Cutaneous Management after Extravasation of High-Concentrated Amino Acid Solution Administered for Renal Protection in PRRT

Abstract

High-concentrated amino acid solution is used to protect the kidneys during peptide receptor radionuclide therapy (PPRT) in patients with neuroendocrine tumors (NETs). Extravasation of the solution can cause cutaneous complications. In this study, we described a 66-year-old man with metastatic medullary thyroid cancer and a 32-year-old woman with metastatic pancreatic NET who developed cutaneous lesions caused by the extravasation of an amino acid solution (25 g of lysine and 25 g of arginine in 1 L of normal saline) during PRRT with [177Lu]Lu-DOTA-TATE. Both were treated conservatively, and these cutaneous lesions gradually improved. The patient with metastatic pancreatic NET rejected the amino acid infusion in subsequent cycles of PRRT and therefore received [177Lu]Lu-DOTA-TATE alone, and her serum creatinine level and estimated glomerular filtration rate (eGFR) remained normal for 2 months after the last treatment. These two cases revealed cutaneous complications resulting from high-concentrated amino acid solution during PRRT because of hyperosmolarity. Health care providers should be aware of this complication to ensure its prevention and appropriate management. Preserved renal function was demonstrated after [177Lu]Lu-DOTA-TATE treatment in the absence of the infusion of a high-concentrated amino acid solution. However, long-term follow-up of renal function is suggested.

Extravasation After [177Lu]Lu-HA-DOTATATE Therapy

“…In literature, skin necrosis is reported in case of extravasation of high amounts of amino acids for PRRT, which is assumed due to the hyperosmolarity of the solution 7,8 . It is likely that a limited amount of amino acids was infused extravenously in the patient presented in this case, because no signs of skin necrosis were observed.…”

“…One week after the PRRT infusion, without additional rescue therapy, soft tissue biodistribution in the right upper arm had normalized, and symptoms had disappeared.In literature, skin necrosis is reported in case of extravasation of high amounts of amino acids for PRRT, which is assumed due to the hyperosmolarity of the solution. 7,8 It is likely that a limited amount of amino acids was infused extravenously in the patient presented in this case, because no signs of skin necrosis were observed.The estimated effective half-life of [ 177 Lu]Lu-HA-DOTATATE in the right upper arm was 3.5 hours using the planar imaging after 4 and 24 hours, which is in concordance with literature. 9 In this patient, subsequent PRRT infusions were performed using a central venous line without any problems.…”

Safety and Therapeutic Optimization of Lutetium-177 Based Radiopharmaceuticals

“…Extravasation may occur with the amino acid solution used for renal protection during the administration of [ 177 Lu]Lu-DOTATATE. Due to its hyper-osmolarity, it can cause serious skin lesions that must be managed by a plastic surgeon [77,78].…”