Skin Necrosis After Ado-Trastuzumab Emtansine Extravasation

Extravasation of monoclonal antibodies commonly used in oncology: Classification, management and the role of the pharmacist

INTRODUCTION

Extravasation by conventional cytotoxics has been well documented. While monoclonal antibodies are not considered to have the necrotic potential of some cytotoxic medicines, they require appropriate management in case of extravasation. However, fewer data are available on their classification and appropriate management when extravasation occurs. As monoclonal antibodies are being more commonly used in current daily oncology practice, this is an issue that cannot be ignored.

METHODS

A scientific literature review on PubMed was conducted. All findings were critically appraised independently by 6 clinical pharmacists in order to provide a classification according to the extravasation hazard.

RESULTS

A classification of non-conjugated and conjugated monoclonal antibodies according to extravasation hazard has been elaborated for different molecules frequently used in oncology. In addition, general management, in case extravasation of monoclonal antibodies occurs, has been proposed and the role of the pharmacist in the extravasation process has been described.

CONCLUSION

A classification of hazard extent of extravasation of monoclonal antibodies with concurrent management based on literature data and expert consensus has been elaborated. In addition, the role of the oncology pharmacist is crucial in terms of follow-up and documentation of the extravasated monoclonal antibody and management is described.

Extravasation of brentuximab vedotin, an antibody-drug conjugate, in a patient with anaplastic large cell lymphoma

Brentuximab vedotin (BV) is an antibody-drug conjugate, consisting of a CD30-directed antibody, conjugated by a protease-cleavable linker to a microtubule disrupting agent auristatin E (MMAE). Although the safety datasheet of BV does not warn of severe toxic effects of extravasation, we report a third case of a patient with anaplastic large cell lymphoma who developed severe epidermal necrosis after extravasation. The reason for what happened could be attributed to the fact that MMAE belongs to the group of vinca alkaloids so it should be handled like other tissue-necrotising chemotherapeutics. Reporting of all cases of extravasation involving new conjugated chemotherapeutic drugs is of the utmost importance to be able to develop updated guidelines. Hospital pharmacists can provide information on how to manage extravasation, assess the potential risk, and have a crucial role in drafting hospital protocols.

Drug extravasation with Enfortumab vedotin

INTRODUCTION

Enfortumab vedotin is an antibody drug conjugate approved for management of pretreated locally advanced or metastatic urothelial carcinoma, which is associated with a rare risk of drug extravasation and soft tissue reactions.

CASE REPORT

We report two cases of EV extravasation with subsequent development of bullae and cellulitis.

MANAGEMENT AND OUTCOME

They were both treated for cellulitis and had conservative management without surgical intervention and were able to resume treatment with Enfortumab vedotin without subsequent adverse events.

DISCUSSION

We propose that EV acts as a vesicant upon extravasation, highlight measures to prevent extravasation events, and encourage appropriate measures when dealing such as attempt of aspiration, removal of catheter, application of compresses, and thorough documentation with photographic evidence.

Monoclonal antibody extravasations: Two case reports and literature review

INTRODUCTION

Extravasation is a rare complication from intravenous chemotherapy administration. Literature about monoclonal antibody (MoAb) extravasations is scarce and also conflicting in how they are classified.

CASE REPORT

We reported two different cases of MoAb extravasations with cetuximab and nivolumab outcome respectively. The administration site appeared inflamed and patients did not report disturbances.Management and outcome: Both extravasations did not require specific treatment. General unspecific measures suffice to properly manage these extravasations and no sequels were observed after long follow-up. Both patients received all further courses of MoAb without any adverse events.

DISCUSSION

To our knowledge, we reported the first case-report of nivolumab extravasation in the literature. In addition, the cetuximab extravasation management and outcome was in accordance with previously published reports. Both MoAb may be considered as non-aggressive or neutral. We reviewed published information about MoAb extravasations. In conclusion, not all MoAb should be classified in the same category when extravasated and special precautions are warranted with conjugated MoAb and bevacizumab.

Extravasation of an antibody-drug conjugate: A case report of epidermal necrosis after trastuzumab-emtansine extravasation

WHAT IS KNOWN AND OBJECTIVE

Trastuzumab-emtansine is an antibody-drug conjugate developed to decrease off-target toxicity. According to the product label, reactions secondary to extravasation are mild or moderate.

CASE SUMMARY

We report on a 51-year-old woman who developed epidermal necrosis after extravasation of trastuzumab-emtansine, which required surgical intervention. Six weeks later, the lesions were healed with residual hyperpigmentation.

WHAT IS NEW AND CONCLUSION

We describe the course of a case of severe toxicity following trastuzumab-emtansine extravasation. We provide treatment recommendations and recommend amending the information on the product label on extravasation.