Hyperbaric oxygen therapy for a refractory skin ulcer after radical mastectomy and radiation therapy: a case report

A 74-year-old Japanese woman underwent left radical mastectomy in 1987 for breast cancer with a size of 6 × 4 cm in the upper outer quadrant (T3N3M0, stage IIIB). Tamoxifen was administered in addition to tegafur and OK-432 as an adjuvant chemotherapy after the surgery. The tumor was negative for both estrogen receptor and progesterone receptor and was evaluated as N2b. Radiation therapy was initiated 6 weeks after the surgery. Initially, the patient received telecobalt-60 treatment, comprising 24 Gy in 12 fractions (days) to the supraclavicular and parasternal regions and 14 Gy in 7 fractions (days) to the left axilla, because of delayed wound healing after the surgery. Her wound was completely healed 15 days after the radiation treatment. The cobalt-60 treatment was resumed, comprising 26 Gy in 13 fractions to the supraclavicular and parasternal regions and 36 Gy in 18 fractions to the left axilla for 27 days, resulting in a total of 50 Gy in 25 fractions in each region. At the same time, electron treatment (9 MeV) to the left chest wall was started such that it did not overlap with the treatment of the supraclavicular, parasternal, and axillary regions. After the patient had received 44 Gy in 22 fractions at 32 days, skin redness and swelling occurred, and the treatment was stopped. After a 1-month rest period, 3 additional fractions were performed to provide a total of 50 Gy in 25 fractions. At that time, a keloidal change corresponding to the electron treatment area on the patient’s left chest wall was noted; her skin became thinner and more fragile, but no severe infections were observed.

The patient noticed a small ulcer at the beginning of 2000, but the ulcer healed over time without treatment. She visited the hospital where she received radiation therapy in December 2012, and at that time she was treated with cadexomer iodine ointment for a skin ulcer on the left chest wall. A fistula eventually developed, and pus discharging from the fistula was observed in January 2013. She was referred to the hyperbaric medical center in February 2013. The fistula (1.5 × 3 cm) with pus discharge on her left chest wall was noted at her first visit (Fig. 1a). The skin around the lesion showed redness and swelling with a keloidal change. The pus discharge was synchronized to her respiratory rhythm, and a bacterial identification test result was positive for Staphylococcus aureus. A pulmonary function test revealed pulmonary restriction (percent predicted vital capacity [%VC] 60.6 %, percent predicted forced expiratory volume in 1 second [FEV_1%] 80.2 %). Chest radiography showed cardiac enlargement. Chest computed tomography (CT) showed no cystic lesions, and the fistula located on the left chest wall did not invade the thorax (Fig. 1b). The patient was diagnosed with a late-onset, radiation-induced skin ulcer that developed 25 years after radical mastectomy. HBO₂ was indicated for the refractory ulcer and osteomyelitis of the ribs. Her medical history included acute myocardial infarction and a stent implanted in 2003. She was instructed to communicate any problems including otalgia, ear fullness, hearing loss, tinnitus, vertigo, and dizziness to a physician at the hyperbaric medical center.

HBO₂ therapy was started in March 2013 after written informed consent was obtained. A multiplace hyperbaric chamber (NHC-412-A; Nakamura Tekko-Sho K.K., Tokyo, Japan) was pressurized up to 2.5 atmospheres absolute (ATA) with 100 % oxygen delivered through a mask. The duration of each treatment session was 105 minutes, including 15 minutes of compression at the beginning and 20 minutes of decompression at the end of treatment. The patient tolerated the HBO₂ protocol without any adverse effects, despite her pulmonary restriction and cardiac enlargement. After 25 sessions over the course of 3 months, granulation tissue was observed around the margin of the ulcer, but massive pus discharge was still noted (Fig. 2a). At this time, a physician suggested that the ulcer be washed with tap water once daily. Granulation tissue gradually increased and pus discharge diminished without use of antibiotics (Fig. 2b, c). After 86 sessions over the course of 11 months, epithelialization was observed and pus discharge disappeared (Fig. 2d). A pulmonary function test at this time still revealed pulmonary restriction (%VC 58.6 %, FEV_1% 85.2 %), with no remarkable change compared with previous findings. After 101 sessions over a period of 1 year, the ulcer was considered to be healed. The patient no longer had to cover her skin wound and was able to bathe after the treatment. At a follow-up visit 6 months after the completion of HBO₂ therapy, no recurrence of skin ulceration was noted (Fig. 3a). Chest CT was performed to evaluate the further development of abnormal lesions. We found that osteomyelitis of the ribs had developed following the formation of the skin ulcer compared with the previous CT. A rib defect was observed on three-dimensional chest CT (Fig. 3b). The rib defect was managed conservatively because the patient’s symptoms were limited to left chest pain in her daily life.