Chemotherapy port "Twiddler's syndrome". A need for preinjection radiography.

Potentially serious extravasation of vincristine occurred when a chemotherapy port, inadvertently withdrawn from the subclavian vein by the patient, was injected. Plain radiography suggested withdrawal of port tubing which was later proven by contrast injection. The need for awareness of possible patient manipulation of their indwelling ports and routine preinjection radiography is suggested.