1Trakya University School of Medicine, Thoracic Surgery Department, Edirne, Turkey
Corresponding author details:
Fazli YANIK
Trakya Tip Fakultesi
Gogus Cerrahisi AD
Edirne,Turkey
Copyright:
© 2018 Yanik F, et al. This is
an open-access article distributed under the
terms of the Creative Commons Attribution 4.0
international License, which permits unrestricted
use, distribution, and reproduction in any
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are credited.
Breast cancer(BC) is described as a malignant development that occurs in the structure
of the mammary gland. BC is the most common cancer in women. It is the major causes of
death from cancer. We present a 62-years-old femalepatient had left radical mastectomy +
axillary lymphnode curettage with a diagnosis of stage IIIA invasive ductal breast cancer 10
years ago. After adjuvant oncological treatment recurrence was detected in the chest wall.
She successful operated with hybrid reconstruction using both synthetic and autologous
grafts.
Breast Cancer, Chestwall, Reconstruction
Breast cancer (BC) is described as a malignant development that occurs in the structure
of the mammary gland. BC is the most common cancer in women. It is the major causes of
death from cancer in the country, particularly in the western countries. BC is one of the few
malignant tumors that can be screened and diagnosed as subclinical. As in most cancers,
there is a multidisciplinary approach to BC that deals with many different branches of
diagnosis and treatment [1,2].
A 62-years-old female patient had left radical mastectomy + axillary lymph node
curettage with a diagnosis of stage IIIA invasive ductal breast cancer 10 years ago. There
was no significant finding in physical examination, laboratory findings, family history, pas
medical history, medications. Adjuvant chemotherapy and radiotherapy were performed
and followed oncologically. She applied to our clinic with symptoms of pain on the left
mastectomy incision and chest wall. Pathological fractures in the left 5,6,7 ribs, skin
defect, tumoral thickening in the chest wall were detected in thorax CT images (Figure
1A,B). PET /CT images showed high FDG uptake(SUVmax: 6.4) only at the same location
(Figure 1 C,D). The patient was discussed at the multidisciplinary council and the operation
decision was taken considering local recurrence. In the operation; left 5,6, 7. The ribs and
hest wall were resected by keeping the 4 cm surgical margin(Figure 2A). The chest wall
defect was reconstructed with two titanium bars and a prolene mesh (Figüre 2B). The
skin defect was reconstructed with latissimusdorsi musculocutaneous flap (Figure 2C,D).
The histopathologic examination result was metastasis of invasive ductal carsinoma with
negative surgical margins. The patient is followed without any problems during the first
post operative year. Control chest CT and PET / CT were used in follow-up, pathological
findings were not detected.
Figure 1:A,B: Chest wall invasion of invasive ductal carcinoma , thorax-CT images, marked with blue arrow
C,D: Chest wall invasion of invasive ductal carcinoma , PET/ CT images.(SUVmax:6,4), marked with blue arrow
A: Macroscopic view of tumor after resection.
B: The intraoperative view of reconstruction with titanium bar andprolene mesh.
C,D: The intraoperative view of reconstruction with latissimus dorsi musculo cutaneous flap
The improvement in chest wall stability explains the postoperative mortality rates being no greater than 2% [1-3]. There are two ways to close defects: prostheti corautologous tissue (pedicled muscular or musculocutaneous flaps) with excellent circulation support. There commended reconstruction methods are the closure of defects by synthetic materials polytetrafluoroethylene mesh, polypropylene mesh, polyester mesh, composite prosthesis- methyl methacrylate bone cement, etc....), titanium osteosynthesis materials, and autologous materials (bone grafts, muscular transpositions, etc....) [3]. In our case we decided that the prosthetic titanium bar can stabilize the chest wall due to the size of the defect. Also for skin defect autologous musculo cutaneous flap were used..Thus providing a hybrid reconstruction using both synthetic and autologous grafts.
The rate of locally recurrent breast cancer after apparently complete excision of stage I or II disease is thought to be between 4% and 20% [4]. Clear surgical margins important for local control in chestwall invasion of BC. 3-20% chest wall recurrence may reveal after mastectomy. It depends on number of axillary nodes involved. 30% of this tumors have distant metastasis at time of chest wall involve mentdiagnosis [5]. However, a detailed analysis of isolated chest wall recurrence ssuggested that local recurrence was associated with a median survival of 5.6 years and a 10-year survival of 30% [6]. In our case surgical margin was clear and there was no axillary node involvement and had no distant metastasis.
It is often thought that local breast cancer recurrence always indicates the presence of distant metastases [7].
Radiotherapy is indicated for patients under going mastectomy as surgical management for breast cancer treatment when clinical
or pathologic tumor and nodal features predict risk of local/regional
recurrence. Such features include: tumor size 5 cm, inadequate
surgical margins; skin, facial, or skeletal muscle invasion; dermally
lymphatic invasion; poorly differentiated tumor histology; four
or more lymph nodes positive; gross extra capsulartum or nodal
extension into soft tissues; and matted lymph nodes or enlarged
lymph nodes> 2 cm. Patients who were treated with irradiation after
mastectomy can develop local/regional recurrences despite such
adjuvant therapy [8]. But the best use of radiotherapy seems to be
adjuvant post-operative treatment after R1 chest wall resection, a
situation in which overall survival and disease free survival rates
are then similar to those seen after R0 chest wallresection [9]. The
most important risk factor for failure of surgical resection in local
recurrences is an insufficient safety margin. Confining there section
of the soft tissues is associated with rerecurrence rates of upto 62%
[10].
In conclusion; invasive ductal breast cancer can be arised by local
recurrence even after many years. Recurrences developing in the
chest wall can be successfully treated with synthetic and autologous
grafts. Surgery should be prefered against other, less-aggressive
treatments such as radiation therapy in appropriate patients.
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