RESUMO
BACKGROUND: Musculocutaneous (MC) flaps are more resistant to infection than implants, but no clinical results have been reported so far about the grafting of MC flap to the overtly infected sites. CASE PRESENTATION: A 66-year-old woman had received radiotherapy, a total dose of 50 Gy, to her large mucinous breast cancer to control bleeding from the tumor and was referred to our hospital for further treatment. On her first visit to our hospital, her left breast showed radiation-induced total necrosis with Pseudomonas aeruginosa infection. Removal of the necrotic breast tissue resulted in direct exposure of the left ribs and intercostal muscles with intractable chest pain requiring analgesics. The presence of concomitant life-threatening multiple lung metastases made us change the treatment from letrozole and palbociclib to bevacizumab and paclitaxel, leading to marked regression of the lung metastases. To alleviate her chest pain and get local wound healing, we treated the patient with latissimus dorsi (LD)-MC flap grafting to the exposed chest wall after four months of taxane-containing chemotherapy. The patient has got marked pain relief immediately after the operation. Skin island of the grafted LD-MC flap showed no problems for 4 days just after the operation but gradually turned out to be edematous to ill-colored in the distal part of the skin island. Post-operative clinical outcome suggested that Pseudomonas aeruginosa infection might have had some adverse effect, e.g., microemboli, on MC flap blood flow. Partial necrosis of the LD-MC flap made the patient receive conservative wound management for a very long period of 11 months, finally leading to complete wound healing. After palliative surgery, the patient has been receiving fulvestrant and palbociclib for 14 months and doing well with good control of multiple lung metastases. CONCLUSIONS: Breast surgical oncologists should note that partial flap necrosis can occur when a LD-MC flap is grafted to the infected recipient site and consider the anti-coagulant therapy just after the operation to avoid the adverse effects of the infection.
RESUMO
A 53-year-old woman with a large, easy-bleeding, and ulcerated breast tumor visited our hospital due to severe anemia. Transfusion and Mohs' chemosurgery gave the patient marked improvement of her local and general condition. After confirming the human epidermal growth factor receptor type 2 (HER2)-positive breast cancer with no distant metastasis, anti-HER2 agents-containing chemotherapy brought about clinical complete response of the locally advanced breast cancer with a shrunken but still large skin defect. We, therefore, treated the patient with mastectomy and axillary node dissection but failed to directly close the skin even after full skin undermining. We then tried to cover the skin defect using a latissimus dorsi flap, that is, horizontal spindle skin 12 × 6 cm in size, but again failed to fully cover the skin defect. We finally and ostensibly covered the skin defect through an additional skin incision to the recipient skin, but could not get complete wound healing. Pathological study showed a marked collagen fiber around the skin defect and faint viable cancer cells beneath the nipple. The patient required 3 months of wound management for complete wound healing, leading to the application of anti-HER2 agents without anticancer agent to the patient during that time as an adjuvant therapy. Regrowth of her hair once lost by the neoadjuvant chemotherapy (NAC) made the patient refuse the adjuvant anthracycline-containing chemotherapy after wound healing. The patient, therefore, received trastuzumab-emtansine for a year and has been well for 17 months postoperatively. Breast surgeons should note that a skin defect after favorable response to NAC is often surrounded by less stretchable skin due to chemotherapy-induced massive collagen fiber and requires careful preoperative planning for skin closure.