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      Management of Cytotoxic Extravasation - ASORS Expert Opinion for Diagnosis, Prevention and Treatment

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          Background: Cytotoxic extravasation is a rare but potentially serious and painful complication of intravenous drug administration in oncology. Literature is anecdotal, and systematic clinical trials are scarce. The German working group for Supportive Care in Cancer (ASORS) has prepared an expert opinion for the diagnosis, prophylaxis and management of cytotoxic extravasation based on an interdisciplinary expert panel. Material and Methods: A Pubmed search was conducted for diagnosis, risk factors, symptoms, prophylaxis, and treatment of extravasation by the respective responsible expert. A writing committee compiled the manuscript and proposed the level of recommendation. In a consensus meeting, 13 experts reviewed and discussed the current practice in diagnosis and management of cytotoxic extravasation. In a telephone voting among the experts, the level of recommendation by ASORS was determined. Results: Every effort should be made to reduce the risk of extravasation. Staff training, patient education, usage of right materials and infusion techniques have been identified to be mandatory to minimalize the risk of extravasation. Extravasation must be diagnosed as soon as possible, and specific therapy including antidotes dependent on the extravasated drug should be initiated immediately. An extravasation emergency set should be available wherever intravenous cytotoxics are applied. Documentation and post-treatment follow-up are recommended. Conclusion: We have developed a literature- and expert-based consensus recommendation to avoid cytotoxic extravasation. It also provides practical management instructions which should help to avoid surgery and serious late effects.

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          Most cited references 43

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          Extravasation management: clinical update.

          To present a clinical update on the prevention, detection, and evidence-based management of vesicant chemotherapy extravasations. Journal articles, published and unpublished case reports, personal experience. In the 4 years that have elapsed since the publication of the original article, much more is known about vesicant chemotherapy extravasation, and effective evidence-based treatments now are available. The antidotes sodium thiosulfate for mechlorethamine extravasations and hyaluronidase for plant alkaloid extravasations are recommended by the manufacturers of these vesicants and cited in nursing guidelines. The anthracycline extravasation treatment dexrazoxane for injection, the first and only extravasation treatment with proven effectiveness, is now available as Totect (dexrazoxane; TopoTarget USA, Rockaway, NJ, USA) in the US and Savene (SpePharm, Amsterdam, The Netherlands) in Europe. Nurses who administer vesicant chemotherapy agents need to be aware of the most current evidence (or lack of evidence) for various types of extravasation treatment. Well-informed nurses are patient advocates and instrumental in detecting, managing, and documenting extravasations. Most importantly, nurses play a key role in preventing vesicant chemotherapy extravasations. Copyright © 2011 Elsevier Inc. All rights reserved.
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            Cutaneous toxicities of cancer therapy.

            This review highlights the cutaneous side effects associated with the administration of chemotherapy and discusses the management of these conditions. Rapidly growing cells are the targets of chemotherapy, so the skin, hair follicles, and nail matrix are frequently affected by chemotherapy. Chemotherapy skin reactions are more likely toxic than allergic reactions. The most common cutaneous reactions are alopecia, hyperpigmentation, hand--foot syndrome, radiation recall, hypersensitivity, extravasation injuries, and nail dystrophies. While these side effects are generally not life threatening, they can be a source of significant distress to patients, especially alopecia.
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              Anthracyclines in haematology: preclinical studies, toxicity and delivery systems.

              The anthracyclines are widely used in the treatment of haematological and non-haematological malignancy and there is now more than 30 years' clinical experience with these agents but despite this, their mechanism of action is incompletely understood. The anthracyclines have been shown to intercalate with DNA and indirectly inhibit the activity of the enzyme topoisomerase II, resulting in DNA strand breaks. More recently, workers have focused on induction of apoptosis and have shown that daunorubicin stimulates production of the apoptotic mediator, ceramide and that the activity of doxorubicin can be blocked by inhibitors of CD95 (fas). One of the major problems with anthracycline therapy is the development of resistance which may be mediated by p-glycoprotein or by other mechanisms. Much recent research has concentrated on methods to modulate the drug-resistant phenotype and these include development of new analogues and use of specific reversal agents. The toxicity profile of the anthracyclines includes bone marrow suppression, severe local reaction following extravasation, radiation recall, alopecia, gastrointestinal and hepatic effects, development of secondary malignancies and significant cardiac toxicity. The risk factors for the development of anthracycline-related cardiac toxicity are well documented and several methods have been exploited in attempts at prevention. Finally, a number of drug delivery systems have been developed in order to improve therapeutic response and reduce toxicity to normal tissues, including the use of liposomal preparations.

                Author and article information

                Oncol Res Treat
                Oncology Research and Treatment
                S. Karger AG
                March 2013
                25 February 2013
                : 36
                : 3
                : 127-135
                aKlinik für Innere Medizin - Hämatologie und Onkologie, Vivantes Klinikum Neukölln, Berlin, bPOMME-med GmbH, München, cApotheke des Universitätsklinikums Tübingen, dKlinik für Frauenheilkunde und Geburtshilfe, Charité Campus Virchow-Klinikum, Berlin, eAkademisches Lehrkrankenhaus der Universität Charité, Berlin, fMedizinische Klinik und Poliklinik, m. S. Onkologie und Hämatologie, Charité Campus Mitte, Berlin, gUniversitätsklinikum Ulm, Comprehensive Cancer Center Ulm (CCCU), Ulm, hUniversitätsklinikum, Hamburg-Eppendorf, Hamburg, iUniversitätsklinik Halle, Klinik für Innere Medizin IV, Halle, Germany
                348524 Onkologie 2013;36:127-135
                © 2013 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Pages: 9
                Self URI (application/pdf): https://www.karger.com/Article/Pdf/348524
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