Prevention and management of extravasation of cytotoxic drugs

GEDEFO-SEFH management of antineoplastic extravasations survey results

INTRODUCTION

Extravasation is a potentially severe complication of intravenous administration of antineoplastic drugs. The limited data makes it difficult to develop an optimal management scheme. The objective of this study is to describe the clinical practice in the extravasation management of antineoplastic agents in Spanish centers.

METHODS

An online survey was distributed to oncology pharmacists using the email distribution list of the Spanish Society of Hospital Pharmacists. Respondents were surveyed on the standard operational protocol (SOP) of extravasation, tissue damage risk classification, and specific measures of extravasation management.

RESULTS

A total of 68 surveys were completed. A specific extravasation SOP was available in 82.4% centers. The pharmacist participates in the authorship (100%) and actively collaborates in extravasation management (76.5%). A tissue damage risk classification based on the three categories was mostly adopted (48.2%) and 73.2% applied specific criteria based on concentration and/or extravasated volume. Extravasation management was mainly performed with the application of physical measures and/or antidotes (91.2%). High variability in the choices of pharmacological and/or physical measures recommended is outstanding.

CONCLUSION

The results of this study highlight the involvement of Spanish pharmacists in extravasation management, the application of physical measures and/or pharmacological measures as the method of choice in extravasation management, as well as the existing discrepancies in tissue damage risk classification and management recommendations.

Delayed presentation of vincristine extravasation

INTRODUCTION

Vincristine is a vesicant chemotherapeutic agent which may leak from the vessel at the infusion site to the perivascular tissue and cause extravasation. Extravasation, a severe complication of chemotherapeutic drugs, can result in tissue necrosis that is considered an oncological emergency.

CASE REPORT

We aimed to report a case of a 29-year-old woman with ALL-B cell (Acute lymphoblastic leukemia) on maintenance chemotherapy regimen including vincristine, methotrexate, prednisolone, and 6-mercaptopurine (POMP). 48 h after administering intravenous vincristine, the patient experienced burning, pain and tenderness at the injection site (left hand - cubital cavity).

MANAGEMENT & OUTCOME

7 days after the onset of symptoms, the patient was hospitalized with a large brown lesion at the site. She was prescribed betamethasone cream, DSMO (Dimethyl sulfoxide) solution, and oral levofloxacin on his second day after admission. The lesion was completely improved 10 days after initiation of therapy and there were no serious problems.

DISCUSSION

Due to the ineffectiveness of antidote therapy for the management of delayed extravasation of vincristine and beneficial effect of our clinical approach, it could consider for the management of similar cases with delayed extravasation following vincristine administration.

Determination of Extravasation Effects of Nal-Iri and Trabectedin and Evaluation of Treatment Options for Trabectedin Extravasation in a Preclinical Animal Model

Background: Extravasation during chemotherapy administration can lead to dangerous adverse effects ranging from pain to tissue necrosis. Evidence-based data about prevention and treatment of extravasation injuries of some clinically used compounds still remains elusive. This work aimed to investigate, in a preclinical mouse model, the effects of extravasation of two chemotherapeutic agents, nanoliposomal irinotecan (nal-Iri) and trabectedin. In addition, we aimed to study treatment options for injuries induced by extravasation of these substances. Methods: Mice were subcutaneously injected with nal-Iri or trabectedin applied in clinically used concentration. Doxorubicin was used as a positive control. In subsequently performed experiments, hyaluronidase, DMSO and tacrolimus were tested as potential treatments against extravasation-induced injuries by trabectedin. Systemic effects were analyzed by observation and documentation of the health status of mice and local reactions were measured and graded. In addition, hematoxylin-eosin stained histological sections of the treated skin areas were analyzed. Results: Of the two tested substances, only trabectedin showed vesicant effects. Subcutaneous injection of trabectedin caused erythema formation in mice by day two that was progressing to skin ulcerations by day five. Furthermore, we found that topical treatment of mice with tacrolimus or DMSO reduced the vesicant effects of trabectedin. The results observed in vivo were supported microscopically by the analysis of histological sections. Conclusions: We recommend classifying trabectedin as a vesicant agent and nal-Iri as a non-vesicant agent. Furthermore, our results obtained in a preclinical model suggest that tacrolimus and DMSO might be suitable treatment options of trabectedin extravasations, a finding that might be further utilized in clinical studies.

