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Development and validation of a LC‐MS/MS quantification method of fourteen cytotoxic drugs in environmental samples
Abstract
Rationale:
Cytotoxic drug preparation in hospital pharmacies is associated with chronic occupational exposure leading to a risk of adverse effects. The objective was to develop and validate a quantification method of the following cytotoxic drugs in environmental wipe samples: cyclophosphamide, ifosfamide, cytarabine, dacarbazine, docetaxel, paclitaxel, doxorubicin, epirubicin, etoposide, 5-fluorouracil, gemcitabine, irinotecan, methotrexate, and pemetrexed.
Methods:
The quantification method was developed using liquid chromatography coupled to mass tandem spectrometry and a wiping technique using viscose swab. Linearity, accuracy, precision, limit of quantification, specificity and stability were assessed, from swab desorbed solution, to validate the analytical method, with respect to ICH guidelines. Environmental samples were collected by wiping 5 work surfaces of 225 cm2 with viscose swabs, during 3 days.
Results:
The quantification method was linear over the calibration range with a lower limit of quantification ranging from 0.5 ng.mL-1 to 5.0 ng.mL-1 depending on the cytotoxic drug. The intra-day and inter-day relatives biases were below 1.5% and 13.5%, respectively. This method was successfully applied to surface wipe sampling and environmental contaminations ranged from 0.7 to 1,840.0 ng.cm-2 for the most contaminated areas.
Conclusions:
This 14 cytotoxic drugs quantification method was successfully applied to environmental contamination monitoring and could therefore be a useful tool for monitoring and toxicological studies.
... In order to quantify environmental contamination by monitoring samples, a highly sensitive analytical method with a low limit of quantification is needed. It has to be able to detect and quantify residual traces of cytotoxic drugs from surface samples [22][23][24][25][26][27][28]. Different analytical methods are reported in the literature, ranging from liquid chromatography (LC) to gas chromatography (GC) coupled to different ultraviolet (UV) or mass spectrometry (MS) detection systems. ...
... Some of the published methods perform quantification of two or three drugs [8,11,15,22,23] including cyclophosphamide in combination with other drugs such as ifosfamide, both belonging to the same drug family [6,7,12,16,24]. On publications that include a greater number of drugs, the analysis was performed under different chromatographic conditions or by separate analytical methods due to different physicochemical properties of drugs [25,26]. Consequently, there are few publications that perform the simultaneous determination of many drugs by using a single analytical method [27,28]. ...
The most common strategy to assess the occupational exposure risk to hazardous drugs in cancer healthcare settings is by monitoring environmental contamination of work surfaces with cytotoxic drugs. Healthcare workers, especially pharmacy technicians and nursing, handle multiple hazardous drugs, so they really may be exposed to different cytotoxic drugs simultaneously. Therefore, simultaneous determination of several cytotoxic drugs provides a more accurate assessment of the real occupational exposure risk in healthcare settings. Our objective was to develop a method for surface wipe sampling and a quantification method for five cytotoxic drugs commonly used in chemotherapy treatments preparation: cyclophosphamide, 5-fluorouracil, epirubicin, gemcitabine and paclitaxel. Wiping procedure was performed using cellulose swabs moistened in a mixture solution containing acetonitrile, water, 2-propanol and methanol with 0.1% formic acid. The obtained extracts were simultaneously quantified by an LC-MS/MS method. Chromatographic separation was achieved using an Acquity UPLC® BEH C18 column by a gradient elution, and detection was carried out in multiple reaction monitoring mode with electrospray source operating in positive and negative ion mode. Wipe and extraction procedures developed were simple and easy to implement, being able to recover the cytotoxic target drugs from two type surfaces sampling, stainless steel surfaces and polyethylene bags surfaces. The analytical method was linear over the calibration range and the limits of quantification were 1 ng/mL for cyclophosphamide, gemcitabine and paclitaxel, 1.5 ng/mL for epirubicin and 5 ng/mL for 5-fluorouracil. Intra- and inter-day precision and accuracy for all drugs were always inferior to 15%. This work provides a suitable procedure to identify cytotoxic contamination on work surfaces, being a useful tool to monitor occupational exposure risk to hazardous drugs, as well as to evaluate the effectiveness of decontamination protocols applied and hazardous drug handling protocols in cancer healthcare settings.
Purpose
The goal of this study was to create a cleaning procedure by comparing the performance of six different cleaning methods on the surfaces in pharmacy intravenous admixture service (PIVAS) work area.
Method
A stainless steel plate was simulating contaminated by gemcitabine, cyclophosphamide, epirubicin, etoposide, and paclitaxel, which was then dried and cleaned by per current cleaning protocols. The residues were collected and quantified by ultra-performance liquid chromatography–tandem mass spectrometry (UPLC–MS/MS). Based on the most appropriate cleaning protocol, three cleaning variables were optimized: (1) use of dry gauze after cleaning agent application; (2) cleaning paths (inside-out vs. outside-in); (3) cleaning times (once or twice). Best conditions were tested with real samples from a hospital PIVAS.
Results
This 10 –2 M sodium dodecyl sulfate (SDS) and dry gauze cleaning protocol increases cleaning efficiency as well as saves time. Different from the traditional cleaning manner, we found that cleaning from outside to inside can not only improve the cleaning efficiency but also overcome the uneven distribution of drug residues caused by cleaning action. When simulating contamination at a high dose (4 mg/mL) level, it was found that the decontamination efficacy increased with repeating one more time.
Conclusion
The 10 –2 M SDS and dry gauze cleaning protocol could obtain the best cleaning effect. The success of cytotoxic drug decontamination is determined not only by the cleaning solution, but also by the cleaning route and frequency. Compared with the traditional cleaning manner, there was a significant reduction in the contamination levels in the PIVAS work area after the cleaning protocol with 10 –2 M SDS and dry gauze.
Introduction
Occupational exposure to antineoplastic drugs can lead to long-term adverse effects on workers’ health. Environmental monitoring is conducted once a year, as part of a Canadian monitoring program. The objective was to describe contamination with 11 antineoplastic drugs measured on surfaces.
