Management and Reconstruction in the Breast Cancer Patient With a Fungating T4b Tumor

Study design and population

This work has been approved by the institutional review board at Rutgers University–New Jersey Medical School. We performed a retrospective review of the electronic medical records of patients treated from 2011 to 2014 at the University Hospital in Newark, NJ. A total of 12 patients underwent reconstructive surgery following resection of fungating T4b breast tumors.

Demographics and preoperative clinical data

Data were collected from patient electronic medical records. Clinical characteristics of interest included age, chief complaint, location of first presentation, and reasons for delayed presentation. Tumor characteristics including tumor dimensions and nature of wound/odor were also analyzed when available. Disease features including pathologic stage and presence of distant metastases were relevant to this study. Preoperative laboratory values of interest included albumin, hemoglobin, white blood cell count, platelet count, international normalized ratio, and creatinine.

Postoperative clinical data

Administration of adjuvant chemotherapy or postoperative radiation was documented. Types of oncologic and plastic surgery performed were recorded and analyzed. Postoperative follow-up, disposition, and survival were also noted.

Patient data

Twelve patients underwent a total of 14 breast tumor resections and 13 pedicled flap reconstructions with or without split-thickness skin grafting of complex chest wall defects. Patient demographic data are listed in Table 1. The mean age within our patient population was 52.6 years, with an age range of 33 to 74 years. Seven of the 12 patients in this study were African American; 4 patients reported Hispanic ethnicity. Five of the 12 patients were English-speaking. One patient reported recent homelessness, and 5 patients were unemployed at the time of presentation.

Preoperative assessment

Data pertaining to clinical presentation and preoperative assessment are listed in Table 2. Three patients first presented to the emergency department at the University Hospital in Newark, NJ. Seven patients initially presented to our charity care clinic. Two of the 12 patients in this study had health care insurance at the time of presentation. The most common chief complaint among these patients was the presence of an open wound (100%) or pain at the lesion site (88%). Hemodynamic instability was noted in a significant percentage of patients (17%); one patient presented in septic shock, whereas another was in hypovolemic shock as a result of blood loss from her lesion. A quarter of the patients studied reported a malodorous discharge at the time of presentation. Among those patients who cited reasons for their delayed presentation, embarrassment and fear of treatment were among the responses provided. One half of patients had a diagnosis of distant metastases by imaging at the time of presentation, whereas a minority (42%) received neoadjuvant chemotherapy prior to surgical intervention. The majority of defects were unilateral, although bilateral breast involvement was noted in 22% of cases. One patient presented to us from a psychiatric institution where she was undergoing treatment of paranoid schizophrenia, whereas another carried a preexisting diagnosis of generalized anxiety disorder.

Preoperative laboratory characteristics are listed in Table 3. The mean hemoglobin level of this cohort was 9.8, although 1 patient presented to our institution with a hemoglobin level of 4.2.

Surgical data

Characteristics of oncologic and reconstructive management of these patients are listed in Table 4. The most common oncologic surgery performed to resect T4b breast tumors in this patient population was a modified radical mastectomy (MRM; 75%). Modified radical mastectomy with removal of the pectoralis major fascia was performed in 4 patients (33%). Axillary lymph node dissections were performed on all patients receiving MRM. Fewer patients required radical mastectomy (17%) or procedures involving chest wall resection (17%). The mean size of the chest wall defect requiring reconstruction was 473 cm². The majority of initial reconstructive surgical procedures occurred immediately following tumor resection (83%), although 2 patients underwent reconstruction more than 3 days after removal of their tumor. Five of the 12 patients required 2 reconstructive surgical procedures. The thoracoabdominal advancement flap and the latissimus dorsi flap were among the most frequently used reconstructive modalities. The mean hospital stay among this group was 7 days, and a significant percentage (33%) of patients were discharged to hospice.

Case 1

A 61-year-old woman of Haitian decent presented to the charity care clinic at the University Hospital in Newark, NJ, complaining of right breast, arm, and back pain. On physical examination, the patient was found to have a 15 × 13.5 × 11-cm right lateral breast mass with peau d’orange and ulceration with pruritic borders (Fig. 1a). She was unemployed and lived with her 2 sons, not citing a specific reason for her delayed presentation. The patient was evaluated by the medical and surgical oncology services and received a diagnosis of inflammatory breast cancer of the right breast, with right axillary lymphadenopathy and no distant metastasis, and was scheduled to receive neoadjuvant therapy prior to surgical consideration.

Figure 1. (a) Preoperative image of the right-sided fungating breast tumor. (b) Extirpative defect of the right chest wall. (c) A 884-cm2 defect, immediately reconstructed. (d) Immediate reconstruction with a latissimus myocutaneous flap and reverse abdominoplasty (rectus abdominis fasciocutaneous flap).

