Breast cellulitis after conservative surgery and radiotherapy

Delayed Breast Cellulitis following Surgery for Breast Cancer: A Literature Review

Background

Delayed breast cellulitis (DBC) is a relatively rare complication following breast-conserving surgery. It is often challenging to distinguish DBC from other clinical conditions such as postoperative infection, inflammatory reaction following radiation, and recurrent inflammatory carcinoma. The definition of DBC, diagnostic approach, and treatment are not well established in the literature.

Methods

We performed a literature search with the keywords 'Delayed breast cellulitis' and 'Breast conservation therapy cellulitis', without limitations to the dates or the article types, in the PubMed database. Information about the number of cases with DBC, the age of the patients, the interval between the onset of symptoms and the time of surgery or radiotherapy, and the type and outcome of DBC treatment were reviewed and tabulated.

Results

We identified only 5 papers that were absolutely related to our subject, reflecting the fact that 'delayed breast cellulitis' is a fairly unknown term and the condition is rather underreported. Although most agree that DBC is primarily an aseptic inflammatory process, bacterial growth may contribute to its development or recurrence. Obesity, breast size, location of the breast tumor, removal of the axillary lymph nodes, and connective tissue disorders are considered as risk factors. There is no clear evidence on how DBC should be best managed. Antibiotic treatment is controversial, and many authors suggest anti-inflammatory agents or sole observation. Prevention of lymph stasis and its consequences with massage and skin care may be helpful. Despite the fact that malignancy is rare, in cases where the condition persists for more than 4 months, a core biopsy should be performed to rule out recurrent or second primary carcinoma.

Conclusion

The correct diagnostic approach is essential as it provides patients with reassurance, minimizes anxiety, and prevents unnecessary medical investigations, treatments, and costs.

Infections associated with solid malignancies

Although solid tumors comprise the vast majority of cancers, the incidence of serious infectious complications in this population is much less than in patients with hematologic malignancies. Most infections involving patients with solid tumors comprise two groups. First, patients acquire infections as a result of the cancer itself, due to either mass effect that interrupts normal function or destruction of the normal barriers to infection. Second, patients acquire infections as a complication of the treatments they receive, such as chemotherapy, radiation, surgery, or medical devices. Advances in the management of cancer have resulted in a gradual stepwise improvement in survival for patients with most types of solid tumors. Much of this improvement has been attributed to advances in cancer screening, diagnosis, and therapeutic modalities. In addition, improvements in the prevention, diagnosis, and treatment of infections have likely contributed to this prolonged survival. This review highlights select articles in the medical literature that shed light on the epidemiology and pathophysiology of infections in patients with solid tumors. In addition, this review focuses upon the diagnosis and treatment of these infections and their recent advances.

A systematic review of bacteremias in cellulitis and erysipelas

OBJECTIVES

Because of the difficulty of obtaining bacterial cultures from patients with cellulitis and erysipelas, the microbiology of these common infections remains incompletely defined. Given the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) over the past decade the proportion of infections due to S. aureus has become particularly relevant.

METHODS

OVID was used to search Medline using the focused subject headings "cellulitis", "erysipelas" and "soft tissue infections". All references that involved adult patients with cellulitis or erysipelas and reported associated bacteremias and specific pathogens were included in the review.

RESULTS

For erysipelas, 4.6% of 607 patients had positive blood cultures, of which 46% were Streptococcus pyogenes, 29% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 11% were Gram-negative organisms. For cellulitis, 7.9% of 1578 patients had positive blood cultures of which 19% were Streptococcus pyogenes, 38% were other β-hemolytic streptococci, 14% were Staphylococcus aureus, and 28% were Gram-negative organisms.

CONCLUSIONS

Although the strength of our conclusions are somewhat limited by the heterogeneity of included cases, our results support the traditional view that cellulitis and erysipelas are primarily due to streptococcal species, with a smaller proportion due to S. aureus. Our results also argue against the current distinction between cellulitis and erysipelas in terms of the relative proportion of infections due to S. aureus.

[Recurrent breast cellulitis associated with lymphangiectasia after tumorectomy for breast cancer]

BACKGROUND

Recurrent breast cellulitis has been described as a complication following breast conservation therapy.

