Successful Conservative Management of Massive Oxaliplatin Extravasation from a Central Venous Port with Early Systemic Corticosteroid Therapy

Abstract

Oxaliplatin is generally classified as an irritant anticancer agent. In certain instances of extravasation, it can provoke severe local reactions such as inflammation, induration, and skin necrosis, suggesting vesicant properties 1,2 . Rare extravasations through a totally implantable venous access device (TIVAD) can lead to extensive tissue exposure and subsequent injury. Conservative or surgical approaches have been reported for oxaliplatin extravasation through a TIVAD [1][2][3][4][5] , but none have yet been established as standard 5 . Herein, we report a case in which massive oxaliplatin extravasation through a TIVAD was successfully managed with early systemic corticosteroid therapy. The patient gave consent for her photographs and medical information to be published in print and online and with the understanding that this information may be publicly available.A 76-year-old woman (body weight, 30 kg) with transverse colon cancer was treated with a modified FOLFOX6 regimen (5-fluorouracil, leucovorin, and oxaliplatin). As part of palliative care, dexamethasone 1.65 mg/day was administered routinely. On day 1 of the third cycle, the patient received oral aprepitant and intravenous dexamethasone 4.95 mg as premedication. Oxaliplatin (75 mg) in 5% glucose solution (250 mL) and leucovorin (220 mg) in 250 mL normal saline were administered via a left chest TIVAD. Complete extravasation of both solutions was observed at the end of the infusion. The patient developed extensive edema and pain in the left chest and back (Fig. 1A).Computed tomography (CT) revealed widespread subcutaneous edema in the affected area (Fig. 1B).Conservative treatment was initiated on the same day and consisted of intravenous dexamethasone 4.95 mg/day for 4 days, oral celecoxib 100 mg twice daily, and topical clobetasol propionate. By day 2, the swelling around the TIVAD subsided, although induration with moderate pain persisted in the left lower chest and back. By day 3, the edema in the affected area had completely resolved, with only mild residual discomfort. Dexamethasone was tapered to 3.3 mg on day 5 and further to 1.65 mg (baseline palliative dose) on day 7. Celecoxib and topical corticosteroids were discontinued on days 8 and 10, respectively. Follow-up CT images taken on day 43 revealed no residual of the subcutaneous abnormality due to the oxaliplatin extravasation (Fig. 1B). No progression to persistent skin inflammation, necrosis, or other alterations was observed during the 9-week follow-up period.The literature describes various approaches for oxaliplatin extravasation through a TIVAD, including surgical options such as early wash-out and debridement. Haslik et al. reported successful outcomes with immediate subcutaneous wash-out procedures 4 , while Van Praet et al. documented complete resolution following surgical excision of necrotic tissue in a case in which conservative management failed over 9 months 5 . Despite the effectiveness of surgical interventions in selected cases, these procedures are highly invasive.In contrast, the present case demonstrates that conservative management with early systemic corticosteroids can achieve complete resolutions even after massive oxaliplatin extravasation. Several reports have supported the use of corticosteroids for oxaliplatin extravasation 1, 2, 5 , although specific doses and durations have not been established. Kretzschmar A et al. reported dexamethasone 8 mg bid for several days had a positive influence in two patients 1 . In the present case, intravenous dexamethasone (equivalent to prednisolone 1 mg/kg/day for the patient), tapered over 7 days, effectively prevented inflammation and necrosis. Therefore, an immediate course of high-dose systemic corticosteroids for several days may be a rational and effective treatment strategy. Surgical intervention should be considered if persistent local inflammation or necrosis develops.The decision to administer corticosteroids either locally or systemically should be made based on an evaluation of the pros and cons of each approach. While the topical application and/or local injection of corticosteroids are commonly employed to manage anticancer drug extravasation, the extensive nature of the oxaliplatin extravasation in the present case made local injections across the entire affected area impractical. Moreover, CT images (Fig. 1B) showed that the extravasated oxaliplatin had infiltrated at least into the deep adipose tissue, where topical formulations would be unlikely to have a therapeutic effect. Therefore, systemic corticosteroids were selected as the mainstay of treatment, with topical corticosteroids as an additional therapy. In cases involving extensive and deep extravasation, systemic administration may be a more effective and rational approach than local application.This study has several limitations. First, the relatively low dose or concentration of extravasated oxaliplatin (75 mg), corresponding to the patient's body weight, might have contributed to the favorable outcome. Although the dose is within the range reported in the previous cases of oxaliplatin extravasation (40-165 mg) 2 , it cannot be ruled out the possibility that our intervention might not have caused the rapid resolution of the patient's symptoms. Secondly, the patient had been receiving a low maintenance dose of dexamethasone for palliative care prior to the event. This corticosteroid use might have dampened the local inflammatory reactivity at baseline.In conclusion, this case demonstrates that even massive oxaliplatin extravasation through a central venous port can be successfully managed with early conservative therapy with systemic corticosteroids.