Methods
Six standardized sites in oncology pharmacy and six in outpatient clinic were sampled in each hospital. Samples were analyzed by ultra-performance liquid chromatography coupled with tandem mass spectrometry (non-platinum drugs) and by inductively coupled plasma mass spectrometry (platinum-based drugs). The limits of detection (in ng/cm ² ) were: 0.0006 for cyclophosphamide; 0.001 for docetaxel; 0.04 for 5-fluorouracil; 0.0004 for gemcitabine; 0.0007 for irinotecan; 0.0009 for methotrexate; 0.004 for paclitaxel, 0.009 for vinorelbine, 0.02 for doxorubicine, 0.0037 for etoposide and 0.004 for the platinum. Sub-analyses were done with a Kolmogorov-Smirnov test
Results
122 Canadian hospitals participated. Cyclophosphamide (451/1412, 32% of positive samples, 90 th percentile of concentration 0.0160 ng/cm ² ) and gemcitabine (320/1412, 23%, 0.0036 ng/cm ² ) were most frequently measured on surfaces. The surfaces most frequently contaminated with at least one drug were the front grille inside the biological safety cabinet (97/121, 80%) and the armrest of patient treatment chair (92/118, 78%).The distribution of cyclophosphamide concentration was higher for centers that prepared ≥ 5000 antineoplastic drug preparations/year (p < 0.0001).
Conclusions
This monitoring program allowed centers to benchmark their contamination with pragmatic contamination thresholds derived from the Canadian 90 th percentiles. Problematic areas need corrective measures such as decontamination. The program helps to increase the workers’ awareness.
Cytostatics are drugs used in cancer treatment, which pose serious risks to healthcare workers. Dermal absorption via surface contamination is the key exposure route; thus, rapid, reliable, and validated analytical methods for multicomponent detection are crucial to identify the exposure risk. A surface-wipe-sampling technique compatible with hospitals’ safety requirements (gauze, 1 mL isopropanol) and a fast and simple extraction method (1 mL acetonitrile, 20 min ultrasonic bath, evaporation, reconstitution in 200 µL acetonitrile), coupled with liquid chromatography–tandem mass spectrometry analysis, were developed. It allowed identification and quantification of 13 cytostatics on surfaces: cyclophosphamide, doxorubicin, etoposide, ifosfamide, paclitaxel, bicalutamide, capecitabine, cyproterone, flutamide, imatinib, megestrol, mycophenolate mofetil, prednisone. Good linearity, sensitivity, and precision were achieved (R2 > 0.997, IDLs < 4.0 pg/cm2, average CV 16%, respectively). Accuracy for four model surfaces (melamine-coated wood, phenolic compact, steel 304, steel 316) was acceptable (80 ± 12%), except for capecitabine and doxorubicin. Global uncertainty is below 35% for concentrations above 100 pg/cm2 (except for capecitabine and doxorubicin)—a guidance value for relevant contamination. Method application in a Portuguese university hospital (28 samples) identified the presence of seven cytostatics, at concentrations below 100 pg/cm2, except for three samples. The widespread presence of cyclophosphamide evinces the necessity to review implemented procedures.
Periodic and adequate environmental monitoring programs are crucial to assess and reduce the occupational exposure of healthcare workers to cytostatics. The analytical methods employed should be rapid, reliable, sensitive, standardized, and include multiple compounds. A critical overview of recent overall procedures for surface and air contamination with cytostatics in workplace settings is presented, with a focus on sampling, sample preparation, and instrumental considerations. Limitations are also addressed and some recommendations and advice are provided. Since dermal absorption is the main exposure route, surface contamination is the preferred indicator of biological uptake and its methods have significantly improved. In contrast, cytostatics’ inhalation is rare; thus, air contamination has been poorly studied, with little improvement. Still, some elements of the analytical methods have not been extensively explored, namely: the amount of wetting solution, the extraction procedure, surface chemistry and roughness, recovery studies from specific surfaces, and cytostatics stability (in surfaces and during shipping and storage). Furthermore, complete validation data (including precision, accuracy, and instrumental and method detection limits) and estimation of global uncertainty are still lacking in most studies, thus preventing method comparison and proposal of standardized procedures.
Introduction:
Healthcare workers exposure to antineoplastic drugs can lead to adverse health effects. Guidelines promote the safe handling of antineoplastic drugs, but no safe exposure limit was determined. Regular surface sampling contributes to ensuring workers safety.
Methods:
A cross-sectional monitoring is conducted once a year with voluntary Canadian centers, since 2010. Twelve standardized sampling sites were sampled. Samples were analyzed by high performance mass coupled liquid chromatography. The limits of detection (in ng/cm2) were: 0.001 for cyclophosphamide and gemcitabine; 0.3 for docetaxel and ifosfamide; 0.04 for 5-fluorouracil and paclitaxel; 0.003 for irinotecan; 0.002 for methotrexate; 0.01 for vinorelbine.
Results:
The surfaces from 109 centers were sampled between 01/01/2020-18/06/2020. Twenty-six centers delayed their participation because of the COVID-19 pandemic. 1217 samples were analyzed. Surfaces were frequently contaminated with cyclophosphamide (34% positive, 75th percentile 0.00165 ng/cm2) and gemcitabine (16% and <0.001 ng/cm2). The armrest of patient treatment chairs (84% to at least one drug), the front grille inside the biological safety cabinet (BSC) (73%) and the floor in front of the BSC (55%) were frequently contaminated. Centers that prepared ≥5000 antineoplastic drugs annually had higher concentration of cyclophosphamide on their surfaces (p < 0.0001). Contamination measured on the surfaces was reduced from 2010 to 2020.
Conclusions:
This large-scale study showed reproducible long term follow up of the contamination of standardized sites of Canadian centers and a reduction in surface contamination from 2010 to 2020. Periodic surface sampling help centers meet their continuous improvements goals to reduce exposure as much as possible. The COVID-19 pandemic had a limited impact on the program.
