Br. J. Surg. 1991, Vol. 78, April, 493-494
R . A. Waters, R . M. Clement" and J. Meirion Thomas Westrninster and Royal Marsden Hospitals, London, and *West Glarnorgan Institute of Higher Education, Swansea, UK Correspondence to: M r J. Meirion Thomas, Department of Surgery,
Westminster Hospital, Dean Ryle Street, London SW1 P 2AP, UK
Carbon dioxide laser ablation of cutaneous metastases from malignant melanoma Multiple cutaneous and superficial subcutaneous metastases from malignant melanoma in 30 patients were treated palliatively by carbon dioxide laser ablation when lesions were too numerous, too large or recurring too rapidly f o r multiple local excisions. The number of lesions per patient ranged f r o m three to 250 (median 30). Patients were treated under local or general anaesthetic and as day cases or inpatients. After a median follow-up interval of 8 months fewer than 1 per cent of lasered metastases have recurred Eocally. Sixteen patients have developed cutaneous metastases at other sites requiring further treatment. Approximately 2000 lesions have been treated on 64 occasions. Patients reported little or no pain after the operation and required only simple dry dressings. Wounds were completely healed in 2-6 weeks with good cosmetic results. This simple and effective treatment is becoming an alternative to isolated limb perfusion.
Malignant melanoma has a diverse pattern of metastatic spread by lymphatic and haematogenous routes with an ability to metastasize selectively to skin and subcutaneous tissue in the absence of detectable spread to other sites. Untreated these lesions enlarge, ulcerate, become painful and unsightly and most patients will die from metastatic disease. Local excision of individual lesions is impractical when they are numerous, large or recurring with a short disease-free interval. Other methods of local ablation such as diathermy or cryosurgery may be used but their efficacy has not been reported. When the lesions are confined to a limb, isolated limb perfusion (ILP) is an important treatment option'. Systemic chemotherapy, immunotherapy and local radiotherapy have all demonstrated only limited effectiveness'. Because of its wavelength, carbon dioxide (CO,) laser radiation is highly absorbed by soft tissues and therefore dissipation of heat to surrounding tissues by conduction is reduced, thus minimizing thermal damage3. Its role in the treatment of widespread metastases of malignant melanoma has not been reported.
Patients and methods Thirty patients with cutaneous metastases of melanoma who had lesions which were too numerous, too large or recurring too frequently for local excision were selected for laser treatment. Patients with recurrences following ILP were included as well as those in whom ILP was contraindicated. i.e. patients with visceral metastases or cutaneous lesions not confined to a limb. Seventeen patients would have been suitable for ILP but were selected for laser ablation knowing that ILP would be an option if laser treatment failed to achieve local control. Lesions up to 2 cm in diameter were considered suitable for laser vaporization as were superficial subcutaneous lesions attached to skin. Deep subcutaneous nodules were treated by local excision and primary suture. Tuhk 1 summarizes the sites of the lesions in the patients. A Shanning Sirius 300 portable CO, laser (Shanning Laser Systems, University Innovation Centre, Swansea, U K ) was used. This has an articulated arm for free hand use and was used with a 50 mm lens which, at its focal point, gives a spot size of 0.05 mrn. The CO, laser beam has a wavelength of 10.6 pm which is in the far infrared range of the spectrum and therefore a visible helium neon aiming beam is incorporated. Local or general anaesthesia was used depending on the number, size and distribution of the lesions to be treated. Many were treated as day cases but elderly patients undergoing general anaesthesia and those travelling from greater distances stayed for one or two nights.
~-
Results Laser vaporization was a highly efficient method of ablating cutaneous metastatic melanoma. Patients with It!-20 small lesions were treated under local anaesthetic in less than 15 min and up to 250 lesions were treated in one session. In most cases the tumours involved the full thickness of skin and, therefore, a full thickness skin defect resulted. Some lesions were found to be very superficial and could be separated from the dermis by the laser beam leaving a wound which scabbed and healed rapidly. After the operation pain was absent or minimal. Only one patient experienced delayed wound healing following laser ablation. This was thought to be due to failure of the smoke evacuator during the procedure since efficient smoke evacuation has been found to be important in limiting thermal damage at the wound edge4. Fourteen patients required only one laser treatment for control of their cutaneous disease with a median follow-up of 8 months. Of these patients ten would otherwise have been suitable for ILP (although in one patient the procedure was Table 1
Sires
of lesions
trruird by luser uhluiion
Site
No. of patients
Limbs only No previous ILP Following ILP Following second ILP Limbs and trunk N o previous ILP Following ILP
3 (2)
Head and neck
1
Head and neck, trunk, limbs, subungual
1
1
Figures in parentheses indicate patients with visceral metastases at the time of their first laser treatment; ILP, isolated limb perfusion
~-
~~
O(l07 1327 91 040491-02
Each lesion was totally destroyed using a fully focused laser beam of spot size 0.05 mm at 1C20 watts (power dcnsity 0.5-1.0 megawatts cm-'). The plume was removed by a powerful smoke evacuator. Scalp and face wounds were left exposed but elsewhere dry dressings were applied until a dry eschar had formed.
