An unusual lesion on thechest wallManoj Pandey, Chandramohan K Nair, Anitha Mathew

Pandey M, Nair CK, Mathew A. An unusual lesion on the chest wall. Int Wound J 2004;1:152—154.

ABSTRACTOsteoradionecrosis is an exceptional complication after the treatment of breast carcinoma. We report here a 63-year-old woman who presented with osteoradionecrosis of the sternum 17 years after initial treatment for breastcancer. Difficulty in diagnosing the lesion and its management is discussed.

Key words: Bone . Breast cancer . Complication . Osteoradionecrosis . Radiotherapy . Sternum

INTRODUCTIONOsteoradionecrosis (ORN) is now an excep-tional complication after the treatment ofbreast carcinoma. It often results from older,less accurate radiotherapy techniques; treat-ment with orthovoltage radiotherapy (1); andinferior fractionation schedules, including theuse of large fractions and alternate day treat-ment (2). With modern machinery and thedelivery of smaller fractions, the dose ofradiotherapy delivered to the skin and bonesis minimised. This has dramatically reducedthe incidence of radiotherapy-related earlyand late complications (3).We report here a 63-year-old woman who

presented with ORN of the sternum 17 yearsafter initial treatment for breast cancer.

CASEA 46-year-old premenopausal lady underwentradical mastectomy for a fine needle aspir-ation cytology (FNAC)-positive malignant4· 4 cm lump in the upper outer quadrant ofright breast with multiple mobile axillarynodes in 1986. Histopathology of the resected

specimen showed an infiltrating ductcarcinoma with lymph node metastasis. Post-operatively, she was treated with adjuvantradiotherapy to the chest wall using a medialand lateral tangential pair delivering 40Gy in20 fractions. The supraclavicular region andaxilla were treated with 45Gy over 20 fractions,and a single 600 cGY boost to posterior axillawas delivered using telecobalt external beamradiotherapy.She further received six cycles of chemo-

therapy using cyclophosphamide, metho-trexate and 5 flurouracil (CMF). She wasdisease free and on regular follow-up untilJanuary 2003, when she developed a5· 5mm swelling over the sternum witherythema and tenderness. She complained ofpain at the site of the lesion. A FNAC wastaken which was inconclusive. A month later,she developed a sinus discharging pus overthe sternum with extensive inflammation(Figure 1). A repeat FNAC was taken whichwas also inconclusive. She was started onantibiotics. In March 2003, the sinus openingbecame bigger, the discharge persisted andpain increased to become unbearable. Aplain anteroposterior (AP) X-ray of the chestwas taken which was normal (Figure 2). Asinogram was taken with 2ml of dilutedcontrast which showed a sinus track leadingto the sternum (Figure 3). Culture of thedischarge showed a heavy growth of groupD streptococci sensitive to ampicillin, amoxi-cillin and coamoxiclav. With a provisionaldiagnosis of ORN of the sterum leading to

Authors: M Pandey, Department of Surgical Oncology,Regional Cancer Centre, Thiruvananthapuram, Kerala, India;Chandramohan K Nair, Department of Surgical Oncology,Regional Cancer Centre, Thiruvananthapuram, Kerala, India;A Mathew, Department of Pathology, Regional Cancer Centre,Thiruvananthapuram, Kerala, IndiaAddress for correspondence: Dr M Pandey, AssociateProfessor, Surgical Oncology, Regional Cancer Centre,Thiruvananthapuram, Kerala 695 011, IndiaE-mail: manojpandey@rcctvm.org

� Blackwell Publishing Ltd and Medicalhelplines.com Inc 2004 . International Wound Journal . Vol 1 No 2152

& CLINICAL CHALLENGES

Key Points

. improvement in radiotherapyreduced the incidence of radio-therapy related complications

. osteoradionecrosis is an excep-tional complication but ischallenging when encountered

. this case details the symptomsand offers one approach to care

chronic osteomyelitis, a sinus explorationwas carried out under local anaesthesia. A1�5· 1�0 cm sequestrum was removed fromthe sternum. The patient was started oncoamoxiclav. Histopathology of the bonepiece revealed avascular bone necrosis.On follow-up after 2 weeks, the inflamma-

tion had subsided considerably, and the sinustrack was showing signs of healing. The

patient was advised to have a sternotomy,but she refused to undergo surgery.

DISCUSSIONAfter mastectomy, radiotherapy is requiredfor patients at high risk of local recurrence(3). ORN is a late consequence of such irradi-ation that does not resolve spontaneously.

Figure 1. Clinical photograph showing the oblique scar of mastectomy with necrotic ulcer on the sternum with inflammation of

the surrounding skin. A piece of dead bone can be seen at the sinus opening.

Figure 2. Plain X-ray chest AP view, showing normal

sternum. A marker is placed over the sinus opening.

Figure 3. Sinogram with 2ml of diluted dye (lateral view)

shows a normal cortical outline of underlying sternum with dye

reaching up to it, no extravasation of dye seen on pleural

cavity. A small lytic area is present below the sinus opening. No

sequestrum could be identified in the X-ray.

