Isolated Limb Perfusion for the Treatment of Unresectable In- Transit Metastases of Cutaneous Squamous Cell Carcinoma
Squamous cell carcinoma (SCC) is the second most common non-melanoma skin cancer and its incidence has been increasing over the past decades. SCC in-transit metastases are rare and predict a poor prognosis. We present the case of a 69-year-old patient with a right lower leg SCC, surgically excised with free margins. One month later, erythematous to violaceous, firm papules begin to erupt on the right lower leg, evolving to ulcerated nodules over a period of weeks. Homolateral inguinal and iliac nodal metastases were documented by percutaneous biopsy of an inguinal palpable lymph node and later documented by positron emission tomography – computed tomography (PET-CT). Given the unresectability of the disease, regional chemotherapy involving isolated limb perfusion (ILP) with melphalan and tumor necrosis factor-alpha (TNFα) was performed in order to avoid amputation. Macroscopic regression ensued, with complete resolution of all visible in-transit metastases 12 weeks after perfusion. However, a fatal outcome was observed 4 months later, due to systemic metastases. ILP is an effective and well-established technique in the treatment of advanced tumors of the extremities. Its main indications are in-transit metastases of malignant melanoma and advanced soft tissue sarcomas. However, studies have shown its effectiveness in other tumors such as locally advanced SCC. Despite the unfortunate outcome, it was possible to avoid amputation of the limb, with complete local disease remission.
Samarasinghe V, Madan V. Nonmelanoma Skin Cancer. J Cutan Aesthet Surg. 2012;5:3–10.
Jiménez Herevia AE, Tavares de la Paz LA, Hinojosa Ugarte D, Nieves Condoy J. Isolated limb perfusion on nonmelanoma skin cancer for limb salvage: a series of four cases. Cureus. 2020;12:e9998. doi: 10.7759/cureus.9998.
Alegre JF, Duarte M, Sureda González M, Bretcha Boix P, Dussan C, Ballester A, et al. Tratamiento regional del sarcoma y melanoma localmente avanzado de la extremidad mediante la perfusión aislada con tumor necrosis factor α y melfalan asociada a hipertermia. Cir Esp. 2012;90:114–20.
Huis In ’t Veld EA, Grünhagen DJ, Deroose JP, Nijsten TC, Wouters MW, Verhoef C, et al. Isolated limb perfusion for unresectable extremity cutaneous squamous cell carcinoma; an effective limb saving strategy. Br J Cancer. 2018;119:429–34. doi: 10.1038/s41416-018-0149-z.
Creech O, Krementz ET, Ryan RF, Winblad JN. Chemotherapy of cancer: regional perfusion utilizing an extracorporeal circuit. Ann Surg. 1958;148:616–32.
Bhangu A, Broom L, Nepogodiev D, Gourevitch D, Desai A. Outcomes of isolated limb perfusion in the treatment of extremity soft tissue sarcoma: a systematic review. Eur J Surg Oncol. 2013;39:311–9. doi: 10.1016/j.ejso.2012.12.018.
Belgrano V, Ben-Shabat I, Bergh P, Bagge RO. Isolated limb perfusion as a treatment option for rare types of tumours. Int J Hyperthermia. 2016;32:595-9. doi: 10.1080/02656736.2016.1188999.
Combalia A, Carrera C. Squamous cell carcinoma: an update on diagnosis and treatment. Dermatol Pract Concept. 2020;10:e2020066.
Brantsch KD, Meisner C, Schönfisch B, Trilling B, Wehner-Caroli J, Röcken M, et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol. 2008;9:713–20.
Cooper JZ, Brown MD. Special concern about squamous cell carcinoma of the scalp in organ transplant recipients. Arch Dermatol. 2006;142:755–8.
Ponte P, Moniz JV, Farricha V, Weinholtz JB. Merkel cell carcinoma: an unusual indication for isolated limb perfusion. Dermatol Online J. 2008;14:6.
Olieman AF, Liénard D, Eggermont AM, Kroon BB, Lejeune FJ, Hoekstra HJ, et al. Hyperthermic isolated limb perfusion with tumor necrosis factor alpha, interferon gamma, and melphalan for locally advanced nonmelanoma skin tumors of the extremities: a multicenter study. Arch Surg. 1999;134:303–7.
Aloia TA, Grubbs E, Onaitis M, Mosca PJ, Cheng TY, Seigler H, et al. Predictors of outcome after hyperthermic isolated limb perfusion: role of tumor response. Arch Surg. 2005;140):1115–20.
Koops HS, Vaglini M, Suciu S, Kroon BB, Thompson JF, Göhl J, et al. Prophylactic isolated limb perfusion for localized, high-risk limb melanoma: results of a multicenter randomized phase III trial. European Organization for Research and Treatment of Cancer Malignant Melanoma Cooperative Group Protocol 18832, the World Health Organization Melanoma Program Trial 15, and the North American Perfusion Group Southwest Oncology Group-8593. J Clin Oncol. 1998;16:2906–12.
Copyright (c) 2021 Journal of the Portuguese Society of Dermatology and Venereology
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles in this journal are Open Access under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).