Six years before presentation at our hospital, a 44-year-old female had a gradually growing tumor in her right breast. She was diagnosed with breast cancer in the right breast at a previous hospital. A core needle biopsy revealed mucinous carcinoma (MC), estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor 2-negative.
The patient had refused standard treatment for her breast cancer. she visited the emergency department of our hospital with the complaint of severe pain and acute bleeding from the right breast cancer six years after the initial diagnosis. She had 1500-2000 ml of exudation from the tumor per day and her weight loss was significant for a month. She had no medical history and no family history of breast cancer or ovary cancer. There was no history of drinking or smoking.
Macroscopically, the tumor in the right breast measured over 20 cm in diameter. The tumor was exudative, exhibited ulceration and slight bleeding, and gave off an odor (Fig. 1). A computed tomography (CT) scan revealed a huge mass in the right breast (Fig. 2). Metastasis of multiple lymph nodes was also observed, but there was no metastasis in the liver and lungs on CT. Bone scintigraphy showed uptake in some thoracic spines and ribs (Fig. 3). The final diagnosis was breast cancer, stage IV (cT4bN1M1).
Although the surgeon recommended standard therapy of chemotherapy for the breast cancer, the patient refused to receive chemotherapy due to concerns about complications during chemotherapy.
The patient initially refused radiation therapy (RT). We explained the risks after RT and the risks of tumor-associated symptoms such as pain, exudation, ulceration and bleeding, the patient finally agreed to receive RT. However, she didn’t accept the hormone therapy before and during RT.
We performed RT of 70 Gy in 35 fractions over a period of 7 weeks. The patient received initial irradiation of 50 Gy in 25 fractions for the right breast without hormone therapy. The response of RT after 50 Gy was relatively good; however, the symptoms such as pain, exudative, exhibited ulceration and slight bleeding were remained. We therefore decided to add the boost. After the initial irradiation of 50 Gy, the patient received a sequential boost of 20 Gy in 10 fractions for the breast cancer (Fig. 4). RT was delivered with 6-10 megavoltage equipment via a multiple leaf collimator by three-dimensional RT. Gross tumor volume (GTV) was defined as the primary tumor without lymph node and bone metastases based on pretreatment examination by CT. The clinical target volume (CTV) was defined as GTV plus 0.5-cm margins. The planning target volume (PTV) was CTV plus 1.0-cm margins. According to the cumulative dose-volume histograms, the ipsilateral lung volume receiving more than 20 Gy was 15 %.
An acute side effect of grade 2 dermatitis according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. occurred after RT, but there was no acute or late complication of more than grade 3. The tumor-associated symptoms such as pain, exudation, ulceration and bleeding were disappeared after RT. At one month after RT, the tumor regressed gradually and had almost disappeared three months after RT (Fig. 5). After improving the local tumor of the right breast, the patient agreed to receive hormone therapy. We could administer the luteinizing hormone-releasing hormone agonists. At two years after RT, she died due to metastatic lesions in liver and appearance of ascites; however, there was no symptom and disease progression in the right breast (Fig. 6).