Japanese Journal of Clinical Oncology 31:122-124 (2001)
© 2001 Foundation for Promotion of Cancer Research
Usefulness of Magnetic Resonance Imaging for Surgical Management of Extravasation of an Antitumor Agent: a Case Report
Departments of 1Radiology, 2Traumatology and Critical Care Medicine and 3Orthopedic Surgery, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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We report a case of extravasation of an antitumor agent by preoperative magnetic resonance (MR) imaging. MR studies demonstrated a decreased signal intensity on T1- and T2-weighted images and a strong enhancement of contrast media in injured tissue, including subcutaneous adipose tissue and deep fascia, which was cicatrical macroscopically. The MR findings were in good agreement with the macroscopic findings. We believe that MR imaging is useful for estimating deep tissue damage due to extravasation of an antitumor agent.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Surgical debridement of tissue necrosis due to extravasation of chemotherapeutic drugs is well accepted (1–5), but a determination of the surgical margin in detail is difficult preoperatively. We report here a case in which magnetic resonance (MR) imaging was used to estimate the deep soft tissue damage due to extravasation of mitomycin C (MMC). The findings from the MR images led us to appropriate surgical treatment.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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A 77-year-old woman who had undergone an operation for rectal carcinoma was subsequently treated with chemotherapy. The drug had been given via the right intermediate cubital vein. Although attempts were made to inject 4 mg of MMC, extravasation of MMC occurred and was treated conservatively. The leakage dose of MMC could not be estimated correctly. The patient then developed erythema, swelling and ulcer (Fig. 1) and was referred to us 23 days after the extravasation. She complained of pain.
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We employed MR imaging to estimate the deep soft tissue damage due to extravasation of MMC on a 1.5 T unit (Horizon Lightening LX; GE Medical Systems, Milwaukee, WI, USA). A T1-weighted fast spin-echo (SE-T1) sequence was carried out at 520 ms/10.2 ms [repetition time (TR)/echo time (TE)], a T2-weighted fast spin-echo (SE-T2) sequence was carried out at 4000 ms/101.5 ms and a contrast-enhanced [0.1 mmol/kg Gd–BMA–DTPA (Omniscan, Daiichi Pharmaceutical and Nycomed, Norway)] T1-weighted fast spin-echo with a fat suppression technique (CE SE-T1) was carried out at 600 ms/8.3 ms. The other parameters were as follows: the slice thickness was 5 mm with a 20% interslice gap and a 320 x 256 matrix, the number of excitations (NEX) was three and the field of view (FOV) included 16 x 16 cm axial images or 20 x 20 cm oblique-coronal images.
SE-T1 images (Fig. 2a) and SE-T2 images (Fig. 2b) showed the subcutaneous adipose tissue as having a reticular low signal intensity and the fascia as a thickening line with low signal intensity. CE SE-T1 images (Fig. 2c) showed strong enhancement of the subcutaneous adipose tissue and the deep fascia. These findings suggest a cicatrical change in the adipose tissue and the deep fascia due to extravasation of an antitumor agent. On all images, the neurovascular bundle, including the median nerve, was shown to have been spared. Twenty-five days after the extravasation of MMC, the patient underwent excision of cicatrical tissue, including the subcutaneous adipose tissue, down to the deep fascia (Fig. 3). The subcutaneous adipose tissue of the gross specimen was cicatrical and ischemic (Fig. 4), with these findings being in good agreement with those from the MR images. Closure was achieved without flaps or skin grafting and the functional and cosmetic results for the arm undergoing surgery were good upon discharge (Fig. 5).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Incidental chemotherapeutic extravasation injuries occur in 0.1–6% of all cases (1–5). The tissue damage can range from mild inflammation to widespread necrosis extending to the periosteum. Chronic ulcer and necrosis may progress because chemotherapeutic drugs cannot be locally metabolized or removed from an affected area by lymphatic circulation. Surgical debridement of damaged tissue due to large amounts of drug extravasation is essential (1–5). Although the early treatment of extravasation injury is controversial, patients in the chronic stage (established skin ulceration) should be debrided immediately (1–5).
To the best of our knowledge, this is the first case of an incidental chemotherapeutic extravasation injury in which MR imaging has been performed preoperatively. MR studies, in our case, demonstrated a decreased signal on T1- and T2-weighted images and a strong enhancement of contrast media in injured tissue, which was macroscopically observed to be cicatrical. The MR findings were in good agreement with the macroscopic findings.
In the past, it has not been possible to determine the surgical margin in detail, including all affected subcutaneous adipose tissue and deep fascia, during the preoperative period. MR imaging, including a contrast enhancement study, is a sensitive approach for detecting soft tissue damage, because MR imaging provides fine overall anatomical resolution and allows the characterization of injured tissue. We believe that MR findings, used in the mode reported here, can establish the extent of deep tissue damage due to extravasation of a chemotherapeutic drug. The information provided by MR images is helpful in determining whether conservative or operative treatment should be undertaken. Moreover, once surgical intervention has been selected, the MR findings make it easier to determine the surgical margin preoperatively.
In conclusion, we are certain that MR imaging is useful for estimating the deep tissue damage due to extravasation of an antitumor agent. We are currently extending our studies in this field.
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FOOTNOTES |
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+ For reprints and all correspondence: Naoya Yama, Department of Radiology, Sapporo Medical University, School of Medicine, S-1 W-16, Chuo-Ku, Sapporo, Hokkaido 060-8543, Japan
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REFERENCES |
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1 Loth TS. Minimal surgical debridement for the treatment of chemotherapeutic agent-induced skin extravasations. Cancer Treat Rep 1986;70:401–4.[Medline]
2 Tsavaris NB, Komitsopoulou P, Karagiaouris P, Loukatou P, Tzannou I, Mylonakis N, et al. Prevention of tissue necrosis due to accidental extravasation of cytostatic drugs by conservative approach. Cancer Chemother Pharmacol 1992;30:330–3.[Web of Science][Medline]
3 Scuderi N, Onesti MG. Antitumor agents: extravasation, management and surgical treatment. Ann Plast Surg 1994;32:39–44.[Medline]
4 Shenaq SM, Abbase EH, Friedman JD. Soft-tissue reconstruction following extravasation of chemotherapeutic agents. Surg Oncol Clin N Am 1996;5:825–45.[Medline]
5 Heitmann C, Durmus C, Ingianni G. Surgical management after doxorubicin and epirubicin extravasation. J Hand Surg 1998;23B:666–8.
Received August 28, 2000; accepted December 18, 2000.
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