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Large ulcer on the chest wall - Ärzteforum

Post#1 »

Today I saw a 65 year-old woman who has ignored a problem with her left breast for several years. When I examined her, I saw a large ulcer (about 10x15 cm) on the chest wall with a necrotic exudate. Perhaps part of the axillary tail of the breast remained, but nothing else. I didn't see any ribs showing, so I assume that the pectoralis muscle was still there.

Oh yeah... there was a large tumor under the nipple of the right breast, which had an inverted retracted nipple which bled. There were no palpable lymph nodes. She is otherwise well, and has no complaints except for pain when she raises her left arm (!). I did a core needle biopsy of the right breast mass.

I haven't seen a breast cancer in several years (they all seem to go to the breast "specialist"). So I will admit that I haven't seen this before. I ordered a bone scan and chest x-ray. I will send her to the medical oncologist for chemotherapy.

My question to our consultants: What will happen to the ulcer on the chest wall? Will chemotherapy eradicate the tumor? If so, will the wound clean itself up? Will she ever be a candidate to have the chest wall closed, presumably by some type of rotation flap? At this point, I can't imagine doing anything to the left side. The wound looks horrible, though I see nothing to debride.

Grandpa Phil

Re: Large ulcer on the chest wall - Ärzteforum

Post#2 »

Congratulation for not attempting a laparoscopic mastectomy!!! Sorry- could not resist.

Now seriously: I agree with you that chemo is the way to start- adding radiotherapy will aid shrinking the tumor. I am sure you sent the specimen for receptors- tamoxifen may play a role in this post-menopausal women.

Obviously there is no role here for any axillary procedure. You should await the response to the chemoradio- when the tumor shrinks it will be possible to perform a so called "toilet mastectomy"-reconstructing the defect with one of the methods available to our esteemed plastic friends.

I hope she does not have deep chest wall involvement.

Interestingly, we saw last week in the clinic a patient with a chest wall recurrence following a mastectomy which on CT directly penetrates into the pericardium (!). Lucky for her- she was uninsured- nobody thus will attempt a cardiac transplant.


Re: Large ulcer on the chest wall - Ärzteforum

Post#3 »

You did not tell us what was the histopathology on the breast, this lady has at present a n advanced bilateral carcinoma of the breast. On the ulcerated left breast she will need a wide excision with a latismus dorsi flap to cover the defect,if the tumour is not attached to the chest wall . If however the tumour is involving the chest wall she will need radiation therapy. she will also need a right mastectomy and axillary clearance. this should be followed with tamoxifen. I dont think she will tolerate aggressive chemotherapy.

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A Doctor

Re: Large ulcer on the chest wall - Ärzteforum

Post#4 »

I have seen similar cases through the years. It is absolutely amazing what patients will put up with before seeking medical care. One of my patients presented with severe neck pain. On X-Ray she had extensive osseous metastases in the C-spine, with a cevical fracture. On breast exam she had an ulcerated fungating mass that she had hidden from her husband for four years!

These wounds seem to be the most malodorous of any you will have to deal with. Dakin's solution seems to be a good method to deal with the wound to minimize the odor if present. I have done "up front" toilet mastectomies on some of these patients, if the tumor is resectable. If not, then chemotherapy is the initial treatment. Tamoxifen can be very effective, but I would not use it alone. I would expect that her open wound would shrink but not heal with chemotherapy.

I have seen some of these patients live five years or more, though her prognosis is not good. If she has a good response to chemotx, then bilateral mastectomies can be used for local control. This may well require removal of the pectoralis muscle on the left, with skin graft. Radiation to the left chest wall will decrease the recurrence risk. If I saw axillary nodes during the mastectomy, I'd remove them, but she does not need an axillary dissection.

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Re: Large ulcer on the chest wall - Ärzteforum

Post#5 »

These cases are really not uncommon! They do repersent some denial and fear from the patient s part ! I still think they should be manged as T4 lesions and Mets work up should be done 1 st prior to any aggressive local control !


Re: Large ulcer on the chest wall - Ärzteforum

Post#6 »

I saw case of breast cancer penetrating into the left ventriculus several years ago. Patient was admitted with profuse bleeding and dead in OR.

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Re: Large ulcer on the chest wall - Ärzteforum

Post#7 »

Maybe I am missing something, but my question is as follows:
Why would you store the skin graft in the first place? If the wound is clean, graft in one setting. If the wound is not clean, do local wound care until it is, and then come back for a skin graft.

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Lady Surgeon

Re: Large ulcer on the chest wall - Ärzteforum

Post#8 »

I store any extra skin I harvest that I don't need for the first grafting (of any small thing I graft: small burns, neglected skin avulsions, open wounds from injuries, large mastectomy defects). I wouldn't harvest skin and not use any of it--I agree with you there.

I had one recent large neglected lower inner quadrant breast cancer--like Mark's case but just the lower inner quadrant. After chemotherapy, I did a mastectomy including complete excision of the necrotic tumor in the lower inner quadrant. This left a skin defect requiring grafting, but I had extra superior flap skin (sideways redundant)--I excised a triangle of full thickness skin from the upper flap which helped this lay flatter (this lady did not want to consider reconstruction) and filled the lower inner quadrant defect. I actually even meshed the full thickness graft to increase the chance of it taking--it was difficult but possible to get a full thickness graft through the mesher. She is actually quite happy with her result.

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