(
1991 Butterworth-Heinernmn Lrd
493
CO, laser ablation of cutaneous metastases: R . A. Waters et al.
contraindicated because she refused blood transfusion). The remaining four patients had already had an ILP previously. Recurrences at a previously lasered site were rare ( < 1 per cent) and, although 16 patients later developed cutaneous metastases at new sites, these were easily treated by further laser ablation (the total number of treatments for each patient was: one treatment, 14 patients; two treatments, seven patients; three treatments, four patients: four treatments, two patients; and five, six and seven treatments, one patient each). Analysis of these 16 patients reveals that four of the patients were unsuitable for ILP either because their lesions were not confined to a limb or because they already had visceral metastases. Five of the patients had previously had an ILP and seven would otherwise have been suitable for ILP. Of the five who had previously had ILP the mean number of laser treatments was 4.6 and for those who would have been suitable for ILP it was 2.7. Four of the patients selected for laser ablation were known to have visceral metastases at the time of their first laser treatment. Two of these have since died of their disease while the other two are well and free of cutaneous disease. All other patients are currently clinically disease-free.
According to the Riverside Health Authority cost returns for 1989/90, the cost of an ILP is about f6500 compared with f 6 8 0 for day case laser treatment, plus &I80for each overnight stay. The capital cost of the laser (f25 000) is not included. Having had considerable experience with ILP', the limited benefits of this complex technique stimulated the search for an alternative treatment option. These initial results with laser ablation are encouraging. Fourteen of 30 patients are disease-free following a single laser treatment after a median interval of 8 months, and ten of these would have been suitable candidates for ILP. Seven patients suitable for ILP have required more than one laser treatment (mean 2.7 treatments) and it could be argued that this sub-group should now be offered ILP. In conclusion, laser ablation of cutaneous and superficial subcutaneous metastases is a simple and safe treatment for patients with post-ILP recurrences and for patients unsuitable for ILP. Laser ablation should be considered as the initial treatment to assess the duration of response for patients otherwise suitable for ILP.
Discussion
This research project was entirely supported by the Ken Oliver Research Trust.
Acknowledgements A method has been described for the local ablation of cutaneous metastases of melanoma. In the absence of a cure the aim of treatment is palliation. implying effective control of cutaneous disease with minimal side effects and minimal disruption of the patient's life. This treatment fulfils these criteria. Good wound healing following treatment depends on using the CO, laser with a high power density. This allows rapid vaporization of tumour with little time for dissipation of heat to surrounding normal tissue. During the vaporization procedure tumour tissue, particularly when melanotic, can easily be distinguished from normal tissue and selective vaporization is thus possible without removal or damage to surrounding normal tissue. Other methods of local ablation such as diathermy or cryosurgery are less precise and a wider margin of normal tissue is destroyed to ensure tumour necrosis. For the treatment of disease which would otherwise be suitable for ILP, laser ablation should be considered as a realistic first option. The morbidity and available results of both treatments require comparison. Laser ablation may be conducted on a day case basis and is a simple procedure allowing the patients to return quickly to their normal daily routine. Local recurrences at previously lasered sites are rare and there is no contraindication to further laser treatment if new lesions appear. No patient in our series has required amputation. In contrast, ILP is a major surgical procedure with significant morbidity' and m ~ r t a l i t y ' . ~rates which lasts approximately 3 h and requires hospitalization for about 25 days'. The objective response rate to ILP is reported as 73-91 per cent'.'.' but the mean duration of response is 14.9-23.3 Overall figures for relapse after complete response are 30 35 per cent'.'.''. Despite an initially good response rate, therefore, ILP offers a limited duration of response and a high relapse rate. The financial saving of treatment by laser is considerable.
494
References I.
2. 3.
4.
5.
6.
7. 8.
9. 10.