In this chapter, the research progress in mining chemodiversity from biodiversity of Taxaceae medicinal plants is highlighted. Various taxane diterpenoids are isolated and characterized, for example, those of T. canadensis, T. baccata, T. mairei, and T. wallichiana. Paclitaxel intermediates are also found in non-Taxaceae plants. Polysaccharide, flavonoid, essential oil, and other compounds are also mined from Taxus species. These components are promising chemotaxonomic markers. Metabolomics techniques and related functional genomics have been used to decipher and compare the complex metabolic profiles of different Taxus species/populations. Chemical synthesis and semisynthesis of medicinally important taxanes are also reviewed. Various methods used in the extraction and purification of Taxus compounds are summarized. In precise analysis and quantification, the innovative chromatography, immunoassay, visualization, and spectroscopy methods are especially useful and introduced in this chapter.
Innovations in extraction phases, extraction modes and hyphenated instrument configurations, are the most important issues to address for progress in the solid phase microextraction (SPME) methodology. In this regard, we have embarked on the development of a novel biocompatible 96-monolithic inorganic hollow fiber (96-MIHF) array as a new configuration for high-throughput SPME on a 96-well plate system. An arrangement of highly ordered 96 titania/Hydroxyapatite (TiO2/HAP) nanocomposite hollow fibers and corresponding stainless-steel needles on a Teflon plate holder were used as the extraction module. The inorganic hollow fibers were prepared via a rapid and reproducible template approach (Polypropylene hollow fiber) in combination with a sol-gel method in the presence of polyvinyl alcohol (PVA), as a network maker. The hollow fiber-shape sorbents were obtained with excellent precision by weight (RSD%=4.98, n=10) and length (RSD%= 1.08, n=10) criteria. The proposed design can overcome a number of geometrically dependent drawbacks of conventional high-throughput SPME methods, mainly the ones related to sorbent amount and surface area due to possessing inner/outer surfaces without additional internal supports. The SPME platform, for the first time, was successfully applied for the extraction and preconcentration of doxorubicin from urine and water media without requiring sample preparation and free from significant matrix effect. The extracted analyte was analyzed by liquid chromatography-ion trap tandem mass spectrometry (LC-MS/MS). Highly satisfactory analytical figures of merit were obtained under optimized conditions. The limit of detection (LOD), limit of quantification (LOQ) and linearity of determination were 0.1 ng mL⁻¹, 0.25 ng mL⁻¹ and 0.25 to 4000 ng mL⁻¹, respectively. The interday, intraday and inter sorbent precisions for three concentration levels ranged from 2.01 to 8.09 % (n=3), 1.02 to 8.65 % (n=5) and 0.99 to 1.02% (n=15), respectively. The mean intra-well RSD value for 96 individual wells in 96-MIHF-SPME-LC-MS/MS (n=3) at the medium concentration level was 7.81%.
Objectives
Recently published works showed that occupational exposure to antineoplastic drugs (ANPD) is still frequent in hospital settings, despite significant safety policy improvements. The aim of this study was to assess the current level of occupational exposure to ANPD and any potentially associated cytogenetic damages in hospital nurses routinely handling ANPD.
Methods
Occupationally ANPD-exposed (n = 71) and ANPD-unexposed (n = 77; control) nurses were recruited on a voluntary basis from five hospitals in Northern and Central Italy. Evaluation of surface contamination and dermal exposure to ANPD was assessed by determining cyclophosphamide (CP) on selected surfaces (wipes) and on exposed nurses’ clothes (pads). The concentration of unmetabolized CP—as a biomarker of internal dose—was measured in end-shift urine samples. Biomonitoring of genotoxic effects (i.e., biological effect monitoring) was conducted by analyzing micronuclei (MN) and chromosome aberrations (CA) in peripheral blood lymphocytes. Genetic polymorphisms for enzymes involved in metabolic detoxification (i.e., glutathione S-transferases) were analyzed as well.
Results
We observed a significant increase in MN frequency (5.30 ± 2.99 and 3.29 ± 1.97; mean values ± standard deviation; p
Several antineoplastic drugs have been classified as carcinogens by the International Agency for Research on Cancer (IARC) on the basis of epidemiological findings, animal carcinogenicity data, and outcomes of in vitro genotoxicity studies. 5-Fluorouracil (5-FU), which is easily absorbed through the skin, is the most frequently used antineoplastic agent in Portuguese hospitals and therefore may be used as an indicator of surface contamination. The aims of the present investigation were to (1) examine surface contamination by 5-FU and (2) assess the genotoxic risk using cytokinesis-block micronucleus assay in nurses from two Portuguese hospitals. The study consisted of 2 groups: 27 nurses occupationally exposed to cytostatic agents (cases) and 111 unexposed individuals (controls). Peripheral blood lymphocytes (PBL) were collected in order to measure micronuclei (MN) in both groups. Hospital B showed a higher numerical level of contamination but not significantly different from Hospital A. However; Hospital A presented the highest value of contamination and also a higher proportion of contaminated samples. The mean frequency of MN was significantly higher in exposed workers compared with controls. No significant differences were found among MN levels between the two hospitals. The analysis of confounding factors showed that age is a significant variable in MN frequency occurrence. Data suggest that there is a potential genotoxic damage related to occupational exposure to cytostatic drugs in oncology nurses.
A wipe-sampling procedure followed by a simple liquid chromatography–mass spectrometry method was developed and validated
for the simultaneous quantification of three cytotoxic drugs [5-fluorouracil (5FU), doxorubicin and cyclophosphamide (CP)]
for the determination of surface contamination. After a solid-phase extraction procedure with wiping filter paper, the separation
was performed within 30 min using a gradient mobile phase. The method was validated according to the recommendations of the
US Food and Drug Administration. Wiping was performed using Whatman® filter paper on different surfaces such as stainless steel, polypropylene and glass. The method was linear, between 10 and
500 ng per wiping sample (i.e., 0.1–5 ng/cm2) for 5FU and doxorubicin, and between 1–100 ng per wiping sample (i.e., 0.01–1 ng/cm2) for CP. The lower limits of detection and quantification were 5 and 10 ng per wiping sample for 5FU and doxorubicin, and
0.5 and 1 ng per wiping sample for CP. This new sensitive methodology for surface contamination studies was successfully applied
on commercial vials and different places in a cancer research hospital. This approach is particularly suitable to assess the
risk of occupational exposure to cytotoxic drugs and to optimize the cleaning process, especially for the most toxic molecule
studied, CP.
