Use of sodium bicarbonate as a means of ameliorating doxorubicin-induced dermal necrosis in rats

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.

Savene® (dexrazoxane) use in clinical practice

INTRODUCTION

Anthracycline extravasation (ACEV) is a rare but potentially devastating event which can result in severe injuries including ulceration and necrosis, slow-healing lesions, serious joint damage and permanent disfigurement. It can delay further scheduled chemotherapy and affect cancer treatment outcome. Savene® (dexrazoxane) is the only approved antidote for ACEV in Europe (Totect® in the USA) and is administered by intravenous infusion. Its efficacy has been demonstrated in clinical trials with biopsy-verified ACEV with a 98% success rate (no need for surgical debridement) allowing for immediate continuation of chemotherapy in 71% of patients. Adverse events, mainly haematological toxicity, were rapidly reversible. The objective of the study was to assess, in clinical practice, the efficacy and safety profile of Savene® for ACEV in different Belgian hospitals.

PATIENTS AND METHODS

A survey of Savene® use was conducted in Belgium from 2007 to 2010 by using a questionnaire sent to 44 hospitals.

MAIN RESULTS

Data were obtained for 41 cancer patients, 68% (28/41) had ACEV from central venous catheters. Surgical debridement due to ACEV could be avoided in 26 out of 28 extravasations from a central venous access and in 95% (39/41) of the total population treated with Savene®. Planned chemotherapy was maintained in 73% (30/41) of patients. Eight adverse events were reported in four patients treated with Savene®, six events were assessed to be of common toxicity criteria grades 1-2 (nausea, leucopenia and arm pain) and two events (neutropenia and pancytopenia) were assessed to be grade 3.

CONCLUSION

These data are comparable with the data from previous clinical trials and confirm the efficacy and safety profile of Savene® in clinical practice for the treatment of anthracycline extravasation, including extravasations from central venous catheters.

Current recommendations for prevention and therapy of extravasation reactions in dermato-oncology

Despite the introduction of many targeted therapies, a wide variety of cytostatic agents are still frequently used in dermato-oncology. In order to avoid further morbidity in tumor patients, prevention of extravasation reactions is of highest importance. The optimal management of extravasation requires an early diagnosis, the application of specific antidotes and a well-trained oncology team.

Dapsone for the treatment of doxorubicin extravasation injury in the rat

Doxorubicin is the most common antitumor drug implicated in serious extravasation injuries. Progressive tissue necrosis may lead to intense pain, chronic ulceration, and disfiguring tissue loss. This progressive necrosis is analogous to that seen with brown recluse spider bites, where dapsone is an established mode of therapy, minimizing the area of tissue loss by a proposed antiinflammatory mechanism. The backs of 50 Lewis rats were injected intradermally with 1 mg of doxorubicin in 1 cc of saline to simulate an extravasation injury. The rats were divided into five groups for treatment with oral dapsone 50 mg/kg/day: 10 were controls (no treatment), 10 were started the day before injury, 10 were started the day of injury, 10 were started the day after injury, and 10 were started 1 week after injury. The area of ulceration was calculated by planimetry. The data suggest that dapsone has little positive effect on healing extravasation ulcers.

Prevention and management of extravasation of cytotoxic drugs

Extravasation of certain cytotoxic agents during peripheral intravenous administration may cause severe local injuries. Most extravasation can be prevented with the systematic implementation of careful administration techniques. However, the management of this complication, the aim of which is to prevent progression to tissue necrosis and ulceration, remains an important challenge in the care of cancer patients. Many antidotes have been evaluated experimentally and a few may be able to reduce the local toxicity of the more common vesicant cytotoxic drugs. Because no randomised trial on the management of cytotoxic drug extravasation in humans has ever been completed, recommendations must be based on the more consistent experimental evidence and on cumulative clinical experience from available case reports and uncontrolled studies, which are reviewed in this article. Empirical guidelines recommend the use of topical dimethylsulfoxide (DMSO) and cooling after extravasation of anthracyclines or mitomycin, locally injected hyaluronidase after extravasation of vinca alkaloids, and locally injected sodium thiosulfate (sodium hyposulfite) after extravasation of chlormethine (mechlorethamine; mustine). Plastic surgery may be necessary when conservative treatment fails to prevent ulceration. The possibility of late local reactions must also be considered in the management of patients receiving chemotherapy.

Prevention of tissue necrosis due to accidental extravasation of cytostatic drugs by a conservative approach

The purpose of the present study was to evaluate comparatively the effectiveness of a conservative approach to treatment, using two therapeutic schedules (with and without sodium thiosulfate (ST), so as to minimize necrosis due to drug extravasation and to avoid the need for reconstructive surgery. The 63 patients entered into this study were separated into two groups; these in group A were treated with hydrocortisone and dexamethasone, and these in group B received the combination plus ST. In both groups, the drugs that had extravasated included doxorubicin, epirubicin, vinblastine, mitomycin C. The healing time varied with the different drugs used and was proportional to the extent of extravasation and to the time at which therapy was begun. The mean healing time for group B, which received ST was about half that for group A, which did not. We conclude that the application of conservative measures during chemotherapy may prevent tissue necrosis due to drug extravasation and the subsequent need for reconstructive surgery. The administration of ST can help in the achievement of this goal.

