Successful Mastectomy and Chemotherapy in a Patient With Breast Cancer and Active Generalized Pyoderma Gangrenosum

Daniel C. Morse, MD; Payal M. Patel, MD; Carter Haag, MD; Alex G. Ortega-Loayza, MD

Disclosures

Wounds. 2020;32(4):E19-E22. 

In This Article

Case Report

A 46-year-old woman with stage II, grade 3 infiltrating ductal carcinoma of the left breast, diagnosed 30 days prior, presented to the emergency department with erythema and pain in her right upper extremity (RUE) near the site where a subclavian implantable venous catheter (PORT-A-CATH; Smiths Medical) was placed 16 days earlier. In addition to the diagnosis of breast cancer, the patient was estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), and human epidermal growth factor receptor 2-positive (HER2+). The patient had no history of autoimmune disorders or previous cutaneous wounds; she also had no previous history of pathergy or wound dehiscence after surgical procedures.

Five days after receiving a round of neoadjuvant chemotherapy, consisting of trastuzumab, pertuzumab, carboplatin, and docetaxel, the patient presented with a 2 cm x 1 cm area of erythema and swelling in her RUE, which rapidly progressed over the next 24 hours to form pustules and blisters (Figure 1). She was admitted with the diagnosis of possible shock (fever, hypotension, and a leukocytosis of 52 000 mm3 neutrophils/μL). A computerized tomography scan of the RUE showed extensive skin thickening and subcutaneous soft tissue stranding, suggestive of possible necrotizing fasciitis (NF).

Figure 1.

Patient was diagnosed with stage II, grade 3 infiltrating ductal carcinoma of the left breast, as well as being identified as estrogen receptor-positive, progesterone receptor-positive, and human epidermal growth factor receptor-positive. (A) Following the placement of an implantable venous catheter and 1 dose of adjuvant chemotherapy (trastuzumab, pertuzumab, carboplatin, and docetaxel), the patient noticed right anterolateral upper arm erythema after 4 days; and (B) pustules and (C) bullae developed in the following days.

The patient was started on empiric antibiotic therapy, which consisted of vancomycin 15 mg/kg every 12 hours, cefepime 1gm intravenous (IV) every 6 hours, and metronidazole 500 mg IV every 8 hours as well as surgical debridement of the RUE and right chest wall (Figure 2A, B). the initial debridement, the wound continued to ulcerate and enlarge, which prompted 2 additional wide debridements of the right chest wall and RUE (Figure 2C). At this point the RUE wound measured 19.3 cm x 15.5 cm and the right upper chest measured 16.5 cm x 12.2 cm. Alarmingly, the patient then began to develop pain and swelling around the catheter line site on her contralateral (Figure 2D) left upper extremity (Figure 2E). This catheter line had been placed upon initial admission. The swelling and pain progressed to overt ulceration and the area was surgically debrided (Figure 2E).

Figure 2.

(A, B) Right upper extremity and port site after first surgical debridement; (C) third surgical debridement; (D) at left upper extremity PICC line; (E) left upper extremity surgical debridement wound site; (F) prednisone started for suspected PG causing cessation of ulcer progression within 3 days; and (G, H) around 7 months after the initial debridement, marked improvement of wounds following weekly treatments with topical timolol 0.5% gel-forming solution to the wound edges for 4 weeks.

At this point, dermatology was consulted and the antibiotic course was switched to amoxicillin 500 mg every 12 hours. Histopathology of tissue samples showed focal necrosis with a diffuse neutrophilic infiltrate within the dermis and subcutaneous tissue. Blood and tissue microbiological cultures taken every other day for the first 12 days of her 29-day hospitalization, and the results were consistently negative. The skin biopsy confirmed the suspected clinical diagnosis of PG, given the patient's progressively worsening condition with repeat debridements, and negative cultures. She was subsequently started on high-dose prednisone (80 mg/day), which resulted in rapid improvement after 2 days and continued to improve after 1 week (Figure 2F).

The patient was discharged on 80 mg of oral prednisone daily for 30 days. Despite significant concern for the risk of pathergy with subsequent surgical procedures, the patient required surgical treatment of her breast cancer. In addition to her current taper of systemic corticosteroids (60 mg/day), perioperative administration of high-dose IV immunoglobulin (IVIG; 2 g/kg) was administered 9 days preoperatively.

After 1 month of initiating prednisone treatment, the patient underwent a left simple mastectomy without complications. Fortunately, over the next month, the surgical incision site healed fully, and no new ulceration was observed. After the procedure, the patient was placed on oral prednisone 60 mg daily and instructed to taper by 10 mg weekly for 6 weeks. After completing the prednisone taper, the wound measured 11.6 cm x 7.9 cm in the RUE and 9.5 cm x 5.5 cm in the right upper chest. After finishing the steroid taper, she began weekly adjuvant chemotherapy (paclitaxel, trastuzumab), which also included dexamethasone 8 mg with every cycle for 12 weeks. Additional infusions of IVIG every 4 weeks for up to 6 doses were recommended, but the patient never received postoperative IVIG treatment due to insurance issues.

A few days after the completion of the 12th week of paclitaxel and trastuzumab infusions, absorbent dressings (calcium alginate) were applied to the wound. At this point, 7 months after the initial debridement, the wounds were noted to measure 10.4 cm x 7.1 cm in RUE and 7.5cm x 4.4 cm in the right upper chest. Reduced drainage, tenderness, erythema, and diameter of the wound were observed. Wound care was optimized with the use of timolol 0.5% gel-forming solution once weekly for 4 weeks (Figure 2G, H). Imaging, performed 8 months after the initial debridement, revealed remission of the breast cancer.

Currently, the patient is taking tamoxifen for the treatment of her breast cancer. After 23 months, the wounds have continued to heal with no recurrence and measure approximately 5.5 cm x 3.2 cm in RUE and 4.1 cm x 3.3 cm in the right upper chest (Figure 3).

Figure 3.

(A, B) After 20 months, the wounds healed with no recurrence.

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