An unusual lesion on the chest wall

� Blackwell Publishing Ltd and Medicalhelplines.com Inc 2004 . International Wound Journal . Vol 1 No 2 153

Key Points

. after extensive radiotherapy thepatient developed a sinus overthe sternum

. wound was painful and heavilyexudative

. effective assessment showed aninfected sinus

. patient received systemic anti-biotics

. bone histopathology confirmedavascular necrosis

ORN is not exceptional, despite advances inirradiation techniques. The irradiation dose(above 3000 rad) is the main factor in ORNwhich may be precipitated by adjuvant factorsand potentiating events such as trauma andinfection. Pathological studies show severallesions in association with ORN: cell lesions,osteoporosis, vascular lesions and foci innecrosis. The pathogenic significance oflesions of bone cells is demonstrated, whilethe part played by vascular lesions is contro-versial (4). Diagnosis rests on an associationof criteria, and fortunately bone biopsy isusually unnecessary. The clinical features,topographical characteristics and course ofthe disease allow differentiation from bonemetastasis; it may be more difficult to distin-guish postirradiation sarcoma, which is rare,or a number of benign conditions, such asaseptic necrosis, infected osteoarthritis anddestructive coxarthrosis (4).Treatment of ORN is difficult; control of

superadded infection with antibiotics, dressingof the wound, removal of the sequestrum andhyperbaric oxygen have been described. Inanother preliminary study, a combination ofpentoxifylline, tocopherol (vitamin E) and clo-dronate has been shown to be of clinical benefitwith more than 50% regression of progressiveORN observed at 6 months in 12 patients (5).Exaggerated acute and late effects are

observed in women with pre-existing collagenvascular disease (CVD). A history of CVDappears to be a contraindication to breast con-servation or for elective irradiation in breastcancer (6).Full-thickness chest-wall resection and

single-stage reconstruction, for ORN of thechest wall, after radiation for breast cancer havebeen described in literature. Reconstructionhas been performed using Marlex1 mesh toreconstruct the bony thorax and a rotatedlatissimus dorsi myocutaneous flap (7).Musculoosseus flaps with latissimus dorsimuscle has also been used for reconstructionof full-thickness anterior chest-wall defects (8).Another new operative method combiningplastic-stabilising reconstruction of the thoracicwall in complete defects larger than >80 cm2

consisting of covering in layers the defect withAmpoxen1, auto-rib and skin-muscle flap hasbeen described (9). Reconstruction by omentaltransposition and mesh skin grafting has alsobeen described (10).

ORN is a rare, late complication of adjuvantradiotherapy for breast cancer presenting as adiagnostic dilemma. The management optionsdepend on the degree and location of ORN.For smaller lesions, conservative managementcan be tried first; however, surgical interven-tion may be required.

SUMMARY. ORN is an unusual complication after thetreatment of breast carcinoma.

. The irradiation dose (above 3000 rad) isthe chief factor in ORN.

. The clinical features, topographical char-acteristics and course of the disease allowdifferentiation from bone metastasis.

. Treatment of ORN is difficult; control ofsuperadded infection with antibiotics,dressing of the wound, removal of thesequestrum and hyperbaric oxygen havebeen described in this condition.

REFERENCES1 Barak F, Werner A, Walach N, Horn Y. Extensive late

bone necrosis after postoperative orthovoltageirradiation of breast carcinoma. Report of a case.Acta Radiol Oncol 1984;23:485—8.

2 Daly M, Junor EJ, Harnett AN. Late effects afterradiotherapy for breast cancer. BMJ 1995;310:669.

3 Sainsbury JRC, Anderson TJ, Morgan DAL,Dixon JM. ABC of breast diseases: breast cancer.BMJ 1994;309:1150—3.

4 Dumont D, Manigand G, Taillandier J, Cohen DL.Osteoradionecrosis in adults. Sem Hop 1984;60:1317—24.

5 Delanian S, Lefaix JL. Complete healing of severeosteoradionecrosis with treatment combiningpentoxifylline, tocopherol and clodronate. Br JRadiol 2002;75:467—9.

6 Fleck R, McNeese MD, Ellerbroek NA, Hunter TA,Holmes FA. Consequences of breast irradiation inpatients with pre-existing collagen vascular dis-eases. Int J Radiat Oncol Biol Phys 1989;17:829—33.

7 Hines GL, Lee G. Osteoradionecrosis of the chestwall. Management of postresection defects usingmarlex mesh and a rotated latissimus dorsi myo-cutaneous flap. Am Surg 1983;49:608—11.

8 Bobin JY, Crozet B, Ranchere JY. Using the costalmuscle flap with latissimus dorsi muscle to repairfull-thickness anterior chest wall defects. AnnPlast Surg 1988;20:471—6.

9 Chalukov P, Vasilev B. A stabilizing plastic repairmethod for reconstruction in extensive completedefects of the chest wall. Khirurgiia (Sofiia)1990;43:40—5.

10 Sato M, Tanaka F, Wada H. Treatment of necroticinfection on the anterior chest wall secondary tomastectomy and postoperative radiotherapy bythe application of omentum and mesh skin graft-ing: report of a case. Surg Today 2002;32:261—3.

An unusual lesion on the chest wall

� Blackwell Publishing Ltd and Medicalhelplines.com Inc 2004 . International Wound Journal . Vol 1 No 2154

Key Points

. careful assessment permits dif-ferential diagnosis

. treatment is difficult but notimpossible