Abstract
Extravasation of vincristine sulfate (VS) is a common complication encountered during canine transmissible venereal tumor treatment and other hematopoietic neoplasms, such as lymphoma and leukemias. The leakage of the chemotherapeutic agent may result in soft tissue damage leading to ulceration and necrosis. Studies have shown that platelet-rich plasma consists of growth factors and cytokines, thus plays a crucial role in wound healing. This study aimed to evaluate the effects of autologous platelet-rich plasma and antimicrobial wound dressing for the treatment of VS extravasation-related acute full-thickness skin wounds. A male Aksaray Malakli shepherd dog (3 years old) was brought to our clinic with a wound on the left forelimb which appeared two days after intravenous injection of VS. Extravasation was suspected. A total of 3.5 mL autologous platelet-rich plasma was injected into the wound margins and an antimicrobial dressing containing chlorhexidine acetate was used weekly to close the wound. The wound healed without any complications in 6 weeks. It was concluded that autologous platelet-rich plasma treatment is a simple and cost-effective method for the treatment of VS extravasation-related acute full-thickness skin wounds.
Introduction
Vincristine sulfate (VS) is an effective chemotherapeutic agent commonly used in the treatment of canine transmissible venereal tumor (CTVT) (Regmi et al., 2020). It can be administered weekly at a dose of 0.025 mg/kg of body weight intravenously (Abedin, 2020). It may cause mild to severe gastrointestinal side effects, such as lethargy, vomiting or diarrhea, and myelosuppression in 5–7% of the patients. However, the majority of these are low-grade (Duckett et al., 2020). The most frequent complication of intravenous vincristine treatment is the extravasation of the drug (Dar et al., 2017). Vincristine is a vinca alkaloid that causes a tissue damage similar to a thermal burn injury. This is associated with cytotoxic damage of the peripheral vessels in the affected limb. Following endothelial damage, the drug may cause local pain, erythema, followed by blister formation and swelling, and may be complicated by crusting, ulceration and ischemic necrosis within a week after the administration (Kreidieh et al., 2016; Miller et al., 2018).
The positive effects of platelet-rich plasma (PRP) on tissue healing have been reported in many studies (Kim et al., 2009; Jee et al., 2016; Tambella et al., 2018; Iacopetti et al., 2020; Perinelli et al., 2020; Soares et al., 2020). Autologous PRP contains a high number of platelets, cytokines and growth factors in a small volume of plasma. Platelet-derived growth factor and TGF-β (transforming growth factor) are the main growth factors that are found in PRP. These factors induce neovascularization and collagen synthesis resulting in rapid endothelial and epithelial regeneration. PRP has been used as a growth factor source in acute and chronic wound healing in veterinary medicine (Perinelli et al., 2020; Soares et al., 2020). Several reports on the use of PRP have shown that it reduced the time needed for healing of acute wounds as well as stimulated the healing of chronic wounds in dogs, cats and farm animals (Kim et al., 2009; Jee et al., 2016; Iacopetti et al., 2020).
This study aimed to evaluate the effects of application autologous PRP on a dog with an acute full-thickness skin wound due to VS.
Case description
A three-year-old, intact male Aksaray Malakli shepherd dog weighing 48 kg was brought to the Veterinary Faculty Clinics of Aksaray University for ongoing treatment of CTVT. An intravenous catheter was placed in the left cephalic vein and VS (0.025 mg/kg i.v., Vincristine®, Kocak Farma, Turkiye) was administered. Two days later, the dog was brought to the clinics again with a wound on the left forelimb.
The physical examination revealed a deep open wound, 7 cm × 5 cm in size, at the iv-injection site, and signs of pain were elicited during palpation of the area. As the dog was excited and restless during the preceding i.v. administration of VS, and based on the clinical signs, extravasation of VS was suspected (Fig. 1). Autologous PRP and antimicrobial wound dressing were used for the treatment of the injury.
PRP was prepared according to the method described by Xu et al. (2020). Briefly, the patient's blood was collected into four citrate-containing tubes (3.2% sodium citrate tube, Vacutainer, USA) and immediately centrifuged. After the first centrifugation (at 300×g for 10 min) the plasma was collected with a pipette and then a second centrifugation (at 300×g for 20 min) was performed to obtain PRP including the buffy coat. A total of 3.5 mL of PRP was obtained and used immediately, except for 0.5 mL that was submitted to analysis. The platelet concentration was determined as 1.412 × 103 platelets/μL by an automated cell counter (Countess, Invitrogen, Life Technologies, USA).
The wound was cleaned with sterile saline and debrided of necrotic tissues. The PRP preparation was injected into the margins and cavity of the wound. No sedation was needed during the injection. A commercially available antimicrobial dressing, paraffin-impregnated gauze dressing containing chlorhexidine acetate (Bactigras® Smith & Nephew plc., London, UK), was used on the wound and a dry covering bandage was applied (Fig. 2).
An Elizabethan collar was applied to the patient throughout the treatment. Amoxicillin-clavulanic acid (20 mg/kg twice daily per os, Synulox® Zoetis, USA) was administered for a week. PRP injection and wound dressing change were repeated weekly. An intravenous catheter was placed in the right cephalic vein and VS administration was continued for 5 additional weeks. After six weeks both, the CTVT and the extravasation injury were healed without any complications (Fig. 3).
Discussion
Vincristine sulfate is the most frequently used drug, which is administered at a dose of 0.025 mg/kg of body weight intravenously or 0.75 mg/m2 of tumor surface area once a week (Abedin, 2020). Improvements are observed in 2–6 weeks. Vincristine therapy must be continued up to two weeks beyond the total disappearance of the macroscopic lesions (Osei et al., 2020).