Combination of ebselen and hydrocortisone substantially reduces nitrogen mustard-induced cutaneous injury

The purpose of the present study was to investigate the vesicant countermeasure effects of hydrocortisone (HC) and ebselen (EB-1), administered as monotherapy or as a combination treatment. The mouse ear vesicant model (MEVM) was utilized and test doses of HC (0.016, 0.023, 0.031, 0.047, 0.063, 0.125 or 0.250 mg/ear), EB-1 (0.125, 0.187, 0.250, 0.375 or 0.500 mg/ear) or the combination of HC + EB-1 were topically applied at 15 min, 4 h and 8 h after nitrogen mustard exposure. Ear punch biopsies were obtained 24 h after mechlorethamine (HN2) exposure. Compared to control ears, ear tissues exposed topically to HN2 (0.500 µmol/ear) presented with an increase in ear thickness, vesication, TUNEL fluorescence and expression of matrix metalloproteinase 9 (MMP-9) and inducible nitric oxide synthase (iNOS). In contrast, HN2 exposed ears treated topically with EB-1 showed a significant decrease in morphometric thickness and vesication vs. HN2 alone. Ear tissues exposed to HN2 and then treated with HC also demonstrated reductions in morphometric thickness and vesication. Combination treatment of HC + EB-1 was found to be the most effective at reducing HN2-induced ear edema and vesication. The combination also dramatically decreased HN2-mediated cutaneous expression of iNOS and MMP-9 and decreased HN2-induced TUNEL staining. Taken together, our study demonstrates that the combination of HC + EB-1 is an efficacious countermeasure to HN2.

Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats

INTRODUCTION

Extravasation injuries are one of the most feared complications of intravenous drug administration. The most common drugs associated with extravasation injury include chemotherapy agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling, inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention, immediate bed-side measures are as important in controlling the extent of tissue damage. Various options, either medical or interventional are next steps in treatment of the condition including antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.

MATERIALS AND METHODS

12 male Wistar albino rats were divided into two groups; one group received fat injections following subdermal doxorubicin infiltration in their right thighs, while other group received saline injection following subdermal doxorubicin infiltration in their right thighs for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed. Histological analyses were conducted using modified Verhofstad scoring system for comparison.

RESULTS

Mean necrotic area was significantly smaller in the fat injection group compared to other groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal thickness, on the other hand, was greater in the fat injection group.

CONCLUSION

Injection of fat grafts following vesicant extravasation might be beneficial in preventing the progression of tissue damage, if employed early.

Adverse cutaneous reactions to chemotherapeutic drugs

Drug reactions resulting from chemotherapy agents are common and frequently affect the skin. Although often benign, a select few of these cutaneous reactions may necessitate immediate changes to the antineoplastic regimens. Given the diversity of chemotherapeutic skin reactions and their complex implications on patient management, an organized conceptual schema is imperative for proper patient care. We evaluate a number of commonly seen chemotherapy-induced skin toxicities organized by pathogenic mechanism and drug class, providing a framework for the identification and categorization of adverse events to prevent unrecognition. Groupings of these reactions include direct cytotoxicity and/or drug accumulation, immunologic hypersensitivity, and aberrant molecular signaling.

Extravasation accidents with liposomal/liposomal pegylated anthracyclines treated with dexrazoxane: an overview and outcomes

The extravasation of chemotherapeutic agents is a challenge for oncologic care teams. The management of nonliposomal (conventional) anthracyclines is well established in clinical practice guidelines, including general measures and specific antidotes, such as dexrazoxane. However, there is little scientific evidence on the management of liposomal and pegylated liposomal anthracyclines. The aim of this paper was to review the scientific literature on the extravasation of liposomal and pegylated liposomal anthracyclines and determine the clinical impact of this type of extravasation, focusing on dexrazoxane. The literature was searched using two databases: PubMed and Embase. Three searches were conducted, using liposomal anthracycline extravasation, pegylated liposomal anthracycline extravasation, and liposomal doxorubicin extravasation as keywords, respectively. Seven articles fulfilled the study eligibility criteria and included seventeen cases in humans. Extravasation occurred with three drugs: liposomal doxorubicin in nine (53%) patients, liposomal daunorubicin in four (23.5%) patients, and pegylated liposomal doxorubicin in four (23.5%) patients. General measures for extravasations were applied in all patients, but only three patients received dexrazoxane. All cases were completely resolved at 2-3 months, except for one patient, in whom dexrazoxane was not used. In animals, dexrazoxane decreased both the frequency of wounds produced by pegylated liposomal doxorubicin and their extent. The pharmacokinetic profiles of liposomal and pegylated liposomal anthracyclines differ from those of conventional anthracyclines, modifying their effectiveness and safety. General measures may be inadequate to heal areas affected by extravasation, which may require the administration of dexrazoxane. However, each case should be evaluated individually for the administration of dexrazoxane in off-label use until scientific evidence is available on its effectiveness and safety as an antidote for these formulations of anthracyclines.