Aim • To assess the possible health risk for personnel occupationally exposed to vaporising pharmaceuticals we investigated the conditions for and the extent of evaporation of selected antineoplastic and antimicrobial drugs. Methods • Vapour pressures of five widely used antineoplastic agents (carmustine, cisplatin, cyclophosphamide, etoposide and fluorouracil) and one antimicrobial drug (fosfomycin) were measured. From these, temperature-dependent saturation concentrations and the evaporation times for particles of different sizes were calculated. A method for the determination of the carcinogenic agent cyclophosphamide in air, which distinguished between the particle-bonded and gaseous phases, was developed and applied in two different hospital pharmacies under defined conditions (no preparation and cyclophosphamide preparation only). Measurements of airborne cyclophosphamide were accompanied by wipe sampling and analysis of the compound in the urine of the three operators who undertook the preparations. Results • The vapour pressures ranged from 1.4-19mPa and saturation concentrations from 0.08-1.7mg/m3 both at 20C. The calculated time for evaporation of small particles (d = 1μm, 20C) was 12s-35 min. In the air of preparation rooms particulate cyclophosphamide was found in 6 of 20 sites (1-65ng/m3). Gaseous cyclophosphamide was detectable in 7 out of 15 locations (45ng/m3-13μg/m3). Cyclophosphamide was present on 17 of the 26 surfaces (0.03ng/cm2-189ng/cm2). No cyclophosphamide was found in the urine of the three operators involved in reconstitution of cyclophosphamide during air sampling. Conclusion • The results indicate that cytostatic (and other) pharmaceuticals may evaporate and form a gas phase during normal handling. This must be taken into consideration when designing safety measures.
A simple wipe sampling procedure was developed for the surface contamination determination of ten cytotoxic drugs: cytarabine, gemcitabine, methotrexate, etoposide phosphate, cyclophosphamide, ifosfamide, irinotecan, doxorubicin, epirubicin and vincristine. Wiping was performed using Whatman filter paper on different surfaces such as stainless steel, polypropylene, polystyrol, glass, latex gloves, computer mouse and coated paperboard. Wiping and desorption procedures were investigated: The same solution containing 20% acetonitrile and 0.1% formic acid in water gave the best results. After ultrasonic desorption and then centrifugation, samples were analysed by a validated liquid chromatography coupled to tandem mass spectrometry (LC–MS/MS) in selected reaction monitoring mode. The whole analytical strategy from wipe sampling to LC–MS/MS analysis was evaluated to determine quantitative performance. The lowest limit of quantification of 10 ng per wiping sample (i.e. 0.1 ng cm−2) was determined for the ten investigated cytotoxic drugs. Relative standard deviation for intermediate precision was always inferior to 20%. As recovery was dependent on the tested surface for each drug, a correction factor was determined and applied for real samples. The method was then successfully applied at the cytotoxic production unit of the Geneva University Hospitals pharmacy.
Figure
Wipe sampling procedure for the determination of cytotoxic drugs
The International Agency for Research on Cancer has classified several antineoplastic drugs in Group 1 (human carcinogens), among which chlorambucil, cyclophosphamide (CP) and tamoxifen, Group 2A (probable human carcinogens), among which cisplatin, etoposide, N-ethyl- and N-methyl-N-nitrosourea, and Group 2B (possible human carcinogens), among which bleomycins, merphalan and mitomycin C. The widespread use of these mutagenic/carcinogenic drugs in the treatment of cancer has led to anxiety about possible genotoxic hazards to medical personnel handling these drugs. The aim of the present study was to evaluate work environment contamination by antineoplastic drugs in a hospital in Central Italy and to assess the genotoxic risks associated with antineoplastic drug handling. The study group comprised 52 exposed subjects and 52 controls. Environmental contamination was assessed by taking wipe samples from different surfaces in preparation and administration rooms and nonwoven swabs were used as pads for the surrogate evaluation of dermal exposure, 5-fluorouracil and cytarabine were chosen as markers of exposure to antineoplastic drugs in the working environment. The actual exposure to antineoplastic drugs was evaluated by determining the urinary excretion of CP. The extent of primary, oxidative and excision repaired DNA damage was measured in peripheral blood leukocytes with the alkaline comet assay. To evaluate the role, if any, of genetic variants in the extent of genotoxic effects related to antineoplastic drug occupational exposure, the study subjects were genotyped for GSTM1, GSTT1, GSTP1 and TP53 polymorphisms. Primary DNA damage significantly increased in leukocytes of exposed nurses compared to controls. The use of personal protective equipment (i.e. gloves and/mask) was associated with a decrease in the extent of primary DNA damage.
Antineoplastic drugs are widely used in anticancer therapy due to their cytotoxic activity but many of them are classified as carcinogenic, mutagenic, or teratogenic to humans. In order to evaluate personal exposure, surface monitoring has been successfully applied for several years. In this study, we present a statistical description of our data set from 102 German pharmacies and propose 'threshold guidance values (TGVs)' to facilitate interpretation of monitoring results.
Our database included 1008 results for platinum (PT) and 1237 for 5-fluorouracil (FU) collected in 102 pharmacies in Germany. Wipe sampling on site was performed with one validated procedure. PT concentrations were measured by voltammetry and FU by gas chromatography/mass spectrometry. Data were stratified into 10 locations and statistically evaluated.
Contamination was detected on all surfaces in the pharmacies with high levels on storage shelves and floors. The median values for the different locations ranged from 0.20 to 1.70 pg cm(-2) (mean: 0.57 pg cm(-2)) for PT and from 2.50 to 10.00 pg cm(-2) (mean: 5.34 pg cm(-2)) for FU. The mean 75th percentiles were 3.92 pg cm(-2) (PT) and 28.90 pg cm(-2) (FU). The TGV 1 value was set at the median value and results below demonstrate good working practices. Contaminations above the TGV 2, which was assigned at the 75th percentile, show a clear need for optimizing the handling procedures.