Lethargy, vomiting, diarrhea, myelosuppression have been reported as the most common side effects of vincristine therapy (Dar et al., 2017; Duckett et al., 2020). Anthracyclines, such as VS can cause local tissue reactions and injury if extravasation of the drug occurs (Venable et al., 2012). As in our case, vincristine extravasation injury resulted in an acute full-thickness skin wound on the patient's forelimb.
It has been demonstrated experimentally that applying cold packs on the extravasation injury site may increase toxicity, while hot packs may limit skin damage (Langer, 2010). Administration of hyaluronidase, dimethyl sulfoxide and dexrazoxane has been applied for the treatment of extravasation injury (Spugnini, 2002; Venable et al., 2012). Intralesional hyaluronidase treartment has been used for doxorubicin extravasation injury in two dogs and healing was observed despite fibrosis of the wound (Spugnini, 2002). In another study, four dogs with doxorubicin extravasation injury have been treated with dexrazoxane. According to the results of the study, three of the dogs healed uneventfully. However severe tissue necrosis was developed in the fourth dog and the limb had to be amputated (Venable et al., 2012). Successful management of extravasation injuries with hyaluronidase and dexrazoxane requires administration of the agents within at most 6 h after the extravasation (Spugnini, 2002; Venable et al., 2012). Detailed information on antidote options for chemotherapy extravasation is given in Table 1. As the injury in the dog reported here was noticed after 48 h of the extravasation, these agents were not preferable.
Antidote options for chemotherapy agent extravasation
Treating compound | Dose and administration route | Outcome of treatment | Comments | Reference |
Hyaluronidase | 300 units of hyaluronidase diluted in 6 mL of saline (0.9% NaCl) solution. Intralesional injection was performed weekly until the clinical signs disappeared. | Good | Suitable for vinca alkaloid and taxane extravasations. Injections were made immediately or 24 h after vincristine extravasation in dogs | Spugnini (2002) |
Dimethyl sulfoxide (DMSO) | 1–2 mL 1 mM 50–99% DMSO topically applied every 6–8 h for 7–14 days | Good, when the antidote is administered within the first 10 min following the extravasation. | Suitable for anthracycline and mitomycin C extravasations. | Ener et al. (2004) |
Dexrazoxane | 500 mg/m2 (750 mg/dose) iv injection was performed 3 doses at 3, 24 and 48 h after extravasation or 359 mg/m2 (350 mg/dose) was administered 2 doses at 48 and 72 h after extravasation | Good, when the antidote is administered within 2 h of extravasation. Poor when the antidote is administered 48 h after extravasation | Suitable for anthracycline extravasations. Doxorubicin extravasation injuries in dogs were studied | Venable et al. (2012) |
PRP is a simple and cost-effective autologous cell therapy. PRP contains a higher number of platelets than peripheral blood. These platelets release important growth factors, including platelet-derived growth factor (PDGF), epidermal growth factor (EGF), TGF-β, vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF) and insulin-like growth factor (IGF). These growth factors induce cell proliferation and angiogenesis, thus, play a great role in tissue healing (Iacopetti et al., 2020). PRP with more than 1 × 106/μL platelet concentrations was reported to affect better than lower concentrations (Tambella et al., 2018). In accordance with this literature, we used PRP having high platelet concentrations.
Topical administration of autologous PRP has been used to treat soft tissue injuries in veterinary practice (Soares et al., 2020). A recent study reported the positive effects of repeated autologous topical PRP treatment on large cutaneous subacute wounds of different etiology in dogs (Iacopetti et al., 2020). Jee et al. reported that intralesional PRP injected wounds in dogs resulted in faster epithelialization, more granulation formation, and collagen deposition than control wounds (Jee et al., 2016). Previous studies have demonstrated that PRP treatment has positive effects on the management of large skin defects (Kim et al., 2009). Tambella et al. (2018) have reported that PRP is an effective therapy in stimulating secondary intention healing of acute wounds in dogs. We also reached the same conclusion in our study.
There are some limitations to the clinical use of autologous PRP in patients with hypovolemia, anemia, coagulopathy and thrombocytopenia. Hypovolemic or anemic donors may not be suitable if a large volume of blood is required for PRP. Donors with thrombocytopenia and/or coagulopathy may not be eligible as this could affect the quality of PRP (Jee et al., 2016).
To obtain high-quality PRP, it is important to elaborate a PRP preparation protocol, thereby establishing a clear standardization to allow comparison between studies and to ensure reproducibility. For this reason, it is desirable to quantify platelets and lymphocytes also within the initial blood sample besides the final product. Additionally, more studies must be conducted on the long-term consequences of cutaneous wound healing using PRP (Chicharro-Alcántara et al., 2018).
Hyaluronidase is an enzyme that is used as an antidote of extravasations by vinca alkaloids. However, according to clinical practice guidelines of the European Oncology Nursing Society (EONS), it has V-C level evidence (Pérez Fidalgo et al., 2012), where “Evidence Level V” marks evidence from systematic reviews of descriptive and qualitative studies, and “C” means poor strength of recommendation. Also, these kinds of antidotes perform best when used immediately after, or within the first hours of, the extravasation. In our patient, the wound was noticed 48 h after the extravasation. Our aim was to test the treatment of extravasation-related open wound by injecting autologous PRP on the wound margins. Our conclusion is that autologous PRP treatment is a simple and cost-effective method for the treatment of VS extravasation-related acute full-thickness skin wounds in dogs.
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