Le.jeune FJ, Lienard D, El Douaihy M. Vadoud Seyedi J, Ewalenko P. Results of206 isolated limb perfusions for malignant melanoma. Eur J Surg Oncol 1989; 5 : 510-19. Hill GJ, Hill HZ, Blumereich M. Treatment of melanoma. In: Schwartz RA, ed. Skin Cunccv. Rec~Jgi7itiiJt'Iund Munugemcwl. New York: Springer, 1988. Polyani TG. Physics of the surgical laser. Inrc~niutioiiulAdcuncc,.c in Surgic,crl Oncology 1978; 1: 205-15. Waters RA, Thomas JM, Clement RM, Davies C. The effect of limiting thermal damage when using the carbon dioxide laser for cutaneous surgery. S P I E Vulunie 1200 Laser Surgerj: Adi:uncecl Cl7uructerisation, Therapeutics, und Sj.stem.v II: Bellingham, Washington, USA: 1990: 151-3. Skene AI, Bulman AS, Williams TR. Thomas JM, Westbury G . Hyperthermic isolated limb perfusion with melphalan in the treatment of advanccd malignant melanoma of the lower limb. Br J Surg 1990; 7 7 : 765-1. Bulman AS, Jamieson CW. Isolated limb perfusion with melphalan in the treatment of malignant melanoma. Br J Sur(/ 1980; 67: 660-2. Hafstrom L, Jonsson PE. Hyperthermic perfusion of recurrent malignant melanoma on the extremities. Actu Chir S u n t l 1980; 146: 313-18. Lejeune FJ, Deloof T, Ewalenko P et ul. Objective regression of unexcised melanoma in-transit metastases after hyperthermic isolated limb perfusion of thc limbs with melphalan. Rcwnr Rc,.Sult.S CUi7Cl'r R ~ 1983: s 86: 268-76. Ghussen F, Nagdl K , Groth W, Miller J M . Stutzer H. A prospective randomised study of regional extremity perfusion in patients with malignant melanoma. Ai7n Surg 1984; 200: 764-8. Martijn H. Oldhoff J, Schraffortd Koops H . Regional perfusion in the treatment of patients with a locally metastasized malignant melanoma of the limbs. Eur J C ' u n c c ~19x1; 17: 471-6.
Paper accepted 17 October 1990
Br. J. Surg., Vol. 78, No. 4.April 1991
R . A. Waters, R . M. Clement" and J. Meirion Thomas Westrninster and Royal Marsden Hospitals, London, and *West Glarnorgan Institute of Higher Education, Swansea, UK Correspondence to: M r J. Meirion Thomas, Department of Surgery,
Westminster Hospital, Dean Ryle Street, London SW1 P 2AP, UK
Carbon dioxide laser ablation of cutaneous metastases from malignant melanoma Multiple cutaneous and superficial subcutaneous metastases from malignant melanoma in 30 patients were treated palliatively by carbon dioxide laser ablation when lesions were too numerous, too large or recurring too rapidly f o r multiple local excisions. The number of lesions per patient ranged f r o m three to 250 (median 30). Patients were treated under local or general anaesthetic and as day cases or inpatients. After a median follow-up interval of 8 months fewer than 1 per cent of lasered metastases have recurred Eocally. Sixteen patients have developed cutaneous metastases at other sites requiring further treatment. Approximately 2000 lesions have been treated on 64 occasions. Patients reported little or no pain after the operation and required only simple dry dressings. Wounds were completely healed in 2-6 weeks with good cosmetic results. This simple and effective treatment is becoming an alternative to isolated limb perfusion.
Malignant melanoma has a diverse pattern of metastatic spread by lymphatic and haematogenous routes with an ability to metastasize selectively to skin and subcutaneous tissue in the absence of detectable spread to other sites. Untreated these lesions enlarge, ulcerate, become painful and unsightly and most patients will die from metastatic disease. Local excision of individual lesions is impractical when they are numerous, large or recurring with a short disease-free interval. Other methods of local ablation such as diathermy or cryosurgery may be used but their efficacy has not been reported. When the lesions are confined to a limb, isolated limb perfusion (ILP) is an important treatment option'. Systemic chemotherapy, immunotherapy and local radiotherapy have all demonstrated only limited effectiveness'. Because of its wavelength, carbon dioxide (CO,) laser radiation is highly absorbed by soft tissues and therefore dissipation of heat to surrounding tissues by conduction is reduced, thus minimizing thermal damage3. Its role in the treatment of widespread metastases of malignant melanoma has not been reported.
