Assay of urinaryα-fluoro-β-alanine by gas chromatography–mass spectrometry for the biological monitoring of occupational exposure to 5-fluorouracil in oncology nurses and pharmacy technicians

Evaluation of the risk of occupational exposure to antineoplastic drugs in healthcare sector: part I - medical gloves

Antineoplastic drugs (ADs) are essential tools in cancer treatment, but their cytotoxicity poses a risk to workers involved in their handling. In a hospital environment fundamental strategies for minimising exposure involve proper use of safety cabinets and closed-circuit transfer devices, along with personnel training and increased awareness of risks. However, medical gloves remain the first line of defence. In this respect the evaluation of glove materials and best choices can improve hospital safety management and prevent potential hazards and long-term consequences. The aim of this study was to assess contamination of gloves in samples taken from AD administration and preparation units of nine Italian hospitals and to raise awareness of the importance of evaluating chemico-physical properties of gloves. Our findings show that 33 % of the analysed gloves were positive for at least one AD, with contaminations ranging from 0.6 to 20,729 pg/ cm2. We proposed the alert glove values (AGVs) for each AD as a limit value for contamination assessment and good practice evaluation. Our findings also point to multiple AD contamination (43 % of positive findings in preparation units), calculated as total AGV (AGV-T), and confirm that gloves should be replaced after 30 min of AD handling, based on cumulative permeation and area under the curve (AUC), to maintain safety and limit dermal exposure.

Evaluation of a safe infusion device on reducing occupational exposure of nurses to antineoplastic drugs: a comparative prospective study. Contamoins-1

PURPOSE

Despite the decreasing of environmental contamination throughout the anticancer drug circuit, the administration of chemotherapies remains at risk of occupational exposure for nurses. Many medical devices aim at securing administration, but none have been scientifically evaluated to verify the actual improvement.

METHODS

A monocentric comparative before/after study was carried out in an oncology day hospital to evaluate the efficacy of Safe Infusion Devices in reducing drug exposure compared to usual infusion practices. The rate of nurses' gloves contamination was estimated. To avoid false negatives and to ensure sampling reproducibility, each sample of gloves was contaminated with a drop of topotecan. Association between contamination and other variables was investigated using a multivariate logistic regression analysis.

RESULTS

The usual practice led to a rate of 58.3% of contaminated samples while Safe Infusion Devices to a rate of 15%: Safe Infusion Devices reduced the risk of gloves contamination by 85% in multivariate analysis (Odds ratio = 0.15; 95% confidence interval = 0.05-0.46; p < 0.001). Topotecan was identified in 100% of the samples. Only one case of cross-contamination has occurred.

CONCLUSION

Despite the current practice of using neutral solvent-purged infusers, the occupational exposure remains high for nurses and Safe Infusion Devices significantly reduced this risk of exposure. However, glove contamination is only a surrogate endpoint. The results confirmed that the disconnection of empty bags resulted in occupational exposure. Except a contamination due to the leakage of a bag, no cross-contamination was detected. Safe Infusion Devices were highly effective but did not completely eliminate exposure.

A new, sensitive and versatile assay for quantitative determination of α-fluoro-β-alanine (AFBA) in human urine by using the reversed-phase ultrahigh performance-tandem mass spectrometry (rp-UHPLC-MS/MS) system

A method for the quantitation of α-fluoro-β-alanine (AFBA), the main metabolite of capecitabine (Cape) and 5-fluoruracil (5-FU), is described. Among antineoplastic drugs (ADs), 5-FU and Cape (the new oral prodrug) are the most commonly applied drugs in cancer therapy. The main objective of this study was to develop a reliable method that would be easy to run on a reversed-phase UHPLC system coupled to tandem mass spectrometry. AFBA was derivatized with Sanger's reagent to ensure complete yield of a stable 2,4 dinitrophenil-α-fluoro-β-alanine derivative. This method was based on the use of a mixed-mode anion exchange solid phase extraction enabling urinary extracts to be clear of endogenous interferences affecting quantitative results. The assay was validated in human urine according to FDA criteria with the use of a labeled internal standard (β-alanine-d4) to minimize experimental error. Good accuracy and precision were demonstrated by determining spiked urine QC samples in four consecutive days. The recovery of AFBA was between 70.0 and 82.6%, with a matrix effect that was 12.8%-18.5%. The lower limit of quantitation (LOQ) was 0.5 ng/mL with a coefficient of variation of 5.3%. This assay was successfully applied to determine the levels of this metabolite in a large number of urine samples taken from personnel who were occupationally exposed to ADs.

