JOURNAL
OF SURGICAL
RESEARCH
53,62-65
(1992)
DMSO Protects against Adriamycin-Induced
Tissue Necrosis’
Lurs LEBREDO, M.D., ROSEMARY BARRIE, M.S., AND EUGENE A. WOLTERING, Division
of Surgical Oncology, Department
of Surgery, Oregon Health Sciences University,
Portland,
M.D.’ Oregon 97201
Submitted for publication December 7,199O
the extravasation site and can progress to tissue necrosis and ulceration. These indolent ulcers remain a source of severe pain or functional impairment for many months. In severe cases, the lesion may extend to deep structures such as underlying tendon and bone, resulting in loss of joint mobility [l-7]. Furthermore, in immunosuppressed patients, ulcers are a possible site of sepsis [8]. Meticulous intravenous techniques are important in preventing ulcer formation, but even in experienced hands the reported extravasation rate ranges from 0.5 to over 6% [2, 4, 51. In an effort to study and thus modify the severe morbidity which results from Adria extravasation, animal models have been used to investigate the mechanism of tissue injury, and Qassible treatment methods. Clinical experience and’animal“models have resulted in a variety of treatments that reduce ulcer size, but no current therapy is available that has been shown to prevent ulcer formation. The molecular mechanism of Adria toxicity is not fully understood; however, it is known that Adria generates free radicals in tissue, and this is believed to be the mechanism that causes skin damage [g-11]. Dimethyl sulfoxide (DMSO) is a known hydroxyl free radical scavenger and its metabolite dimethyl sulfide (DMS) is an oxygen free radical scavenger. Because of its ability to scavenge free radicals DMSO has been proposed as a therapy to limit the skin necrosis caused by Adria extravasation. Topical DMSO (90%) when applied topically to the site of extravasation has been shown to decrease ulcer size [12-161. However, topical DMSO therapy requires prompt recognition of the extravasation, which is often difficult. We hypothesized that the simultaneous delivery of Adria in low DMSO concentrations would decrease the ulcer size and incidence. These DMSO concentrations were chosen based on a safe intravenous concentration and a low systemic dose. Smith et al. [17] reported the LD,, of intravenous DMSO in various species and noted it to range between 2.5 and 8.9 g/kg. He also noted that monkeys could be injected intravenously with concentrations of 4 g/kg without significant side effects. DMSO doses of 4 g/kg/ day have been given as 10% solutions intravenously to patients with intractable brain edema without significant side effects [18].
Inadvertent extravasation of Adriamycin (Adria) can result in severe tissue necrosis. The mechanism of this tissue damage is believed to be the release of free radicals into the tissue. Topical applications of dimethylsulfoxide (DMSO) used after Adria extravasation have been shown to decrease ulcer size. This may be due to DMSO’s ability to scavenge free radicals. However, effective topical therapy requires prompt recognition of extravasation, which is often difficult. We hypothesized that the delivery of Adria in low concentrations DMSO would reduce Adria-induced ulcer size and ulcer incidence caused by Adria extrasasation. To test this hypothesis, 180, male Sprague-Dawley rats were randomly allocated into three treatment groups of 60 each. All three groups received intradermal injections of Adria (1 mg) diluted in 0.5 cc of saline (Group l), 10% DMSO (Group 2), or 20% DMSO (Group 3). Rats were observed for 4 weeks. Ulcer incidence (X) and size of ulcers (mm2) were assessed over time. Area of skin ulceration was calculated as the product of the two greatest diameters. Statistical evaluation of the differences in incidence and ulcer size between Group 1 and Groups 2 or 3 were evaluated using analysis of variance. Delivery of Adriamycin in 10 or 20% DMSO resulted in a statistically significant (P < 0.001) decrease in the incidence of ulceration caused by intentional Adria eXtraVaSatiOn. 0 1992 Academic press, I~C.
