Isolated limb infusion and isolated limb perfusion

These are ways of having chemotherapy so it stays in the arm or leg (limb) and doesn’t go around the rest of the body. They are also called:

ILI - isolated limb infusion
ILP - isolated limb perfusion

They are types of regional chemotherapy. You may have one of them as treatment for melanoma skin cancer.

Your doctor or specialist nurse will tell you what treatment you’ll be having.

What is ILI and ILP?

Chemotherapy uses anti cancer drugs to destroy cancer cells. Sometimes doctors use the word cytotoxic to describe the way chemotherapy works. Cytotoxic means toxic to cells.

Doctors usually use a chemotherapy drug called melphalan for ILI or ILP. Sometimes they also give you another cancer drug called tumour necrosing factor alpha (TNF alpha) with the melphalan.

Your doctor puts a tight band (tourniquet) around the top of your limb where the melanoma is. They inject chemotherapy into the blood supply to your limb. The tourniquet stops the blood containing the chemotherapy from going to the rest of the body. Because the chemotherapy stays in the limb, you normally have fewer side effects.

You have ILI or ILP under a general anaesthetic so you are asleep for the procedure.

When you might have ILI or ILP

Doctors use ILI or ILP for melanoma skin cancer that:

is just in a limb and you are not able to have other treatments
has spread away from the original (primary) melanoma but not as far as the lymph nodes – these are called in transit or satellite metastases

Which treatment you have depends on a number of factors. This includes where in the UK you live and where on the limb the melanoma is.

What happens before ILI or ILP?

Your doctor will examine your limb. And you may have some scans and tests to check the blood vessels are working normally.

They work out how much chemotherapy you need. They do this by either:

measuring your body weight
measuring around your limb and asking you to put it in water so they can see how much the water level rises - this is called water displacement
using a special machine called a perometer - this uses infrared light to work out the measurements

Your doctor will explain the treatment and how it is given. They will ask you to sign a consent form saying you agree to the treatment.

You normally go to the pre operative assessment clinic in the weeks before your treatment. This is to make sure you are well enough for both the treatment and the general anaesthetic. And to make sure you are prepared for them.

At your appointment, the pre operative assessment team will:

ask you questions about your health and any medicines you are taking
tell you when to stop eating and drinking before your treatment
tell you if you need to stop taking any medicines before your treatment
check your weight, blood pressure, pulse and temperature
ask what help and support you have at home

It helps to write down any questions you have and take them with you to the appointment. The more you know about what is going to happen, the less frightening it will seem. You can ask more questions when you go into hospital so don’t worry if you forget to ask some.

What happens during the treatment?

What happens during the treatment depends on if you are having ILI or ILP.

ILI

Your doctor comes to see you and they go through the consent form with you again. You have a chance to ask them any questions before you go for your treatment. Your anaesthetist will also come and see you.

Before you have the chemotherapy, you have 2 tubes (catheters) put through the skin in your groin. One catheter goes in the blood vessel that takes blood to the limb (artery). The other goes in the blood vessel that takes blood away (vein). A specialist doctor (radiologist) may do this in the x-ray department. Or your doctor may put the catheters in after you have had the general anaesthetic.

If you’re having ILI in your leg, the catheters are put into your groin on the opposite side to where the melanoma is.

If you’re having ILI in your arm, the catheters are still put in your groin. Your doctor then moves them up through your body’s large veins and arteries until they get to your arm.

Your doctor will give you some medicine to lower the risk of blood clots. And your limb will be kept warm until you are ready to go for the treatment.

You have ILI in the operating theatre. When you get there, your anaesthetist will give you a general anaesthetic.

Once you’re asleep, your doctor puts the tourniquet around your limb above the melanoma. They then attach a tube to the 2 catheters making a loop. As your blood flows out through the loop, they inject the chemotherapy into it. Your blood then flows back in and around your limb.

The chemotherapy works better if your limb is warm. A heater keeps your blood warm while it’s in the loop. And your limb is kept warm with a special blanket. A thermometer is put on your limb to keep a close eye on its temperature.

The chemotherapy goes around your limb for 20 to 30 minutes.

ILP

You have ILP in the operating theatre. When you get there, your anaesthetist will give you a general anaesthetic. Your doctor then makes a cut into your vein and artery for the 2 catheters.

If you’re having ILP in your leg, your doctor puts the catheters into the vein and artery in your thigh on the same side as the melanoma.

If you’re having ILP in your arm, your doctor puts the catheters into one of the main veins and arteries in your arm the same side as the melanoma.