Biomonitoring of occupational exposure to 5-FU by assaying α-fluoro-β-alanine in urine with a highly sensitive UHPLC-MS/MS method

5-Fluorouracil (5-FU) is one of the most widely antineoplastic drugs handled by healthcare professionals.

A review of high performance liquid chromatographic-mass spectrometric urinary methods for anticancer drug exposure of health care workers

This review describes published high performance liquid chromatography/mass spectrometry (HPLC-MS) methods for the determination of anticancer drugs in human urine as non-invasive tool for monitoring of health care worker exposure to antineoplastic and cytotoxic drugs. HPLC-MS is a sensitive and specific method for analysis of anticancer drugs and their metabolites in biological fluids. In this review, a tabular summary and overview of published HPLC-MS methods are presented, as well as future trends and limitations in this area of research.

Comprehensive Evaluation of Protein Coding Mononucleotide Microsatellites in Microsatellite-Unstable Colorectal Cancer

Approximately 15% of colorectal cancers exhibit microsatellite instability (MSI), which leads to accumulation of large numbers of small insertions and deletions (indels). Genes that provide growth advantage to cells via loss-of-function mutations in microsatellites are called MSI target genes. Several criteria to define these genes have been suggested, one of them being simple mutation frequency. Microsatellite mutation rate, however, depends on the length and nucleotide context of the microsatellite. Therefore, assessing the general impact of mismatch repair deficiency on the likelihood of mutation events is paramount when following this approach. To identify MSI target genes, we developed a statistical model for the somatic background indel mutation rate of microsatellites to assess mutation significance. Exome sequencing data of 24 MSI colorectal cancers revealed indels at 54 million mononucleotide microsatellites of three or more nucleotides in length. The top 105 microsatellites from 71 genes were further analyzed in 93 additional MSI colorectal cancers. Mutation significance and estimated clonality of mutations determined the most likely MSI target genes to be the aminoadipate-semialdehyde dehydrogenase AASDH and the solute transporter SLC9A8 Our findings offer a systematic profiling of the somatic background mutation rate in protein-coding mononucleotide microsatellites, allowing a full cataloging of the true targets of MSI in colorectal cancer. Cancer Res; 77(15); 4078-88. ©2017 AACR.

Longitudinal biomonitoring of nurses handling antineoplastic drugs

AIMS AND OBJECTIVES

To assess a possible trend in the genotoxic risk of oncologic nurses during the working year, cytogenetic biomonitoring was performed.

BACKGROUND

Exposure to cytostatic agents is a major occupational concern in oncologic personnel. In contrast to the controlled environment in oncology pharmacies, nurses may be subject to unexpected events of exposure due to the intensive contact with patients.

DESIGN AND METHODS

The entire nursing staff of an oncology inpatient ward (n = 15) participated in a biomonitoring study over a period of nine months using the sister chromatid exchange test and the comet assay to detect DNA strand breaks. Blood samples were taken after a three-week summer break (base level), one, three, six and nine months thereafter. Airborne contaminations of cytotoxics were addressed by chromatographic methods.

RESULTS

With regard to the single monitoring points, the comet assay revealed no significant alteration of the genotoxic burden within nine months. By contrast, the sister chromatid exchange levels were significantly increased after six and nine months when compared with base levels. A trend analysis covering the whole observation period revealed an increase in genotoxicity as shown by the sister chromatid exchange test and the alkaline but not the neutral comet assay. This increase, however, was small and reversible as shown by the trend analysis of sister chromatid exchange rates during the years of service. Air samples were negative for cytotoxic contaminants.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

The small, but statistically significant genotoxic burden observed in oncologic nurses of an inpatient ward emphasises the need for a continuing effort to eliminate residual occupational risks. In comparison with historical controls, the current situation is characterised by beneficial safety improvements over the last years. Nevertheless, periodic training and awareness of the problems should be an integral part of advanced education.

