Jonathan Zager, M.D., Professor of Surgery Director of Surgery and Director of Regional Therapies in the Department of Cutaneous Oncology at Moffitt Cancer Center in Tampa, Florida, talks about how a new approach at a therapy is saving some people from amputation.
Interview conducted by Ivanhoe Broadcast News in September 2016.
Tell me a little bit about what exactly is an isolated limb fusion, what exactly is it, who’s a good candidate?
Dr. Zager: Isolated limb fusion is a way of minimally invasively isolating an extremity, upper or lower extremity with catheters that are placed by either vascular surgery or interventional radiology in the artery in vein. Those catheters are then snaked in to the affected extremities, arteries and veins. We place it via the groin and the catheters are snaked up, placed in the affected area, like an arm artery and vein, and we put a tourniquet above those catheters. This way we can perfuse the arm with high dose heated chemotherapy; the tourniquet prevents that chemotherapy from getting to any other place in the body which allows us to target the disease whether it’s melanoma or sarcoma with ten times the dose of chemotherapy that we would normally give systemically. Patient sare candidates when they have unresectable, maximally treated sarcoma that is only treatable by amputation, or melanoma in an intransit fasion where the melanoma recurs up and down the extremity.
Can you tell us a little bit about isolated limb fusion is?
Dr. Zager: An isolated limb fusion is a way of minimally invasively profusioning an extremity with high dose chemotherapy. We usually put catheters in the artery in vein in a groin; then the interventional radiologist will snake those catheters up to the effected extremity. It could be the leg, it could be the arm. The catheters will sit in the artery in vein of the effected extremity and we have a tourniquet proximal to those catheters. We blow up the tourniquet and it allows us to deliver high dose chemotherapy to the limb that has the cancer in it whether it’s melanoma or sarcoma. It allows us to give super high doses that usually wouldn’t be given systemically.
And you recently hit a milestone for isolated limb fusion, tell me about that.
Dr. Zager: We just did our two hundredth ILI or isolated limb fusion here at Moffitt Cancer Center. It took a little under nine years to do two hundred cases.
Who is a good candidate for this type of treatment?
Dr. Zager: Patients can have usually its melanoma, sometimes sarcoma that’s limited to the extremity and not resectable, meaning I can’t take it out surgically. We give the patients some alternatives as well. There are alternative therapies like systemic chemotherapy, sometimes radiation, but often times these patients aren’t candidates for systemic therapy, at least in the sarcoma patients, and they’ve already maxed out their radiation dosage. The melanoma patients sometimes are candidates for other therapies and want an ILI or an isolated limb fusion, other times they’re not candidates for systemic therapy. But as long as they don’t have disease outside the limb they are a good candidate for the procedure.
How often can someone undergo and ILI procedure?
Dr. Zager: I’ve done it three to even four times in the same patient. We usually space it out at least three to four months and we’ll only repeat it if there’s a response. If you haven’t responded to the first ILI and your disease progressed through it, then there is no reason to go ahead and do another one. Usually the patients who have a very good partial response down the road might start to have disease recurrence in the extremity; we’ll go ahead and entertain another isolated limb fusion.
Tell me a little bit about the patient Mike and what happened with him where he was told that he would actually have to have his arm amputated before he met you.
Dr. Zager: Mr. Lackey had a sarcoma in the flexor compartment of his forearm that was un-resectable. He saw surgeons out in Denver who said he needed a below the elbow amputation and sought a second opinion at MD Anderson who said that he likely needed an amputation; however, they actually sent him over here to talk to me about a potential isolated limb fusion. I told him it was worth a shot, that there’s a thirty to forty percent chance that his tumors could respond with an ILI and that he wouldn’t need an amputation. We did the first of two isolated limb fusions about two years ago. He’s had his arm for two years with no progression of disease and no disease systemically. He’s very happy right now.
And so he’s doing really well.
Dr. Zager: He’s doing great. Very happy, he’s coming in to see me in a couple of weeks for a re-evaluation. I usually see him every three to four months with an MRI of his arm and a CT scan of the chest just to make sure that there’s no disease recurrence in his arm and no spread of disease elsewhere.
When was his last ILI?
Dr. Zager: About a year ago, maybe a little over a year ago. I think we’ve done it in every July and August the past couple years.
Is this a clinical trial or is this already approved?
Dr. Zager: It’s an approved form of treatment. We did it outside of the clinical trial at Standard of Care for his case. With the sarcoma program here I will do an isolated limb fusion for un-resectable maximally treated sarcomas that the only other option really is an amputation.
END OF INTERVIEW
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