DOI: https://doi.org/10.21203/rs.3.rs-679417/v1
Introduction:
Chest wall osteoradionecrosis(ORN) in breast cancer is one of the most serious complications of radiation therapy. Treatment requires wide debridement and coverage with a well-vascularized flap. However, the extensive radiation-induced injury, and a limit to performing wide resection of the injured bones are challaged to treatment. Herein, we present our experience with chest wall ORN treated with contralateral breast Y-V flap.
Case presentation
An 81-year-old woman diagnosed with ORN of the chest wall had a severe ptotic breast. Reconstruction was planned to cover the open wound of the chest wall using redundant contralateral breast tissue. The flap was elevated in the subfascial plane after an inverted-T incision was made in the lower pole and inframammary fold of the contralateral breast while preserving the perforators of the left lateral thoracic artery. The flap was spread in a Y-V advancement fashion to cover the open wound. The patient was discharged 2 weeks after surgery following suture removal. At 19 months post-operation, there were no complications or recurrences of ulcers. The patient was satisfied with the short recovery time and the surgical results.
Conclusion
The contralateral breast Y-V flap allows simple and quick reconstruction, and having more options for chest wall reconstruction will allow for a more flexible treatment plan for each patient.
In addition to surgery and chemotherapy, radiation therapy is used to treat breast cancer. High-energy rays used in radiation therapy destroy cancer cells, but these can also cause early and late radiation-induced soft tissue injury mediated by reactive oxygen species [1]. One of the most serious complications of radiation therapy is chest wall osteoradionecrosis(ORN) in breast cancer treatment [2, 3]. Chest wall ORN is usually accompanied by ulceration, full-thickness skin necrosis, superimposed infection of soft tissue and bone, and in severe cases, rib fractures [4].
Because of radiation-induced tissue damage in the skin and soft tissue around the necrosis, wide debridement and coverage with a well-vascularized flap are required for the treatment of ORN [5]. However, this is highly challenging in the chest wall for the following reasons: First, the use of local flaps is limited by the extensive radiation-induced skin and soft tissue changes around the necrosis. Second, in the case of free flap, recipient vessel candidates could be affected by radiation injury. Third, there is a limit to performing wide resection of the injured ribs and sternum, since these are essential for maintaining the respiratory system.
Radiation-unaffected contralateral breast tissue can be a useful source of local flaps for the coverage of extensive chest wall wounds. There is a paucity of literature regarding the use of contralateral breast tissue for the reconstruction of chest wall defects. We present our experience with chest wall ORN treated with a contralateral breast Y-V flap.
An 81-year-old female patient had an open wound with a diameter of 1 cm accompanied by discharge on the right chest wall four years ago. As the size of the wound started increasing with turbid discharge one year ago, the patient was referred to our department (Fig. 1). This patient underwent a modified radical mastectomy with axillary lymph node dissection for right breast cancer 21 years ago, followed by radiation therapy (20.94 Gy in 33 fractions). A computed tomography scan of the chest and a bone scan revealed osteomyelitis in the right 3rd to 6th ribs. Bone biopsy confirmed osteomyelitis in the right 3rd to 6th ribs, and the patient was finally diagnosed with ORN accompanied by osteomyelitis and abscess. Methicillin-Susceptible Staphylococcus Aureus was identified from the wound culture, and levofloxacin was administered intravenously. Under general anesthesia, the radiation-induced fibrotic tissue around the wound was removed, and the right 3rd to 6th ribs were partially excised. As a result, a 113 cm² open wound was observed (Fig. 2).
The contralateral breast had grade 3 ptosis with a length of 18 cm from the inframammary fold to the nipple-areolar complex. Reconstruction was planned to cover the open wound of the chest wall using redundant contralateral breast tissue. The flap was elevated in the subfascial plane after an inverted-T incision was made in the lower pole and inframammary fold of the contralateral breast while preserving the perforators of the left lateral thoracic artery. The flap was spread in a Y-V advancement fashion to cover the open wound (Fig. 3). Before completing the surgery, two surgical drains were inserted under the flap (Fig. 4). The operation took 1 hour and 50 minutes.
