Fluorescence microscopic demonstration and demarcation of doxorubicin extravasation. Experimental and clinical studies

Anthracycline Extravasation: A Comprehensive Review of Experimental and Clinical Treatments

An accidental extravasation of anthracycline-containing chemotherapy is a feared complication that may lead to necrosis and severe tissue destruction. For four decades, much effort has been done to prevent and treat this devastating condition. Savene™ has recently been proved to be very effective, and is the only approved treatment against anthracyline extravasation. It is thus now widely recommended. The present article represents a comprehensive review of, and historical insight to, the experimental and clinical studies of surgical and non-surgical treatments of extravasation during forty years of clinical anthracycline treatment.

Extravasation of chemotherapy

Extravasation of chemotherapy is a feared complication of anticancer therapy. The accidental leakage of cytostatic agents into the perivascular tissues may have devastating short-term and long-term consequences for patients. In recent years, the increased focus on chemotherapy extravasation has led to the development of international guidelines that have proven useful tools in daily clinical practice. Moreover, the tissue destruction in one of the most dreaded types of extravasation (ie, anthracycline extravasation) now can effectively be prevented with a specific antidote, dexrazoxane.

Extravasation Management

OBJECTIVES

To describe the mechanisms of injury associated with DNA binding and DNA non-binding vesicants. To review various procedures used in clinical practice to manage vesicant extravasations.

DATA SOURCES

Journal articles, published case reports, personal experience.

CONCLUSION

There is a lack of evidenced-based information and consensus about vesicant extravasation management. The antidotes sodium thiosulfate for mechlorethamine extravasations and hyaluronidase for plant alkaloid extravasations are recommended by the manufacturers of these vesicants. Data suggest that administration of IV dexrazoxane is effective in preventing tissue necrosis following anthracycline extravasation. Dimethyl sulfoxide also may have a role in treating anthracycline extravasations, but further research is needed.

IMPLICATIONS FOR NURSING PRACTICE

Nurses who administer vesicant chemotherapy agents must be aware of the most current (or lack of) evidence for extravasation treatment. Well-informed nurses can serve as patient advocates and may be instrumental in detecting, managing, and documenting these injuries. Most importantly, nurses play a key role in preventing vesicant extravasation injuries.

[Extravasation of cytostatic agents: a serious complication of oncological treatment]

The extravasation of cytostatic agents is a known, serious situation that can easily occur and cause chronic, irreversible damage. The incidence of extravasation ranges from 0.1 %-6.5 %, according to different studies. Many cases of extravasation can be prevented by systematizing the administration techniques for cytostatic agents. We present the clinical and histological characteristics of a series of patients with extravasation lesions. Included in the study were all patients treated with chemotherapy who developed localized lesions in the area of the cytostatic injection after extravasation was detected during administration. The patients were studied and followed up for a three-year period, from January 2000 to December 2003, inclusive. We found nine cases of extravasation among the 2,186 patients who were treated with chemotherapy, which represents an incidence of 0.41 %, and 3.4 % of all chemotherapy-induced skin lesions. The cytostatic agent most often involved was vinorelbine, and the most frequent location was the antecubital fossa. The intensity of the lesions made it necessary to delay the next cycle of treatment in 55 % of the cases. The histological findings varied depending on when the biopsy was done, showing panniculitis with low cellularity together with epidermal lesions attributable to direct cytotoxicity. The best treatment for extravasation is prevention, but when it has already occurred, measures vary depending on the cytostatic drug extravasated and the intensity of the lesions. Conservative measures are advisable before surgery.

Effects of growth factors on doxorubicin-induced skin necrosis: documentation of histomorphological alterations and early treatment by GM-CSF and G-CSF

