Dose-dependent skin ulcers in mice treated with DNA binding antitumor antibiotics

Extent of extravasation: Patients on parenteral plant alkaloids

BACKGROUND

Plant alkaloids remain an essential part of many chemotherapeutic regimens. Although many adverse effects have been studied with appropriate management guidelines, extravasation (EV) is one adverse event that is yet to be studied at a regional scale to frame population-specific guidelines.

METHODOLOGY

A hospital-based observational study was done for 1 year to understand the extent of extravasation among patients on parenteral plant alkaloids. Clinical pharmacists congregated information about patients satisfying the study criteria. The incidence of EV injuries associated with parenteral plant alkaloids was assessed. The severity was scored using the Common Terminology Criteria for Adverse Events (CTCAE) v4.3. The ESMO-EONS guidelines were followed for the classification of chemotherapeutic agents as well as management of the incidents of EV.

RESULTS

Among the 80 patients recruited into the study, 26.25% of patients experienced EV injuries, of which 66.67% were grade 2 and 33.33% were grade 3. Females were prevalent at 62% among the injured group. Patients in the age group 31-50 years and 51-60 years sustained 28.57% of the injuries each. In 76.19% of injured patients, ambulation status was positive during the infusion. ESMO-EONS drug classification showed that 54.84% of the drugs prescribed were vesicants. Paclitaxel was seen in 33.33% of prescriptions in the injured group, among other plant alkaloids.

CONCLUSION

Our study saw a trend of vesicant-induced extravasation injury among patients prescribed parenteral chemotherapeutic regimens with a combination of plant alkaloids, indicating the significant risk they may pose.

Skin Penetration Enhancement Strategies Used in the Development of Melanoma Topical Treatments

Malignant melanoma is an aggressive form of skin cancer for which there is currently no reliable therapy and is considered one of the leading health issues in the USA. At present, surgery is the most effective and acceptable treatment; however, surgical excision can be impractical in certain circumstances. Topical skin delivery of drugs using topical formulations is a potential alternative approach which can have many advantages aside from being a non-invasive delivery route. Nevertheless, the presence of the stratum corneum (SC) limits the penetration of drugs through the skin, lowering their treatment efficacy and raising concerns among physicians and patients as to their effectiveness. Currently, research groups are trying to circumvent the SC barrier by using skin penetration enhancement (SPE) strategies. The SPE strategies investigated include chemical skin penetration enhancers (CPEs), physical skin penetration enhancers (PPEs), nanocarrier systems, and a combination of SPE strategies (cream). Of these, PPEs and cream are the most advanced approaches in terms of preclinical and clinical studies, respectively.

Facile synthesis of 1,2,3-triazole-fused indolo- and pyrrolo[1,4]diazepines, DNA-binding and evaluation of their anticancer activity

A facile synthetic strategy has been developed for the generation of structurally diverse N-fused heterocycles. The formation of fused 1,2,3-triazole indolo and pyrrolodiazepines proceeds through an initial Knoevenagel condensation followed by intramolecular azide-alkyne cycloaddition reaction at room temperature without recourse to the traditional Cu(I)-catalyzed azide-alkyne cycloadditions. The synthesized compounds were evaluated for their in vitro anti-cancer activity against the NCI 60 cell line panel. Among the tested compounds, 3a and 3h were found to exhibit potent inhibitory activity against many of the cell lines. Cell cycle analysis indicated that the compounds inhibit the cell cycle at sub G1 phase. The DNA- nano drop method, viscosity experiment and docking studies suggested these compounds possess DNA binding affinity.

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 epirubicin/vincristine and ifosfamide/ mesna from a central venous catheter

A 50-year-old female diagnosed with high-grade infil trating ductal carcinoma of the left breast was planned for insertion of a central venous catheter for a 6-week continuous infusion regimen including weekly ifosfamide/mesna alternating with weekly epi rubicin/vincristine via a CADD portable infusion pump; then radiotherapy followed by a further 6 weeks of VIE infusional chemotherapy.

The initial 6 weeks of therapy was complicated by infected central venous catheter during week 2. Central venous catheter was removed and chemother apy was administered peripherally. After completion of XRT, a new central venous catheter was inserted and the second cycle of epirubicin/vincristine chemo therapy was commenced.

During week 3 of the second cycle the patient developed right neck pain and swelling, which was diagnosed as a haematoma and cellulitis which was treated with cephalexin. The following week she was admitted for intravenous antibiotics and drainage of the haematoma. Exploration of the neck swelling revealed fat necrosis and extravasation of chemother apy into the subcutaneous tissues. Chemotherapy was stopped, and treatment was commenced for extrava sation of an unknown volume of ifosfamide/mesna administered weeks 1 and 3, and epirubicin/vincris tine administered weeks 2 and 4 for unknown period, possibly 3 weeks.

