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Radiation Therapy to the Breast Mass (A) Fungating mass at the time of radiation simulation; (B) An additional subcutaneous nodule in the left upper back (red circle); (C) A representative axial computed tomography slice showing the distribution of the radiation isodose line, 3,640 cGy over 13 fractions; (D) Appearance of the mass at the end of the first radiation course; (E) Mass at 10-day follow-up visit showing viable tumor in the superior aspect; (F) Electron beam therapy to the residual viable tumor, 1,500 cGy in five fractions.
Source publication
Although advances in screening mammography have dramatically improved the early detection of breast cancer, a subset of breast cancer cases still present as locally advanced disease. Some of these patients develop fungating lesions, which are difficult to manage and can have a severe impact on the quality of life. Palliative treatment options inclu...
Contexts in source publication
Context 1
... exam, the patient appeared withdrawn and teary. She had an impressive 15 x 10 cm fungating mass emanating from the right breast with necrotic tissue seen in the medial inferior aspect ( Figure 2A). No foul smell or active bleeding was observed. ...
Context 2
... foul smell or active bleeding was observed. She was also noted to have painful violaceous subcutaneous nodules over the left scapula, left flank, and forehead ( Figure 2B). Radiotherapy was subsequently delivered to the right breast and symptomatic subcutaneous nodules. ...
Context 3
... was subsequently delivered to the right breast and symptomatic subcutaneous nodules. Her right breast mass initially received 3,640 cGy given over 13 daily fractions via 6 MV/10 MV tangential photons with a 0.5 cm bolus, while the skin nodules were treated with 2,000 cGy over five fractions using either photon or electron beam depending on the target depth ( Figure 2C). Her right breast tumor regressed during treatment with significant portions of the exophytic mass becoming necrotic ( Figure 2D). ...
Context 4
... right breast mass initially received 3,640 cGy given over 13 daily fractions via 6 MV/10 MV tangential photons with a 0.5 cm bolus, while the skin nodules were treated with 2,000 cGy over five fractions using either photon or electron beam depending on the target depth ( Figure 2C). Her right breast tumor regressed during treatment with significant portions of the exophytic mass becoming necrotic ( Figure 2D). The patient returned 10 days later for a follow-up visit at which time further tumor regression was noted in both her breast and subcutaneous nodules ( Figure 2E). ...
Context 5
... right breast tumor regressed during treatment with significant portions of the exophytic mass becoming necrotic ( Figure 2D). The patient returned 10 days later for a follow-up visit at which time further tumor regression was noted in both her breast and subcutaneous nodules ( Figure 2E). However, there was clear evidence of viable tumor superiorly in her breast, and a decision was made to boost this area with an additional 1,500 cGy in five daily fractions using 15 MeV electron beams with a 0.5 cm bolus ( Figure 2F). ...
Context 6
... patient returned 10 days later for a follow-up visit at which time further tumor regression was noted in both her breast and subcutaneous nodules ( Figure 2E). However, there was clear evidence of viable tumor superiorly in her breast, and a decision was made to boost this area with an additional 1,500 cGy in five daily fractions using 15 MeV electron beams with a 0.5 cm bolus ( Figure 2F). She tolerated the radiation exceedingly well, experiencing only a mild skin reaction and no other side effects. ...
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Citations
... A single institution retrospective Indian study of 2,394 breast cancer patients revealed that 316 (29 %) had stage T4b cancer at diagnosis and 79 (3.3 %) had a fungating tumor. 13 Advanced breast cancer, in our local experience, commonly presents as a fungating breast mass with symptoms of pain, a bulky tumor mass, bleeding, and malodorous discharge with subsequent infection. 12 Fungating tumors present an enormous challenge and have a significant impact on the patient's quality of life and social wellbeing. ...
... 12 Fungating tumors present an enormous challenge and have a significant impact on the patient's quality of life and social wellbeing. 13 The management of fungating breast lesions is not particularly well-researched. A 2020 paper by Rupert and Fehl provides care recommendations, but international guidelines are lacking. ...
... 15 However, there is no consensus on the radiation dose, treatment technique or timing of this intervention. 13,15 Current guidelines for palliative RT for symptomatic breast tumors suggest several RT fractionation regimes based on the patient's prognosis and performance status and these include a single fraction of 8 Gy, 20 Gy in five fractions through to 30/39 Gy in 10/13 fractions, and 50 Gy in 25 fractions. 13,6 Common palliative doses in this setting such as 20 Gy in 5 fractions or 30 Gy in 10 fractions would seem reasonable. ...
Kilovoltage (kV) radiotherapy, also called superficial radiotherapy (SXT) or orthovoltage radiotherapy (DXT), is a well-known and effective treatment option for non-melanoma skin cancer and some benign skin and musculoskeletal conditions. Given its surface dose delivery, its use in radiation oncology beyond superficial skin cancers is generally limited, but it has also been shown to be extremely useful for specific palliative applications. Here, we describe the characteristics of kilovoltage radiotherapy and report on six cases of locally advanced and/or metastatic breast cancer in which kilovoltage radiotherapy was used as the primary modality or as supportive treatment to linac-based radiotherapy to gain local tumor control and improve the patient’s quality of life.
