Osteoradionecrosis of the chest wall in a patient with invasive ductal carcinoma of the breast: a case report

Abstract

Introduction and importance:

Osteoradionecrosis following radiotherapy is quite rare in locations other than the jaw. In this case report, we described a patient with breast cancer who developed osteoradionecrosis of the chest wall following radiotherapy treatment for breast cancer.

Case presentation:

A 60-year-old woman with a history of right breast invasive ductal carcinoma treated with mastectomy and radiotherapy presented with extensive soft tissue and rib necrosis on the right chest wall. Due to the severity of the necrosis, she underwent surgical debridement and reconstruction, including resection of five anterior ribs and part of the lateral sternum. Part of the defect was covered using a latissimus dorsi and serratus anterior myocutaneous flap, while the remaining area was managed with negative-pressure wound therapy and later skin grafting, achieving full healing within 2 weeks.

Clinical discussion:

Osteoradionecrosis of the chest wall can present with ulcers, infection, hemorrhage, rib pain, or even pathological fractures, sometimes presenting up to a year after radiotherapy. Early recognition is often delayed, especially outside the jaw, but timely diagnosis and management can reduce necrosis and improve outcomes, including aesthetic results. Imaging, such as positron emission tomography or contrast-enhanced computed tomography, may aid in early differentiation from other conditions like metastasis.

Conclusion:

Osteoradionecrosis can develop in any area of the body exposed to radiotherapy and may occur in unusual sites such as the chest. Early diagnosis and management are crucial, as delayed intervention may lead to extensive necrosis and poor aesthetic outcomes.

Introduction

Radiotherapy is one of the commonly used treatment modalities for cancers that has had a substantial effect on improving survival among these patients by damaging the DNA of cancer cells and their vasculature^[1,2^]. It is shown that the addition of radiotherapy to breast cancer treatment, particularly in patients with low-risk tumors, can reduce the local recurrence rate and the mortality rate due to breast cancer^[3,4^]. However, despite the efficacy of radiotherapy and its beneficial effects, it has its own acute and late complications, which include both local and systemic ones^[5,6^]. Various complications of radiotherapy, such as mucositis, acute and chronic infections, fibrosis, cardiac arrhythmia, and cardiac block, have been reported in the literature^[7,8^]. In patients undergoing radiotherapy for breast cancer, most complications cause mild-to-moderate symptoms. However, more severe effects, including pulmonary complications, lymphoedema, upper limb complications, and even secondary cancers, have also been reported in the literature^[9^].

HIGHLIGHTS

• Osteoradionecrosis is a rare but serious complication of radiotherapy outside the jaw.

• Chest wall osteoradionecrosis may occur following breast cancer radiotherapy.

• Delayed diagnosis can lead to extensive rib and soft tissue necrosis.

• Surgical debridement and reconstruction with myocutaneous flaps can achieve successful healing.

• Early recognition is essential to prevent severe tissue destruction and poor aesthetic outcomes.

Osteoradionecrosis is one of the complications described in relation to radiotherapy^[10,11^]. Osteoradionecrosis, typically described in the jaw bones after radiotherapy for head and neck cancers, involves both bone and soft tissue, leading to necrosis in these areas^[10,12,13^]. Radiotherapy has both direct and indirect effects on bone tissue. By damaging DNA, it triggers inflammation, vascular injury, osteoblast loss, and cellular alterations, which can lead to osteoradionecrosis through mechanisms such as hyperinflammation, vascular occlusion, hypoxia, hypovascularity, and hypocellularity^[13,14^]. It is shown that hyperfractionation in radiotherapy and higher radiotherapy doses can increase the risk of osteoradionecrosis^[13,15^]. Tumor size and location are also among the other factors that impact the risk of osteoradionecrosis^[14^]. The majority of osteoradionecrosis cases after radiotherapy occur in the jaw bones, although its occurrence has also been reported in other sites, such as the ribs and chest wall^[16–19^]. However, the incidence of osteoradionecrosis is very low in patients receiving radiotherapy for breast cancer, with a single-center study reporting a rate of approximately 0.07%^[20^]. As a result, considering such a low incidence, there is not much information on the clinical presentations and course of osteoradionecrosis in patients undergoing radiotherapy for breast cancer, its risk factors, and optimum treatment. Therefore, in this case report, we described a patient with breast cancer who developed osteoradionecrosis of the chest wall following radiotherapy. This work has been reported according to the SCARE criteria^[21^].