Patients and methods Thirty patients with cutaneous metastases of melanoma who had lesions which were too numerous, too large or recurring too frequently for local excision were selected for laser treatment. Patients with recurrences following ILP were included as well as those in whom ILP was contraindicated. i.e. patients with visceral metastases or cutaneous lesions not confined to a limb. Seventeen patients would have been suitable for ILP but were selected for laser ablation knowing that ILP would be an option if laser treatment failed to achieve local control. Lesions up to 2 cm in diameter were considered suitable for laser vaporization as were superficial subcutaneous lesions attached to skin. Deep subcutaneous nodules were treated by local excision and primary suture. Tuhk 1 summarizes the sites of the lesions in the patients. A Shanning Sirius 300 portable CO, laser (Shanning Laser Systems, University Innovation Centre, Swansea, U K ) was used. This has an articulated arm for free hand use and was used with a 50 mm lens which, at its focal point, gives a spot size of 0.05 mrn. The CO, laser beam has a wavelength of 10.6 pm which is in the far infrared range of the spectrum and therefore a visible helium neon aiming beam is incorporated. Local or general anaesthesia was used depending on the number, size and distribution of the lesions to be treated. Many were treated as day cases but elderly patients undergoing general anaesthesia and those travelling from greater distances stayed for one or two nights.
~-
Results Laser vaporization was a highly efficient method of ablating cutaneous metastatic melanoma. Patients with It!-20 small lesions were treated under local anaesthetic in less than 15 min and up to 250 lesions were treated in one session. In most cases the tumours involved the full thickness of skin and, therefore, a full thickness skin defect resulted. Some lesions were found to be very superficial and could be separated from the dermis by the laser beam leaving a wound which scabbed and healed rapidly. After the operation pain was absent or minimal. Only one patient experienced delayed wound healing following laser ablation. This was thought to be due to failure of the smoke evacuator during the procedure since efficient smoke evacuation has been found to be important in limiting thermal damage at the wound edge4. Fourteen patients required only one laser treatment for control of their cutaneous disease with a median follow-up of 8 months. Of these patients ten would otherwise have been suitable for ILP (although in one patient the procedure was Table 1
Sires
of lesions
trruird by luser uhluiion
Site
No. of patients
Limbs only No previous ILP Following ILP Following second ILP Limbs and trunk N o previous ILP Following ILP
3 (2)
Head and neck
1
Head and neck, trunk, limbs, subungual
1
1
Figures in parentheses indicate patients with visceral metastases at the time of their first laser treatment; ILP, isolated limb perfusion
~-
~~
O(l07 1327 91 040491-02
Each lesion was totally destroyed using a fully focused laser beam of spot size 0.05 mm at 1C20 watts (power dcnsity 0.5-1.0 megawatts cm-'). The plume was removed by a powerful smoke evacuator. Scalp and face wounds were left exposed but elsewhere dry dressings were applied until a dry eschar had formed.
(
1991 Butterworth-Heinernmn Lrd
493
CO, laser ablation of cutaneous metastases: R . A. Waters et al.
contraindicated because she refused blood transfusion). The remaining four patients had already had an ILP previously. Recurrences at a previously lasered site were rare ( < 1 per cent) and, although 16 patients later developed cutaneous metastases at new sites, these were easily treated by further laser ablation (the total number of treatments for each patient was: one treatment, 14 patients; two treatments, seven patients; three treatments, four patients: four treatments, two patients; and five, six and seven treatments, one patient each). Analysis of these 16 patients reveals that four of the patients were unsuitable for ILP either because their lesions were not confined to a limb or because they already had visceral metastases. Five of the patients had previously had an ILP and seven would otherwise have been suitable for ILP. Of the five who had previously had ILP the mean number of laser treatments was 4.6 and for those who would have been suitable for ILP it was 2.7. Four of the patients selected for laser ablation were known to have visceral metastases at the time of their first laser treatment. Two of these have since died of their disease while the other two are well and free of cutaneous disease. All other patients are currently clinically disease-free.
According to the Riverside Health Authority cost returns for 1989/90, the cost of an ILP is about f6500 compared with f 6 8 0 for day case laser treatment, plus &I80for each overnight stay. The capital cost of the laser (f25 000) is not included. Having had considerable experience with ILP', the limited benefits of this complex technique stimulated the search for an alternative treatment option. These initial results with laser ablation are encouraging. Fourteen of 30 patients are disease-free following a single laser treatment after a median interval of 8 months, and ten of these would have been suitable candidates for ILP. Seven patients suitable for ILP have required more than one laser treatment (mean 2.7 treatments) and it could be argued that this sub-group should now be offered ILP. In conclusion, laser ablation of cutaneous and superficial subcutaneous metastases is a simple and safe treatment for patients with post-ILP recurrences and for patients unsuitable for ILP. Laser ablation should be considered as the initial treatment to assess the duration of response for patients otherwise suitable for ILP.
