A 72 years old woman with a personal history of breast, lung and rectal cancer presented with an ulcerated breast local recurrence on her right breast. She had no familial history of breast and ovarian cancer and refused any genetic testing. In 1994, when she was 46 and premenopausal, she was diagnosed with hormone receptor positive breast cancer, no special type (NST). She had breast conserving surgery and axillary clearance along with twenty-five applications of conventional external beam radiation therapy. Anatomic stage by TNM was pT2N0M0. She was prescribed five years endocrine therapy with tamoxifen and ovarian suppression with luteinizing hormone-releasing hormone (LHRH) agonists.
In 2010 she was diagnosed with right non-small cell lung cancer (NSCLC) complicated by pleural effusion. Stage at diagnosis was T2N1M1a. She was treated with first line chemotherapy 4 cycles of cisplatinum and pemetrexed and obtained partial response. Ten months later, she had a local relapse. She was screened for epidermal growth factor receptor mutation and deletion of exon 19 (Ex19Del) was found. Thus she started with EGFR tyrosine kinase inhibitor (TKI) gefitinib.
Since August 2013, following mediastinal lymph node progression, the patient was administered platinum-based doublet chemotherapy. After further progression, patient was treated with third line with EGFR tyrosine kinase inhibitor (TKI) erlotinib –- and targeted radiotherapy on lung lesion.
In 2015 she complained with abdominal pain. Rectal examination showed a rigid mass close to the dentate line. She underwent colonoscopy that revealed an ulcerated mass occupying half of the circumference of the colon -rectal lumen and rectal biopsy was performed. She was diagnosed with locally advanced rectal cancer and scheduled for neo-adjuvant chemo-radiotherapy. She had complete response and refused completion rectal surgery.
In 2016 she developed right in-breast lump complicated by mediastinal lymphadenopathy. Mammography and ultrasound scan were suspicious for breast local relapse, then confirmed by right breast core biopsy showing receptor positive HER2 amplified breast cancer (ER 85%; PgR 40%; Ki67 20%; HER2 +++). She started weekly paclitaxel, antiHER2 monoclonal antibody trastuzumab every 21 days and oral vinorelbine. She developed peripheral neuropathy, asthenia and dyspeptic syndrome, thus suspended paclitaxel and kept on with trastuzumab. Disease was deemed stable after six months follow up.
In 2018, lung cancer progressed therefore patient underwent 45 Gy Cyber-knife System radiotherapy. The PET-CT scan showed good response on the lung.
In 2019 rectal cancer recurred and underwent robotic Miles’ abdominoperineal resection surgery and left colostomy. At the same time breast recurrence progressed with skin ulceration, redness and infiltration of pectoralis muscle (Fig. 1).
The infiltrated area was eight centimeter large and extended all over the right hemi-thorax.
Multidisciplinary meeting (MDM) went through different surgical options. Modified radical mastectomy without tissue flap reconstruction was excluded as there was not enough skin to bridge the gap. Skin salvage mastectomy and reconstructive tissue flap was first offered to patient who refused that.
After a second MDM electrochemotherapy on the breast was proposed. Patient was explained about risks and benefit of the procedure and signed the informed consent. She was scheduled for electrochemotherapy on the right breast under general anesthesia. After intravenous injection of bleomycin 15 mg/m2, 101 pulses at 5000 Hz frequencies were delivered by hexagonal needle electrode 40 mm length, at 730V voltage with Cliniporator™ (IGEA Srl, Carpi [MO], Italy). The treatment was administered following the ESOPE guidelines(10). The procedure lasted 30 minutes. At the end of the procedure greasy meshed gauzes dressing were applied. After treatment patient was brought in the post-anesthetic recovery room and then to the ward. Patient was discharged the day after in good condition. The post-treatment follow up was scheduled on day 7th − 15th − 30th -60th − 90th (Fig. 2; Fig. 3). After ninety days the whole breast was replaced by necrotic tissue as shown in Fig. 4. Escharotomy to remove the necrotic tissue was performed under local anesthesia, leaving the chest wall free from macroscopic disease and the result was a mastectomy induced by electrochemotherapy. In order to evaluate the residual burden of disease after escharotomy we performed multiple punch biopsies on the living tissue underneath the eschar. Pathology report showed few residual of breast cancer cells surrounded by disease-free margins (Fig. 5). Advanced dressings were applied during follow up. After two months the wound closed (Fig. 6). Six months after the wound closed the patient was clinically free from disease on the chest wall. PET-CT scan showed non-evident disease from rectal cancer whereas lung metastases are stable. Patient is satisfied with the procedure and continues her routinely follow up with improved quality of life.