Clinical Applications of Hyaluronidase

Hyaluronidases are enzymes that degrade hyaluronic acid, which constitutes an essential part of the extracellular matrix. Initially discovered in bacteria, hyaluronidases are known to be widely distributed in nature and have been found in many classes including insects, snakes, fish and mammals. In the human, six different hyaluronidases, HYAL1-4, HYAL-P1 and PH-20, have been identified. PH-20 exerts the strongest biologic activity, is found in high concentrations in the testicles and can be localized on the head and the acrosome of human spermatozoa. Today, animal-derived bovine or ovine testicular hyaluronidases as well as synthetic hyaluronidases are clinically applied as adjuncts to increase the bioavailability of drugs, for the therapy of extravasations, or for the management of complications associated with the aesthetic injection of hyaluronic acid-based fillers. Further applications in the fields of surgery, aesthetic medicine, immunology, oncology, and many others can be expected for years to come. Here, we give an overview over the molecular and cellular mode of action of hyaluronidase and the hyaluronic acid metabolism, as well as over current and potential future clinical applications of hyaluronidase.

Prevention and Management of Antineoplastic Extravasation Injury

Goal

The goal of this program is to inform the participant of practical ways to prevent, identify, and manage the extravasation of anti-neoplastic agents.

Objectives

At the completion of this program the participant will be able to: 1. List antineoplastic agents known to be vesicants or irritants. 2. Identify the signs and symptoms of extravasation injury. 3. Recommend a procedure for the safe administration of vesicant medications. 4. Describe the appropriate management of antineoplastic-induced extravasation injury.

Extravasation emergencies: state-of-the-art management and progress in clinical research

In cancer treatment, extravasation is defined as an inadvertent instillation or leakage of cytotoxic drugs into the perivascular space during infusion. As a dreaded complication of chemotherapy, extravasation has gained increasing attention in recent years. Classified according to their subcutaneous toxicity, three types of cytotoxins have been established: vesicants, irritants and nonvesicant drugs. Vesicant cytotoxic drugs may induce tissue damage, ulceration and tissue necrosis. Although we have established measures to manage extravasation emergencies, prevention is of paramount importance. This may be achieved within hospitals through regular training and education, which is best provided by a specialised and experienced task force including all disciplines involved in cancer therapy. Moreover, clinical and translational studies contribute to a better management of chemotherapy-induced extravasation as shown by our group in recent years. We were able to demonstrate that the evaluation of blood flow by indocyanine green angiography in the extravasation area predicts the extent of damage and the need of future surgical intervention. When a Port-a-Cath® extravasation is detected early, a subcutaneous wash-out procedure was found to be beneficial, corroborated by the analytical evaluation of the removed cytotoxic compound epirubicin. In another study, the tissue distribution of platinum was quantified at the anatomic level in cryosections of various tissues. This novel knowledge complements and supports our current efforts to handle extravasations better. On the other hand, a number of new drugs (chemotherapy, monoclonal antibodies, checkpoint inhibitors etc.) with many open issues to reliably classify their tissue toxicity still require our attention.

[Emergency management of extravasation in children]

The subcutaneous diffusion of intravenous drips, or extravasation, is a frequent iatrogenic complication in children, mainly in the neonatal period. This potentially severe pathology can lead to local ischemia that sometimes mimics compartment syndrome. It can also evolve towards vast soft-tissue necrosis. Nursing staff often underestimate the risk of functional, aesthetic, and psychological consequences. The speed and quality of the initial medical and surgical management can greatly decrease morbidity associated with extravasation. Prevention is fundamental, such as raising awareness in and training medical and paramedical staffs and creating efficient protocols. Surgical management involving aspiration and washing the site as early as possible improves the prognosis. Aspiration and washing can be done on a larger area if one criteria of severity is met, particularly in cases of extravasation using a vesicant or hyperosmolar agent. If necrotic lesions appear, it is wise to wait until they become delimited. Debridement and coverage can be performed using classical methods.