Identification of Knowledge Gaps Regarding Healthcare Workers' Exposure to Antineoplastic Drugs: Review of Literature, North America versus Europe

We have been examining the issue of healthcare workers' exposure to antineoplastic drugs for nearly a decade and have observed that there appears to be more publications on the subject matter originating from Europe than from North America. The concern is that findings from Europe may not be generalizable to North America because of differences in handling practices, regulatory requirements, and training. Our objective was to perform a literature review to confirm our observation and, in turn, identify gaps in knowledge that warrants addressing in North America. Using select keywords, we searched for publications in PubMed and Web of Science. All papers were initially classified according to the originating continent and then categorized into one or more subject categories (analytical methods, biological monitoring, occupational exposure, surface contamination, and probability of risk/exposure). Our review identified 16 papers originating from North America and 55 papers from Europe with surface contamination being the subject matter most often studied overall. Based on our results, we are of the opinion that North American researchers need to further conduct dermal and/or urinary drug contamination studies as well as assess the exposure risk faced by healthcare workers who handle antineoplastic drugs. Trends in exposure levels should also be explored.

Association between occupational exposure and control measures for antineoplastic drugs in a pharmacy of a hospital

OBJECTIVES

To investigate the association between occupational contamination and exposure levels to antineoplastic drugs and the application of control measures in a hospital work environment.

METHODS

Wipe samples of equipments were collected at a hospital in Osaka Prefecture, Japan, from 2007 to 2011. These samples were subjected to measurements of cyclophosphamide (CP), gemcitabine (GEM), platinum-containing drugs (Pt), and fluorouracil (5FU). Additionally, 24-h urine samples were collected from pharmacists who handled antineoplastic drugs, which were analyzed for CP and alpha-fluoro-beta-alanine (AFBA). The application of control measures was scored according to a checklist, which consisted of the following five items: safety equipment and maintenance, training and documentation, devices for safe handling, personal protective equipment, and emergency care. The aim was to obtain a score of 80%.

RESULTS

The median CP, GEM, and 5FU concentrations of all wipe samples were significantly lower during the period when the mean score was >80% (attainment period) versus when the mean score was ≤80% (nonattainment period; all P < 0.001, Mann-Whitney's U-test). Additionally, the median urinary CP and AFBA concentrations of pharmacists during the attainment period tended to be lower than that of those during the nonattainment period (P = 0.061 and 0.061, respectively, using Mann-Whitney's U-test).

CONCLUSIONS

Contamination and levels of exposure to antineoplastic drugs decreased with a score higher than 80%. The scores of the items on the checklist appeared to adequately reflect the condition of the control measures, as increases in all five items were associated with reductions in the contamination by and levels of exposure to all drugs.

Current literature in mass spectrometry

In order to keep subscribers up‐to‐date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of mass spectrometry. Each bibliography is divided into 11 sections: 1 Books, Reviews & Symposia; 2 Instrumental Techniques & Methods; 3 Gas Phase Ion Chemistry; 4 Biology/Biochemistry: Amino Acids, Peptides & Proteins; Carbohydrates; Lipids; Nucleic Acids; 5 Pharmacology/Toxicology; 6 Natural Products; 7 Analysis of Organic Compounds; 8 Analysis of Inorganics/Organometallics; 9 Surface Analysis; 10 Environmental Analysis; 11 Elemental Analysis. Within each section, articles are listed in alphabetical order with respect to author (6 Weeks journals ‐ Search completed at 4th. Oct. 2006)

Systemic absorption of 5-fluorouracil during vitrectomy

PURPOSE

The aim of this study is to determine if systemic absorption is present after 5-fluorouracil (5FU) is used in the vitrectomy infusion.

DESIGN

A two-case clinical study.

METHODS

A catabolite of 5FU, alpha-fluoro-beta-alanine (FBAL), was measured in urine samples of two patients who underwent vitrectomy using 5FU in the infusion fluid.

RESULTS

In both patients, FBAL was found in the urine samples collected up to 48 hours after the surgery, although in significantly different concentrations.

CONCLUSIONS

The use of 5FU in the vitrectomy infusion fluid to prevent the formation of proliferative vitreoretinopathy may lead to significant general absorption and may be avoided in children and young adults.