Port-a-Cath extravasation of vesicant cytotoxics: surgical options for a rare complication of cancer chemotherapy. Eur J Surg Oncol. 2015;41:378-385. [PMID: 25515823 DOI: 10.1016/j.ejso.2014.11.042]

Vascular access device type for systemic anti-cancer therapies in cancer patients: A scoping review

BACKGROUND

Patients with cancer can expect to receive numerous invasive vascular access procedures for intravenous therapy and clinical diagnostics. Due to the increased incidence and prevalence of cancer globally there will be significantly more people who require first-line intravenous chemotherapy over the next ten years.

METHODS

Our objective was to determine the types of evidence that exist for the vascular access device (VAD) type for the delivery of systemic anti-cancer therapy (SACT) in cancer patients. We used JBI scoping review methodology to identify the types of VADs used for SACT and with a specific search strategy included articles from 2012-2022 published in the English language. We identify (i) type of VADs used for SACT delivery (ii) the type of insertion and post-insertion complications (iii) the geographical location and clinical environment (iv) and whether VAD choice impacts on quality of life (QOL). Findings were presented using the PAGER framework.

MAIN FINDINGS

Our search strategy identified 10,390 titles, of these, 5318 duplicates were removed. The remaining 5072 sources were screened for eligibility, 240 articles met the inclusion criteria. The most common design include retrospective study designs (n = 91) followed by prospective study designs (n = 31). We found 28 interventional studies with 21 registered in a clinical trial registry and identified no core outcome sets papers specific to VAD for SACT. The most prevalent publications were those that featured two or more VAD types (n = 70), followed by tunnelled intravenous VADs (n = 67). Of 38 unique complications identified, the most frequent catheter related complication was catheter related thrombosis (n = 178, 74%), followed by infection (n = 170, 71%). The county where the most publications originated from was China (n = 62) with one randomized controlled multicenter study from a comprehensive cancer centre. Of the thirty three studies that included QOL we found 4 which reported on body image. No QOL measurement tools specific to the process of SACT administration via VAD are available INTERPRETATION: Our findings suggest a systematic review and meta-analysis of VAD use for intravenous SACT can be considered. However, the development of a core outcome set for SACT should be prioritised. Funding for high quality programs of research for VAD in cancer are needed. Comprehensive cancer centres should lead this research agenda.

Surgical management after Oxaliplatin extravasation: A case report and literature review

This case report describes a unique case of chronic reaction after extravasation of oxaliplatin. The pain and extensive subcutaneous induration did not resolve after 9 months of conservative treatment. Surgical debridement with removal of the totally implantable venous access device (TIVAD) resulted in immediate resolution of the symptoms. Oxaliplatin has both irritant and vesicant properties that are difficult to distinguish at initial clinical presentation. In most literature cases complaints resolve within 3 months with conservative treatment yet surgical debridement should be considered if complaints persist beyond this period.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Cervical dissecting extravasation of oxaliplatin: A case report

Oxaliplatin is a chemotherapy drug considered to be an irritant and vesicant. Peripheral extravasation could happen following oxaliplatin chemotherapy administration, but mediastinal or cervical events are rare. The present study focused on the case of a 64-year-old female patient with KRAS-mutated colorectal adenocarcinoma. The patient was prescribed folinic acid, fluorouracil and oxaliplatin chemotherapy via a subcutaneous pump or port-a-cath device, which was inserted into the right subclavian vein. The patient reported a sudden throbbing pain in the chest wall and anterior cervical region. After performing a computed tomography scan, anterior cervical collection and jugular-subclavian venous confluence at the distal end was observed at the venous access site of the subcutaneous port-a-cath device, which extended cranially, dissected cervical planes and forming a hydro-aerial collection in the submaxillary region. Subsequently, the port-a-cath device was removed and a warm dry compress was applied. After 2 weeks, the patient had fully recovered without any sequelae at the cervical level. To the best of the authors' knowledge, this is the first case of cervical extravasation of oxaliplatin reported in the literature to date and will help to manage similar situations.

Efficacy, safety, and cost-effectiveness of intracavitary electrocardiography-guided catheter tip placement for totally implantable venous access port

OBJECTIVE

Intracavitary electrocardiography (IC-ECG) has been extensively used for locating the catheter tip of the central venous access devices (CVADs) with favorable safety and accuracy. We aimed to evaluate the efficacy, safety, and cost-effectiveness of IC-ECG-guided catheter tip placement for totally implantable venous access port (TIVAP) by comparing with the standard fluoroscopy method.

METHODS

231 patients who underwent TIVAP implantation from September 2019 to April 2021 were enrolled in the retrospective study. Fluoroscopy and IC-ECG were conducted intraoperatively to confirm the position of catheter tips. Demographic characteristics, surgical data, the catheter tip position, complication rate, and incidence, cost of procedures, and indwelling time were compared between the two groups. Univariate and multivariate analyses were used to identify the risk factors of TIVAP-related complications.