Role of dimethylsulfoxide for management of chemotherapy extravasation

Extravasation of anthracyclines is a rare complication that can lead to severe tissue necrosis and ulceration. With conservative measures (e.g., limb elevation, cooling), ulceration may develop in 28% of patients. Topical dimethylsulfoxide is commonly suggested as an antidote. However, there are inconsistent and sometimes conflicting animal data on its efficacy and safety. Ovid Medline (1966 to April 2004) was searched using the medical subject headings of ‘Dimethyl Sulfoxide’ and ‘Extravasation of Diagnostic and Therapeutic Materials’, and limited to English language and human articles. There have been no controlled trials on dimethylsulfoxide comparing its efficacy with cooling alone. Of a total of 147 patients, ulceration was uncommon after anthracycline extravasation when patients were managed with dimethylsulfoxide with or without cooling. Dimethylsulfoxide was well tolerated, with the most common toxicities being early mild reversible burning sensation, blistering, followed later by itch, erythema and superficial scaling. Dimethylsulfoxide is probably effective in preventing ulceration in patients who may not respond to cooling alone. When applied appropriately, dimethylsulfoxide seems well tolerated, with self-limiting local irritation to be the most common adverse effect. Hence, it is reasonable to consider topical dimethylsulfoxide 99% solution when managing extravasation of anthracyclines and mitomycin.

Case report: A pulseless radial artery in a child under anesthesia for radiotherapy

Treatment of cancer in children often requires a combination of chemotherapy, surgery, and/or radiotherapy. Radiotherapy and chemotherapy are not painful processes, but children undergoing these procedures must be made motionless through anesthesia or sedation. There are a few reports of complications during these procedures in relation to the procedures themselves or to the anesthesia given. This report describes an unexpected pulseless radial artery which was preliminarily and unduly attributed to anesthesia. A 2.5 year-old male pediatric patient with an acute lymphoblastic leukaemia was scheduled for radiotherapy. Anesthesia with intramuscular ketamine was induced before starting radiotherapy. About 5 minutes after injection of ketamine we found the right radial pulse undetectable. There was no other manifestation of hypoxia or hypo-perfusion. Carotid pulsation was normal. Examination of the left radial pulse and other peripheral pulses showed normal pulsation. The procedure was continued uneventfully. The next follow-up after radiotherapy, showed a scar and swelling on the right antecubital area, caused by extravasation of chemotherapeutic agent in the prior period of chemotherapy. Doppler ultrasonography of the antecubital vein confirmed the diagnosis. This case study therefore demonstrates that proper intravenous cannula establishment before chemotherapy is of great importance. Furthermore, accurate history and physical examination before induction of anesthesia or sedation may be useful in preventing mismanagement in pediatric cancer procedures.

Extravasation of Pt-based chemotherapeutics – bioimaging of their distribution in resectates using laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS)

Spatially resolved quantification of platinum distribution in patients that exhibited extravasation was feasible up to 4 weeks upon drug application.

Extravasation injuries in adults

Insertion of an intravascular catheter is one of the most common invasive procedures in hospitals worldwide. These intravascular lines are crucial in resuscitation, allow vital medication to be administered, and can be used to monitor the patients' real-time vital parameters. There is, however, growing recognition of potential risks to life and limb associated with their use. Medical literature is now replete with isolated case reports of complications succinctly described by Garden and Laussen (2004) as "An unending supply of "unusual" complications from central venous catheters." This paper reviews complications of venous and arterial catheters and discusses treatment approaches and methods to prevent complications, based on current evidence and endeavours to provide information and guidance that will enable practitioners to prevent, recognise, and successfully treat extravasation injuries in adults.

