Classification of chronic radiation-induced ulcers in the chest wall after surgery in breast cancers

We searched the patient records at our institution and identified 64 patients who had been diagnosed with CRUCW from January 2001 to December 2012. CRUCW was defined as an ulcer or ulcers in the irradiated region of the chest wall after mastectomy. Biopsies were performed prior to treatment planning to eliminate the possibility of cancer recurrence or radiation-induced sarcoma. If a CRUCW was confirmed, surgical management was required. This study was approved by the local Research Ethics Board, and informed consent was obtained from all patients. Patient follow-up period was 2.6 years (range 1–4). The ulcer repairing situation was assessed by professionals.

We obtained demographic, clinical, and treatment information as well as follow up from the patients’ records. The following clinical and CRUCW characteristics were recorded: ulcer size, position, shape, and depth; granulation tissue of the ulcer base, surrounding skin color and texture, morphology and function of the upper limbs, and presence of associated bone necrosis or heart and lung disease.

Prior to classification for CRUCW, all patients underwent computed tomography, magnetic resonance imaging, X-ray imaging, ultrasonography, and electromyography. Emphasis was placed on whether the CRUCW was associated with radiation pneumonitis, collarbone and/or rib osteonecrosis, and/or radioactive brachial plexus injury.

The LENT-SOMA (late effects of normal tissue–subjective, objective, management, and analytic criteria) of breast scale represents a good tool to score toxicity after RT. While surgical treatment is chosen for CRUCW, this scale lacks clear guidance. Thus, we divided the CRUCWs into three types based on its clinical manifestations: 1) mild type: the ulcer area was less than 10cm²; the depth reached the subcutaneous layer; and there was a relatively healthy granulation tissue in ulcer base without any upper limb movement disorder; 2) moderate type: the ulcer area was larger than 10cm² and was accompanied by partial bone exposure in ulcer base without health granulation tissue, and partially upper limb sensory as well as motor disorders; and 3) severe type: the ulcer area was larger than 100cm², and was accompanied by obvious collarbone and/or rib osteonecrosis in ulcer base, as well as complete loss of upper limb function (Table 1).

The patients were treated with one of the following three surgical methods: (1) Conservative therapy: simple debridement was performed until healthier basal granulation tissue appeared. Then the wounds were covered with silver sulfadiazine dressings or Vaseline gauze. The dressing could be changed every 2–3 days according to the rate of drainage. After 2007, a vacuum sealing drainage (VSD) apparatus was adopted for processing wounds. The VSD system could be changed for once or twice during the wound-healing process. Stamp skin grafting was used to cover the wound when the basal granulation tissue began growing well. (2) Axial-pattern flaps and local flaps: once the ulcer became larger, basal conditions worsened, more severe fibrosis of the surrounding skin emerged, or bone tissue exposure and/or necrosis occurred, a vascularized flap became necessary. After debridement, the wound was repaired using one of a variety of flaps, the most popular of which were the rectus abdominis myocutaneous flaps (RAM), latissimus dorsi myocutaneous flaps (LDM), and contralateral breast and lateral thoracic rotation flaps. (3) Filleted flaps: when the CRUCW was accompanied by a severely function-impaired upper limb due to irreversible and chronic progressive brachial plexus injury and lymphedema, the ulcers became huge wounds that were hard to repair with conventional methods, left necrotic ribs and collarbone exposed, and caused the patients to suffer from refractory and excruciating pain. After the patient’s opinion was carefully solicited, filleted flaps from the dysfunctional ipsilateral upper limbs were used to repair the wounds. All the patients’ wounds were cured within 1–4 years after follow up.

The 64 patients were exclusively female, aged 22 to 75 years with a mean age of 54 years (Table 2). Ulcers emerged from 3 to 24 years after radiotherapy, with an average duration of 11 years. The severity of CRUCWs had an obvious dose-effect relationship with the radiation dose (p < 0.001). Furthermore, the CRUCW type was associated with the age of onset and course of disease. In older patients and those with longer course of CRUCW, the degree of radiation damage was more severe (p < 0.001; p = 0.011).

The 64 CRUCWs were divided into mild (n = 11), moderate (n = 45), and severe (n = 8) types.

Among the mild CRUCWs, 8 cases were cured by conservative surgical treatment. In 2 cases in young patients, the CRUCW was repaired by a transverse rectus abdominis myocutaneous flap (TRAM) with an acceptable aesthetic outcome (Figure 1). One case had a recurrence 6 months after conservative surgical treatment and was cured by a LDM flap. Among the 45 medium CRUCW cases, 23 were reconstructed with TRAM flaps (Figure 2), 10 with LRAM flaps, 6 with LDM flaps, 3 with CLB flaps, and 5 with LTR flaps. Two of the TRAM flaps and 2 of the LDM flaps developed small areas of distal necrosis. The resulting wounds were salvaged with skin grafts, and full healing was achieved. Eight severe CRUCWs were treated by 7 filleted flaps (Figure 3) and 1 TRAM flap. One filleted flap developed a postoperative infection due to incomplete clavicle debridement and formed a chronic fistula, resulting in delayed healing due to anti-inflammatory treatment and another debridement. After 1 to 4 years’ follow-up, all the wounds were cured (Table 3).