Friday, August 11, 2006

Delayed Breast Cellulitis Following Breast Conserving Therapy for Stage 1 and 2 Breast Carcinoma.

Delayed Breast Cellulitis Following Breast Conserving Therapy for Stage 1 and 2 Breast Carcinoma.

Sub-category: Breast Cancer

Category: Breast Cancer

Meeting: 2000 ASCO Annual Meeting

Abstract No: 532

Citation: Proc Am Soc Clin Oncol 19: 2000 (abstr 532)
Author(s): Douglas Zippel, Moshe Papa, Gur Ben-Ari


The advent of breast conserving surgery in appropriate breast tumors has allowed an adequate therapeutic advantage while at the same time ensuring a better cosmetic result along with a shorter hospital stay. Overall, breast conservation is well tolerated. One complication, which has been increasingly reported , is delayed breast cellulits (DBC) in the treated breast. This cellulitis can often be mistakenly interpreted as an aggressive early recurrence in the breast, thus presenting both surgeon and oncologist with a difficult diagnostic dilemma. The cellulits is to be distinguished from a post lumpectomy wound infection which can occur in the immediate post operative period. DBC appears several months after the surgical procedure, and is characterized by pain, erythema and edema in the affected breast, mimicking inflammatory carcinoma. There may be associated systemic symptoms such as chills, fever and leukocytosis. We present 16 cases of DBC from a population of 360 women undergoing breast conserving therapy for stage 1 and 2 breast cancer. The location of the primary tumor in all these patients was the upper outer quadrant or tail of the breast. There were no medial or inferior tumors. All patients underwent radiotherapy to the affected breast. 13 patients underwent axillary dissection, 9 node positive and 4 node negative. The mean number of lymph nodes removed was 16. All patients underwent FNA aspiration of the affected area, and fluid was sent for cytology and culture. There where no recurrent carcinomas found, and all cultures were negative. Treatment consisted mainly of symptomatic relief with NSAID drugs. The mean time to resolution of symptoms was 7.5 months. The manifestation of DBC is not uncommon in woman after lumpectomy and radiation therapy. It is probably a result of the disruption of lymphatic channels after surgery, coupled with some element of tissue damage secondary to radiation. The surgical oncologist should be aware of this particular entity, and while recurrent carcinoma should be considered and ruled out, the most appropriate therapy for such cases is symptomatic relief and encouragement, for the entity is usually self limiting.

American Society of Clinical Oncology

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Related Discussion from National Lymphedema Network

Oct-Dec 2005 Kathleen D. Francis, MD

Q: I had a lumpectomy for breast cancer 8 months ago followed by chemotherapy and radiation. Recently I developed redness, soreness and swelling of the breast, but otherwise have been feeling well. Is this an infection?

A: There are several diagnostic considerations in evaluating someone with the symptoms you describe. The main things that need to be ruled out include infection, inflammatory reaction to surgery and radiation, or a form of breast cancer called inflammatory breast carcinoma.

In persons who have had surgery and irradiation to the breast, lymphatic pathways in the breast presumably have been damaged or impaired. This can result in inefficient drainage of fluid and proteins from the breast, and also decreases the body's immune response in that area. Both of these processes lead to an increased risk of infection, or cellulitis, of the breast.
Cellulitis is an acute inflammation of skin and subcutaneous fat often associated with fever and other systemic symptoms such as tiredness and nausea. The infective organism in the vast majority of cases is presumed to be non-group A streptococcus, but in more than 80% of cases, no bacterial pathogen is ever isolated in the tissue or blood cultures. Infective cellulitis usually responds rapidly to a penicillin or erythromycin, although other antibiotics also may be effective.
In one study, the most important risk factor for the development of breast cellulitis was lymphedema of the breast. Other factors included seroma aspiration or drainage of a hematoma following breast surgery, and a larger volume of breast tissue removed in a lumpectomy.
Cellulitis can also occur in persons who do not have lymphedema or any risk of lymphedema. However, inflammatory and systemic symptoms in persons with lymphedema who develop cellulitis may take longer to resolve than in persons who do not have lymphedema. It is postulated that in persons with lymphedema or who are at risk for lymphedema, the toxins released by bacteria that have been killed by antibiotics or immune responses are not removed efficiently and these toxins set up a persistent local inflammatory response. This may also explain why the bacterial pathogen is infrequently isolated from patients with cellulitis-it may be the inflammatory response to the bacterial toxins rather than proliferation of the bacteria itself that is causing most of the symptoms.

Another consideration in evaluating redness, soreness, and edema of the breast occurring after treatment for the breast cancer is what may be described as non-infective inflammation. In these cases, the symptoms are similar to cellulitis, but are not accompanied by fever or systemic complaints and the onset of the symptoms is often more gradual. For instance, an inflammatory reaction can occur following radiation to the breast and may last for many months. One study referred to an entity called "delayed breast cellulitis" (using the term to mean inflammation rather than infection) in which pain, redness, and skin edema of the breast occurred between 4-15 months after lumpectomy without systemic symptoms, with negative tissue and blood cultures, and with negative biopsies for recurrent cancer. The majority of patients recovered without antibiotic treatment, but the mean time to resolution of symptoms was 7 months.

Because it can be very difficult to distinguish acute infection from the inflammation, the term acute inflammatory episode (AIE) is becoming more common to describe these episodes.

Lastly, breast inflammation and edema that is unresponsive to antibiotic therapy raises the possibility of inflammatory breast cancer, a diffuse neoplastic process that involves the skin lymphatics. Since mammography can be difficult to interpret in this situation, patients may require fine needle aspiration or core biopsy to rule out cancer.

As you can see, evaluation of the symptoms you describe can be a complicated process. In any case of new onset breast redness, soreness and edema, it is important to have medical evaluation to arrive at a proper diagnosis and institute appropriate treatment when needed.


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