Cervical extravasation of bevacizumab

Monoclonal antibodies such as bevacizumab are widely used in medical oncology, either alone or in combination with chemotherapy. No specific recommendations on the management of monoclonal antibodies extravasation exist. Incidence rates vary considerably. Estimates of 0.5-6% have been reported in the literature. Also, patient-associated and procedure-associated risk factors of extravasation are multiple, such as bolus injections or poorly implanted central venous access. We report on an 86-year-old woman with colon cancer with liver metastasis who was treated with 5-fluorouracil, folinic acid, and bevacizumab. Extravasation occurred during chemotherapy infusion because of a catheter migration of the port outside of the superior vena cava, causing cervical pain without skin modifications. Diagnosis was confirmed with the appearance of clinical right cervical tumefaction and cervicothoracic computed tomography scan indicated a perijugular hypodense collection, corresponding to the extravasation. Conservative management was proposed. The patient recovered within 3 weeks from all symptoms. Physicians should be aware that in cases of bevacizumab extravasation, a nonsurgical approach might be effective.

Oncologic emergencies: Pathophysiology, presentation, diagnosis, and treatment

Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end-stage disease. Although some of these conditions are related to cancer therapy, they are by no means confined to the period of initial diagnosis and active treatment. In the setting of recurrent malignancy, these events can occur years after the surveillance of a cancer patient has been appropriately transferred from a medical oncologist to a primary care provider. As such, awareness of a patient's cancer history and its possible complications forms an important part of any clinician's knowledge base. Prompt identification of and intervention in these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This article reviews hypercalcemia, hyponatremia, hypoglycemia, tumor lysis syndrome, cardiac tamponade, superior vena cava syndrome, neutropenic fever, spinal cord compression, increased intracranial pressure, seizures, hyperviscosity syndrome, leukostasis, and airway obstruction in patients with malignancies. Chemotherapeutic emergencies are also addressed.

A sarcoma at the site of previous extravasation of adriamycin

We report the case of a 66-year-old man presenting with a high-grade pleomorphic sarcoma at the left elbow 16 years after the extravasation of adriamycin given for a malignant ifbrous histiocytoma of the tibia.We suggest that this sarcoma originated in a multistep way over many years, out of the chronic inflammatory tissue that developed due to a non-specific cellular damage at the nuclear level, interfering with normal cell replication necessary for normal healing tissue healing. As a result, the non-healed chronic inflammatory tissue transformed over several years into a preneoplastic mesenchymal tumour and later into a high-grade pleomorphic sarcoma.

Extravasational side effects of cytotoxic drugs: A preventable catastrophe

In addition to their therapeutic effects on malignant cells, cytotoxic agents have the potential of causing destruction of healthy, normal cells. Extravasation of the drug can produce extensive necrosis of the skin and subcutaneous tissue. Management of these extravasational effects differs from one centre to another and prevention is usually strongly emphasized. We analyzed our management of 12 patients referred to us over five years with extravasation of cytotoxic drugs and reviewed the literature for different approaches with regard to prophylaxis and management of extravasational effects.

Infiltration and extravasation: update on prevention and management

Infiltration and extravasation are risks of intravenous administration therapy involving unintended leakage of solution into the surrounding tissue. Consequences range from local irritation to amputation. While immediate action using appropriate measures (ie, dilution, extraction, antidotes, and supportive treatments) can decrease the need for surgical intervention, many injuries may be prevented by following established policy and procedures. However, timely surgical intervention, when necessary, can prevent more serious adverse outcomes. Clinicians should be prepared to act promptly when an event occurs. Thorough incident documentation helps determine whether infusion care meets the standard of practice and is a keystone to medicolegal defense.

Surgical treatment of ulcers caused by extravasation of cytotoxic drugs

Despite preventive measures, the extravasation of cytotoxic drugs still occurs in 0.6% to 6% of cases. The aetiology is thought to be that tissue necrosis develops into a chronic ulcer, which causes problems if the harmful action of the drug is not blocked. From 1988-2002 at the Department of Plastic Surgery of Rome University "La Sapienza", 240 patients presented with extravasation of cytotoxic drugs; all had been treated with an original conservative protocol first described in 1994, based on the repeated local infiltration of a large quantity of saline solution (90-540 ml) into the area of extravasation. We considered only cases with actively necrotic lesions. Eleven of the 240 patients (5%) had ulcers ranging from small ulcers to extensive areas of tissue necrosis. Of the 11 patients, eight had already had ulcers, while the remaining three were those in whom our conservative protocol had not prevented necrosis. They were all operated on and given grafts, local flaps, reverse radial flaps, and free flaps.