OBSERVATION

A 50-year-old woman undergoing tumour excision, postoperative radiotherapy and chemotherapy presented recurrent breast cellulitis in the same region. The presence of lymphangiectasia suggested a complication subsequent to lymph stasis.

DISCUSSION

Conservative therapy for breast cancer, allowing the development of subclinical or patent lymphœdema, constitutes a prominent risk factor for recurrent cellulitis. This complication has also been considered in patients with lower extremity cellulitis following saphenous venectomy for coronary bypass surgery. The unusual presence of lymphangiectasia observed in our patient provides clear evidence that lymphœdema is the most prominent risk factor for the development of cellulitis after breast conservation therapy.

Complications in Breast Surgery

Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection, lymphatic mapping/sentinel lymph node biopsy, and reconstruction.

Delayed breast cellulitis: An evolving complication of breast conservation

PURPOSE

Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC.

METHODS AND MATERIALS

From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome.

RESULTS

Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC.

CONCLUSION

Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.

Angiosarcoma after conservation treatment for breast carcinoma: Our experience and a review of the literature

The development of angiosarcoma of the breast is a recognized complication of breast conservation therapy (BCT), but the evolution, prevalence, and outcome have not been accurately established. We sought to evaluate and review the clinicopathologic, prognostic, and treatment attributes of angiosarcoma arising in the irradiated breast after BCT. We conducted a retrospective chart and slide review of 8 patients seen between 1996 and 2004 with a diagnosis of secondary angiosarcoma. All were treated with mastectomy. Clinical and histopathologic findings were studied and previously reported cases were reviewed. Primary surgery-related breast edema and cellulitis was observed in 7 and 5 patients of the 8 patients studied, respectively. Postirradiation breast edema and grade 2/3 fibrosis occurred in 5 and 8 patients, respectively. The mean age of the patients at onset of the breast cancer and angiosarcoma was 65 and 72 years, respectively. The mean latency period between the treatment of the breast cancer and the diagnosis of angiosarcoma was 75 months. The actuarial rate of 2-year survival for patients presented with single (n = 4) compared with multiple (n = 4) skin lesions was 50% and 0%, respectively (P = .0233). The estimated incidence of angiosarcoma after BCT was found to be 0.14 %. BCT-associated angiosarcoma arises after a relatively brief interval, and breast edema-fibrosis can possibly contribute to its development. Special attention should be paid to skin changes occurring after BCT. The extent of skin lesions is predictive of survival. As shown by a review of the literature, angiosarcomas are often resistant to surgery, chemotherapy, and radiotherapy, and targeted therapy against tumor biological properties may be a new approach to angiosarcoma treatment.

Prospective trial of intraoperative radiation treatment for breast cancer

BACKGROUND

A new device, Intrabeam, is available for intraoperative radiotherapy. We have prospectively examined its feasibility and tolerability in delivering adjuvant breast cancer treatment.

METHODS

Thirty-five patients undergoing breast-conserving surgery received targeted tumour bed irradiation consisting of 5 Gy (at 10 mm) in a single fraction. This single intraoperative treatment was used to replace the external beam radiotherapy "boost" that would usually be given in 10 daily treatments following 5 weeks of whole breast irradiation. Patients later completed external beam radiotherapy as usual. Potential toxicities were prospectively assessed fortnightly prior to external beam radiotherapy, weekly during it, and 3 monthly subsequently.

RESULTS

The intraoperative radiotherapy was able to be delivered without difficulty, either at time of initial cancer surgery or as a second procedure. When performed as a separate procedure the median operating time was 56 min. The treatment was well tolerated, with only one patient experiencing any grade 3 or 4 toxicities--this was acute grade three itch. There was an overall early breast infection rate of 17%. No unexpected toxicities were seen.

CONCLUSIONS

This simple and well-tolerated treatment delivers a useful radiation dose to the area of highest risk of tumour recurrence. The early infection rate is similar to that reported in the literature, for treatments without intraoperative radiotherapy. Whether such a treatment may adequately replace the entire adjuvant radiation therapy treatment for low-risk patients is now being studied in a randomized trial.

