BACKGROUND: Isolated limb perfusion (ILP) is a well-established surgical procedure for the administration of high dose chemotherapy to a limb for the treatment of advanced extremity malignancy. Although the technique of ILP was first described over 60 years ago, ILP is utilised in relatively few specialist centres, co-located with tertiary or quaternary cancer centres. The combination of high dose cytotoxic chemotherapy and the cytokine tumour necrosis factor alpha (TNFα), mandates leakage monitoring to prevent potentially serious systemic toxicity. Since the procedure is performed at relatively few specialist centres, an ILP working group was formed with the aim of producing technical consensus guidelines for the procedure to streamline practice and to provide guidance for new centres commencing the technique. METHODS: Between October 2021 and October 2023 a series of face to face online and hybrid meetings were held in which a modified Delphi process was used to develop a unified consensus document. After each meeting the document was modified and recirculated and then rediscussed at subsequent meeting until a greater than 90% consensus was achieved in all recommendations. RESULTS: The completed consensus document comprised 23 topics in which greater than 90% consensus was achieved, with 83% of recommendations having 100% consensus across all members of the working group. The consensus recommendations covered all areas of the surgical procedure including pre-operative assessment, drug dosing and administration, perfusion parameters, hyperthermia, leakage monitoring and theatre logistics, practical surgical strategies and also post-operative care, response evaluation and staff training. CONCLUSION: We present the first joint expert-based consensus statement with respect to the technical aspects of ILP that can serve as a reference point for both existing and new centres in providing ILP.

2nd Department of Surgery Department of Cardiovascular Surgery General University Hospital Prague and 1st Faculty of Medicine Charles University Prague Czech Republic

Belpharma s a Luxembourg Luxembourg

Chairman surgical subgroup EORTC Melanoma Group Brussels Belgium; Direttore divisione dermatologia Oncologica Image Institute Milan Italy

Clarunis University Center for Gastrointestinal and Liver Disease Basel Basel Switzerland

Department of Abdominal and Paediatric Surgery Oslo University Hospital Norwegian Radium Hospital Oslo Norway

Department of Academic Surgery Royal Marsden Hospital London UK; Department of Surgery Royal Prince Alfred Hospital Sydney Australia; The University of Sydney Sydney Australia

Department of Academic Surgery Royal Marsden Hospital London UK; Institute of Cancer Research London UK

Department of Cardiovascular Surgery Clinica University of Navarra Pamplona Spain

Department of General and Visceral Surgery Friedrich Alexander University Erlangen Nürnberg Erlangen Germany

Department of Orthopaedic Oncology and Soft Tissue Sarcoma Essen University Hospital Hufelandstraße 55 45147 Essen Germany

Department of Orthopedic Oncology Helios Klinikum Berlin Buch Schwanebecker Chaussee 50 13125 Berlin Germany

Department of Surgery Institute Curie Paris France

Department of Surgery Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Amsterdam the Netherlands

Department of Surgery Oncology and Gastroenterology DISCOG University of Padua Padua Italy; Department of Surgery Veneto Institute of Oncology IOV IRCCS Padua Italy

Department of Surgical Oncology and Gastrointestinal Surgery Erasmus MC Rotterdam the Netherlands

Department of Surgical Oncology Instituto Nacional de Cancerología Bogota Colombia

Department of Surgical Oncology University Hospitals Leuven Belgium

Department of Surgical Oncology University Medical Center Groningen University of Groningen the Netherlands

Deputy Direction of Surgical Oncology Instituto Nacional de Cancerología Mexico

Emeritus Professor of Surgical Oncology University of Crete Greece

Institut Bergonié Sarcoma Unit '229 cours de l'Argonne 33000 Bordeaux France

Institute of Oncology Ljubljana Slovenia

Instituto Português De Oncologia De Porto 4200 Porto Portugal

IRCSS Istituto Europeo di Oncologia Milan Italy

Lausanne University Hospital and University of Lausanne Centre Hospitalier Universitaire Vaudois Rue du Bugnon 46 1011 Lausanne CHUV Switzerland

Melanoma and Sarcoma Unit Department of Surgery Portuguese Institute of Oncology Lisbon Portugal

Peter MacCallum Cancer Centre Victoria Australia; Sir Peter MacCallum Department of Oncology University of Melbourne Victoria Australia

Policlinico San Martino University of Genoa Genoa Italy Clinical Oncology Department; Italy Clinical Oncology Department Italy

Sahlgrenska Center for Cancer Research Department of Surgery Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden

Sarcoma Service Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy

Sarcoma Unit Department of Cancer Medicine Gustave Roussy Cancer Campus 114 Rue Edouard Vaillant Villejuif France

Sarcoma Unit Interdisciplinary Tumor Center Mannheim University Medical Center University of Heidelberg Mannheim Germany

Surgical Oncology Melanoma Division of Surgery Sourasky Tel Aviv Medical Center Tel Aviv University Israel

University Hospital Virgen Macarena Seville Spain

University Medical Center Utrecht and Princess Maxima Center Utrecht the Netherlands; Comprehensive Cancer Center München Technical University München and Ludwig Maximilian University Munich Germany

Varisano Klinikum Frankfurt Höchst Frankfurt Germany

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