Port-a-Cath® extravasation of vesicant cytotoxics: Surgical options for a rare complication of cancer chemotherapy

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Abstract

Background

Although implantation of a central venous device such as a Port-a-Cath was initially considered safe, extravasation rates up to 4.7% have been reported. Therefore, the objective of this study was to propose a structured procedure for the management of extravasation of a cytotoxic treatment.

Methods

A total of eight patients were evaluated after port extravasation of epirubicin (n = 3), platinum compounds (n = 3), paclitaxel (n = 1), or trabectedin (n = 1) into the subcutaneous space. Immediate explantation of the port was performed in combination with a “Subcutaneous Wash-Out Procedure” (SWOP). When removal of the port was delayed, débridement and flap coverage were performed as necessary. Epirubicin concentrations present in the samples obtained during surgical intervention were subsequently analysed using high-performance liquid chromatography (HPLC). Patients were followed for at least six months and were examined for sequelae such as pain, induration, redness, and limited movement.

Results

All three patients whose extravasation event was detected during chemotherapy administration benefited from SWOP with acceptable side effects (e.g., erythema). The analysis of epirubicin concentrations demonstrated the active removal of relevant amounts of the compound by wound rinsing. In contrast, late detection of extravasation led to major débridement and flap coverage in four out of five patients. A high body mass index (BMI) value was associated with all of the patients that experienced port extravasation.

Conclusion

Depending on when Port-a-Cath® extravasations into subcutaneous tissue are detected, different treatments are appropriate. When extravasation is detected early, the SWOP was found to be beneficial.

Introduction

Due to therapeutic advances over the last decade, long-term survival of cancer patients has increasingly been observed,1, 2, 3 and systemic chemotherapy is a cornerstone in the treatment of solid tumours. However, problems associated with the administration of cytotoxic chemotherapy via peripheral veins has led to increased use of implanted central venous access devices such as Port-a-Cath®.4, 5 Although the use of a totally implanted venous access port system (TIVAP) was initially considered safe, subsequent studies have reported that extravasations from a port have occurred in 0.3%–4.7% of cases.6 In addition, management of central port extravasation is poorly defined. To the best of our knowledge, no relevant series of patients has been published that has addressed the management of port extravasations with vesicant compounds into the subcutaneous space. Correspondingly, due to the insufficient knowledge available in this field and the lack of clinical evidence, there are no standard procedures to adhere to Ref. 7.

Detection of an extravasation event is also hampered by delayed local swelling.8, 9 Compared with peripheral extravasations, loose subcutaneous tissue in the infraclavicular region is combined with reduced pain sensitivity. As a consequence, the amount of extravasated cytotoxic agent is potentially greater and possibly associated with more severe and prolonged sequelae in comparison with peripheral extravasation events.10, 11, 12

In the present study, eight patients with port extravasation into the subcutaneous space were assessed. These patients either underwent explantation of the central venous device and a subcutaneous Wash-Out Procedure (SWOP) immediately after detection, or the patients experienced a delay in detection and this was followed by removal of the port, débridement, and flap coverage when necessary.

Section snippets

Patients and methods

Data obtained from patients receiving anticancer therapy that was administered via a TIVAP (Port-a-Cath®) between 2006 and 2014 were analysed. During this period, a total of 4101 TIVAPs had been implanted at our institution. Of these cases, eight patients experienced extravasation of a vesicant or highly cytotoxic compound. Due to the tissue damage that was caused by the extravasation, surgical intervention was necessary for all of these patients. Four women and four men with a mean age of 53

Patient management

In three out of eight patients, extravasation was detected during the infusion of cytotoxic agents. Explantation of the TIVAP in combination with the SWOP was performed for two of these patients on the same day the extravasation was detected, or two days thereafter for another patient. A total of 2000 ml saline solution (0.9%) was used to rinse the tissue surrounding the TIVAP for each patient. Due to the delayed detection of extravasation in the remaining five patients, the SWOP was not

Discussion

For this small series of patients, a standard procedure for the surgical management of highly toxic extravasation events was applied to patients receiving antineoplastic therapy via TIVAP. To our knowledge, this represents the largest series of homogenously treated patients with port extravasation events to date (Fig. 4). Previously, investigations of port complications have focused on general events including damage to neighbouring organs, the pneumothorax, port infections and sepsis,

Acknowledgements

The authors would like to thank Zeljka Stojanovic for her commitment and analysis of epirubicin concentrations in the collected fluids.

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