... A major risk factor in fungation development is delayed diagnosis [19], and this coincides with our findings that the median time from lump sensation to clinical assessment was 6.5 months. But it should be emphasized that there are numerous other factors to be considered, including tumor biology [20] and location/breast volume (superficial and near the skin surface, or within breast quadrants and less volume of breast tissue), lack of availability of screening services, and limited use of the multidisciplinary approaches in clinical management [21,22]. ...
... Palliative wound care involves debridement, frequent dressing, topical antibacterial, and topical and systemic analgesics [9,28]. Local and systemic therapies include neoadjuvant chemotherapy (NACT) [20,29,30], hormone therapy, radiation therapy [20,31], surgical resection with or without reconstruction [30,32], and endovascular embolization [33][34][35][36]. The major problem facing oncoplastic surgeons in managing fungating breast cancer is that many patients at the time of presentation are not candidates for upfront surgery due to the inability to perform safe and sound wound closure, or obtain R0 or R1 resection margins [20,28]. ...
... Palliative wound care involves debridement, frequent dressing, topical antibacterial, and topical and systemic analgesics [9,28]. Local and systemic therapies include neoadjuvant chemotherapy (NACT) [20,29,30], hormone therapy, radiation therapy [20,31], surgical resection with or without reconstruction [30,32], and endovascular embolization [33][34][35][36]. The major problem facing oncoplastic surgeons in managing fungating breast cancer is that many patients at the time of presentation are not candidates for upfront surgery due to the inability to perform safe and sound wound closure, or obtain R0 or R1 resection margins [20,28]. ...
Fungating breast cancer severely affects patients’ daily lives, and patient management poses major oncology challenges. To present 10-year outcomes of unique tumor presentation, suggesting a focused algorithm for surgical management and providing deep analysis for factors affecting survival and surgical outcomes. Eighty-two patients with fungating breast cancer were enrolled in the period from January 2010 to February 2020 in the Mansoura University Oncology Center database. Epidemiological and pathological characteristics, risk factors, different surgical treatment techniques, and surgical and oncological outcomes were reviewed. Preoperative systemic therapy was used in 41 patients, with the majority (77.8%) showing progressive response. Mastectomy was performed in 81 (98.8%) patients, with primary wound closure in 71 (86.6%), and wide local excision in a single patient (1.2%). Different reconstructive techniques in non-primary closure operations were used. Complications were reported in 33 (40.7%) patients, of which 16 (48.5%) were of Clavien-Dindo grade II category. Loco-regional recurrence occurred in 20.7% of patients. The mortality rate during follow-up was 31.7% (n = 26). Estimated mean overall survival (with 95% CI) was 55.96 (41.98–69.9) months; estimated mean loco-regional recurrence-free survival (with 95% CI) was 38.01 (24.6–51.4) months. Surgery is a cornerstone fungating breast cancer treatment option, but at the expense of high morbidity. Sophisticated reconstructive procedures may be indicated for wound closure. A suggested algorithm based on the center’s experience of wound management in difficult mastectomy cases is displayed.
... 3 Locally advanced breast cancer continues to account for 30% to 60% of new diagnoses of breast cancer worldwide and 10% to 20% of those in the United States. [4][5][6] Patients with LABC often present with a large palpable mass that erodes the overlying skin, resulting in a fungating, ulcerative, or necrotic lesion. In advanced cases, the entire breast is replaced by tumor (Fig. 1A). ...
... Accompanying features of pain, physical deformity, recurrent bleeding, drainage, and large open wounds, with superimposed infections, are common and ultimately compel these patients to seek medical treatment. [5][6][7][8][9][10][11][12][13] Malodorous discharge can force patients to selfisolate, while breast deformity impacts their body image. 14,15 Despite their significant symptoms and advanced disease, these patients are often deemed "unresectable" and only palliative options, such as chemotherapy, radiation, or topical agents, are offered. ...
Background
Patients with locally advanced invasive breast cancer (LABC) are often considered inoperable, because of the anticipated chest wall defect and need for complex reconstruction. We present a series of patients who underwent mastectomy with extensive skin resection and immediate chest wall reconstruction using a local thoracoabdominal advancement flap (TAAF). All patients were managed after surgery with an ERAS (Enhanced Recovery After Surgery) protocol, to decrease length of stay in hospital. We also present 1 patient who subsequently had satisfactory bilateral delayed breast reconstruction with pedicled latissimus dorsi myocutaneous flaps with prepectoral silicone implants.
Methods
This is a single-surgeon, single-institution retrospective chart review of patients with LABC who underwent mastectomy with skin resection and local TAAF from May 2017 to October 2019, with minimum 3-month follow-up.
