Extravasation of antineoplastic agents: a practical drug-by-drug guide for the clinical oncologist

Extravasation is defined as the inadvertent leakage of an antineoplastic drug from the vascular compartment into surrounding tissues. Although uncommon, it is a potentially serious complication of systemic anticancer therapy. Reported frequencies vary substantially because studies use different populations, vascular devices, and chemotherapy regimens. Unrecognized vesicant extravasation can cause skin necrosis, tendon or nerve injury, and therefore functional impairment and a need for reconstructive surgery or interruption of cancer treatment. This narrative review provides a practical, drug-by-drug reference for clinical oncologists and multidisciplinary infusion teams. We address related definitions, prevention, risk factors, clinical presentation, differential diagnosis, severity assessment, drug classification, and immediate management suggestions. We discuss four commonly recommended antidotes — dexrazoxane, dimethyl sulfoxide, hyaluronidase, and sodium thiosulfate — focusing on indications, formulations, dosing schedules, and evidence-based medicine (EBM) limitations. Additionally, we cover delayed presentation, central venous access devices, immune checkpoint inhibitors, unconjugated monoclonal antibodies, antibody–drug conjugates, wound care, referral, documentation, and staff training. Because much of the evidence is observational and recommendations differ for several agents, treatment should follow a current, pharmacy-approved, drug-specific institutional protocol. Prompt recognition, avoidance of flushing, timely administration of the appropriate antidote, and structured follow-up remain central to limiting injury after extravasation.