Extravasation of vesicant antineoplastic agents such as doxorubicin into the skin or subcutaneous tissues may result in loss of the full thickness of the skin or underlying structures. Several treatment methods have been advocated but none has demonstrated any superiority to the others. The authors designed a controlled animal study in 88 rats to test three methods of early treatment of extravasation of the vesicant antineoplastic agent doxorubicin. The first step of the study included 48 Sprague-Dawley rats. All animals received intradermal injections of 1 mg doxorubicin superficially to the panniculus carnosus in the dorsum. The rats were then divided into four groups of 12 rats each, as follows: group 1, no treatment; group 2, immediate intradermal injection of 0.1 ml saline to the same site; group 3, immediate intradermal injection of 10 microg granulocyte macrophage-colony stimulating factor (GM-CSF) in 0.1 ml saline to the same site; group 4, immediate intradermal injection of 10 microg granulocyte-colony stimulating factor (G-CSF) in 0.1 ml saline to the same site. During the next 6 weeks the rats were observed for the development of necrosis. Ulcers developed and reached maximum size two weeks after the injections. The largest ulcers according to area were observed in group 1 and the mean value was 21.25 mm (p < 0.05). Although wound areas were significantly smaller in the saline group than in the control group and the mean value was 7.58 mm (p < 0.05), the smallest lesions were observed in groups 3 and 4, and the mean values were 1.08 mm and 0.83 mm respectively (p < 0.05). There was statistically no difference with regard to mean ulcer area between groups 3 and 4. During the second step of the experiment, the remaining 40 Sprague-Dawley rats were used. Groups containing 10 rats each were designed similarly after all animals received intradermal injections of 1 mg doxorubicin into the back. On the 10th day after the injection, the entire area of the ulcer together with the underlying panniculus carnosus was excised for pathological examination and for determination of glucose 6-phosphate dehydrogenase (G6PD) activity. On microscopic examination, the extravasated ulcer consisted of a large area of ischemic necrosis. There was marked damage to small blood vessels in the form of fibrinoid necrosis and vasculitis. Injured vessel counts were higher in the control group (group 1; p < 0.05). No difference was observed in G6PD activity between the groups. The authors conclude that both saline and tissue growth factors (GM-CSF and G-CSF) are useful for the early treatment of doxorubicin extravasation; however, GM-CSF and G-CSF are more beneficial.

Doxorubicin chemomyectomy: effects on evoked vocal fold tension and mucosal wave

Chemomyectomy of the thyroarytenoid muscle is a potential alternative approach to the management of spasmodic dysphonia (laryngeal dystonia) that could provide a prolonged response. To be useful, chemomyectomy should produce weakening of vocal fold closure without disruption of the mucosal wave. Sixteen dogs were studied. In 8 animals, doxorubicin hydrochloride (3 mg) and verapamil hydrochloride (0.5 mg) were injected unilaterally into the thyroarytenoid muscle 2 months before evaluation. The remaining animals served as noninjected controls. Injection of doxorubicin and verapamil decreased the average evoked tension of the vocal fold by 74.7%, compared to an average side-to-side difference of 12.7% in the control group (p = .001). A mucosal wave was recognized bilaterally with videostroboscopy in all dogs. Doxorubicin did not significantly change the vocal fold appearance or mucosal wave amplitude. These results support further laboratory study of chemomyectomy as a potential alternative treatment for laryngeal dystonia.

The cutaneous histopathology of chemotherapeutic reactions

The histological diagnosis of chemotherapy-induced cutaneous reactions is a difficult problem for the dermatopathologist. The initial effort should be directed towards obtaining as much clinical history as possible since the provided information is often incomplete and clinical correlation is usually required. The biopsy should be examined in a systematic fashion to assess the presence of damage to specific cutaneous structures. A recommended approach is to initially examine the epidermis and then proceed to hair follicles, eccrine sweat glands, vessels and dermis. The degree and pattern of damage will usually indicate whether or not a cytotoxic reaction is present. The intensity, pattern, and components of the inflammatory response should be assessed since they provide clues to whether a hypersensitivity reaction or immunomodulating chemotherapeutic reaction is present. In addition to the possibility of a chemotherapeutic reaction, the dermatopathologist must also consider the possibility of an infection since the host is usually immunocompromised and must also exclude the presence of a residual malignancy. After examination of the biopsy specimen and determination of the pathologic process or precesses, the observed findings should be correlated with the clinical history before rendering an interpretation.

Clinical results after doxorubicin extravasation treated with excision guided by fluorescence microscopy

Doxorubicin (DR) and epirubicin (ER) produce progressive tissue necrosis when extravasation occurs. Early detection and excision of all affected tissue is important. The clinical experience with fluorescence microscopic guided detection and excision in 24 patients is evaluated. 9 patients with fluorescence negative specimens were kept under observation without excision. None developed necrosis. Wide excision was performed on 15 patients with fluorescence positive specimens. Sequelae, defined as impaired function of the affected limb at the last control examination in the out-patient clinic, were observed in 8 patients. 4 of 5 patients with extravasation in the hand and 2 of 3 with extravasation in the cubital fossa were among these. Delay, defined as time from injury to surgery, was a median of 7 h, range from 3 h to 69 days. Patients developing sequelae had a median delay of roughly 4-fold that of patients without these complications. Patients with extravasation in the cubital fossa were hospitalised for the longest period: 30 days, range 24-45 days, vs. 12 days, range 7-80 days, for those with extravasation at other sites (P < 0.03). Our conclusions are: (1) fluorescence microscopic analysis is a reliable method for the detection and delineation of extravasation of DR or ER. (2) Do not use the cubital fossa or hand for the infusion of these cytostatics. (3) Act promptly if extravasation is suspected--delay leads to sequelae.