduces the amount of time that chemotherapy can circulate in the limb. The usual process for having ILI is:
- The tubes (catheters) used are smaller than for ILP. They are put in through a small cut made in the groin or armpit. This happens in the x-ray department. You are usually awake for this, but the doctor uses a local anaesthetic to numb the area. For ILI treatment in the leg, they sometimes put the catheters into the groin on the opposite side of the body to the leg that is being treated.
- After the catheters are in place, you are taken to the operating theatre and given a general anaesthetic.
- A tourniquet is applied to the limb. This is to stop the chemotherapy drugs circulating into the rest of the body.
- High doses of anti-cancer drugs are given into the blood supply in the limb. The drugs circulate for about 20 to 25 minutes. Tumour necrosis factor (TNF) is not used with ILI. The blood going back into the limb may be heated.
- Once the treatment is finished, the drugs are flushed out of the limb using saline (salt water).
- The surgeon removes the tourniquet and reconnects the blood-flow from the limb to the rest of the body. They then remove the catheters and seal the blood vessels to prevent any bleeding.
Your doctors will be able to tell you more about isolated limb infusion if this is a suitable treatment for you.
The nurses and doctors will monitor you closely. You will have to rest and raise (elevate) your limb. This improves the blood circulation and allows time for the tissues in your limb to heal. Your surgeon will advise you on how long you need to do this for.
You will also be monitored after the operation to make sure you do not have any complications. If anything does happen, it will usually be picked up early.
The nurses will check the pulse in your limb regularly to make sure the blood flow is good. There is a small risk of developing a blood clot. This would cause symptoms such as:
- redness and swelling in the limb
- breathlessness and chest pain.
Blood clots can be very serious, so it is important to tell your doctor straight away if you have any of these symptoms. Most clots can be treated with drugs that thin the blood. Your doctor or nurse can tell you more about this.
The side effects usually only affect the treated limb. Your specialist will explain them to you and tell you what you can expect. Side effects usually get better after 6 to 8 weeks, but in some people, they may last longer.
Tell your doctor or nurse about any side effects or problems you are having. There is usually something they can do to make things easier.
Pain and stiffness
After the procedure, you are likely to have some pain in the limb, and your muscles and joints might be inflamed. This means you will feel stiff and uncomfortable when you are moving about. You will be given painkillers to take regularly to control the pain. You will probably need to take them for several weeks.
Tell your doctor or nurse if you are still in pain so that they can prescribe a stronger painkiller.
Swelling and redness
Your limb may become red and swollen. This usually starts about 48 hours after your treatment and is most noticeable after a week. The swelling gradually reduces over 4 to 6 weeks. The redness will gradually fade and become lighter over the next few months. The skin colour of your limb should go back to normal after about 6 months. But some people are permanently left with a slight darkening of the skin.
Blisters and peeling skin
Rarely, you can get blisters or peeling skin after treatment. This can be on the sole of your foot if you have treatment on your leg, or on the palm of your hand if you have treatment on your arm. This usually happens in the first 2 weeks after treatment, but it will gradually heal.
Risk of infection
Very rarely, small amounts of the chemotherapy drug may get into the rest of your body. This can temporarily reduce the number of white blood cells made by the bone marrow. White blood cells help to fight infection. If the number of white cells is low, you are more likely to get an infection.
Your white blood cells will gradually recover, but you may have to stay in hospital for a bit longer until they do. You will have regular blood tests to check this.
You will lose the hair on the leg or arm that has been treated, but this will grow back again. Very occasionally, people also have some thinning of the hair on their head, but this is not usually noticeable.
Numbness or tingling
You may get numbness or tingling after treatment. This will be in your foot if you have treatment on your leg, or in your hand if you have treatment on your arm. It is due to the effect of the chemotherapy drugs on your nerves and is called peripheral neuropathy.
Tell your doctor if this happens. It usually improves slowly over a few months but is sometimes permanent.
You will usually be seen about 6 weeks after the procedure. After this, you will be seen every few months, unless you live a long way from the hospital where you had treatment. In this situation, you will be seen by your own cancer specialist so that you do not have to travel far.
It can take time for regional chemotherapy to shrink the tumours, and you may still notice them getting smaller months after the procedure.