Some chemotherapy drugs bind to tissue and go on destroying it long after the drip has been stopped. What looks like a small area of redness on the back of the hand can become an ulcer exposing tendon weeks later.
Extravasation is leakage of chemotherapy out of the vein into surrounding tissue. With vesicant drugs such as anthracyclines and vinca alkaloids the damage progresses for days to weeks because the drug binds to tissue and is re-released. Immediate measures are stopping the infusion, aspirating, and drug specific antidotes or washout. Established necrosis needs excision and reconstruction.
Most substances that leak from a drip cause a brief chemical irritation that settles. Vesicant chemotherapy behaves differently. Anthracyclines such as doxorubicin bind to DNA in the surrounding cells, and as those cells die they release the drug again to be taken up by neighbouring cells. The injury therefore spreads outward over days and weeks after the original leak has long stopped.
The consequence is that the visible injury on day one badly understates what is coming. A patch of redness and discomfort on the back of the hand can, over three to four weeks, become a deep ulcer with exposed tendon. Sites over the wrist, the back of the hand and the antecubital fossa are the worst, because skin is thin and tendons, nerves and joints lie immediately beneath.
Early management matters more than almost anywhere else in wound care. The infusion is stopped and the cannula left in place to aspirate what can be recovered. Specific measures follow depending on the drug: cooling and an antidote for anthracyclines, warming and dispersal for vinca alkaloids. Where a large volume of a vesicant has gone in, early surgical washout of the tissue can remove drug before it binds, and that intervention is most useful in the first hours.
Once tissue has died, the treatment is surgical: excise everything that is not viable and reconstruct. Delaying that in a patient who is due more chemotherapy simply postpones the reconstruction into a period when healing is worse.
Any suspected vesicant extravasation deserves assessment the same day, because the useful interventions are early ones.
The infusion is stopped immediately and the cannula left in place to aspirate as much of the drug as can be recovered before it is removed.
Cooling and an antidote for anthracyclines; warming and dispersal for vinca alkaloids. Getting this the right way round matters.
Where a significant volume of a vesicant has extravasated, the tissue can be flushed through small incisions in the first hours to remove drug before it binds.
The limb is elevated and the area marked and reviewed, because the injury evolves over days.
Once necrosis has declared itself, all non viable tissue is excised. Leaving any behind means the wound will not heal.
A graft where the bed is healthy, a flap where tendon, nerve or joint is exposed. Timing is coordinated with the oncology team.
Elevation, marking of the affected area, and review. Early movement of the fingers to prevent stiffness.
The injury declares its true extent during this period. Dressings, with surgery planned once the boundary of dead tissue is clear.
Graft or flap monitored, splinting as needed, hand therapy started early to limit stiffness.
Scar management and continued therapy. Chemotherapy scheduling reviewed with the oncology team.
Recognised and managed within hours, many extravasations settle without tissue loss. Once full thickness necrosis has developed, the outcome depends on what lies underneath: skin alone heals well after excision and grafting, whereas exposed tendon or joint needs flap cover and a longer recovery. Function after a hand extravasation is frequently imperfect, with stiffness and altered sensation. Chemotherapy timing is a real constraint, and the oncology team is involved in every decision about when to operate.
These are patients on cancer treatment, often with low immunity and poor healing, and the risks reflect that.
Elevation and early movement protect function while the wound heals.
With a vesicant drug the redness on day one is the beginning, not the extent. The injury progresses for days to weeks, which is precisely why it should be assessed early rather than watched.
Aspiration, the correct drug specific antidote and early washout can all reduce or prevent tissue loss, but they only work in the first hours.
It depends on the drug. Anthracyclines are managed with cooling; vinca alkaloids with warming and dispersal. Applying the wrong one makes the injury worse.
Waiting lets the wound extend and pushes reconstruction into a period when healing is no better. Timing is coordinated with oncology rather than simply deferred.
Extravasation injuries are frequently watched for too long, on the reasonable but mistaken assumption that redness which is not yet an ulcer will settle. Knowing that vesicant injury progresses for weeks is what makes early referral and early washout worthwhile.
Treatment of a treatment related injury is commonly covered by health insurance and by government schemes as part of the cancer care pathway. Cost depends on whether washout alone or excision and flap reconstruction is required. A written estimate follows assessment.
Usually asked by someone in the middle of chemotherapy.
Ask your question →Yes, the same day if a vesicant drug was involved. The drug binds to tissue and is re-released as cells die, so the injury spreads over days and weeks. What looks minor now can expose tendon in a month, and the treatments that prevent that only work early.
It depends entirely on the drug. Anthracyclines are managed with cooling, vinca alkaloids with warmth. Getting it the wrong way round makes things worse, so check before applying anything.
Possibly, and that is weighed carefully. Leaving a progressing wound untreated usually causes more disruption in the end than dealing with it promptly. Decisions about timing are made jointly with your oncology team.
If the injury is limited to skin and treated early, usually yes. Where tendons or joints were exposed, some stiffness and altered sensation are common, and hand therapy makes a real difference to the final result.
Often, with careful cannula placement and monitoring, and vesicants are increasingly given through central lines for this reason. When it does happen it is not usually anyone's fault, and dwelling on that helps less than acting quickly.
Seeing patients from across the city and beyond: read about the practice on the plastic surgeon in Surat page, or check what a written estimate covers on the costs and insurance page.
