CHEMOTHERAPY SKIN REACTION

Q. A 57-year-old man with metastatic adenocarcinoma of the lung is attending for cycle three of his palliative pemetrexed/cisplatin chemotherapy. During his cisplatin infusion, he noticed his arm becoming painful, swollen and red at the cannula site. The most likely cause of this is:

A. Cellulitis

B. Venous thrombosis

C. Extravasation of chemotherapy

D. Adverse drug reaction

E. Normal chemotherapy reaction

Ans: C

 Extravasation of chemotherapy (C) is describing the inadvertent administration of drugs into the surrounding tissues rather than into a vein. This may be caused by a displaced cannula. Depending on the agent being administered, the degree of injury may range from a mild skin reaction to skin necrosis and thus, it requires urgent attention. The chemotherapy infusion should be stopped, the arm elevated and the affected area marked. A senior doctor should be informed and the guidelines on extravasation for that particular agent should be checked. Cisplatin is classified as an exfoliant, which can cause inflammation and shedding of the skin. A cold pack should be applied and advice of a plastic surgeon sought. Saline washout of the extravasation site may be necessary in this case. Acute onset of cellulitis (A) after administration of chemotherapy is an unlikely answer. Cancer patients are at higher risk of venous thrombosis (B) and all patients attending hospital should have a venous thromboembolism risk assessment and prescription of a low-molecular weight heparin if required.

In this situation though, it is more likely that extravasation has caused the pain and swelling, particularly in light of the skin reaction. Since this is his third cycle of chemotherapy, an adverse drug reaction (D) is unlikely. You are not expected to know the details of managing extravasation of chemotherapy. However, it is important to know that such a reaction after administration of chemotherapy is not normal (E) and senior attention should be sought.