Your doctor puts the tourniquet on your limb. They also put a thermometer on it. This is so they can keep a close eye on its temperature.

They attach a tube to the ends of the 2 catheters making a loop. Your blood flows out through the loop and into a machine called a perfusion machine or bypass machine. This:

keeps your blood pumping around your limb
adds oxygen to your blood – this means the treatment can go around your limb for up to an hour and a half.
warms your blood – the chemotherapy works better if your limb is warm

The chemotherapy is added to your blood as it goes through the machine.

Sometimes your doctor might also add TNF alpha. This targets the blood vessels around the cancer. TNF alpha can cause severe side effects if it gets into the blood going around the rest of your body. Your doctor will check for this by adding a radioactive liquid to the drug. They put a small device on your chest. This measures radioactivity and tells your doctor if any of the drug has leaked out of your limb.

At the end of ILI or ILP

When the treatment has finished, your doctor injects special salty water (saline) into the loop. This flushes the blood and drugs out of your limb.

They remove the tourniquet, take out the catheters and repair your blood vessels. This lets the blood from the rest of your body flow back around your limb. Your body will make new blood to replace the blood that has been flushed out. Sometimes you may need a blood transfusion Open a glossary item to replace some of the blood.

Your doctor will close the wounds where the catheters were and put on a dressing.

After ILI or ILP

You go to the recovery area. When you’re awake your nurse will take you back to the ward. You need to rest in bed for a few days afterwards. So, it’s a good idea to take something to keep you occupied whilst you rest.

If you’ve had ILP you may stay on the high dependency unit (HDU) or intensive care unit (ITU) for the first night.

While you’re in hospital, your doctors and nurses will regularly measure your limb and check:

how soft it is
the colour
they can feel your heart beat (pulse) in it
if you have any pain

How long you stay in hospital for afterwards depends on whether you’ve had ILI or ILP. But you usually go home between 3 and 10 days after.

Problems after ILI or ILP

You don't have the usual side effects of chemotherapy with this type of treatment. This is because the drugs only go around the limb and not the rest of your body. But you may get some.

Soreness

Your arm or groin will be sore where the catheters go in and out. And you may be stiff in those joints and muscles. Your nurse will give you painkillers as you need them. If they don't control your pain, tell your doctor or nurse as soon as possible. You may need stronger painkillers, or a different type.

Changes to skin colour and swelling

You normally have some change of skin colour and swelling in the limb. Skin colour changes will depend on your normal skin tone. This can start a couple of days after treatment. Your skin colour is usually back to normal around 6 months after treatment. But some people may have a permanent change of skin colour in their limb.

Blisters

Some people get blisters after treatment. Or peeling skin on the soles of their feet or palms of their hands. This depends on where you had the treatment. The blisters can be quite large but they will heal.

Change in sensation

You might have some changes to sensation in the limb that’s been treated. This may feel like pins and needles. Or you may get numbness or tingling. Let your doctor or nurse know if you have any of these symptoms.

Hair loss and nail changes

You might lose hair on the limb you’ve had treated. And the hair may stop growing for a while. Your nails may also stop growing on that limb. Or you might lose them.

Compartment syndrome

Muscles have a layer of tissue called fascia around them. Fascia isn’t very flexible. So, if the muscle in the limb swells after treatment, the fascia doesn’t expand. This means everything inside the muscle gets squeezed, including the blood vessels. Doctors call this compartment syndrome. Symptoms include severe pain in the muscle, and it feeling cold, weak or tight.

Compartment syndrome is a rare but serious complication of ILI or ILP. It can happen in the first few days after treatment. Tell your doctor or nurse if you have any of the symptoms. You may need an emergency operation to treat it.

Lymphoedema

This is rare. Lymphoedema is a build up of fluid in part of the body. You may get this in the limb that you have had treated. It is a long term condition. Unfortunately, it can’t be cured, but it can usually be well controlled.

Other rare complications

On rare occasions, small amounts of the drug may get into the rest of your body. What affect this has, depends on what drugs your doctor gave you. Your doctors and nurses will be checking for it, so it should be picked up quickly if it happens.

There is also a risk of getting a blood clot after treatment. If you have pain anywhere in your limb, tell your doctor or nurse straight away because this can be one of the symptoms.

Where can you have ILI or ILP?

ILI and ILP is only available in some hospitals in the UK. This means you may not be able to have treatment locally. So you may need to travel to another hospital to have it.

Talk to your doctor if you are interested in having ILI or ILP. They can tell you if it is suitable for you and if it’s available in your area.