Patients with treatment-resistant, locally advanced soft tissue sarcomas (STS), a malignant cancer of the arms or legs, have typically faced amputation of the afflicted limb as the only treatment option. The rationale for amputation has been to prevent the cancer from spreading to other parts of the body. However, a technique that limits the application of chemotherapy to the cancerous region has shown to preserve limbs in almost 80 percent of patients, according to a study published online February 15 in the Journal of the American College of Surgeons.
The researchers used a treatment technique known as regional chemotherapy with isolated limb infusion (ILI) in 77 patients with treatment-resistant, locally advanced STS and were able to salvage limbs in 77.9 percent of the cases. The research, conducted at five cancer centers in the United States and Australia from 1994 through 2016, is the largest study of limb preservation using ILI for sarcoma. ILI has primarily been used for melanoma of the limbs; the use of this technique in sarcoma is a more novel approach.
The ILI technique involves circulating the chemotherapy agents melphalan and actinomycin D in the blood vessels of the affected area of the arm or leg, and the use of a tourniquet to block the chemotherapy drugs from circulating through the rest of the body, thus creating a closed circuit. The drugs circulate in the target area for 30 minutes, and then are flushed out before the tourniquet is removed and full circulation is restored. ILI for soft tissue sarcoma of the extremities can be repeated, whereas another procedure to administer chemotherapy to the arms or legs, hyperthermic isolated limb perfusion, requires an incision to openly cannulate the vessels and generally cannot be repeated.
The study patients who underwent ILI had 17 different subtypes of STS. In the study population, 19 patients had 21 procedures for upper-limb STS and 58 patients had 63 infusions for lower-limb STS. The results varied significantly for the two groups. The overall three-month response rate to ILI was 58 percent, but it was only 37 percent for those with upper-limb STS and 66 percent for lower-limb STS. Likewise, those who had upper-limb sarcomas had a lower median overall survival than their lower-limb counterparts-27.9 months versus 56.6 months. For the entire study population, the median overall survival was 44.3 months. With median follow-up of 20.6 months (range 0.6 to 146.1 months), the overall limb salvage rate was 77.9 percent. For those who underwent amputation due to a progression of the disease, the median time to amputation was 4.5 months.
Entering the study, all the patients had sarcomas that could only be removed with an amputation, but afterward 30 percent had a complete response to ILI, many of these because patients could have a surgical procedure to remove the tumors without amputation. For those who eventually needed an amputation, the median time to do so was 4.5 months following ILI.
One limitation of the study was that it did not randomize patients between ILI and amputation, so a comparison of response to treatment and survival cannot be performed with this dataset. The study also did not evaluate quality of life or patient-related factors for those who had limb salvage compared to those who had amputations.
Editor’s note: This story was adapted from materials provided by the American College of Surgeons.
