Poster Presentation New Zealand Association of Plastic Surgeons Annual Scientific Meeting

Missed and Mismanaged: The Clinical Fallout of Delayed Management of Doxorubicin Port-a-Cath Extravasation (1784)

Teresa Liew 1 , Lisa Davenport 1 , John Nguyen 1 , Veneshree Nair 2
  1. Plastic and Reconstructive Surgery PHO, Cairns Base Hospital, Cairns North , QLD , Australia
  2. Plastic and Reconstructive Surgeon, Cairns Base Hospital , Cairns North , QLD, Australia

Background

Doxorubicin is an anthracycline used in a wide range of anti-cancer regimens including breast cancer. Extravasation in chemotherapy, especially of vesicant cytotoxic drugs such as anthracyclines, is a dreaded complication that should be promptly recognised and managed. It can induce extensive tissue damage, ulceration, and necrosis.  Implanted central venous access such as Port-a-Cath is increasingly used in the administration of chemotherapy to minimise risk. However, studies report extravasation rates of up to 4.7%.[1] Within Australia, there are 161 regional hospitals administering chemotherapy.[2] Whilst protocols may include immediate management through infusion cessation, aspiration, and initialising medical management, most do not include guidelines defining failure of conservative therapy, and when to escalate to Plastic Surgery. 

Case Report

We present a case of a 69-year-old woman from Atherton on adjuvant chemotherapy for locally advance right breast cancer. Delayed management of doxorubicin extravasation from her Port-a-Cath resulted in extensive tissue necrosis and inflammation. This involved the chest wall and breast parenchyma, with an overlying ulcerated and necrotic non-healing wound present for 9 months post extravasation.

Management

The patient underwent radical debridement 10 months post extravasation. This led to a rapid improvement in wound healing. She was temporarily reconstructed with a split thickness skin graft 2.5 weeks post debridement with good outcome.

Discussion

This case demonstrates a failure in recognition and missed opportunity for early management of Doxorubicin extravasation injury, which could have been mitigated with robust local guidelines and early consultation with surgical specialty. The extent of injury following vesicant extravasation cannot be reliably predicted by the superficial appearance of the wound as demonstrated in the serial clinical photographs provided. There should be a low threshold for treatment, and management should be early and aggressive to prevent extensive tissue damage. Radical debridement to healthy viable tissue is key in cases of delayed management.[3]

  1. Haslik W., Hacker S., Felberbauer FX., Thallinger C., Bartsch R., Kornauth C., Deutschmann C., Mader RM. Port-a-Cath extravasation of vesicant cytotoxics: surgical options for a rare complication of cancer chemotherapy. Eur J Surg Oncol. 2015 Mar;41(3):378-85.
  2. Underhill C., Bartel R., Goldstein D., Snodgrass H., Begbie S., Yates P., White K., Jong K., Grogan P. Mapping oncology services in regional and rural Australia. Aust J Rural Health. 2009 Dec;17(6):321-9.
  3. Haslik W., Hacker S., Felberbauer FX., Thallinger C., Bartsch R., Kornauth C., Deutschmann C., Mader RM. Port-a-Cath extravasation of vesicant cytotoxics: surgical options for a rare complication of cancer chemotherapy. Eur J Surg Oncol. 2015 Mar;41(3):378-85.