Approximately 6 months after receiving neoadjuvant chemotherapy, she underwent oncologic surgery of her right breast consisting of MRM and lymph node dissection (Figs. 1b and 1c). The wound measured 28.5 × 24 cm (684 cm²), and she immediately underwent reconstruction with a latissimus myocutaneous flap and reverse abdominoplasty (rectus abdominis fasciocutaneous flap) (Fig. 1d). Pathologic stage was determined to be T4bN2a with clear margins. Her hospital stay was 4 days, and she was ultimately discharged home with nursing care. She continued to receive outpatient chemotherapy.

The patient followed up in our clinic up to 8 months postoperatively. Throughout her postoperative course, she reported improved pain but claimed it was still present because of her surgery. She had no postoperative drainage, bleeding, or dehiscence. Her reconstruction was not complicated by infection, nor did she experience any complications requiring further operation from her first reconstructive surgery. Approximately 11 months after her initial surgery on her right breast, she underwent a second operation for an enlarging left breast mass considered to be a new primary site of cancer, consisting of a radical mastectomy and coverage of the defect with a pectoralis minor flap, adjacent tissue transfer of axillary skin, and placement of a negative pressure wound dressing. Her second reconstruction, on her left breast, was complicated by infection, which was treated with intravenous antibiotics. She went on to heal without any complication. Her postoperative survival time from her initial surgery was 294 days.

Case 2

A 53-year-old woman of Hispanic descent presented to the emergency department at our institution complaining of foul-smelling discharge and pain at the left breast, as well as fatigue and a 24-lb weight loss over the prior 2 months. The patient reports that she first began to experience pain within her breast 3 months ago, at which time she began to treat herself with “alternative therapies.” On examination, she was noted to have a large, ulcerated, fungating breast mass with foul-smelling purulent drainage and bleeding (Fig. 2a). Her hemoglobin level on admission to the hospital was 4.2. The patient reported that she avoided seeking medical treatment of her breast mass until this admission because of fear of treatment. Her 44-year-old sister died of breast cancer after a long treatment course and multiple operations. At the time of her presentation, the patient lived at home with her mother, husband, and son.

Figure 2. (a) Perioperative image of the left-sided fungating breast tumor. (b) A 240-cm2 defect, initially managed with negative pressure wound therapy. (c) Stage 2 reconstruction with split-thickness skin grafting over a 240-cm2 defect. (d) Two months after discharge, recurrent left breast mass protruding through graft site.

After receiving 4 units of packed red blood cells, the patient underwent MRM with removal of the pectoralis major fascia and axillary lymph node dissection. Pathologic stage was found to be T4bN4p3a with a mass size of 19 × 15 × 12 cm. Reconstruction was performed in 2 stages, the first of which involved closure of axillary contents with the application of a negative pressure wound therapy dressing on the day of initial resection (Fig. 2b). The second stage of reconstruction involved a 240-cm² split-thickness skin graft (Fig. 2c). The patient had a 15-day hospital course at our institution. She refused discharge to hospice and was instead discharged home.

The patient refused postoperative radiation therapy and missed multiple chemotherapy appointments with medical oncology. When contacted via telephone, the patient cited “excessive breast pain” as the reason for her poor follow-up. She never returned to our clinic for a postoperative examination. She subsequently revisited the emergency department 2 months after her discharge complaining of a recurrent left breast mass and discharge from the breast. Examination revealed a large fungating breast mass protruding through the graft site (Fig. 2d). At this point, the patient was discharged home without further surgical or medical intervention for her disease.

Case 3

A 38-year-old Hispanic woman presented to our clinic complaining of minimal pain at her chest with movement of her left arm for several years’ duration. On examination, she was found to have a large ulcerative lesion on her left lateral breast, measuring 9 × 8.4 × 4 cm and not associated with any drainage or bleeding (Fig. 3a). At the time of this presentation, the patient was employed as a housekeeper and lived at home with 3 children. She had noticed a left breast mass 4 years prior while in the Dominican Republic, which was finally diagnosed in the United States 2 years later after which she underwent neoadjuvant chemotherapy with an unfavorable response. The patient was evaluated by medical, surgical, and radiation oncology and received a diagnosis of invasive ductal carcinoma with metastasis. She underwent MRM and axillary lymph node dissection shortly thereafter with immediate reconstruction of the 15 × 20-cm (300 cm²) defect with advancement of local axillary skin and split-thickness skin grafting to the defect (Figs. 3b–3d). Pathology revealed diseased margins and a stage T4bN0 tumor.

Figure 3. (a) Preoperative image of the left-sided fungating breast tumor. (b) A 300-cm2 defect, immediately reconstructed. (c) Immediate reconstruction with split-thickness skin grafting over a 300-cm2 defect. (d) One month postoperatively, revealing a well-healed recipient site.

Her postoperative course demonstrated no complications, and she was discharged home on postoperative day 6. She was followed up in our clinic regularly and stated she no longer had any pain at her surgical site as early as 2 weeks postoperatively. She received postoperative radiation to her breast subsequently due to remaining disease. She is currently living and during her last visit expressed that she would undergo the procedure again due to alleviation of her pain symptoms and no complications from the procedure.