Chest Wall Defect With an Extensively Encroached Heart and Severely Impaired Cardiac Function
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Dr. Zhang, Dr. Huang, and Dr. Peng are from the Institute of Burn Research and Dr. Wang is from the Department of Cardiothoracic Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
Address correspondence to:
Jiaping Zhang, MD, PhD
Institute of Burn Research
Southwest Hospital, Third Military Medical University
A radiation ulcer of the chest wall following breast cancer treatment presents a severe physiological and psychological problem, which can last several years with progressive tissue necrosis, superimposed infections, scarring, and even carcinogenesis.1 A radiation-induced ulcer of the chest wall with cardiac encroachment and dysfunction is rare, but nevertheless life threatening, as a result of the high risk of cardiac dysfunction, myocardium hemorrhage, traumatic cardiac injury, and even accidental heart damage. Surgical reconstruction of this defect presents a two-fold challenge: covering the defect while preserving cardiac function. Early reconstruction of such a chest wall defect, though challenging, is recommended as outlined in this report.
A 36-year-old woman with a non-healing ulcer on the left anterior chest wall was referred to the burn department of the authors’ hospital. The patient noted occasional arrhythmia and fatigue in addition to frequent pain from the scar tissue surrounding the ulcer. Eleven years prior, a left-sided radical mastectomy was performed to treat breast cancer followed by local radiotherapy. Despite ongoing wound management, a progressive ulcer developed in the radiation field 1 year after the mastectomy, and an operation in another hospital was performed 3 years prior to presentation, but failed to close the defect.
The physical examination upon admission to the hospital revealed a deep radiation ulcer (5.0 cm × 6.5 cm) on the patient’s left anterior chest wall with exposure of the stumps of the third and forth ribs, the left edge of the sternum, and the anterior part of the heart with visible pulsations. The ulcer was filled with foul-smelling necrotic tissue. Several hemorrhagic spots were present on the exposed heart. Scar tissue around the ulcer and the encroached heart are shown in Figure 1. Laboratory tests showed an increased proportion of neutrophils of 75% and an elevated serum troponin T (4.2 ng/mL). Electrocardiogram (ECG) revealed an enhanced ST-T segment. Spiral computerized axial tomography (CT scan) revealed a mild left ventricular dilation and a moderate mitral regurgitation with decreased ejection fraction of 48%. Histopathology of the ulcer border indicated a chronic inflammatory response without carcinomatous transformation.
Intravenous antibiotics and local wound care were employed to control infection. Defect reconstruction was performed on day 12 after admission. Scar tissue and any areas of necrotic tissue were excised. For safety, only dissolved necrotic cardiac tissues were removed from the exposed heart by curette, with bulks of non-separated devitalized tissues remaining in situ.