INTRODUCTION
Skin necrosis following Adriamycin (Adria) extravasation is an infrequent but recognized complication of the intravenous administration of this compound. The tissue injury may not appear for several weeks and may continue to worsen for several months. This local toxicity is characterized by pain, erythema, and swelling at
’ Supported in part by the Medical Research Foundation of Oregon, and the American Cancer Society Clinical Fellowship 00162. ’ To whom reprint requests should be addressed at Division of Surgical Oncology L-224A, Oregon Health Sciences University, 3181 SW. Sam Jackson Park Road, Portland OR 97201-3098. 0022-4804/92 $4.00 Copyright 0 1992 by Academic Press, All rights of reproduction in any form
62 Inc. reserved.
LEBREDO,
BARRIE,
AND
WOLTERING:
DMSO
PROTECTS
AGAINST
TISSUE
63
NECROSIS
50
CONTROL x
x CONTROL 10% DMSO *
l
20% OMSO T F
I
?
3
4
I-
a -2
1
1
TIME IN WEEKS
FIG. 1. Incidence of tissue necrosis of treatment group by week. Peak incidence of ulceration occurs at 2 weeks in all groups studied.
MATERIALS
AND METHODS
One hundred and eighty male Sprague-Dawley rats weighing between 180 and 200 g were randomly separated into three groups of 60 rats each and housed four per stainless steel cage. They were placed in a controlled environment, 22°C with a 12-hr light-dark cycle. The rats were given water and standard rat chow (Lot 1028, Raulston Purina Co., St Louis, MO) ad lib&urn. A 5 x 5-cm area of the rat’s back was shaved using number 22 surgical clippers. Each rat was injected intradermally above the panniculus carnosus at a standardized site with 0.5 cc of Adria (2 mg/cc) in saline or vehicle (10% DMSO or 20% DMSO), yielding a total Adria dose of 1 mg. Group 1 was injected with 0.5 cc of the Adria solution in saline. Group 2 was injected with 0.5 cc of the Adria solution in 10% DMSO. Group 3 was injected with 0.5 cc of the Adria solution in 20% DMSO. DMSO (10 and 20%) concentrations were chosen based on preliminary studies done in our lab using a range of 5 to 50% concentrations. Using methods described by other investigators, [24, 26,271, ulcer area (in mm2) was calculated as the product of the two greatest dimensions as measured on a weekly basis by independent investigators with Vernier calipers. Ulcer progression was measured for a total of 4 weeks. Photographs of the ulcers were taken at Week 2. Statistical significance of ulcer incidence and ulcer size was determined by the use of one-way analysis of variance and the Student-Newman-Keuls test. RESULTS Maximal ulcer incidence and maximal ulcer size occurred at 2 weeks in all three groups (Figs. 1 and 2). In Group 1, 63% of the rats injected with Adria in saline developed necrotic ulcers at the site of intentional extravasation. Ulcers ranged in size from 9 to 196 mm2 (mean
3
2
4
TIME IN WEEKS
FIG. 2. Mean ulcer area in mm* in three treatment groups. Maximal ulcer area is seen 2 week after adriamycin extravasation.
of 46.61 mm2). In Group 2,23% of the rats injected with Adria in 10% DMSO developed necrotic ulcers at the injection site. The ulcer size in this group ranged from 4 to 90 mm2 with a mean ulcer size of 32.5 mm2. In Group 3, 21% of the rats injected with Adria in 20% DMSO developed ulcers at the extravasation site with the ulcer size ranging from 9 to 64 mm2 and a mean ulcer size of 21.1 mm2 (Table 1). There was a statistically significant (P < 0.001) decrease in the incidence of ulcers in the rats injected with Adria in saline as compared to those injected with Adria in DMSO. No difference was seen in the ulcer incidence between the groups injected with Adria in 10% DMSO and those injected with Adria in 20% DMSO. There was a decrease in ulcer size between the three groups which while not statistically significant, suggested that 20% DMSO was more protective than 10% DMSO and/or saline (Table 1). There were no secondary infections at the ulcer site, and no rats had to be sacrificed prior to the completion of the experiment. There were no deaths in
TABLE Size and Incidence Group Adriamycin Adriamycin DMSO Adriamycin DMSO
saline 10%
1
of Adriamycin-Induced
Ulceration
