Extravasation associated with cancer drug therapy: multidisciplinary guideline of the Japanese Society of Cancer Nursing, Japanese Society of Medical Oncology, and Japanese Society of Pharmaceutical Oncology

BACKGROUND

Extravasation (EV), or the leakage of anticancer drugs into perivascular and subcutaneous tissues during intravenous administration, can cause serious conditions that may require surgical intervention. Therefore, updated guidelines for EV based on systematic review are needed. Additionally, classifications for anticancer drugs that cause EV are not standardized across the current guidelines, and some novel drugs have not been classified. Therefore, this study aimed to formulate guidelines using evidence-based information for shared decision making on prevention, early detection, treatment, and care for EV in Japan and provide additional classification for tissue injury based on systematic review.

MATERIALS AND METHODS

The members of the Japanese Society of Cancer Nursing (JSCN), Japanese Society of Medical Oncology (JSMO), and Japanese Society of Pharmaceutical Oncology (JASPO) were surveyed about significant clinical challenges related to EV, and 17 clinical questions (CQs) were formulated. PubMed and ICHUSHI Web were searched using the Patient, Intervention, Comparison, and Outcomes terms listed in each CQ as key words. For the classification of new drugs, articles published through February 2021 were selected using the search terms 'extravasation', 'injection-site reaction', 'adverse events', and the names of individual drugs as key words.

RESULTS

Recommendations based on the results of randomized controlled trials (RCTs) were made with regard to the selection of central venous (CV) devices (CQ2, CQ3a, CQ3b, and CQ3c), regular replacement of peripheral venous catheters (CQ5), and use of fosaprepitant (CQ7). These CQs are novel and were not mentioned in previous guidelines. Warm compression monotherapy (CQ10b) and local injection of steroids (CQ12) are discouraged for the management of EV. Ten new drugs were classified for EV tissue injury.

CONCLUSIONS

This study provides updated guidelines for the prevention and treatment of EV, which can be used to help health care providers and patients and their families practice better EV management.

Damage to subcutaneous tissue at the catheterization site during chemotherapy: A prospective observational study using ultrasonography

PURPOSE

Chemotherapy administration can affect subcutaneous tissue at the catheterization site with no macroscopic signs or subjective symptoms. Yet clinical studies about the impact of chemotherapy on tissue at the catheterization site, except for apparent extravasation cases, are limited. This study aimed to investigate subcutaneous tissue changes in nonmacroscopically damaged catheterization sites after chemotherapy administration.

METHODS

Participants were people with cancer receiving outpatient chemotherapy. Ultrasonographic images were used to assess the condition of subcutaneous tissues, including the vein, at the catheterization site before catheterization, immediately after chemotherapy, and on the next scheduled treatment day. Data on macroscopic inspection, palpation, and subjective symptoms were also collected and analyzed.

RESULTS

Data from 41 participants were analyzed. All had normal subcutaneous tissues before catheterization. After treatment, 16 (39.0%) manifested abnormalities such as subcutaneous edema, vessel wall thickening, and/or thrombosis; there was no extravasation immediately after treatment. On the next treatment day, 15 (36.6.%) showed persistent or new onset of abnormalities, including subcutaneous edema. Eight of the 15 did not exhibit any subjective symptoms or macroscopic or palpation findings.

CONCLUSION

After chemotherapy administration via peripheral intravenous catheters, it was found that this damage, which was difficult to detect by the conventional assessment method, persisted. Ultrasonography can provide useful information to avoid reusing damaged sites for chemotherapy administration.

Infusion Site Reactions: Classification in the Setting of Fosaprepitant Administration With Chemotherapy

BACKGROUND

Studies report a wide range of incidence and severity of infusion site adverse events (ISAEs) following fosaprepitant administration.

OBJECTIVES

The purposes of this study were (a) to determine the incidence of suspected extravasation in patients with cancer receiving fosaprepitant infusions with chemotherapy and (b) to determine whether the documented signs, symptoms, and management strategies aligned with the diagnostic criteria for extravasation versus non-extravasation ISAEs.

METHODS

Electronic health records were used to identify patients who received fosaprepitant infusion with chemotherapy and had documentation for suspected extravasation. Chart reviews were conducted for a sample of patients to determine whether documentation was consistent with extravasation.

FINDINGS

About 3% (n = 460 of 15,667) of patients who received fosaprepitant had documentation for suspected extravasation. Among a random sample of patients (N = 110) with suspected extravasation, 6% (n = 6) had documentation consistent with extravasation.

Study on the infusion-site adverse events and vascular distribution of epirubicin in chemotherapy with epirubicin and fosaprepitant

In breast cancer patients on a fluorouracil-epirubicin (EPI)-cyclophosphamide (FEC) regimen and intravenous fosaprepitant (FAP) during chemotherapy, infusion-site adverse events such as vascular pain and induration and/or phlebitis are observed. In the present study, adverse events induced by the FEC regimen and FAP, a prodrug of aprepitant (AP), were studied based on the vascular tissue distribution of EPI in rats. Rats were treated with intravenous FAP (3 mg/kg, 10 min-constant rate infusion) or oral AP (3 mg/kg) and then intravenous EPI (1 mg/kg, 5 min-constant rate infusion) as follows: FAP-S Group, FAP and then EPI was infused from the same site on the jugular vein; FAP-D Group, FAP and then EPI was infused from different jugular veins (left and right); and AP Group, AP was administered orally and EPI was infused from the jugular vein. Concentrations of EPI in vascular tissue at the EPI infusion sites and opposite sites of the jugular vein (left and right, respectively) were measured at 30 min and 24 h after EPI infusion. Histological observation of the EPI infusion site was also made separately. In rats, the tissue concentrations of EPI at the infusion site in the FAP-S group were higher than those in the FAP-D and AP groups. Inflammation and necrosis were observed at the EPI infusion-site vascular tissue of the FAP-S group, but not of the FAP-D and AP groups. These findings could aid the development of an approach to avoid infusion-site adverse events in anthracycline-based chemotherapy in the clinical practice.