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Locally advanced breast cancer made amenable to radical surgery after a combination of systemic therapy and Mohs paste: two case reports
© Tsukada et al.; licensee BioMed Central Ltd. 2012
Received: 27 March 2012
Accepted: 25 September 2012
Published: 24 October 2012
Chemotherapy and other systemic therapies are the primary treatments for patients with unresectable, locally advanced breast cancer. The clinical application of supportive care using Mohs paste has become widespread for the purpose of improving patients’ quality of life. Here, we report two cases of locally advanced breast cancer, for which the patients underwent radical surgery after a combination of systemic therapy and Mohs chemosurgery.
Patient 1 was a 90-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4bN1M0). The treatment included Mohs paste application and hormonal therapies. Patient 2 was a 60-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4cN2aM0). Her treatment included Mohs paste application, together with chemotherapy (four cycles of 5-fluorouracil, epirubicin, and cyclophosphamide, and four cycles of docetaxel). In both cases, a reduction in the primary tumor volume was observed, and radical mastectomy and axillary lymph node dissection were possible without relaxation incision or skin flap.
We report patients with no distant metastases who were able to undergo radical resection after a combination of systemic therapy and Mohs chemosurgery. For locally advanced breast cancer, Mohs chemosurgery, in addition to multidisciplinary treatment, is useful.
For patients with unresectable, locally advanced breast cancer with skin invasion, the primary therapy is systemic, such as chemotherapy. However, the presence of bleeding, exudates, and/or strong odor from infection can adversely impact quality of life (QOL). These symptoms are collectively referred to as malignant wounds and are managed with palliative treatment[2, 3]. Patients with breast, head and neck, and primary skin cancers have the highest prevalence of malignant wounds (47.1%, 46.7%, and 39.1% of patients, respectively), and Mohs chemosurgery has been applied for such patients[5–7]. Mohs chemosurgery is a technique of chemical fixation of a cutaneous tumor and subsequent excision[8, 9]. The fixative used in a Mohs procedure contains zinc chloride and is referred to as Mohs paste. In this technique, fixation and excision are repeated until no residual tumor can be found in the specimen by microscopic examination. In recent years, the use of Mohs chemosurgery has become widespread for the primary purpose of improving QOL. However, in patients with breast cancer, there is little reported experience with the application of Mohs paste for the purpose of tumor reduction. To the best of our knowledge, there are no reports of patients who underwent radical surgery after a combination of systemic therapy and Mohs chemosurgery. Here, we report two cases of locally advanced breast cancer for which the patients underwent radical surgery after a combination of systemic therapy and Mohs chemosurgery. Furthermore, as frequent dressing changes are necessary due to exudates from ulcers after Mohs chemosurgery, we report easy management of these issues in the out-patient setting by an appropriate choice of wound dressing.
Formulation of Mohs paste
Saturated zinc chloride
Powdered Sanguinaria canadensis
Zinc oxide starch powder
Paste containing stibnite
Protocol for the Mohs method in our hospital
Apply petroleum jelly to the surrounding normal skin, and cover with gauze to protect from Mohs paste.
Uniformly apply the Mohs paste at a thickness of 1mm on the surface of tumor and protect using gauze.
Remove the gauze and Mohs paste 24 hours after application.
After removal of Mohs paste, apply petroleum jelly and protect using gauze.
Observe the tumor at the same time every day. Necrotic tissue may be removed bluntly, or it might fall off naturally.
Continue above cycle every 2–3 days until the elevated tumor is flattened.
The patient was hospitalized, with bedrest as treatment for the compression fracture, and letrozole was selected as systemic therapy for the breast cancer. Alendronate, calcium L-aspartate and alfacalcidol were also administered. Written informed consent was obtained from the patient, and Mohs paste was applied to control local bleeding and exudates. After using Mohs paste for three cycles, the tumor flattened, and there was no further need for daily dressing changes. Versiva® XC® (ConvaTec Japan, Tokyo, Japan), which contains hydrocolloid and hydrofiber, was used for wound closure. The Versiva® XC® dressing required once-weekly dressing changes. The wound could be left uncovered starting on day 28 from the first Mohs chemosurgery. Letrozole was continued for approximately 6 months in the out-patient setting. The skin infiltration reduced gradually (Figures 1c,1d). Radical mastectomy of the right breast and axillary lymph node dissection (level 1) were performed. The infiltrated skin was resected at the same time, without the need for relaxation incision or skin flap. Histologic examination showed mucinous carcinoma with lymph node metastasis (metastatic axillary lymph nodes/dissected lymph nodes: 3/26); the histologic evaluation of the therapeutic effect was grade 1b. The patient was discharged on postoperative day 16 without any postoperative complications. She has continued oral letrozole since her surgery of 15 months ago.