N
Incidence (%I
P
Size (mm’)
SD
P
60
63
NA
47
36
NA
60
23
OF SURGICAL
RESEARCH
53,62-65
(1992)
DMSO Protects against Adriamycin-Induced
Tissue Necrosis’
Lurs LEBREDO, M.D., ROSEMARY BARRIE, M.S., AND EUGENE A. WOLTERING, Division
of Surgical Oncology, Department
of Surgery, Oregon Health Sciences University,
Portland,
M.D.’ Oregon 97201
Submitted for publication December 7,199O
the extravasation site and can progress to tissue necrosis and ulceration. These indolent ulcers remain a source of severe pain or functional impairment for many months. In severe cases, the lesion may extend to deep structures such as underlying tendon and bone, resulting in loss of joint mobility [l-7]. Furthermore, in immunosuppressed patients, ulcers are a possible site of sepsis [8]. Meticulous intravenous techniques are important in preventing ulcer formation, but even in experienced hands the reported extravasation rate ranges from 0.5 to over 6% [2, 4, 51. In an effort to study and thus modify the severe morbidity which results from Adria extravasation, animal models have been used to investigate the mechanism of tissue injury, and Qassible treatment methods. Clinical experience and’animal“models have resulted in a variety of treatments that reduce ulcer size, but no current therapy is available that has been shown to prevent ulcer formation. The molecular mechanism of Adria toxicity is not fully understood; however, it is known that Adria generates free radicals in tissue, and this is believed to be the mechanism that causes skin damage [g-11]. Dimethyl sulfoxide (DMSO) is a known hydroxyl free radical scavenger and its metabolite dimethyl sulfide (DMS) is an oxygen free radical scavenger. Because of its ability to scavenge free radicals DMSO has been proposed as a therapy to limit the skin necrosis caused by Adria extravasation. Topical DMSO (90%) when applied topically to the site of extravasation has been shown to decrease ulcer size [12-161. However, topical DMSO therapy requires prompt recognition of the extravasation, which is often difficult. We hypothesized that the simultaneous delivery of Adria in low DMSO concentrations would decrease the ulcer size and incidence. These DMSO concentrations were chosen based on a safe intravenous concentration and a low systemic dose. Smith et al. [17] reported the LD,, of intravenous DMSO in various species and noted it to range between 2.5 and 8.9 g/kg. He also noted that monkeys could be injected intravenously with concentrations of 4 g/kg without significant side effects. DMSO doses of 4 g/kg/ day have been given as 10% solutions intravenously to patients with intractable brain edema without significant side effects [18].
Inadvertent extravasation of Adriamycin (Adria) can result in severe tissue necrosis. The mechanism of this tissue damage is believed to be the release of free radicals into the tissue. Topical applications of dimethylsulfoxide (DMSO) used after Adria extravasation have been shown to decrease ulcer size. This may be due to DMSO’s ability to scavenge free radicals. However, effective topical therapy requires prompt recognition of extravasation, which is often difficult. We hypothesized that the delivery of Adria in low concentrations DMSO would reduce Adria-induced ulcer size and ulcer incidence caused by Adria extrasasation. To test this hypothesis, 180, male Sprague-Dawley rats were randomly allocated into three treatment groups of 60 each. All three groups received intradermal injections of Adria (1 mg) diluted in 0.5 cc of saline (Group l), 10% DMSO (Group 2), or 20% DMSO (Group 3). Rats were observed for 4 weeks. Ulcer incidence (X) and size of ulcers (mm2) were assessed over time. Area of skin ulceration was calculated as the product of the two greatest diameters. Statistical evaluation of the differences in incidence and ulcer size between Group 1 and Groups 2 or 3 were evaluated using analysis of variance. Delivery of Adriamycin in 10 or 20% DMSO resulted in a statistically significant (P < 0.001) decrease in the incidence of ulceration caused by intentional Adria eXtraVaSatiOn. 0 1992 Academic press, I~C.
