Medical Minute 4-15: Chemo Blast for Melanoma

By: Vanessa Welch Email
By: Vanessa Welch Email

George Pittman is back in class and back in the saddle.

"All third, fourth and fifth graders come to me, so I've got 150 kids."

He's a volunteer math and science tutor, and he just loves watching little minds grow.

"The elementary school kids are neat because they really want to learn."

Also growing in the prostate cancer survivor: Malignant melanoma in his left leg. Doctors cut out four in less than a year.

"I got a little melanoma factory in here. They just keep coming, so, you know, I've got to do something different," said George Pittman.

"If you cut it out, it's going to come back, most certainly."

Mercy Medical Center's Vadim Gushchin treated him with an intense, isolated blast of chemotherapy. Using small catheters, surgeons infused a massive dose of chemo into George's leg alone. The procedure took just 30 minutes.

"I was a little set back with it because 'chemotherapy…' that's a scary word."

In a third of cases, though, all nodules disappear. The old method meant larger incisions and catheters. It's minimally invasive all-around.

"The nodule stopped growing, at least stopped growing for three to four weeks since we did the procedure," said Vadim Gushchin, M.D., Mercy Medical Center.

Good news for George who got back to class as fast as he could.

"After the surgery, I really felt pretty good, so I went back and tried to teach for a day."

Getting back up to speed shouldn't be a problem.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500,


BACKGROUND: Chemo Blast is a surgical procedure to allow you to get high doses of chemotherapy only in one limb (an arm or leg). The benefit of method is that you do not get effects of the anticancer treatment in other areas of your body. After years of advancements, Isolated Limb Infusion -- or ILI -- is a minimally invasive technique that uses the same principles of regional high-dose chemotherapy but through smaller catheters. These specific catheters allow are similarly used by cardiologists to study vessels of the heart. For many people, ILI is the only option to avoid amputation. (Source: Mercy Medical Center)

WHAT TO EXPECT IN THE OR: You will be admitted to the hospital and should expect to stay for four to five days. This procedure is done in the surgery area. You will receive general anesthesia. The limb to be treated will be warmed to help the chemotherapy have the most effect. A type of tourniquet is used to stop the flow of blood in and out of the limb being treated. This also prevents the chemotherapy from spreading throughout your body. The chemotherapy will be given through an incision into a major artery and vein in the limb to be treated. After surgery you will have a bandage (dressing) over the surgical site. If you had any lymph nodes removed during the surgery you will likely have a drain in place to prevent fluid build-up. You may spend the first night in the Surgical Intensive Care Unit where you will have frequent attention. The pulse, color, sensation and movement will be checked often on the affected limb. You will be given medication to help control pain.
Before discharge you and your caregivers will be instructed about all your care needs. After you go home you will still need to care for your wound, for a drain, to manage swelling. (Source: The Ohio State University Medical Center)


Wound infection/separation: You will be told how to care for the surgery site after you leave the hospital.

Nerve damage: You may have damage to nerves in the limb treated with chemotherapy or from swelling that may occur after the procedure.

Pain: You will be checked and treated for pain while in the hospital. Pain medication will be used to help control pain after your discharge as well.

Swelling or Lymphedema: The treated limb will have a tendency to swell. You will be given instruction how you can help manage swelling. This may include patient education handouts to help you care for this condition.

Skin changes: The skin on the treated limb will be discolored and may peel. Gentle skin lotions with no alcohol may be used. The lotion should not be used near the incision or wound.

Blood clots or vein inflammation: These are more rare complications. It is possible but not likely that blood clots may develop in the artery or vein of the treated limb.

Stacey Sherman
Institute for Cancer Care at Mercy Medical Center
(410) 332-9349


Vadim Gushchin, M.D., from Mercy Medical Center in Baltimore, discusses Isolated Limb Infusion (ILI) and how this novel technique rarely used in the United States is saving patients' lives.

Can you discuss melanoma and the vast strides that you have made over the years with Isolate Limb Infusion?

Dr. Vadim Gushchin: Absolutely. Melanoma is a disease that is very difficult to treat once it comes back or progresses to the lymph nodes and other organs. We haven’t made many strides in the area of chemotherapy or immunotherapy, and once we have a recurrence of the disease it is very difficult to treat. If the occurrence happens in the extremity (i.e. arm or leg) – if you cut it out it is going to come back most certainly. If you cut some more, many more nodules will come up. With time, they will grow and bleed very quickly; the extremity will become disfigured, and very few if any medical options are possible. Even amputation does not save the patient from the tumors growing back at the site of the amputation. It happens very quickly, even when patients are recovering from amputation. I have seen this many times, and that’s what you have to keep in mind when you consult patients with recurrence of the tumor in an extremity.

The possibility of losing a limb?

Dr. Vadim Gushchin: Or even that wouldn’t solve the problem. The melanoma will come back in the stump, for example. With limited options, one of the effective strategies is perfusing the limb with high concentration of chemotherapy. The dose is lethal if they appear in the systemic circulation in the rest of the body. The trick is to perfuse only the affected area. So, an arm or a leg is the perfect setup for this technique where you can isolate the rest of the circulation with a tourniquet and give chemotherapy only to their arm or their leg with melanoma. So the goal is to expose melanoma to very high toxic doses of chemotherapy. Another technique is when you cut out the vessels; it is a very invasive technique that requires a relatively big incision. You can do it several times for example (one or two times – that is the maximum that you can do it). With ILI technique, when you insert catheters – when patients have cardio catheterization (similar technique, similar equipment) – you put catheters in the leg similar to a tourniquet and give chemotherapy to the rest of the leg.