The introduction of TGVs helps to reduce occupational exposure and allows pharmacy personnel to benchmark their own contamination levels. This provides a basis for improvement in occupational safety precautions and for regular contamination controls.
Workplace dermal exposure assessment is a complex task that aims to understand the dynamic interaction between the skin and the hazardous substances present in the surrounding environment. A European project known as RISKOFDERM gathered dermal exposure data in 85 workplaces (industrial and other types) in five countries in Europe. In order to optimize data collection and to develop a representative picture of dermal exposure, scenarios (tasks made up of a series of activities) were grouped together into dermal exposure operation units (DEOs). The allocation of scenarios to relevant DEOs was achieved on the basis of similarities of exposure routes, tasks and professional judgement. Sampling and quantification procedures were based on the approaches recommended by the OECD protocol. The laboratories involved in the analysis of the samples participated in quality assurance programmes. This exercise resulted in 419 body measurements and 437 measurements on hands expressed in terms of formulation (product) in use. Exposures for a given scenario varied by several orders of magnitude. The extent and patterns of exposure were found to be dependent on various exposure determinants, including inter- and intra-scenario variations. Hands were found to be the most contaminated parts of the body. Exposure patterns for liquid and solid contaminants were different. On the basis of the analysis of the data presented here, the averaged results (median and 95th percentile) for a given DEO unit should not be used as a representative measure of dermal exposure for all scenarios within that DEO without taking the exposure determinants into account. However, the data could be used to develop an exposure matrix (indicative exposure distributions) for different types of scenario and workplace, using determinants of exposure and a Bayesian approach to integrating expert opinion.
Several studies have shown that exposure to antineoplastic drugs can cause reproductive toxic effects as well as carcinogenic effects. Presence of these drugs in the urine of hospital personnel has been widely studied and some work has been done on exposure by inhalation. So far, assessment of dermal exposure to antineoplastic drugs has not been extensively studied. In this pilot study we assessed potential and actual dermal exposure for several common hospital tasks. Results were used to derive an optimal measurement strategy for a currently ongoing exposure survey.
Dermal exposure to cyclophosphamide was determined in three Dutch hospitals during five tasks (preparation, decanting urine, washing the patient, removing bed sheets and cleaning the toilet) using pad samples on 10 body locations. In addition, protective medical gloves (worn during the performance of these activities) were collected to estimate potential exposure of the hands. Subsequently, hands were washed to measure actual exposure of the hands. Bulk samples (i.e. application and body fluids) were collected and possible contact surfaces were monitored to assess the amount of cyclophosphamide potentially available for exposure.
The results show that hospital personnel (i.e. pharmacy technicians and oncology nurses) are dermally exposed to cyclophosphamide during performance of their daily duties. Exposure occurred predominantly on the hands and sporadically on other body locations (i.e. forehead and forearms). Gloves used during preparation of cyclophosphamide were more contaminated than gloves used in other tasks, however, actual exposure of the hands (underneath the gloves) was highest during decanting of urine of treated patients. Glove samples correlated significantly with handwash samples (r = 0.57, P = 0.03, n = 15). The level of protection from gloves varied between tasks, being highest for gloves used during preparation (median = 98%) and lowest for gloves used during decanting urine (median = 19%).
This pilot study demonstrated that dermal exposure to cyclophosphamide is common among hospital personnel. The results showed that hands, forearms and forehead accounted for 87% of the cyclophosphamide total body exposure. Glove samples together with handwash samples enabled estimation of glove efficiency, which appeared to vary strongly between tasks observed.
To develop, validate, and apply a method for the determination of platinum contamination, originating from cisplatinum, oxaliplatinum, and carboplatinum.
Inductively coupled plasma mass spectrometry (ICP-MS) was used to determine platinum in wipe samples. The sampling procedure and the analytical conditions were optimised and the assay was validated. The method was applied to measure surface contamination in seven Dutch hospital pharmacies.
The developed method allowed reproducible quantification of 0.50 ng l(-1) platinum (5 pg/wipe sample). Recoveries for stainless steel and linoleum surfaces ranged between 50.4 and 81.4% for the different platinum compounds tested. Platinum contamination was reported in 88% of the wipe samples. Although a substantial variation in surface contamination of the pharmacies was noticed, in most pharmacies, the laminar-airflow (LAF) hoods, the floor in front of the LAF hoods, door handles, and handles of service hatches showed positive results. This demonstrates that contamination is spread throughout the preparation rooms.
We developed and validated an ultra sensitive and reliable ICP-MS method for the determination of platinum in surface samples. Surface contamination with platinum was observed in all hospital pharmacies sampled. The interpretation of these results is, however, complicated.
In order to assess exposure levels of hospital personnel involved in the preparation and administration of antineoplastic drugs, environmental monitoring should be carried out. Wipe samples, pads, gloves and air samples should be collected at the end of each work shift, properly treated and then analysed using instrumental techniques which are sufficiently sensitive and specific to detect even trace amounts of drug. In this study, a method using high performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS), incorporating solid phase extraction (SPE), was validated for determination of methotrexate (MTX) in wipe and air samples. Each step of the method was first developed and optimised using ultraviolet detection (UV), and afterwards tandem mass spectrometry was used to obtain a lower limit of quantitation when the expected drug level was less than the analytical UV detection limit. SPE enabled a 20‐fold preconcentration of the analyte when using HPLC/UV and a further 30‐fold preconcentration was obtained when analysing samples by HPLC/MS/MS. For example, the limit of quantitation (LLQ) was lowered from 3000 ng on wipe (direct injection onto an HPLC/UV system) to 5 ng on wipe (SPE plus HPLC/MS/MS). 7‐hydroxymethotrexate was used as internal standard to assess precision and accuracy. Copyright © 2000 John Wiley & Sons, Ltd.