INTRODUCTION
Skin necrosis following Adriamycin (Adria) extravasation is an infrequent but recognized complication of the intravenous administration of this compound. The tissue injury may not appear for several weeks and may continue to worsen for several months. This local toxicity is characterized by pain, erythema, and swelling at
’ Supported in part by the Medical Research Foundation of Oregon, and the American Cancer Society Clinical Fellowship 00162. ’ To whom reprint requests should be addressed at Division of Surgical Oncology L-224A, Oregon Health Sciences University, 3181 SW. Sam Jackson Park Road, Portland OR 97201-3098. 0022-4804/92 $4.00 Copyright 0 1992 by Academic Press, All rights of reproduction in any form
62 Inc. reserved.
LEBREDO,
BARRIE,
AND
WOLTERING:
DMSO
PROTECTS
AGAINST
TISSUE
63
NECROSIS
50
CONTROL x
x CONTROL 10% DMSO *
l
20% OMSO T F
I
?
3
4
I-
a -2
1
1
TIME IN WEEKS
FIG. 1. Incidence of tissue necrosis of treatment group by week. Peak incidence of ulceration occurs at 2 weeks in all groups studied.
MATERIALS
AND METHODS
One hundred and eighty male Sprague-Dawley rats weighing between 180 and 200 g were randomly separated into three groups of 60 rats each and housed four per stainless steel cage. They were placed in a controlled environment, 22°C with a 12-hr light-dark cycle. The rats were given water and standard rat chow (Lot 1028, Raulston Purina Co., St Louis, MO) ad lib&urn. A 5 x 5-cm area of the rat’s back was shaved using number 22 surgical clippers. Each rat was injected intradermally above the panniculus carnosus at a standardized site with 0.5 cc of Adria (2 mg/cc) in saline or vehicle (10% DMSO or 20% DMSO), yielding a total Adria dose of 1 mg. Group 1 was injected with 0.5 cc of the Adria solution in saline. Group 2 was injected with 0.5 cc of the Adria solution in 10% DMSO. Group 3 was injected with 0.5 cc of the Adria solution in 20% DMSO. DMSO (10 and 20%) concentrations were chosen based on preliminary studies done in our lab using a range of 5 to 50% concentrations. Using methods described by other investigators, [24, 26,271, ulcer area (in mm2) was calculated as the product of the two greatest dimensions as measured on a weekly basis by independent investigators with Vernier calipers. Ulcer progression was measured for a total of 4 weeks. Photographs of the ulcers were taken at Week 2. Statistical significance of ulcer incidence and ulcer size was determined by the use of one-way analysis of variance and the Student-Newman-Keuls test. RESULTS Maximal ulcer incidence and maximal ulcer size occurred at 2 weeks in all three groups (Figs. 1 and 2). In Group 1, 63% of the rats injected with Adria in saline developed necrotic ulcers at the site of intentional extravasation. Ulcers ranged in size from 9 to 196 mm2 (mean
3
2
4
TIME IN WEEKS
FIG. 2. Mean ulcer area in mm* in three treatment groups. Maximal ulcer area is seen 2 week after adriamycin extravasation.
of 46.61 mm2). In Group 2,23% of the rats injected with Adria in 10% DMSO developed necrotic ulcers at the injection site. The ulcer size in this group ranged from 4 to 90 mm2 with a mean ulcer size of 32.5 mm2. In Group 3, 21% of the rats injected with Adria in 20% DMSO developed ulcers at the extravasation site with the ulcer size ranging from 9 to 64 mm2 and a mean ulcer size of 21.1 mm2 (Table 1). There was a statistically significant (P < 0.001) decrease in the incidence of ulcers in the rats injected with Adria in saline as compared to those injected with Adria in DMSO. No difference was seen in the ulcer incidence between the groups injected with Adria in 10% DMSO and those injected with Adria in 20% DMSO. There was a decrease in ulcer size between the three groups which while not statistically significant, suggested that 20% DMSO was more protective than 10% DMSO and/or saline (Table 1). There were no secondary infections at the ulcer site, and no rats had to be sacrificed prior to the completion of the experiment. There were no deaths in
TABLE Size and Incidence Group Adriamycin Adriamycin DMSO Adriamycin DMSO
saline 10%
1
of Adriamycin-Induced
Ulceration
N
Incidence (%I
P
Size (mm’)
SD
P
60
63
NA
47
36
NA
60
23
