March 28, 2019

Hot chemotherapy surgery helps save patient’s leg

Tom Deweese can keep up with his grandchildren because of a highly specialized surgery using hot chemotherapy that saved his leg.

Tom Deweese can keep up with his grandchildren because of a highly specialized surgery using hot chemotherapy that saved his leg.

Tom Deweese

In certain advanced melanoma and sarcoma or bone cancers, amputation is used to treat these cancers that develop in a person’s limb. Faced with that prospect, Deweese opted for isolated limb infusion instead of amputation. He had multiple tumors that were eradicated with the procedure.

Vanderbilt University Medical Center is one of few hospitals where chemotherapy can be administered during surgery. The treatment is offered by Vanderbilt-Ingram Cancer Center’s (VICC) Regional Cancer Therapy clinic.

“The concept is that there are areas or regions of the body that are unique where we can surgically administer heated chemotherapy in that particular region or organ without affecting the rest of the body,” said Kamran Idrees, MD, MSCI, MMHC, director of Pancreas and GI Surgical Oncology and director of the Peritoneal Surface Malignancy Program at VICC.

Those areas include the abdominal cavity, liver and limbs.

“This allows us to give a really high dose to that particular organ that is diseased while sheltering the rest of the body from the side effects and toxicities of chemotherapy,” Idrees said.

The treatment is more often done for abdominal cancers, and is referred to as hyperthermic intraperitoneal chemotherapy (HIPEC).

Idrees has performed more than 100 HIPEC surgeries at Vanderbilt, but the isolated limb infusion was a first.

“Dr. Idrees was very honest and very open,” Deweese said. “He told me all about it, that it was the first one done at Vanderbilt. My wife and I talked it over and said, ‘Let’s go with it.’ He had said you can go somewhere else if you want a second opinion. I said, ‘No, Vanderbilt has a good reputation. I’m very comfortable with Vanderbilt.’”

During the procedure, tumors are targeted and treated by delivering as much as 10 times the normal amount of chemotherapy. First, catheters are placed in the blood vessels of the affected limb followed by placement of a tourniquet above the catheters.

Then, high-dose, heated chemotherapy is administered to kill cancer cells while the treated limb is clamped off, which keeps the chemotherapy from circulating through the blood system to the rest of the body. The heat improves the absorption of the chemotherapy in the targeted area for about 30 minutes before being flushed out.

In Deweese’s case, the tumors were so prolific they couldn’t be surgically removed individually, which would have necessitated amputation, but the hot chemotherapy proved effective.

He underwent isolated limb infusion in August 2017. The cancer had been discovered two years earlier.

“The first find of the cancer was in the late fall of 2015,” he said. “I went to a dermatologist because the spot was on the top of my foot. My shoe was rubbing it and making it sore. He took a sample and sent it off. It was melanoma. He then made an appointment for me within a week or so with a surgeon. The surgeon did a wide incision and a skin graft on top of my foot.”

However, a year later he noticed a couple of lesions around his ankle.

“I went back to my dermatologist, and he did another biopsy,” Deweese said. “Those came back melanoma. It had returned so he suggested that I go to Vanderbilt.”

At VICC, Deweese was initially treated with two immu-notherapies, an immune checkpoint inhibitor called pembrolizumab and T-VEC, a genetically engineered oncolytic virus designed to attack cancer cells.

After the melanoma didn’t respond to either of those treatments and grew in numbers, Deweese was referred to Idrees.

HIPEC and isolated limb infusion procedures require a specially trained surgery team in the operating room. Nationwide, Idrees is one of only 108 surgeons who are members of the American Society of Peritoneal Surface Malignancies.

“It’s a team effort between the surgeon, anesthesiologists, perfusionists, pharmacy staff and medical oncologists,” Idrees said.

Deweese, 69, of Nashville, said he’s glad his leg was saved, and his disease remains in remission 18 months later.

Now that it has completely healed from surgery, he has returned to work and in his spare time he and his wife enjoy playing with their grandchildren.