Introduction
Cytotoxic drug exposure of hospital staff preparing intravenous chemotherapy is a major issue and related mutagenic risks should be more explored. The aim of this study was to assess the mutagenicity of several cytotoxic mixtures prepared at fixed concentrations, and the mutagenicity of environmental samples collected in a hospital centralized reconstitution unit. In parallel cytotoxic exposure in environmental samples was quantified.
Methods
Environmental samples were performed by wiping method using swabs in five critical production unit areas. Mutagenicity was assessed with a liquid microplate AMES test using two salmonella typhimurium strains (TA98 and TA100), in prepared cytotoxic mixtures containing 14 cytotoxic drugs (cyclophosphamide, cytarabine, dacarbazine, docetaxel, doxorubicin, epirubicin, etoposide, 5-fluorouracil, gemcitabine, ifosfamide, irinotecan, methotrexate, paclitaxel and pemetrexed) according a dichotomous strategy and in environmental samples. Cytotoxic drugs were quantified in samples using liquid chromatography coupled to mass tandem spectrometry.
Results
Mutagenesis was observed for the mix of 14 cytotoxic drugs with TA98 strain ± S9 fraction but not TA100 strain. After dichotomous approach, only doxorubicin and epirubicin exposure were associated to mutagenesis. The mutagenesis observed was expressed at lower concentrations with the mix of the 14 drugs than with anthracyclins alone, assuming a synergistic effect. Despite measurable level of cytotoxic contamination in environmental samples, no mutagenesis was highlighted in Ames tests performed on these environmental samples.
Conclusions
The analyses carried out show the conservation of the mutagenicity of cytotoxic drugs found in very low quantities in the environment. The traces of cytotoxic drugs found in our unit regularly exceed the limits given by some authors. This approach may be considered as a new tool to monitor environmental contamination by cytotoxic drugs.
Background
To prevent occupational exposure of hospital staff to cytostatics, a mandatory national guideline describing a set of safety measures was issued in the Netherlands in 2004. The guideline includes, among other directives, obligatory annual wipe testing to assess the efficacy of the local cleaning protocol. Full implementation of this guideline was executed in all Dutch hospital pharmacies over the next couple of years.
Objective
We aimed to investigate the effect of the national guideline on contamination levels, and specifically on the phenomenon of carry-over of traces of antineoplastic drugs through contact with surfaces, since this is a potential route of exposure.
Methods
From a database including wipe sample results of 9 hospitals over 10 years, we extracted all sampled locations in the compounding areas as well as in adjacent or bypass rooms and locks. We considered only the locations outside safety cabinets or isolators, to examine the containment of contamination and to address possible routes of how a contamination can migrate through the preparation and distribution areas. The dataset consisted of 2647 wipe samples.
Results
In adjacent rooms, 18 out of 275 wipe samples were contaminated (6%). Inside the compounding room, the extracted locations away from the safety workbench showed a positive percentage for contamination of 13% (39 out of 297). When stratifying the data to sample year, it was shown that contaminations outside the preparation room were no longer detectable after 2008.
Conclusion
With this study, we show that implementation of a set of guidelines on safety measures can prevent spreading of cytostatic traces from the compounding area in hospital pharmacies.
Purpose:
Surface wipe sampling for various hazardous agents has been employed in many occupational settings over the years for various reasons such as evaluation of potential dermal exposure and health risk, source determination, quality or cleanliness, compliance, and others. Wipe sampling for surface residue of antineoplastic and other hazardous drugs in healthcare settings is currently the method of choice to determine surface contamination of the workplace with these drugs. The purpose of this article is to review published studies of wipe sampling for antineoplastic and other hazardous drugs, to summarize the methods in use by various organizations and researchers, and to provide some basic guidance for conducting surface wipe sampling for these drugs in healthcare settings.
Methods:
Recommendations on wipe sampling methodology from several government agencies and organizations were reviewed. Published reports on wipe sampling for hazardous drugs in numerous studies were also examined. The critical elements of a wipe sampling program and related limitations were reviewed and summarized.
Results:
Recommendations and guidance are presented concerning the purposes of wipe sampling for antineoplastic and other hazardous drugs in the healthcare setting, technical factors and variables, sampling strategy, materials required, and limitations. The reporting and interpretation of wipe sample results is also discussed.
Conclusions:
It is recommended that all healthcare settings where antineoplastic and other hazardous drugs are handled consider wipe sampling as part of a comprehensive hazardous drug 'safe handling' program. Although no standards exist for acceptable or allowable surface concentrations for these drugs in the healthcare setting, wipe sampling may be used as a method to characterize potential occupational dermal exposure risk and to evaluate the effectiveness of implemented controls and the overall the safety program. A comprehensive safe-handling program for antineoplastic drugs may utilize wipe sampling as a screening tool to evaluate environmental contamination and strive to reduce contamination levels as much as possible, using the industrial hygiene hierarchy of controls.
An effective wipe sampling and LC-MS/MS method was developed to simultaneously analyze six commonly administered antineoplastic drugs in stainless steel surface. The analyzed drugs were methotrexate, paclitaxel, cyclophosphamide, 5-fluorouracil, vincristine, and oxaliplatin, a frequently prepared antineoplastic drug that has not been included among any of the published simultaneous detection methods. The established method was used to evaluate the recoveries of antineoplastic drugs on brand new and worn stainless steel surfaces by wiping the plates with a Whatman filter paper wetted with 0.5 mL of water/methanol (20:80) with 0.1 % formic acid followed by LC-MS/MS before desorbing the filter with a water/methanol (50:50) solution. A significant decrease in the recovery of all evaluated drugs was found when worn plates were used. Additionally, the inter-personnel variability on drug recoveries during wiping procedures was evaluated. Significantly higher recoveries were achieved by the personnel with more training and experience versus personnel without prior experience. Finally, a laboratory stability test was developed to assess the degradation of the antineoplastic drugs during replicated shipping conditions. With the exception of vincristine sulfate which exhibited a significant (p < 0.05) degradation after 48 h, all evaluated drugs were stable during the first 24-48 h. However, after 144 h, an increase in the degradation of all evaluated drugs was observed, with oxaliplatin and 5-fluorouracil exhibiting the most degradation.