Anthracycline extravasation injuries: management with dexrazoxane

The application of anthracyclines in anticancer therapy may result in accidental extravasation injury and can be a serious complication of their use. Tissue necrosis with skin ulceration is a possible outcome in the inadvertent extravasation of anthracyclines during intravenous administration. Until recently, there has been no effective treatment against the devastating effect of extravasated anthracycline. Preclinical and clinical studies are leading to the clinical implementation of dexrazoxane as the first and only proven antidote in anthracycline extravasation. In two multicenter studies dexrazoxane has proven to be highly effective in preventing skin necrosis and ulceration. This review focuses on the development and management of dexrazoxane in anthracycline extravasation injuries.

IV therapy: recognizing the differences between infiltration and extravasation

Infiltration and extravasation are complications that can occur during intravenous therapy administered via either peripheral or central venous access devices. Both can result in problems with the siting of future venous access devices, nerve damage, infection and tissue necrosis. The nurse is the key to reducing the risk of infiltration and extravasation, through her knowledge and skill in cannulation and the intravenous administration of drugs (by bolus injection or infusion). The nurse must also be able to recognize the early signs and symptoms of infiltration and extravasation and act promptly and effectively to limit tissue damage. The first sign of possible leakage of drugs into the tissues is pain and discomfort, so patients must be informed of what symptoms to look out for and be asked to report any change in sensation as soon as they are aware of it. Finally, accurate documentation of the event is vital to facilitate patient care and in case of litigation.

Semisolid formulations containing dimethyl sulfoxide and α-tocopherol for the treatment of extravasation of antiblastic agents

The topical treatment with dimethyl sulfoxide (DMSO) and/or alpha-tocopherol (alpha-T) is widely used in order to prevent the local complications of extravasation of cytostatic drugs and protect patients against skin ulceration. Till now, DMSO and alpha-T have been mainly used in solution. The goal of this study was to formulate semisolid preparations for cutaneous application differing in the hydrophilic and lipophilic properties and containing DMSO and alpha-T in combination. With respect to solutions, the use of semisolid preparations containing DMSO and alpha-T could be advantageous in patients having extravasation as DMSO and alpha-T can remain in contact with the skin over an extended period of time. As a consequence, the action of the active principles can be limited specifically on the injured skin area, reducing the cutaneous irritative effects of DMSO. The following types of semisolid formulations containing 50% m/m DMSO and 2.5% m/m alpha-T were prepared: hydrophilic ointment, o/w emulsion, hydrophilic gel and lipophilic gel. The ex vivo skin permeation of DMSO and alpha-T was evaluated by using modified Franz's diffusion cells and human stratum corneum and epidermis (SCE) as a membrane. The permeated and retained amounts of DMSO and alpha-T were determined. The oleogel preparation, the hydrophilic gel and the o/w emulsion were uniform in colour and aspect, without any evidences of phase separation over the period of the study. Hydrophilic ointments were discarded as they showed phase separation after 12 h. All formulations had a different behaviour in terms of skin permeability. In particular, hydrogel and o/w emulsion showed the best control on the drug release considering the interactions of the vehicle components with the SCE and the drugs partition between the vehicle and the SCE. The DMSO permeated amount after 24 h was 4.1 mg/cm(2) for hydrogel and 2.5 mg/cm(2) for emulsion while the permeated amount of pure DMSO after 24 h was 47.5 mg/cm(2). Therefore, aiming to reduce side effects after the topical application of the antidotes DMSO and alpha-T, these results suggested that hydrogel and o/w emulsion could be considered the most promising formulations for further clinical evaluations in managing of extravasation of anthracyclines.

Intrapleural extravasation of epirubicin, 5-fluouracil, and cyclophosphamide, treated with dexrazoxane

The extravasation of DNA-binding vesicant drugs, such as epirubicin, is a feared complication of chemotherapy and can lead to extensive damage at injury sites. We describe a 56-year-old woman with breast cancer who received adjuvant chemotherapy after a breast-preserving surgical procedure. Due to catheter tip misplacement, epirubicin, 5-fluouracil, and cyclophosphamide were administered intrapleurally. To minimize long-term sequelae, flushing of the cavities and systemic administration of steroids were performed. Besides this treatment, empirically, 3-day therapy with dexrazoxane was added to prevent tissue damage and the risk of cardiac damage. Because of the potential benefits of dexrazoxane and its relatively mild side effects, its use should be considered in cases of the intrapleural extravasation of anthracyclines. We do emphasis the need for stringent surgical and oncological nursing procedures when using central venous access catheters in oncology.