RESULTS

There was no significance between the fluoroscopy group and the IC-ECG group in terms of the rate of ideal position (p = 0.733). Nine patients (3.9%) developed TIVAP-related complications. Complication rates and incidence were similar in the fluoroscopy group and the IC-ECG group (3.1% and 0.114/1000 catheter days vs 4.4% and 0.105/1000 catheter days). The Kaplan-Meier curve showed that there was no significant difference in indwelling time between the two groups (Log Rank p = 0.634). Binary logistic regression analysis showed that body mass index (BMI) was an independent risk factor for TIVAP-related complications (OR = 1.334, 95%CI: 1.139 - 1.563, p < 0.001). The IC-ECG group was less costly than the fluoroscopy group (¥9928 ± 362 vs ¥11762 ± 431, p <0.001).

CONCLUSIONS

IC-ECG-guided catheter tip placement for TIVAP is feasible, safe, and cost-effective, with high accuracy, low risk of complications, and lower cost. It may be considered as an alternative to the standard fluoroscopy method for catheter tip placement of TIVAP.

Chemotherapy Extravasation: Incidence of and Factors Associated With Events in a Community Cancer Center

BACKGROUND

The administration of chemotherapy is a high-risk and nurse-sensitive practice. One complication is extravasation.

OBJECTIVES

The purpose of this study was to determine the incidence of and iatrogenic factors associated with extravasation in the ambulatory and inpatient settings of a community cancer center.

METHODS

Events were reviewed by agent, route of administration, patient characteristics, and RNs administering the agent. A one-year, retrospective review of electronic health records and pharmacy and nursing reports was conducted.

FINDINGS

The number of vesicants, irritants, and irritants with vesicant properties administered was 12,260 in the ambulatory setting and 612 on the inpatient unit, with 21 and 1 extravasation events, respectively. Incidence rates for both settings were 0.001%. The most common agent to extravasate was docetaxel, and all events occurred via peripheral route. The incidence of events was lower than the reported benchmark for National Cancer Institute-designated cancer centers.

Epirubicin: Biological Properties, Analytical Methods, and Drug Delivery Nanosystems

Epirubicin (EPI) is a chemotherapeutic agent belonging to the anthracycline drug class indicated for treating several tumors. It acts by suppressing the DNA and RNA synthesis by intercalating between their base pair. However, several side effects are associated with this therapy, including cardiotoxicity and myelosuppression. Therefore, EPI delivery in nanosystems has been an interesting strategy to overcome these limitations and improve the safety and efficacy of EPI. Thus, analytical methods have been used to understand and characterize these nanosystems, including spectrophotometric, spectrofluorimetric, and chromatography. Spectrophotometric and spectrofluorimetric methods have been used to quantify EPI in less complex matrices due to their efficiency, low cost, and green chemistry character. By contrast, high-performance liquid chromatography is a suitable method for detecting EPI in more complex matrices (e.g., plasm and urine) owing to its high sensitivity. This review summarizes physicochemical and pharmacokinetic properties of EPI, its application in drug delivery nanosystems, and the analytical methods employed in its quantification in different matrices, including blood, plasm, urine, and drug delivery nanosystems.

Extravasation of Epirubicin chemotherapy from a port-a-cath causing extensive breast necrosis: Sequential imaging findings and management of a breast cancer patient

Extravasation of chemotherapy is rare with an estimated incidence of 0.01%-7% but can cause significant morbidity, delay in cancer treatment and potential mortality. We present a case of 55-year-old woman with a metastatic right axillary lymph node with no identifiable breast primary, commenced on chemotherapy as per multidisciplinary team decision. Extravasation of 25 mls of Epirubicin chemotherapy at the porta-a-cath (site) caused extensive inflammatory change in the breast parenchyma and chest wall with a necrotic ulcerating skin-defect. Even with ensuring port or peripheral catheter patency and position, extravasation can occur. This is the first case report to describe the use of MRI to help plan management, identifying the extent of the tissue damage and vascular compromise which could impair healing. In this case the necrotic ulcer was managed with surgical debridement and human ADM matrix (Matriderm dermal matrix) which has not been described in the literature previously.

Tissue distribution of epirubicin after severe extravasation in humans

PURPOSE

As critical parameter after extravasation of cytotoxic vesicants, anthracyclines were determined in removed tissue from patients requiring surgical intervention due to tissue necrosis. We monitored their distribution within the affected lesion to establish a possible dose-toxicity relation.

METHODS

From six patients scheduled for surgery, removed tissue flaps were systematically analysed by HPLC (epirubicin: 5 subjects; doxorubicin: 1 subject).