Purpose To evaluate the chemical contamination of surfaces by cytotoxic agents during preparation of injectable chemotherapies in hospital pharmacies.
Methods 526 wipe samples collected in 24 Swiss hospital pharmacies were analysed using a validated liquid chromatography–mass spectrometry/mass spectrometry method able to quantify 10 cytotoxic agents: cytarabine, gemcitabine, cyclophosphamide, ifosfamide, methotrexate, etoposide phosphate, irinotecan, doxorubicin, epirubicin and vincristine. Information on chemotherapies produced, equipment and production processes used were collected from all the hospital pharmacies on a voluntary basis in order to investigate their association with contamination rates.
Results In two pharmacies, no trace of the 10 cytotoxic agents was detected. Chemical contamination was found in the other 22 hospital pharmacies, with combined total contamination of the 10 cytotoxic agents ranging from 8 ng to more than 41 000 ng per sample. Most contaminated samples came from inside biosafety cabinets, but some came from other clean room areas and logistics rooms. Statistically significant associations were observed between contamination rates and sampling locations, the number of chemotherapies prepared per year and types of cleaning solutions used.
Conclusions This study demonstrated that most of the hospital pharmacies tested had some contamination of surfaces by different cytotoxic agents. Even if highest levels of contamination were mainly detected inside biosafety cabinets, technicians were also exposed to cytotoxic agents detected in logistical and storage areas. Protective measures should therefore be maintained or even reinforced in these areas in order to limit technicians’ risks of exposure when handling cytotoxic products.
No occupational exposure limit exists for antineoplastic drugs. The main objective of this study was to describe environmental contamination with cyclophosphamide, ifosfamide, and methotrexate in pharmacy and patient care areas of Canadian hospitals in 2013. The secondary objective was to compare the 2013 environmental monitoring results with previous studies.
Six standardized sites in the pharmacy and six sites on patient care areas were sampled in each participating center. Samples were analyzed for the presence of cyclophosphamide, ifosfamide, and methotrexate by UPLC-MSMS. The limit of detection (LOD) in pg/cm² was 1.8 for cyclophosphamide, 2.2 for ifosfamide, and 7.5 for methotrexate. The 75th percentile of cyclophosphamide concentration was compared between the 2013, 2008–2010, and 2012 studies.
Thirty-six hospitals participated in the study and 422 samples were collected. Overall, 47% (198/422) of the samples were positive for cyclophosphamide, 18% (75/422) were positive for ifosfamide, and 3% (11/422) were positive for methotrexate. In 2013, the 75th percentile value of cyclophosphamide surface concentration was reduced to 8.4pg/cm² (n = 36), compared with 9.4pg/cm² in 2012 (n = 33) and 40pg/cm² (n = 25) in 2008–2010. The 75th percentile for ifosfamide and methotrexate concentration remained lower than the LOD.
The 2013 study shows an improvement in the surface contamination level, and a plateau effect in the proportion of positive samples.
Progress in chemotherapy leads to increased numbers and variety of chemotherapeutic drugs, and multicomponent analysis of these drugs is a necessary step. We used liquid chromatography-tandem mass spectrometry and developed a multicomponent analysis of ten drugs used in chemotherapy: vindesine, vincristine, vinblastine, doxorubicin, epirubicin, ifosfamide, cyclophosphamide, irinotecan, docetaxel, and paclitaxel. We selected five internal standards for each category of drug, because the ionization efficiencies of product ions varied widely. The total run time was 22min, applying a gradient elution of water and acetonitrile in the presence of 0.1% formic acid. The lower limit of quantification was 50ng/wipe samples for vindesine, vincristine, and vinblastine, and 5ng/wipe samples for the remaining seven drugs. Accuracy (88.6-112.9%, 85.2-111.7%) and precision (1.0-11.5%CV, 3.6-14.4%CV) in within-run and between-run assays of QC solutions were acceptable. Without outliers, in within-run and between-run assays of QC samples, accuracy was 90.6-113.9% and 91.1-130.4%, respectively, and precision was 2.2-19.0%CV and 4.8-14.9%CV, respectively. Accuracy and precision of High QC samples of irinotecan were deviated. Our analysis procedure has sufficient sensitivity and is convenient enough for regular monitoring.
Workers in the pharmaceutical industry may be exposed to many potential carcinogens. We investigated cancer morbidity in a Danish plant where enzymes, insulin, antibiotics and sex hormones were produced in substantial quantities.
Altogether 10,889 people ever employed (1964-1988) at the pharmaceutical plant were retrieved from the files of a compulsory pension fund, and followed-up in the nationwide Danish Cancer Registry (1964-1989). Site-specific standardized incidence ratios (SIR) were estimated, based on cancer rates for the national population. Information on risk factors for breast cancer, e.g. number of children, age at menarche and first delivery, obesity, and non-occupational use of sex hormones was obtained from samples of the female employees, and compared to equivalent variables from the general population.
The overall SIR for women was significantly elevated (n = 5554; SIR = 1.2). Excess risk was particularly seen for breast cancer (n = 97; SIR = 1.5), especially in a subgroup who had started work at the factory aged 30-39 and had continued to work for 1-9 years (SIR = 2.8). The SIR was near unity for men (n = 5335); however, three men with breast cancer versus 0.4 expected were found. Lifestyle components explained only about one-quarter of the excess female breast cancers. Proxy measures of intensity of occupational exposure to sex hormones or insulin showed no association with the risk for breast cancer.
It seems unlikely that either a single occupational factor or an unusual reproductive pattern can explain the elevated breast cancer risk. Therefore, the finding requires further study.