Surgical considerations in the treatment of early stage breast cancer with accelerated partial breast irradiation (APBI) in breast conserving therapy via intersitial brachytherapy

OBJECTIVE

To examine early and late toxicities, evaluate cosmetic results, and determine the need for reoperation or additional diagnostic procedures in patients treated with accelerated partial breast irradiation (APBI) delivered by way of an interstitial implant in breast-conserving therapy.

METHODS

A total of 199 patients with stage I or II breast cancer were managed with lumpectomy followed by radiation restricted to the tumor bed using an interstitial implant (APBI). Retrospective analyses were performed for early and late toxicities (infection, fat necrosis, breast pain, edema, erythema, fibrosis, pigmentation changes, and telangiectasias), need for reoperation or additional diagnostic procedures, cosmetic results, and local control. Patient selection criteria by the surgeon for referral to RT for APBI included age, tumor size, histology, nodal status, margin status, and absence of extensive intraductal component. Treatment was delivered with either a low-dose or high-dose rate implant. Median follow-up was 5.7 years, and 54% of the patients were followed-up for >7 years.

RESULTS

Infections developed in 22 of 199 (11%) patients: 7% early (</=1 month after implant removal) and 4% late (>1 month after implant removal). Five of the 22 patients (2% of all patients) required operative intervention for the infection, either incision and drainage or debridement. There was a statistically significant difference between infection rates with open (8.5%) versus closed (2.5%) cavity placement of the interstitial needles (P = 0.005). There was no statistically significant difference between low-dose rate (inpatient) and high-dose rate (outpatient) treatment (P = 0.207). Forty-five patients (23%) had an additional diagnostic procedure to evaluate a suspicious or uncertain finding on physical examination or mammogram. Fibrosis and fat necrosis were found in 26 of the 45 patients. The incidence of fat necrosis increased with time. More patients were found to have fat necrosis after 5 years. One patient had fat necrosis diagnosed at <6 months; 8 patients (4% of total) at >/=6 months to <2 years; 10 patients (5% of total) at >/=2 years to <5 years; and 22 patients (11% of total) at >/=5 years. The majority of fat necrosis was detected on mammogram (80%) and was asymptomatic (78%). Cosmesis and toxicities were assessed at 3 defined time points: </=6 months, 2 years, and >/=5 years of follow-up. Using Harvard criteria, good to excellent cosmetic results were observed in >90% of patients. Breast pain, edema, and erythema diminished with time. Of the 199 cases, there were only 5 ipsilateral breast failures, yielding a 5-year actuarial local recurrence rate of 1.2%. Of these 5 failures, 2 were true recurrences/marginal misses, yielding a 5-year actuarial true recurrence/marginal miss rate of 0.5%. The 5-year actuarial cause-specific survival rate was 99% for APBI patients.

CONCLUSIONS

In selected patients with early-stage breast cancer, APBI with targeted interstitial brachytherapy offers 5-year results comparable with conventional breast-conserving therapy employing whole-breast radiation therapy. Minimal long-term toxicities were noted, most of which demonstrated continued resolution over time. Acceptable acute (7%) and delayed (4%) infection rates were observed. Fat necrosis was identified with increasing frequency with time, but the majority was asymptomatic. Cosmetic results are good to excellent (>90%). Continued follow-up by the surgeon will be required to determine the long-term efficacy of this alternative treatment approach.

Possible role of cellular immunity: a case of cellulitis

On the basis of the observation that there was a "skip" area in an otherwise diffuse drug eruption where cellulitis had previously occurred, it is theorized that both delayed hypersensitivity type of dermatologic drug reaction and cellulitis share pathogenic mechanisms.

Risk factor analysis for breast cellulitis complicating breast conservation therapy

Women who undergo breast conservation therapy for early-stage breast cancer can develop breast cellulitis, a complication for which risk factors are undefined. A matched case-control investigation was conducted to identify risk factors for the development of breast cellulitis among patients who have undergone breast conservation therapy. Patients comprised 17 patients with cases of breast cellulitis diagnosed after partial mastectomies that had been performed from 1992 through 1997 and 34 control patients who were matched to case-patients by date of breast lumpectomy and by primary surgeon. Statistical analyses indicated the following factors were associated with breast cellulitis: drainage of a hematoma (P=.010); postoperative ecchymosis (P=.021); lymphedema (odds ratio [OR], 10. 154; 95% confidence interval [CI], 1.348-208.860); resected breast tissue volume (OR, 1.456; 95% CI, 1.035-2.168); and previous number of breast seroma aspirations (OR, 3.445; 95% CI, 1.036-19.771). This is the first matched case-control study to identify risk factors for the development of breast cellulitis after breast conservation therapy.