RESULTS

After extravasation, tissue concentrations were highly variable with an individual anthracycline distribution pattern ranging from a few nanograms up to 17 µg per 100 mg tissue, which indicated a substantial difference in tissue sensitivity among patients. The resection borders coincided with the extension of the erythema and guided the surgical intervention after demarcation of the lesion, which occurred usually 2 or 3 weeks after extravasation. At that time, drug was hardly detected at the resection borders. Wound drains were negative for the extravasated drugs while showing a time profile of vascular growth factors and inflammatory cytokines, which was highly similar to routine surgery. In all six patients, surgical debridement with immediate wound closure led to healing within approximately 2 weeks, when therapy was resumed in all patients with reasonable time delay.

CONCLUSION

Surgical intervention after demarcation of the extravasation lesion allows for almost uninterrupted continuation of treatment independent of the amount of extravasated anthracycline. As even minor amounts of the vesicants may trigger tissue necrosis, preventive measures merit the highest priority.

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique

BACKGROUND

Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment.

METHODS

We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes.

RESULTS

We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation.

CONCLUSION

This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

Safety and efficacy of trabectedin when administered in the inpatient versus outpatient setting: Clinical considerations for outpatient administration of trabectedin

Background

The results of the randomized, phase 3 ET743‐SAR‐3007 trial demonstrated that trabectedin had a significantly longer progression‐free survival (PFS) compared with dacarbazine in patients with advanced leiomyosarcoma/liposarcoma after the failure of prior chemotherapy. Patients randomized to trabectedin received a 24‐hour intravenous infusion either in an inpatient or outpatient setting. Herein, the authors reported the safety, efficacy, and patient‐reported outcomes based on first infusion site of care.

Methods

Patients were randomized 2:1 to trabectedin (at a dose of 1.5 mg/m²) or dacarbazine (1 g/m² over 20‐120 minutes) with overall survival (OS) as the primary endpoint and PFS, time to disease progression, objective response rate, duration of response, safety, and patient‐reported symptom scoring as secondary endpoints. The setting of the trabectedin infusion was based on institutional preference and categorized based on the setting of the first infusion.

Results

Of the 378 patients who were treated with trabectedin, 100 (27%) and 277 (73%), respectively, first received trabectedin in the inpatient and outpatient setting. No differences were observed with regard to PFS or OS based on site of care. The median PFS was 4.1 months versus 4.2 months (hazard ratio, 0.90; P = .49) for inpatients versus outpatients, respectively, and the median OS was 14.3 months versus 13.7 months (hazard ratio, 0.89; P = .40), respectively. Grade 3/4 adverse events (classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 4.0]) were reported in 87 inpatients (87%) compared with 219 outpatients (79%); grade 3/4 serious adverse events were reported in 43 inpatients (43%) and 92 outpatients (33%). Extravasation occurred in 0 inpatients and 5 outpatients (2%), whereas the incidence of catheter‐related complications was similar between groups (16% vs 15%).

Conclusions

Although the majority of patients who were randomized to trabectedin received outpatient therapy, the outcomes of the current study suggested equivalent safety and efficacy in either setting.

The majority of patients randomized to trabectedin in the ET743‐SAR‐3007 trial have received the drug in the outpatient setting. The results of the current analysis suggest that trabectedin has equivalent efficacy and comparable safety when administered in an inpatient or outpatient setting.

Negative-pressure wound therapy and early pedicle flap reconstruction of the chest wall after epirubicin extravasation

PURPOSE

Accidental extravasation is a serious iatrogenic injury among patients receiving anthracycline-containing chemotherapy. The aim of this work is to present a combination therapy for chest wall reconstruction following epirubicin extravasation.

METHODS

Herein, we report a 68-year-old woman with massive soft tissue necrosis of the anterolateral chest wall after epirubicin extravasation from a port implanted in the subclavicular area.

RESULTS

The necrotic tissue was resected, the port was removed, and negative-pressure wound therapy was applied. Three weeks later, a latissimus dorsi pedicle flap was successfully used to cover the defect.

CONCLUSIONS

To the best of the authors' knowledge, this is the first report of a strategy comprising the combination of negative-pressure wound therapy and a latissimus pedicle flap for reconstruction of the chest wall after soft tissue necrosis following epirubicin extravasation.

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.

Overview, prevention and management of chemotherapy extravasation

Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. We review in this article the clinical aspects of chemotherapy extravasation and latest advances in definitions, classification, prevention, management and guidelines. We review the grading of extravasation and tissue damage according to various chemotherapeutic drugs and present an update on treatment and new antidotes including dexrazoxane for anthracyclines extravasation. We highlight the importance of education and training of the oncology team for prevention and prompt pharmacological and non-pharmacological management and stress the availability of new antidotes like dexrazoxane wherever anthracyclines are being infused.