In order to assess exposure levels of hospital personnel involved in the preparation and administration of antineoplastic drugs, environmental monitoring should be carried out. Wipe samples, pads, gloves and air samples should be collected at the end of each work shift, properly treated and then analysed using instrumental techniques which are sufficiently sensitive and specific to detect even trace amounts of drug. In this study, a method using high performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS), incorporating solid phase extraction (SPE), was validated for determination of methotrexate (MTX) in wipe and air samples. Each step of the method was first developed and optimised using ultraviolet detection (UV), and afterwards tandem mass spectrometry was used to obtain a lower limit of quantitation when the expected drug level was less than the analytical UV detection limit. SPE enabled a 20-fold preconcentration of the analyte when using HPLC/UV and a further 30-fold preconcentration was obtained when analysing samples by HPLC/MS/MS. For example, the limit of quantitation (LLQ) was lowered from 3000 ng on wipe (direct injection onto an HPLC/UV system) to 5 ng on wipe (SPE plus HPLC/MS/MS). 7-hydroxymethotrexate was used as internal standard to assess precision and accuracy.
5-Fluorouracil (5-FU) is one of the most widely used antineoplastic drugs. It can be therefore considered to be a model compound for the identification of exposure routes during preparation and administration of cytostatic agents, especially for nucleoside analogue drugs. In this study, an HPLC-UV method was validated for determination of 5-FU in wipe samples by direct analysis of the aqueous solutions and in air samples by using solid-phase extraction (SPE). When samples were pre-treated on styrene-divinylbenzene resin SPE columns, a 20-fold preconcentration of the analyte was achieved. As regards air samples, correlation coefficients were always higher than 0.998 and the limit of detection was assessed at 15 ng on filter. In order to verify the reliability of these procedures, 5-chlorouracil was used as internal standard. The procedure presented here has been applied to the environmental monitoring of occupational exposed subjects. The amount of 5-FU ranged from 0.043 to 0.23 microg/m3 in air samples and from 0.2 to 470.1 microg/dm2 in wipe samples. 5-FU was also detected on the internal side of the gloves (0.07 to 3.77 microg/pair of gloves).
Occupational exposure to cytotoxic drugs of hospital personnel involved in their preparation and administration is a major issue: ever since the introduction of protective measures in recent decades, the handling of these drugs has always been referred to as an occupational health hazard. Isolator technology was one of the protective equipments aimed at providing safe handling, but it has not yet been studied regarding contamination. The present study evaluates surface contamination with four cytotoxic drugs [cyclophosphamide (CP), ifosfamide (IF), 5 fluorouracil (5FU) and methotrexate (MTX)] by wipe sampling in two hospital pharmacies. Wipe samples were taken from work surfaces both located inside and outside the isolators. In addition, working gloves, the surface of infusion bags filled with 5FU or CP, and gloves used in simulation of drug administration were analyzed. Contamination was routinely found inside the isolators but rarely outside the isolators, indicating that the isolator technology is offering good protection of the cytotoxic drug handlers as well as the environment during preparation. On the other hand, contamination was found on the surfaces of infusion bags and gloves in contact with infusion bags filled with cytotoxic drugs. Consequently, personal protective equipment is still recommended during the manipulation and administration of the drugs because of potentially contaminated drug vials and final products.
The continuous introduction of new antineoplastic drugs and their use as complex mixture emphasize the need to carry out correct health risk assessment. The aim of this study was to evaluate genotoxic effects of antineoplastic drugs in nurses (n=25) and pharmacy technicians (n=5) employed in an oncology hospital. The nurses administered antineoplastic drugs in the day-care hospital (n=12) and in the wards (n=13), and pharmacy technicians prepared the drugs in the central pharmacy. We performed the micronucleus (MN) test with lymphocytes and exfoliated buccal cells and conducted traditional analysis of chromosomal aberrations (CA). Thirty healthy subjects were selected as controls. Monitoring of surface contamination with cyclophosphamide, 5-fluorouracil, ifosfamide, cytarabine, and gemcitabine showed the presence of detectable levels only for cyclophosphamide, 5-fluorouracil and ifosfamide. In addition, we measured the 5-fluorouracil metabolite alpha-F-betaalanine in the urine of all subjects and found significant concentrations only in 3 out of 25 nurses. The micronucleus assay with lymphocytes did not show significant differences between exposed and control groups, while the same test with exfoliated buccal cells found higher values in nurses administering antineoplastic drugs than in pharmacy employees. In the CA analysis, we detected in exposed groups a significant increase (about 2.5-fold) of structural CA, particularly breaks (up to 5.0-fold). Our results confirm the genotoxic effect of antineoplastic drugs in circulating blood lymphocytes. Moreover, in exfoliated buccal cells the data show more consistent genetic damage induced during administration of the antineoplastic drugs than during their preparation. The data also stress the use of this non-invasive sampling, to assess occupational exposure to mixture of chemicals at low doses.
Measurable levels of anticancer agents are still detected on work surfaces in health-care settings. However, application of recent guidelines for the protection of workers' safety and health has resulted in lowered contamination levels. To assess occupational exposure to antineoplastic agents, very sensitive and specific procedures for environmental sampling and analysis are therefore needed. In the present study an assay for simultaneous determination of gemcitabine, taxol, cyclophosphamide, and ifosfamide in wipe samples, using two internal standards (trofosfamide and cephalomannine), was developed and validated by high-performance liquid chromatography/tandem mass spectrometry (HPLC/MS/MS). Solid-phase extraction (SPE) was used for sample concentration and cleanup. The assay was found to be linear up to 1000 ng/wipe, with limits of quantitation of 25.0 ng/wipe for gemcitabine and taxol, and 12.5 ng/wipe for cyclophosphamide and ifosfamide. In order to investigate the effectiveness of the surface sampling, removal efficiency tests were repeated on different types of surfaces. Recovery rates of between 62 and 81% were obtained at two contamination levels (50.0 and 250 ng/100 cm2). Precision and trueness were determined on three different days. The within-day precision was found to be always less than 12.1% for all the analytes. The overall precision, expressed as relative standard deviation (RSD), was always less than 9.4%. Recoveries varying from 75.0 (gemcitabine) to 95.0% (taxol) were obtained at three levels. In order to obtain a quantitative indication of the quality of the result, the overall uncertainty of measurement (UOM) was evaluated according to the EURACHEM/CITAC guide. The relative combined uncertainty was found to be always less than 9.5%. The relative expanded uncertainty was also calculated, at three contamination levels.
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