Immediately after surgery, the patient's vital signs were stable, and a stable state with no congestion or ischemic signs in the flap was confirmed. On the 6th day after surgery, there was no necrosis of the flap, but partial dehiscence had occurred in the right costal margin, which is the distal side of the flap, and an additional 8 cm² local transposition flap was created. No other complications were observed. The patient was discharged with all sutures removed two weeks after the surgery. No complications or ulcer recurrence were found at 19 months after surgery (Fig. 5). The patient was satisfied with the fast recovery and surgical outcomes.
In breast cancer, radiation therapy is an important treatment for controlling local recurrence [6]. Despite many advances in radiation therapy, complications such as ORN persist. ORN mainly occurs in the mouth after radiation therapy for head and neck cancers. Although rare, it has also been found in patients with breast cancer [7]. ORN occurring in the chest wall is often accompanied by osteomyelitis, with a high possibility of recurrence, and the presence of radiation-induced fibrotic tissue is likely to delay wound healing; hence, extensive surgical resection is important [4].
This patient was an 81-year-old woman with hypertension, diabetes, and chronic kidney disease as underlying diseases. Due to fibrosis and calcification in the right lung caused by radiation, pulmonary function was reduced. In the pulmonary function test, the forced expiratory volume in one second (FEV1) / forced vital capacity (FVC) was 67%, indicating moderate obstruction. The left ventricular ejection fraction was 40% on preoperative echocardiography, indicating reduced heart function. The overall American Society of Anesthesiologists score was 3, indicating a high risk of postoperative cardiopulmonary complications. Therefore, it was necessary to shorten the operation time and minimize the scope of the operation.
Local flaps of various forms are used for the reconstruction of extensive soft tissue defects in the chest wall. The pectoralis major muscle flap, latissimus dorsi (LD) muscle flap, and vertical or transverse rectus abdominis myocutaneous flaps are the most commonly used, and thoracoabdominal and thoracoepgastric flaps are also sometimes used [8]. The wound in this patient was a deep and exposed to the pleura, and the pectoralis major muscle was damaged during the debridement process, preventing its use. The LD flap is advantageous for covering a large wound, but it requires changing position during surgery and may cause donor site morbidity. The rectus abdominis myocutaneous flap has a wide surgical range and long operative time, with a high risk of postoperative complications. The surgical range of the contralateral breast flap, on the other hand, is relatively small, not beyond the chest area, resulting in quick recovery after surgery. The patient's vital signs were stable immediately after surgery, and she was able to resume daily activities, including ambulation, one day after surgery. No donor site morbidity occurred after surgery, with only some partial dehiscence, which required minor repair.
Reconstruction of the chest wall using a contralateral breast flap should be considered in the following cases: first, patients with severe ptotic or large breast that can cover the contralateral side; second, patients with a high risk of postoperative complications due to old age or poor general condition; and third, patients for whom a LD or rectus abdominis based flap has been used or cannot be used.
This technique has two limitations. First, the anatomy of the contralateral breast may be deformed, making breast cancer screening difficult in the future. Second, covering the entire chest with a single breast is not esthetically pleasing.
Nevertheless, the contralateral breast Y-V flap allows simple and quick reconstruction, and having more options for chest wall reconstruction will allow for a more flexible treatment plan for each patient.
Osteoradionecrosis: ORN; Latissimus dorsi: LD; Frced expiratory volume in one second: FEV1; Forced vital capacity: FVC
Acknowledgments
We thanks Hye Seong Park for drawing the schematic illustration.
Funding
This work was supported by the 2018 Yeungnam University Research Grant.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
Conflict of interest
No potential conflict of interest of relevant to this article was reported.
Ethics approval and consent to participate
The study was approved by the Institutional Review Board of Yeungnam University Hospital (IRB No. 2021-05-038) and performed in accordance with the principles of the Declaration of Helsinki.
Consent for publication
The patient provided written informed consent for the publication and the use of her images.
Competing interests
The authors declare that they have no competing interests.