Results
Thirteen patients met inclusion criteria. Twelve of 13 patients presented with stage III or IV invasive breast cancer, with skin involvement. The mean chest wall defect measured 248.7 cm2 (140–336 cm2; SD, 63.2 cm2), and all were successfully reconstructed with immediate local TAAF. There were no intraoperative complications, but 1 patient developed a postop hematoma. The mean hospital stay was 1.3 nights, with 9 patients (69.2%) staying less than 23 hours and 4 patients (30.8%) staying 2 nights. Nine patients (69.2%) underwent adjuvant therapy, beginning on average 32 days (13–55 days; SD, 13.1 days) after surgery. The mean follow-up time was 13.8 months (4.5–31.6 months; SD, 9.2 months). One patient underwent successful delayed bilateral breast reconstruction with pedicled latissimus dorsi myocutaneous flaps and silicone implant placement.
Conclusions
Our study demonstrates that reconstruction with local TAAF is an outpatient procedure that reliably provides durable, immediate chest wall coverage, after mastectomy in patients with LABC. This technique has a short operative time, low blood loss, and low complication rate, allowing timely adjuvant therapy. Using an ERAS postop protocol we were able to reduce mean hospital stay to 1.3 days. Compared with other described techniques of reconstruction, the additional scars and donor site morbidity are minimal, allowing for delayed breast reconstruction. We also present survival outcomes data on these surgically managed patients.
... There were no differences between patients who received below or above the median dose of 39 Gy (EQD2 46.6 Gy) or a dose of 30 Gy (EQD2 34.5 Gy). Other series describe diverse, non-uniform treatment protocols: doses, fractionation, ± hyperthermia [13][14][15] . In our cohort, single fraction RT was inferior to fractionated RT in terms of clinical benefit and need for re-irradiation. ...
In this study, we evaluated the effectiveness of palliative breast radiation therapy (RT), with single fraction RT compared with fractionated RT. Our study showed that both RT fractionation schemas provide palliation. Single fraction RT allowed for treatment with minimal interference with systemic therapy, whereas fractionated RT provided a more durable palliative response. Due to equivalent palliative response, at our institution we have increasingly been providing single fraction RT palliation during the COVID-19 pandemic.
... G lobally, there are over one million cases of breast cancer diagnosed each year (Global Cancer Obsevatory, 2019). Locally advanced breast cancer accounts for 10% to 30% of new breast cancer diagnoses (Gao, Edlund, & Yuan, 2017). Approximately 2% to 5% of locally advanced breast cancers develop a fungating breast wound (FBW;Lund-Nielsen, Müller, & Adamsen, 2005). ...
... Unfortunately, there is no consensus on when women with FBW should have a radiotherapy intervention, or on the optimal radiation dosing. In previously published data, it was found that a dose of 30 Gy to 50 Gy may be needed to sustain a durable response with minimal toxicity (Gao et al., 2017). ...
Nearly 2% to 5% of locally advanced breast cancers develop a fungating breast wound (FBW). Fungating breast wounds develop when malignant cells infiltrate the skin and cause breakdown, ulceration, and infection. Although systemic and locoregional control of locally advanced breast cancer is necessary, appropriate management of the wound is also crucial. With limited research and reference literature involving FBW, management of FBW is not well understood. The following article will highlight the comprehensive care approach needed to manage the patient with FBW, including medical management of the locally advanced breast cancer, addressing psychosocial complications, pain management, and wound care with appropriate dressing recommendations according to the specific wound characteristics. In addition, examples and brand names will be given, as the availability of products may be dictated by the facility, or price comparisons may need to be made for the patient who will have out-of-pocket costs.
... Locoregional progression-free survival (p=0.2) and overall survival (p=0.4) were not significantly different between patients with and without distant metastases at presentation 2 . Similar results were noticed by other authors who reported isolated case reports of patients with unresectable breast cancers who received palliative RT 3,34 . ...
“Extensive” T4 malignant breast tumors are not uncommon and can be either primary or recurrent. Theycan present without or be accompanied by distant metastases at the time of initial presentation. They share one or more of the following symptoms: mass effect, pain, malodor, esthetic distress, exudation, pruritus, bleeding, and crusting. The aim of their treatment is therapeutic, when possible, or palliative, which is quite often the case. A small case series of three female patients with “extensive” T4 breast cancer is presented. The various surgical options for excision of the tumor and reconstruction of the resulting defect are discussed. Methods of management of odor, infection control, and pain, especially when surgery or radiotherapy is contraindicated, is also discussed.
General purpose:
To provide information on the surgical management of fungating malignancies as a distinct wound entity.
Target audience:
This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.
Learning objectives/outcomes:
After participating in this educational activity, the participant will:1. Identify characteristics of patients in a study examining the treatment of fungating malignancies.2. Select common symptoms experienced by patients with fungating malignancies.3. Explain issues related to the surgical treatment of fungating malignancies.4. Identify a reason why patients with fungating breast masses may avoid medical care.