Conservative approach to the treatment of chemotherapy-induced extravasation

One of the local complications of certain chemotherapeutic agents is tissue necrosis resulting from extravasation. The purpose of this study was to evaluate the effectiveness of a conservative approach to treatment in order to minimize necrosis and the need for reconstructive surgery. Fifty-three patients entered this study. Twenty-one had old lesions while 32 had recent extravasations. Drugs responsible for the extravasations were doxorubicin, epirubicin, vinblastine, mitoxantrone, and mitomycin C. The basis of treatment was betamethasone ointment, which was applied to the lesion with a tight elastic bandage and was replaced every 12 hours for the first 2 days and then every 24 hours until complete healing. For old lesions a keratolytic ointment was initially applied, whereas in the new lesions multiple subcutaneous injections with hydrocortisone solution preceded the application of betamethasone ointment. None of our patients developed tissue necrosis and sloughing that necessitated surgery. All lesions healed in patients. Healing time varied with the different drugs used and was proportional to the extension of extravasation and to the time when therapy was begun. We conclude that the application of conservative measures in extravasated areas from chemotherapy may avoid tissue necrosis and reconstructive surgery.

Treatment methods for extravasations of chemotherapeutic agents: a comparative study

A rat model was used to compare early surgical intervention with injectable and topical antidotes with regard to their effectiveness in preventing cutaneous ulcers that were caused by intradermal injections of vesicant chemotherapeutic agents. The (animals) rats received bilateral flank injections of doxorubicin, vincristine, actinomycin D, mitomycin C, or carmustine (BCNU) in concentrations that were comparable to concentrations used for human patients; after the injections they underwent debridement at various intervals or received immediate applications of selected antidotes. Many "antidotes" which were frequently used, were not effective in limiting the size of the ulcer and in producing rapid healing of ulcers that were caused by experimental vesicant extravasations. Early surgical debridement was the most effective method of decreasing vesicant ulcer size and facilitating rapid ulcer healing of all the interventions tested.

Amelioration of doxorubicin-induced skin necrosis in mice by butylated hydroxytoluene

The effect of butylated hydroxytoluene (BHT) on doxorubicin (Adriamycin)-induced skin ulcers was investigated in mice. The skin lesions produced by a single intradermal (ID) injection of doxorubicin (0.05 mg; 1 mg/ml) reached maximum size between 5 and 10 days after injection of ADR. Different concentrations of BHT were administered by different routes and at different times in relation to the injection of doxorubicin. The most effective dose of BHT was 4 mg/animal. The topical application of BHT immediately following doxorubicin injection reduced the area of the ulcer by 57%; the immediate ID injection of BHT reduced the size of the ulcer by 84%. Additional studies are required to determine whether BHT will be a clinically useful modifier of the toxicity associated with doxorubicin extravasation in cancer patients.

Prevention of extravasation injuries secondary to doxorubicin

Intravenously administered drugs with potentially devastating consequences should be given only by personnel highly knowledgeable regarding the side effects and skilled in intravenous cannulation. A strict protocol should be followed. The earliest signs heralding extravasation should be recognized and infusion discontinued immediately. If extravasation occurs, prompt surgical consultation is necessary. Injection into the volar wrist, dorsum of the hand, and antecubital fossa should always be avoided. Polyethylene catheters are preferable to butterfly needles for administering chemotherapeutic agents. A careful history of the venous problems of patients who require long-term therapy should be maintained in their chart. Ideally, vascular access should avoid these problems.

Management of extensive doxorubicin hydrochloride extravasation injuries

Forty patients with extensive doxorubicin hydrochloride extravasation injuries are reviewed. These injuries were located in critical anatomic areas such as the palmar aspect of the wrist, dorsum of the hand, and antecubital fossa. Contributing factors were related to local venous pathology, the mode of administration, and the lack of recognition of extravasation. Treatment of these injuries consisted of extensive debridement of all involved tissue and delayed closure by a variety of techniques. The complications and morbidity secondary to doxorubicin hydrochloride extravasation are often more disabling than the patient's primary disease. The degree of disability is related to the site of extravasation, patient's age, and delay before surgical complication. Early recognition and excision and delayed closure yield the most successful results.

Treatment of tissue extravasation by antitumor agents

Infiltration of antitumor agents into subcutaneous tissues may either result in a local area of self-resolving inflammation, or progress to full-thickness loss of skin and underlying vital structures. The immediate treatment of 50 extravasations occurring over a 20-month period resulted in our developing a protocol of appropriate care. Once extravasation is suspected, the intravenous line is removed, ice is applied intermittently for three days, and the wound is observed closely. No drugs are even given locally. If local pain persists or skin changes progress, the area of involvement is debrided and, a skin graft is applied two to three days later. As a result of this conservative approach, only 12 of 50 patients have required surgery. This method of treatment has minimized patient mortality, hospitalizations, and loss of synchronization of chemotherapy.