ASCO and the Oncology Nursing Society (ONS) have released their first joint guideline on managing extravasation, an uncommon but potentially life-threatening complication of intravenous antineoplastic therapy.1
Extravasation occurs when an agent with tissue-damaging properties leaks from the intended site of venous delivery, leading to pain, swelling, and erythema in the surrounding area; in severe cases, it can progress to blistering, ulceration, and tissue necrosis. Although extravasation related to antineoplastic therapy is uncommon (the estimated rate, 0.01%–6.5%), complications can increase the likelihood of treatment delay and potentially jeopardize patients’ outcomes.
Tanya Thomas, DNP, APRN
The goal of the new guideline is to address common questions about extravasation management all in one place and, ultimately, to aid timely recognition and treatment, said lead author Tanya Thomas, DNP, APRN, of UVA Health in Charlottesville, Virginia.
A Recommendation for Antidotes
In developing the guidelines, interdisciplinary panel members prioritized several key clinical questions. They then performed a systematic review of studies published within the past 10 years that investigated those questions.
One result of this review was a strong recommendation to provide antidotes to patients who develop extravasation related to chemotherapy agents that are categorized as vesicants or irritants with vesicant properties.1 These drugs include anthracyclines, such as doxorubicin and daunorubicin; alkylating agents, such as trabectedin and lurbinectedin; carboplatin, cisplatin, and oxaliplatin; and vinca alkaloids, such as vincristine and vinorelbine, among others.
According to the evidence review, antidotes may improve tissue preservation as well as help prevent hospitalization, surgery, and delayed cancer treatment.1 Fortunately, the potential harms of the four available antidotes—dexrazoxane, hyaluronidase, dimethyl sulfoxide, and sodium thiosulfate—appear to be small.
“If there’s an approved antidote, then we should use that antidote as soon as there is suspicion of extravasation,” Dr. Thomas said. The specific choice of antidote, she added, depends on the antineoplastic agent involved; the guideline includes a table detailing antidote choice, dosage, and clinical considerations.1
The panel did make a separate, conditional recommendation on extravasation related to paclitaxel and docetaxel therapy, about which there is less certainty regarding progression to severe complications. In this case, ASCO and ONS suggest using an antidote (as opposed to none), and the preferred treatment is hyaluronidase (the antidote used in all studies of taxane-related extravasation).1
Support for Thermal Compresses
Clinicians commonly have questions about the use of thermal compresses in managing extravasation, Dr. Thomas said, which includes whether to use warm or cool compresses and what the duration of use should be. On the basis of six studies, the guidelines give a conditional recommendation to use thermal compresses, noting that the potential benefits—greater tissue preservation and possibly reduced need for surgery—outweigh any “trivial” harm.2-7 One study reported no adverse events from using a cooling compress for as long as 60 minutes, every 8 hours, for 3 days.2
Similar to antidote choice, Dr. Thomas said, the decision to use warm or cool compresses depends on the antineoplastic agent involved. In some cases, the goal is to contain the drug to prevent further spread into the surrounding tissue; in other cases, drug dispersal is the aim.
As for duration, the guidelines suggest applying compresses several times per day for several days vs for less than 24 hours. This, too, is a conditional recommendation based on low certainty of evidence. The panel also notes some potential downsides, including cost to patients treated in the outpatient setting.
When to Seek Surgical Consult
Another common question in managing extravasation, Dr. Thomas said, is when to refer patients to specialty care and/or surgical consult. The panel’s review found that all relevant studies focused on patients with central lines, and, in these cases, the evidence favors “prompt” referral, in addition to conservative care.1
Although not all patients with central lines with extravasation need surgery, they do stand to benefit from an early consult, Dr. Thomas remarked. Per the evidence, the guidelines conclude that prompt referral may minimize the potential for skin ulcerations, necrosis, loss of mobility, and life-threatening complications.1
Because of lack of evidence, as well as concerns about resource constraints, the panel could not make any recommendations for patients with peripheral lines. Decisions about care escalation, the guideline notes, should be based on clinical judgment, considering factors such as extravasation severity and the agent involved.
The Bigger Picture
The panel also identified some important knowledge gaps, including a scarcity of evidence on managing extravasation of novel cancer agents. Dr. Thomas said that a separate article on those drugs, gathering the information available at this point, is in development.
Dr. Thomas also emphasized the importance of basic awareness and education. All clinicians on the care team should know if the antineoplastic agents they are providing are vesicants or irritants with vesicant potential, and they should be aware of the potential signs that extravasation has occurred. Patients must also be informed of any symptoms they should bring to the attention of their care team.
“The earlier we can recognize something’s wrong, the earlier we can intervene,” Dr. Thomas said.
REFERENCES
1. Thomas T, Clark C, Backler C, et al: ONS/ASCO guideline on the management of antineoplastic extravasation. J Oncol Pract. September 18, 2025 (early release online).
2. Bertelli G, Gozza A, Forno GB, et al: Topical dimethylsulfoxide for the prevention of soft tissue injury after extravasation of vesicant cytotoxic drugs: A prospective clinical study. J Clin Oncol 13:2851-2855, 1995.
3. Molas-Ferrer G, Farré-Ayuso E, doPazo-Oubiña F, et al: Level of adherence to an extravasation protocol over 10 years in a tertiary care hospital. Clin J Oncol Nurs 19:E25-E30, 2015.
4. Khan MS, Holmes JD: Reducing the morbidity from extravasation injuries. Ann Plast Surg 48:628-632, 2002.
5. Langstein HN, Duman H, Seelig D, et al: Retrospective study of the management of chemotherapeutic extravasation injury. Ann Plast Surg 49:369-374, 2002.
6. Larson DL: What is the appropriate management of tissue extravasation by antitumor agents? Plast Reconstr Surg 75:397-405, 1985.
7. Sakaida E, Sekine I, Iwasawa S, et al: Incidence, risk factors and treatment outcomes of extravasation of cytotoxic agents in an outpatient chemotherapy clinic. Jpn J Clin Oncol 44:168-171, 2014.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, September 24, 2025. All rights reserved.