[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.

Extravasation of chemotherapeutic agents: prevention and treatment

Most chemotherapeutic agents can cause varying degrees of local tissue injuries when extravasated. The medical treatment of extravasation is based on proper maintenance of the intravenous (IV) line and application of cold or warm compresses, plus the use of antidotes when available. Antidotes for extravasation that have been shown to be useful are sodium thiosulfate for nitrogen mustard, dimethylsulfoxide for anthracyclines and mitomycin, and hyaluronidase for the vinca alkaloids. New treatments include dexrazoxane, sargramostim, and hyperbaric oxygen for doxorubicin extravasations. Tissue damage secondary to drug infiltration occurs as a result of one of two major mechanisms: (1) the drug is absorbed by local cells in the tissue and binds to critical structures (eg, DNA, microtubules), causing cell death; and (2) the drug does not bind to cellular DNA. Damage to immediately adjacent tissue is more readily neutralized than is damage to surrounding tissue.

Cutaneous reactions to chemotherapy and their management

International data from 2002 report 10.9 million new cases of cancer and 6.7 million cancer deaths. Chemotherapy is an essential component in the multidisciplinary management of most cancers. Cutaneous reactions to chemotherapeutics are common and may contribute significantly to the morbidity, and rarely to the mortality, of patients undergoing such treatments. Recognition and management of these reactions is important to provide optimal care. This article aims to present the most common cutaneous reactions to frequently used chemotherapies and provides management guidelines. A MEDLINE search from 1966 through June 2005 was conducted to identify reports of common cutaneous toxicities with systemic chemotherapy and their appropriate management. An analysis of our literature search is presented in review form outlining common chemotherapy-related cutaneous reactions and their management, as well as the chemotherapeutics responsible for the cutaneous toxicity. Chemotherapy-related cutaneous toxicity includes generalized rashes such as the spectrum between erythema multiforme and toxic epidermal necrolysis, and site-specific toxicity such as mucositis, alopecia, nail changes, extravasation reactions, or hand-foot syndrome. Most of the toxicity is reversible with chemotherapy dose reductions or delays. Certain toxicities can be effectively treated or prevented, allowing optimal delivery of chemotherapy (e.g. premedications to prevent hypersensitivity, prophylactic mouthwashes to prevent mucositis). Newer non-chemotherapeutic targeted therapies such as epidermal growth factor receptor inhibitors (e.g. gefitinib, cetuximab) may also be associated with cutaneous toxicity and can be distressing for patients. Recent data suggest that skin toxicity associated with these agents may correlate with efficacy. Cutaneous toxicity occurs frequently with chemotherapy and non-chemotherapeutic biologic therapies. Early recognition and treatment of the toxicity facilitates good symptom control, prevents treatment-related morbidity, and allows continuation of anti-cancer therapy.

Extravasation of systemic hemato-oncological therapies

Systemic intravenous chemotherapeutic agents can cause multiple emergency situations including acute and chronic local and systemic reactions. Amongst them, drug extravasation is one of the most devastating complications, as many drugs can cause varying degrees of local tissue injury when extravasated. Although it is difficult to give an accurate measurement, the incidence of extravasation of systemic infusional chemotherapeutic agents has been reported to occur in 0.1-6.5% of cases. Since most extravasations can be prevented with the systematic implementation of careful administration techniques, guidelines have been published for the administration of vesicant drugs. The proper maintenance of intravenous lines, application of local cooling or warming for certain extravasations, and the use of antidotes to prevent the local toxic action of the extravasated drugs are the basis of medical management. The specific antidotes for certain chemotherapeutic agents are also discussed in this article.

Paravasation von Zytostatika

A variety of antineoplastic agents is associated with toxicity to healthy tissue and therefore represents a hazard for patients in case of extravasation. The most common risk factors include patient associated and iatrogenic risk factors. Due to the possible complications after extravasation, the knowledge of these risk factors is the basis for prevention, which is of utmost importance. A classification of antineoplastic agents according to the type of tissue damage includes the categories vesicant, irritant, and non-vesicant. Dependent on the extravasated agent, a series of emergency measures should be considered, preferably adhering to a standard operation procedure. There is good evidence for the successful use of antidotes to some antineoplastic agents. These antidotes are dimethylsulfoxide or hyaluronidase, often combined with topical measures such as cooling or application of heat. The application of sodium bicarbonate, sodium thiosulfate, and heparin is not recommended, whereas the usefulness of corticosteroids is still a matter of controversial discussions. Ambiguity in the management of extravasation is often a consequence of limited clinical evidence. Due to our deficient knowledge about some of the administered cytotoxics, there is ongoing need for action even after decades of therapy with antineoplastic agents.

