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Re: Goutos I, Cogswell LK, Giele H. Extravasation injuries: a review. J Hand Surg Eur. 2014, 39: 808–18

We would like to thank Goutos et al. for their reply to our letter (J Hand Surg Eur. 40: 326–8) that was published in response to their article. We are however, concerned that their solitary opinion will convey the wrong message to the readership. Extravasation injuries, especially those involving chemotherapy agents, can have significant and devastating affects due to their cytotoxic nature (Langer, 2010). We agree that hyaluronidase can be successfully used to reduce local tissue damage by dispersing the vesicant in cases of DNA-non-binding extravasation injuries only (Laurie et al., 1984). The response by Goutos et al. however, suggests that the use of hyaluronidase is also advisable for DNA-binding cytotoxic agents. This goes against guidelines issued by the UK’s two largest cancer hospitals (the Royal Marsden (Doughty and Lister, 2011) and Christie Hospitals (The Christie NHS Foundation Trust, 2012)) and also current European guidelines (Wengström and Margulies, 2008). All the papers quoted, except for one, do not support his argument, as they advise the use of hyaluronidase for DNA-non-binding extravasations and not DNA-binding. The quoted paper by Heckler offers little weight to his argument, with the author himself stating ‘it is difficult to claim this series as an unqualified success’ (Heckler, 1989). While the evidence in the literature is poor, we feel strongly that his response goes against the current weight of expert opinion and that hyaluronidase should only be used for non-DNA-binding cytotoxic extravasations, as per UK and European guidelines. Furthermore, recent research has shown that deviation from national protocols, as suggested by Goutos et al., can adversely affect patient outcome in extravasation injuries and cause unnecessary harm (Ghanem et al., 2015).