She underwent four cycles of 5-fluorouracil 500mg/m2, epirubicin 100mg/m2, and cyclophosphamide 500mg/m2 (FEC100) and four cycles of docetaxel (75mg/m2) as neoadjuvant chemotherapy. Chemotherapy was initiated with an 80% dose reduction due to pancytopenia from idiopathic thrombocytopenia and chronic hepatitis C. Thereafter she was able to complete therapy without cessation or further reduction of chemotherapy drugs. Written informed consent was obtained from the patient, and Mohs paste was applied for exudates. After using Mohs paste for three cycles, the wound was closed with Versiva® XC® on day 15 from the first Mohs chemosurgery. Although she could have been discharged from the hospital before her the third course of FEC100, weekly dressing changes of the Versiva® XC® were required. After neoadjuvant therapy was changed to docetaxel, tumor reduction occurred slowly, and the tumor did not epithelialize (Figure2c). After completion of chemotherapy, invasion of the pectoralis major muscle was still present (Figure2d). Radical mastectomy of the right breast and axillary lymph node dissection (level 2) were performed. The invaded portions of the pectoralis major and pectoralis minor muscles were also resected. Relaxation incision or skin flap was not required. Histologic examination showed papillotubular carcinoma with lymph node metastasis (metastatic axillary lymph nodes/dissected lymph nodes: 4/17), and the histologic evaluation of therapeutic effect was grade 1b. The patient was discharged on postoperative day 24 without any postoperative complications. She began oral letrozole 9 months ago after her surgery.
Mohs chemosurgery is minimally invasive and relatively simple. This method has been applied widely in areas such as palliative care and is considered a very useful treatment. Although no guiding philosophy exists regarding the use interval and contact time with Mohs paste, the progress and depth of consolidation depend on contact time. Reported contact times range from a few minutes to 48 hours. Hemostatic effects have been seen with times ranging from a few minutes to 10 minutes. The intended purpose of Mohs paste application is to determine the appropriate use interval and contact time. When using Mohs paste, it is important to protect normal, healthy skin. Several methods for containing the oil, such as thick application of petroleum jelly or affixing dressing agents, have been applied. For the formulation of Mohs paste, a saturated solution of zinc chloride (purified water:zinc chloride, 1mL:2g) was made, then mixed with zinc oxide starch powder, and the viscosity was adjusted using glycerin. This preparation method allowed the production of a roughly common product. With the aim of tumor reduction, a relatively long contact time (24 hours) was determined and the concentration was reduced to 50%, instead of a saturated solution, for the purpose of achieving slow infiltration. Tissue fixation can be obtained even at concentrations of 50%; therefore, a saturated solution was deemed unnecessary. After using Mohs paste, necrotic tissue is formed. In many cases, necrotic tissue is removed bluntly, without local anesthesia, or it falls off naturally. After removal, an ulcer might form, and exudates might reduce; however, regular dressing changes remain necessary.
Closure therapy was performed according to pressure ulcer protocol using Versiva® XC®. Versiva® XC® is an adhesive patch, with reported effectiveness; it creates a moist environment to promote wound healing and can protect the surrounding environment by containing the exudate. Daniels et al. demonstrated ease-of-use and no problems with use of the patch for an average of between 5 and 6 days. Similarly, the present patients experienced no problems with weekly dressing changes in the out-patient setting. Complete epithelialization was achieved in Case 1. In Case 2, complete closure was not achieved due to a decline in the antitumor effects of docetaxel, but weekly dressing changes could be continued without complications such as infection. Versiva® XC® is a useful dressing in the out-patient setting.
In breast cancer treatment, few experiences have been reported with the primary goal of cytoreduction. To the best of our knowledge, radical surgery after a combination of systemic therapy and Mohs chemosurgery has not been reported. In skin tumor resection, Mohs chemosurgery is not a first-line choice, but good results have also been reported[5, 15, 16]. For patients with locally advanced breast cancer, multidisciplinary treatment should be applied. However, Mohs chemosurgery can aid in tumor reduction when combined with multidisciplinary treatment in patients with no distant metastases. In particular, Mohs chemosurgery is a useful method in patients with bleeding and exudates.
This report demonstrates that for patients with no distant metastases, radical resection through a combination of systemic therapy and Mohs chemosurgery is useful. Mohs paste resulted in tumor reduction, and wound closure was completed under out-patient care. Combination therapy allowed a simple suture closure of the dermis.
For locally advanced breast cancer, Mohs chemosurgery, in addition to multidisciplinary treatment, is a useful approach.
Written informed consents were obtained from the patients for publication of these two case reports and accompanying images. Copies of the written consents are available for review by the Editor-in-Chief of this journal.
We are grateful to members of the Department of Breast Oncology of Kanazawa University: Dr. Masafumi Inokuchi and Dr. Hiroyuki Furukawa for helpful suggestions. We thank Mr. Minoru Oshinoya and Ms. Tomiyo Shima for providing technical support in the formulation of Mohs paste and wound management.
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