Discussion
This research project was entirely supported by the Ken Oliver Research Trust.
Acknowledgements A method has been described for the local ablation of cutaneous metastases of melanoma. In the absence of a cure the aim of treatment is palliation. implying effective control of cutaneous disease with minimal side effects and minimal disruption of the patient's life. This treatment fulfils these criteria. Good wound healing following treatment depends on using the CO, laser with a high power density. This allows rapid vaporization of tumour with little time for dissipation of heat to surrounding normal tissue. During the vaporization procedure tumour tissue, particularly when melanotic, can easily be distinguished from normal tissue and selective vaporization is thus possible without removal or damage to surrounding normal tissue. Other methods of local ablation such as diathermy or cryosurgery are less precise and a wider margin of normal tissue is destroyed to ensure tumour necrosis. For the treatment of disease which would otherwise be suitable for ILP, laser ablation should be considered as a realistic first option. The morbidity and available results of both treatments require comparison. Laser ablation may be conducted on a day case basis and is a simple procedure allowing the patients to return quickly to their normal daily routine. Local recurrences at previously lasered sites are rare and there is no contraindication to further laser treatment if new lesions appear. No patient in our series has required amputation. In contrast, ILP is a major surgical procedure with significant morbidity' and m ~ r t a l i t y ' . ~rates which lasts approximately 3 h and requires hospitalization for about 25 days'. The objective response rate to ILP is reported as 73-91 per cent'.'.' but the mean duration of response is 14.9-23.3 Overall figures for relapse after complete response are 30 35 per cent'.'.''. Despite an initially good response rate, therefore, ILP offers a limited duration of response and a high relapse rate. The financial saving of treatment by laser is considerable.
494
References I.
2. 3.
4.
5.
6.
7. 8.
9. 10.
Le.jeune FJ, Lienard D, El Douaihy M. Vadoud Seyedi J, Ewalenko P. Results of206 isolated limb perfusions for malignant melanoma. Eur J Surg Oncol 1989; 5 : 510-19. Hill GJ, Hill HZ, Blumereich M. Treatment of melanoma. In: Schwartz RA, ed. Skin Cunccv. Rec~Jgi7itiiJt'Iund Munugemcwl. New York: Springer, 1988. Polyani TG. Physics of the surgical laser. Inrc~niutioiiulAdcuncc,.c in Surgic,crl Oncology 1978; 1: 205-15. Waters RA, Thomas JM, Clement RM, Davies C. The effect of limiting thermal damage when using the carbon dioxide laser for cutaneous surgery. S P I E Vulunie 1200 Laser Surgerj: Adi:uncecl Cl7uructerisation, Therapeutics, und Sj.stem.v II: Bellingham, Washington, USA: 1990: 151-3. Skene AI, Bulman AS, Williams TR. Thomas JM, Westbury G . Hyperthermic isolated limb perfusion with melphalan in the treatment of advanccd malignant melanoma of the lower limb. Br J Surg 1990; 7 7 : 765-1. Bulman AS, Jamieson CW. Isolated limb perfusion with melphalan in the treatment of malignant melanoma. Br J Sur(/ 1980; 67: 660-2. Hafstrom L, Jonsson PE. Hyperthermic perfusion of recurrent malignant melanoma on the extremities. Actu Chir S u n t l 1980; 146: 313-18. Lejeune FJ, Deloof T, Ewalenko P et ul. Objective regression of unexcised melanoma in-transit metastases after hyperthermic isolated limb perfusion of thc limbs with melphalan. Rcwnr Rc,.Sult.S CUi7Cl'r R ~ 1983: s 86: 268-76. Ghussen F, Nagdl K , Groth W, Miller J M . Stutzer H. A prospective randomised study of regional extremity perfusion in patients with malignant melanoma. Ai7n Surg 1984; 200: 764-8. Martijn H. Oldhoff J, Schraffortd Koops H . Regional perfusion in the treatment of patients with a locally metastasized malignant melanoma of the limbs. Eur J C ' u n c c ~19x1; 17: 471-6.
Paper accepted 17 October 1990
Br. J. Surg., Vol. 78, No. 4.April 1991
