Late radiation sequelae as a consequence of breast-conserving therapy with cobalt irradiation aggravated by various risk factors

Abstract

This report deals with a 71-year-old female patient who developed cancer in her right breast 20 years ago, underwent breast-conserving surgery and received normofractionated radiotherapy with a 60Co unit. 19 years later, fibroids and calcified tissue appeared in her right mammary fold. Furthermore, a deep ulceration developed in this region during chemotherapy of bronchial carcinoma. Apart from being a Type 2 diabetic with arterial hypertension, she was also a habitual smoker. After extensive wound debridement and vacuum-assisted sealing therapy, the affected ribs were dissected and a latissimus dorsi flap was implanted. Our focus here is on the interaction of contributing risks for the development of late radiation sequelae, such as physical (especially unintended hot spots during 60Co irradiation) and pathophysiological factors (comorbidities and morbid affections). Fortunately, side-effects such as these are rare nowadays. As this case shows, however, they can be effectively handled by employing modern plastic surgery techniques.

Symptomatic Calcifications after Mastectomy: A Rare Case Report with a Review of the Literature

“…The only similar case report worldwide was published by Hermann et al The authors presented a patient with calcifications in the scar, manifesting 20 years after breast cancer surgery and radiotherapy [ 2 ]. The treatment involved antibiotics, debridement with a VAC system, and subsequent reconstruction by a latissimus dorsi flap, resulting in a successful outcome [ 2 ]. The latissimus dorsi flap is commonly chosen for immediate reconstruction after mastectomy or for defect coverage in locally advanced breast tumors [ 11 ].…”

“…The most common clinical manifestations of calcifications, as described by multiple authors, include skin edema, fibrosis, and ulcerations [ 1 , 2 , 5 , 7 , 9 , 10 ]. However, serious radiation sequelae, such as osteonecrosis, are rarely observed in the modern era of radiotherapy [ 2 ].…”

“…The most common clinical manifestations of calcifications, as described by multiple authors, include skin edema, fibrosis, and ulcerations [ 1 , 2 , 5 , 7 , 9 , 10 ]. However, serious radiation sequelae, such as osteonecrosis, are rarely observed in the modern era of radiotherapy [ 2 ]. The described clinical manifestations could also be signs of breast cancer relapse; therefore, histological examination must be performed in all patients with these symptoms.…”

“…with different approaches and conclusions. Only one author presented surgical excision with subsequent reconstruction by a latissimus dorsi flap, but no article mentioned reconstruction by a thoraco-epigastric flap [ 2 ]. The thoraco-epigastric fascio-cutaneous flap is well-established technique used by surgeons in breast cancer patients for reconstruction after mastectomy, usually in locally advanced tumors requiring coverage of a large defect in the lower thoracic region [ 3 , 4 ].…”