The extravasation was treated as per the institu tional policy for anthracycline extravasation; topical dimethyl sulphoxide and cold packs were applied every six hours for 14 days and plastic surgeons were consulted. Central venous catheter was removed 10 days after detection of the extravasation. Inflamma tion and pain resolved slowly over 4 weeks. The patient has had no further chemotherapy, and re mains in CR. There have been no long-term sequelae from the extravasation.

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.

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.

Treatment of anthracycline extravasation in mice with dexrazoxane with or without DMSO and hydrocortisone

Dexrazoxane has been reported to be protective against anthracycline induced subcutaneous ulceration in mice. It is currently under clinical investigation as an acute antidote in accidental anthracycline extravasation, for which indication topical dimethylsulfoxide (DMSO) and intralesional hydrocortisone are used empirically. We studied the effect in 72 mice of monotherapy with and combined therapy of intraperitoneal dexrazoxane, topical DMSO, and intralesional hydrocortisone as acute antidotes against ulceration after subcutaneous daunorubicin. Dexrazoxane completely prevented wounds from occurring, while neither DMSO nor hydrocortisone had any preventive effect. The addition of topical DMSO actually reduced the efficacy of dexrazoxane. In conclusion, the present study does not support the concomitant use of topical DMSO + systemic dexrazoxane or intralesional hydrocortisone + systemic dexrazoxane. Monotherapy with systemic dexrazoxane seems preferable and is highly efficacious in preventing ulceration.

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.

Dexrazoxane is a potent and specific inhibitor of anthracycline induced subcutaneous lesions in mice

BACKGROUND

Recently, we have shown that dexrazoxane (ICRF-187) is an effective antidote against accidental extravasation of anthracyclines. Thus, it inhibits the lesions induced by subcutaneous (s.c.) daunorubicin, idarubicin, and doxorubicin in mice and has proven to be successful clinically as well. Dexrazoxane is a potent metal ion chelator as well as being a catalytic inhibitor of DNA topoisomerase II. However, the mechanism behind the protection against anthracycline extravasation is not known.

MATERIALS AND METHODS

Mice were injected s.c. with daunorubicin or doxorubicin. Systemic N-acetylcysteine, alfa-tocoferol, amifostine, merbarone, aclarubicin, ADR-925, and EDTA were administered i.p. immediately hereafter or as a triple-treatment over six hours. Intralesional (i.l.) adjuvants were injected immediately after and into the same area as the anthracycline. The frequency, duration, and sizes of wounds were observed until complete healing of all wounds.

RESULTS

Triple-treatment with systemic dexrazoxane was superior to single dosage and completely prevented lesions after s.c. daunorubicin and doxorubicin. Low-dose i.l. dexrazoxane was effective in protecting as well. In contrast, none of the other seven adjuvants was effective. Protection was not achieved with local cooling, however, topical ice did not impair the efficacy of dexrazoxane.

CONCLUSIONS

Dexrazoxane is extremely effective and apparently quite specific in protecting against lesions after s.c. doxorubicin and daunorubicin.

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.

Extravasation injury potential of CI-980, a novel synthetic mitotic inhibitor

Severe soft-tissue ulceration is known to result from inadvertent extravasation of a number of anticancer drugs, including tubulin-binding vinca alkaloids, during intravenous administration. CI-980 is a novel anticancer drug candidate that also inhibits mitosis by binding to tubulin. Intradermal administration of CI-980 to mice at doses of 0.02 and 0.05 mg produced ulcerative lesions in 3/5 and 2/5 animals, respectively, that were significantly smaller than those produced in all animals at vinblastine doses of 0.05 and 0.1 mg. Ulcerative lesions resulting from CI-980 treatment were also less persistent, resolving in 2-8 days versus 7-16 days following vinblastine administration. As based on the common dose of 0.05 mg, CI-980 appears to have significantly less vesicant activity than vinblastine.

Skin and perivascular toxicity induced experimentally by doxorubicin

Extravasation of antitumor drugs and particularly doxorubicin (DXR) can be followed by skin ulceration and slowly evolving perivascular necrosis. DXR lesions have some characteristics in common with those induced by ionizing radiation and, with respect to gross morphology, are reminiscent of skin lesions induced by necrotizing agents. Time course and histopathology of toxic phenomena induced by intradermal or perivascular injection of various doses of either DXR or caustic chemicals have been studied in hairy outbred and hairless inbred (MF1 hr/hr) mice. The latter strain has been found to be intrinsically more sensitive to DXR induced toxic effects, particularly as far as perivascular administration is concerned. Long lasting lesions and, in a few cases, systemic involvement have been observed. On the contrary, necrotic foci induced by caustic chemicals rapidly regressed in both strains. The perivascular administration model, which has not been previously investigated, appears to be representative of what happens in clinical conditions and can be of use for assessing either skin toxicity of antitumor compound or the protective effect of candidate antidotes.