For patients with unresectable, locally advanced breast cancer with skin invasion, the primary therapy is systemic, such as chemotherapy[
1]. 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)[
4], 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[
10]. 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.
After obtaining approval from the Committee on Pharmaceutical Affairs in our hospital and written informed consent from the patients, we obtained Mohs paste formulated by the pharmaceutical department. Zinc chloride was ground into a powder in a mortar and dissolved using purified water. Next, zinc oxide starch powder was mixed gradually. Finally, glycerin was added to a viscosity individualized according to the patient’s need (Table
1). Mohs paste was formulated on the day of use. After petroleum jelly was applied to the surrounding normal skin, Mohs paste was applied to the tumor and covered with gauze. Mohs paste was removed 24 hours after application, and petroleum jelly was reapplied. Gauze was changed every day. Necrotic tissue was removed bluntly. This method was repeated until the tumor flattened (Table
2).
Table 1
Formulation of Mohs paste
Saturated zinc chloride | 34.5mL | |
Zinc chloride | | 10g |
Purified water | | 10mL |
Powdered Sanguinaria canadensis
| 10g | |
Zinc oxide starch powder | | 5g |
Paste containing stibnite | 40g | |
Glycerin | | 5–10mL |
Table 2
Protocol for the Mohs method in our hospital
1. | Apply petroleum jelly to the surrounding normal skin, and cover with gauze to protect from Mohs paste. |
2. | Uniformly apply the Mohs paste at a thickness of 1mm on the surface of tumor and protect using gauze. |
3. | Remove the gauze and Mohs paste 24 hours after application. |
4. | After removal of Mohs paste, apply petroleum jelly and protect using gauze. |
5. | Observe the tumor at the same time every day. Necrotic tissue may be removed bluntly, or it might fall off naturally. |
6. | Continue above cycle every 2–3 days until the elevated tumor is flattened. |