Images in Clinical Medicine

Extravasation of Epirubicin

Sergio Vano-Galvan, M.D., and Pedro Jaen, M.D., Ph.D.

N Engl J Med 2009; 360:2117May 14, 2009

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A 63-year-old woman with a diagnosis of infiltrative ductal carcinoma of the breast (stage T2N1M0[IIB], according to the tumor–node–metastasis staging system) that was estrogen receptor–negative and HER2-negative was referred for adjuvant chemotherapy after undergoing modified radical mastectomy and axillary lymph-node dissection. Epirubicin, at a dose of 90 mg per square meter of body-surface area, was infused at 21-day intervals, along with fluorouracil and cyclophosphamide. During the third period of administration, the patient reported having excruciating pain in the left wrist, near the intravenous-catheter site (arrow). The infusion was stopped, and a diagnosis of extravasation of epirubicin was made. Physical examination at that time revealed slight erythema only (Panel A). The patient was hospitalized for purposes of observation, and over the next few days, progressive ulceration developed at the site of extravasation. Sterile dressings were applied, local treatment with free-radical–scavenging dimethyl sulfoxide was given three times daily, and oral antiinflammatory and antibiotic therapy was administered, with little improvement. After 10 days, the superficial skin had necrosed, exposing the underlying musculature (Panel B). The patient was treated with collagenase clostridiopeptidase A and protease ointment once daily for 2 months; the wound healed after 6 months (Panel C). To minimize the risk of this toxic effect of epirubicin, many centers use central venous access for its administration.

Sergio Vano-Galvan, M.D.
Pedro Jaen, M.D., Ph.D.
Ramon y Cajal Hospital, Madrid 28034, Spain
sergiovano@yahoo.es

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