Cellulitis syndromes: an update

Cellulitis is a commonly seen clinical syndrome that is most often associated with beta-haemolytic streptococci and Staphylococcus aureus. Several medical conditions and a variety of procedures can predispose to the development of cellulitis by a common mechanism: venous and lymphatic compromise. The precise pathophysiologic and immunologic details involved in the predisposition to cellulitis remain poorly understood. Therapy is directed at resolution of acute infection and prevention of recurrent episodes of cellulitis.

Breast cellulitis complicating breast conservation therapy

Breast conservation therapy has gained acceptance as treatment for limited disease due to breast cancer. Unfortunately, a minority of patients who undergo this therapy will develop cellulitis of the breast, often recurrently, months to years later. A definitive pathogen has not been identified in the large majority of cases reported to date. Whilst some patients develop systemic toxicity with local skin changes of cellulitis, others manifest no fever, chills or leukocytosis. Local breast findings gradually clear with antibiotic treatment: when breast changes persist, non-inflammatory causes, including tumour recurrence, of the breast should be considered. More study is needed to define risk factors for the development of breast cellulitis complicating breast conservation therapy.

Delayed cellulitis associated with conservative therapy for breast cancer

BACKGROUND AND OBJECTIVES

Delayed breast cellulitis is an infrequently reported entity after conservation therapy for breast cancer. We describe our experience with this entity at Naval Medical Center, San Diego.

METHODS

Eight patients who presented with delayed cellulitis after wide local excision/axillary dissection and breast radiotherapy (RT) are presented. Their clinical characteristics and therapy are described and possible causative factors are analyzed.

RESULTS

The latency of breast cellulitis is variable after breast conservation therapy, although most cases in our experience and in the literature occur within a year post-RT. These infections are frequently refractory to a single course of antibiotics (n = 4 cases in our experience). Some patients suffer multiple episodes separated by months.

CONCLUSIONS

Breast cancer patients are at risk for delayed cellulitis after conservative surgery and RT. The mechanism of such events probably involves lymph stasis, however, therapy is no different from the more frequently occurring cases of cellulitis presenting perioperatively.

Cellulitis of the breast as a complication of breast-conserving surgery and irradiation

Breast-conserving therapy (BCT) has become a standard treatment option for patients with early-stage breast cancer. We have observed cellulitis of the treated breast as a complication occurring before, during, and after breast irradiation. The cases of five women (median follow-up, 28 months; range, 24-65 months) who developed cellulitis before (n = 1), during (n = 2), or after (n = 2) breast irradiation were reviewed. A consecutive series of BCT patients at Emory University was reviewed to determine the incidence of this complication. Four of five women had an axillary dissection, yielding a median of 14 negative lymph nodes (range, 6-22 nodes). Two of four patients developed axillary seromas requiring aspiration. In these four patients, only the breast was irradiated. A fifth patient had no axillary dissection and had breast and supraclavicular/axillary irradiation. The median whole breast dose was 50 Gy (range, 46-50.4 Gy). The clinical features of cellulitis included erythema, edema, tenderness, and warmth in all patients. Cellulitis was a relapsing problem for four of the five patients. The incidence of this complication in our series of BCT patients was approximately 1%. Cellulitis in the ipsilateral breast can be a relapsing complication of BCT and can be seen before, during, or after breast irradiation. Axillary seromas and aspiration seem to indicate a subset of patients at risk of early cellulitis. Late cellulitis may be caused by a variety of factors related to modifications of vascular and skin integrity by surgery and radiotherapy. Prompt diagnosis and appropriate antibiotic therapy is recommended. This problem need not interrupt a course of breast irradiation, and does not necessarily lead to a poor cosmetic result.