So previous techniques included larger incisions via more invasive techniques?

Dr. Vadim Gushchin: Correct. And you can do it only a limited number of times.

With this technique, however, you are using smaller catheters?

Dr. Vadim Gushchin: Yes. The patient heals quicker and you can do it multiple times if needed.

How long have you been implementing this new fangled technique that uses smaller catheters?

Dr. Vadim Gushchin: The technique has been around for about 7 years or so. It started in Australia. I actually learned it from Dr. Thompson, who pioneered this technique in Sydney, Australia. I have been using it for about 5 years now.

How much more beneficial is it for you as well as the patient to be able to use this less invasive technique?

Dr. Vadim Gushchin: It is beneficial for the patient, because the patient doesn’t need to heal from a big wound. I have a better option of dealing with more complex patients, whether it is difficult to make the incision for various reasons where it is difficult to reach vessels, and I can do the procedure several times. On one patient I did it 3 times too much success, and this allowed the patient to keep the extremity for more than a year.

So there is more flexibility all around?

Dr. Vadim Gushchin: Correct. It is not a replacement of the old technique, but you gain additional benefits from doing a similar procedure with different equipment.

The catheter that you were holding earlier, that is the approximate size of it?

Dr. Vadim Gushchin: Yes. That is the actual catheter.

George Pitman, a patient of yours who you performed the ILI procedure on, had a real possibility of losing his leg; is that correct?

Dr. Vadim Gushchin: With time, the lesions grow in both number and size. It is sometimes amazing to see that the tumor grows in front of you within mere days to weeks. So it is impossible to see when it implodes, but yes . . . he does have a real possibility of losing a leg.

Can you explain the extent of the melanoma in his case?

Dr. Vadim Gushchin: His first presentation was probably 8 months ago when he presented (as do many of our patients) with what we call regular melanoma. I did the appropriate treatment with removing a lot of the skin around the melanoma – it’s called wide local incisions, which have the lymph nodes that came back as negative. I hoped that he would have the same course that many patients do. Basically, he would come to me every now and then to check if there was any new melanomas or any recurrence of them. Alas, he came back to me within a month or so with new nodule next to the area where we excised . . . and it was melanoma. I excised it and he came back again with yet another nodule. We were playing ‘excision and watching’ several times this way. A new nodule would pop up, I would excise it, and another one would grow. He understood my concern that you can’t go forever with the excision of these nodules. We have a limited amount of skin on the leg. More and more he was thinking about the ILI procedure. So far, it was a bit difficult to say whether it was effective or not, but he had told me that the nodules had stopped growing for about 3-4 weeks following the last procedure. He is very meticulous in taking measurements and pictures every day, so I hope that it is effective.

Will you see him again to check?

Dr. Vadim Gushchin: Yes. Typically, the effectiveness is evident two months after the procedure.

How do you determine whether this treatment has been effective or not?

Dr. Vadim Gushchin: We observe the lesion that we are treating. We purposefully leave the lesion intact and monitor the progress. If it doesn’t grow, sometimes it changes the colors and other times it disappears. Those are the criteria. Other criteria includes that it doesn’t grow or other new lesions appear. That is a sign of partial success.

In certain cases, there have been instances when lesions have disappeared altogether; is that correct?

Dr. Vadim Gushchin: Yes.

What is the utmost point that you want to get across to viewers?

Dr. Vadim Gushchin: The important point that I want to make is this: It doesn’t cure all melanoma. It takes care of a serious percentage of morbidity including but not limited to growth (uncontrolled growth of nodules that bleed and moreover get infected to the point that it may disfigure the extremities) – we are still searching for new techniques that are less invasive and more affective – medication, immunotherapy, procedures; but it has a role in the treatment of melanoma, and in some patients it allows for them to save their extremities and continue a high quality of life. Still, we are in search for better techniques. Patients receive a full response with a disappearance of the lesions in approximately one third of the cases, the other one third will have the disease stabilized to the point that it is no longer growing (partial response), and unfortunately the remaining one third of patients see little benefits as they progress through the treatment. Those numbers compare very favorably, however, with the results of other treatments such as chemotherapy, radiation or immunotherapy. This should be taken in to context with the comparison of other treatments and their results.

How widely implemented is this procedure in the United States?

Dr. Vadim Gushchin: This procedure requires a great deal of corroboration between myriad branches of the oncology department. To my knowledge, it is rarely performed in the United States. We are the only center in the D.C., Philadelphia, Baltimore area that performs this procedure.

Can you explain the procedure as well as the catheter that you are holding?

Dr. Vadim Gushchin: This is the actual size of the catheter. It is quite thin and quite long. It goes on the opposite side of the groin on the patient, and travels across the body in the affected limb and goes down the leg. Chemotherapy is delivered through this catheter (placed in the aria of the patient), and the blood gets out of the leg from the vein of the patient through a similar catheter. The heated drug is circulated for 30 minutes, and that is how the procedure is done. At the same time, a tourniquet affectively protects the rest of the body from the chemotherapy agent.

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