Vesicant characteristics of oxaliplatin following antecubital extravasation

Oxaliplatin is a novel class of platinum chermotherapeutic agent used in refractory adenocarcinoma. It has previously been regarded as a non-vesicant, and as such was considered safe to administer through peripheral veins. This report documents severe muscle and subcutaneous reaction with a single dose of oxaliplatin at the site of extravasation in a patient aged 58 years. Conventional therapeutic modalities were employed to reduce the effect of the soft tissue infiltrate. Despite that, significant muscle necrosis and fibrosis occurred. Surgery was deferred secondary to patient choice, and eventual extensive physical therapy restored function to the elbow joint. This case shows that oxaliplatin may not be an appropriate cytotoxic agent to be administered through a peripheral line and consideration must be made for central access when this drug is used. In addition, when extravasation does occur, the current report indicates that non-surgical management can be successful.

Intrathoracic extravasation of antineoplastic agents: case report and systematic review

A case history is presented of a 34-year-old woman who was treated postoperatively for breast cancer with combination chemotherapy including epirubicin. The catheter of the port penetrated the wall of the superior vena cava, and extravasation in the mediastinum occurred. Severe pain, fever, and bilateral pleural effusion developed that necessitated two drainage procedures. She recovered well without sequelae. A comprehensive search of the medical literature was conducted using MEDLINE including bibliographies of all selected articles. Six additional cases of intrathoracic cytostatic agent extravasation were identified and the etiologic factors, clinical course, treatment strategy, and outcome were reviewed for each case.

Use of hyaluronidase for the treatment of extravasation of chemotherapeutic agents in six dogs

Six dogs had perivascular extravasation of antineoplastic agents during IV administration. Treatment with 300 units of hyaluronidase injected locally in the affected site was initiated following the extravasation event. Injections were repeated weekly until signs of toxic effects within the tissues resolved satisfactorily. All dogs recovered within 6 weeks, and residual fibrosis at the extravasation sites most was considered minimal. Many chemotherapeutic agents cause severe cytotoxic reactions when extravasated during cycles of chemotherapy, resulting in tissue necrosis with ulceration and sloughing of skin during the following weeks. Surgical treatments and skin grafting are often necessary to achieve healing. The sequelae of extravasation may result in discontinuation of chemotherapy or euthanasia of the animal. Hyaluronidase appears to be a safe treatment for the adverse effects of extravasation of various chemotherapeutic agents and may be used effectively to reduce the severity of cutaneous toxicosis.

Retrospective study of the management of chemotherapeutic extravasation injury

Despite the now widespread experience with the administration of chemotherapeutic agents in oncology, extravasation injuries still occur. Furthermore, the most appropriate management of such injuries is not known. The authors examined the current treatment options for extravasation injury and the incidence of this problem. All cases of extravasation referred to the plastic surgery service at one institution from 1994 through 1996 were examined. During a 6-year period there were 44 cases of extravasation injury identified in 42 patients. Comparison with a previous study conducted 15 years before at the same institution revealed a significant reduction in the incidence of extravasation injuries during that time (0.01% vs. 0.1%; = 0.00). The site of extravasation was peripheral in 32 cases and central in 12. Paclitaxel and doxorubicin were the two most common drugs involved. The local infusion of antidotes was not performed routinely. Only 26 of the 42 patients were referred to the plastic surgery service for care. Only 10 of those 26 patients required local ulcer excision and closure to achieve a healed wound. The mean time between injury and referral was 40 days. This time did not predict the subsequent need for a surgical procedure. Most patients, including the remaining 16 referred to the plastic surgery service, did not require surgical intervention. All were watched expectantly, and their injuries healed spontaneously. In conclusion, the incidence of extravasation is decreasing, most likely as a result of the diligence in the administration and identification of extravasation injuries as well as the result of the use of more central infusion sites. Most cases can be managed conservatively, with directed surgical treatment of the ulceration when appropriate.