Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids

Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids.

LEVEL OF EVIDENCE

5.

Abstract P4-14-09: Feasibility of liposuction for treatment of arm lymphedema from breast cancer

Background: Lymphedema is a dreaded complication of breast cancer treatment affecting 20% of women having axillary node dissection. Liposuction minimizes unwanted fat in targeted areas. Our objective was to explore the feasibility of liposuction to reduce fat volume and thus arm lymphedema.

Methods: An IRB-approved prospective trial was conducted of women having unilateral arm lymphedema resulting from breast cancer treatment. At enrollment there was no evidence of cancer recurrence or arm cellulitis. Arm measurements (circumferential), volumes (water displacement and geometric calculation), and muscle strength differences between the affected and unaffected arms and quality of life/functionality were measured pre-operatively and post-operatively at 6 weeks, 6 months and one year(s). Descriptive statistical analysis was performed.

Results: Six breast cancer survivors underwent the liposuction procedure from 12/2008–4/2011. Median age was 54 yrs (range: 43–60) and median volume of fat aspirated was 700mls (range: 350–700). Average volume difference between the affected and unaffected arms at baseline was 522.5 mls (176–867) (geometric) and 589.2mls (280–770) (water displacement). No immediate complications; 1 cellulitis at 4 months post-operative. Average percent volume reductions for 5 of the 6 women at 6 weeks, 6 months and 1 year were 70%, 47%, 71% mls geometrically and 63%, 18%, 54% by water displacement respectively. Quality of life and functionality improved in all patients. Muscle strength remained unchanged. Pain lessened. Average follow-up is 15.49 months (range: 1.8–24.84 months).

Conclusion: Liposuction can safely reduce volume of arm lymphedema and improve functionality/quality of life. Larger studies (longer follow-up) are required to validate the durability of these early results.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-09.

Abstract P4-17-01: The effect of body mass index on breast reconstruction outcomes

Introduction: With increasing numbers of women choosing mastectomy for breast cancer treatment, breast reconstruction is consequentially on the rise. Obesity, a known predictor for wound healing complications, is also on the rise. Our objective is to review our institutional experience with the association between Body Mass Index (BMI) and breast reconstruction complications.

Methods: An IRB approved retrospective review of prospectively gathered patients having mastectomy with reconstruction was conducted. Data including patient demographics, stage at diagnosis, adjuvant treatment, type of mastectomy, type of reconstruction, and complications were collected. Patients were stratified by BMI into two categories: Normal weight (BMI 18.5–24.9), and overweight/obese (BMI 25 or greater). The statistical analysis was preformed using Wilcoxon Rank-Sum Test and Chi Squared Test, both using exact method with Monte Carlo estimation.

Results: From 06/1996 to 08/2011, 443 patients were identified having mastectomy and reconstruction. Of these, 218 patients had a normal weight at the time of mastectomy; 225 patients were overweight/obese. The overall median age was 49 years (range: 18–82). 780 mastectomies with reconstruction (106 unilateral, 337 bilateral) were performed. The most common reconstruction types included 477 tissue expander with implant reconstructions (62.8% of breasts), 106 latissimus flap with prosthesis (14.0%), and 103 pedicled TRAM flaps (13.6%). 245 patients (55.3%) experienced at least one complication; the most common complications were fat necrosis (80 patients, 18.1% of patients), infection (57, 12.9%), epidermolysis (41, 9.3%), and skin necrosis (39, 8.8%).

The overweight/obese group had a significantly higher prevalence of diabetes (6.3% vs. 0.9%, p = 0.0036) and hypertension (26.7% vs. 11.1%, p < 0.0001) and was more likely to receive neoadjuvant chemotherapy (16.2% vs. 4.8% p = 0.0005), possibly due to presentation at a later stage, but no significant differences were identified. Other comorbid conditions, including smoking, history of breast cancer, adjuvant chemotherapy, and history of or postsurgical radiation, were similar between the two groups. One significant difference was that the overweight/obese group was significantly older than the normal weight group (p = 0.0005).

There were no significant differences identified in the incidence of any individual complication between the two BMI groups. Additionally, the incidence of a patient having any complication was similar between the two groups (128 overweight/obese patients for 56.9% and 117 normal weight patients for 53.7%, p = 0.4918). When using breasts instead of patients as the unit of measure, when an overweight/obese patient had a complication they were significantly more likely to require an unanticipated return to the OR (93/160 breasts with a complication for 58.1% vs. 67/154 for 43.5%, p = 0.0124).

Conclusion: Obesity does not increase the risk of breast reconstruction complications, but increases the severity of complications if one should arise. This supports the continued use of breast reconstruction in patients regardless of their weight, and emphasizes that when the correct procedure is selected for an overweight/obese patient, outcomes can be similar to patients that are of a normal weight.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-17-01.