Case presentation

The patient was a 60-year-old woman who was referred to our center, a tertiary hospital in Tehran, capital of Iran, with extensive necrosis of soft tissue and ribs on the right side of the chest wall (Fig. 1). The patient had been diagnosed with invasive ductal carcinoma of the right breast 1 year before admission to our center and had since undergone a mastectomy followed by 30 sessions of radiotherapy (40 Gy). She developed extensive necrosis of the right chest wall after the treatment and was referred to our center for treatment (Fig. 1) The diagnosis was primarily established based on clinical findings. Histopathological examination of the resected specimen obtained during surgery further confirmed the diagnosis of osteoradionecrosis. No preoperative radiological evaluation was performed prior to surgical intervention. Her medical history was significant for diabetes mellitus, for which she was taking metformin. She did not mention a history of smoking. The diagnosis of osteoradionecrosis of the chest wall was confirmed for the patient, considering the symptoms and history of radiotherapy in the patient. Considering the extent of rib and skin necrosis, the patient was considered a candidate for surgical debridement and reconstruction. Cardiology and endocrinology consultations due to her background of diabetes were obtained preoperatively. Table 1 provides the chronological progression from radiotherapy exposure to symptom onset and surgical intervention.

Figure 1.

Clinical presentation of the patient and intra-operative images of the defect.

Table 1.

Timeline of clinical events and therapeutic interventions.

Event	Date
Mastectomy	Month 0
Radiotherapy	Month 1
Onset of symptoms	Month 11
Diagnostic investigations (e.g., imaging, labs)	Month 11
Diagnosis confirmed	Month 11
Intervention/Treatment	Month 11
Negative-pressure wound therapy	Months 12–13
Skin grafting	Month 13
Discharge	Month 13

The superior margin of the defect was at the level of the clavicle, the inferior margin reached the eighth rib, and the lateral margin corresponded to the edge of the latissimus dorsi muscle (Fig. 1). As a result, approximately five anterior ribs and a small portion of the lateral sternum were resected. Furthermore, during surgery, extensive necrotic tissue was excised, and a considerable amount of fluid was drained from the thoracic cavity (Fig. 2). A latissimus dorsi and serratus anterior myocutaneous flap was mobilized and rotated to cover the chest wall defect. The flap successfully covered about 60% of the defect, leaving only the uppermost area partially uncovered (Fig. 2). Although muscle was present at the superior margin, there was no overlying skin. Negative-pressure wound therapy was applied to this region for 1 month. Afterward, minor debridement was performed, followed by split-thickness skin grafting. In the follow-ups, complete wound healing was achieved within 2 weeks. During the follow-up 1 month after surgery, the patient had no new complaints, and the wound condition was satisfactory. There was no sign of infection (Fig. 3).

Figure 2.

Reconstruction process of the defect.

Figure 3.

Reconstructed area during follow-ups.

Discussion

In this case report, we described a patient with osteoradionecrosis of the chest wall following radiotherapy for breast cancer, contributing to the limited existing literature on the topic. Although the patient was referred to our center in the later stages of the disease, which could have affected the outcome, she successfully underwent surgical debridement of the defect, resection of the affected area, and reconstruction of the region.

Osteoradionecrosis is one of the rare complications following radiotherapy treatment for breast cancer, with an incidence rate of less than 0.1%^[20^]. A number of factors, including the formation of free radicals and inflammation and thrombosis in the microvasculatures, are believed to play roles in the pathophysiology of osteoradionecrosis^[22^]. While the exact risk factors for osteoradionecrosis of the chest wall have not been completely identified, several factors, such as radiation dose, tumor location, and its invasion to bones, trauma, and inflammation, are believed to predispose patients to a higher risk of osteoradionecrosis^[18^]. Osteoradionecrosis presents with a wide range of symptoms. In our patient, due to delayed surgical treatment, there were extensive areas of necrosis and a large defect in the chest wall. This highlights the importance of considering osteoradionecrosis in the differential diagnosis in any area that has undergone radiotherapy. Although the patient was successfully managed in our center, one of the common complaints in such cases is aesthetic concerns following reconstruction^[23^]. While these issues may be more significant in patients with osteoradionecrosis of the mandible and facial bones, they are still of importance in osteoradionecrosis of the chest wall. Therefore, a timely diagnosis and management could be helpful in the early management of these patients to achieve a more favorable outcome with regard to aesthetic aspects and the overall patient’s outcome.

One of the crucial aspects in diagnosis is clinical awareness of the possibility of incidence of osteoradionecrosis in areas other than the jaw. Even though the patient presented in this case report had developed many symptoms that were suggestive of osteoradionecrosis, the diagnosis was not made until she was referred to our center. Patients with osteoradionecrosis of the chest wall may present with ulcers ranging from mild to severe, which can be accompanied by infection, hemorrhage, rib pain that might be pleuritic, or even pathological fractures^[17–19,24^]. The presence of these symptoms in an area previously exposed to radiotherapy may raise suspicion of osteoradionecrosis, as they can appear even up to a year after treatment^[17^]. Even though in our patient, given the extent of symptoms, we did not need to use imaging modalities to confirm the diagnosis, at earlier stages, they might be helpful to differentiate osteoradionecrosis from other possible differential diagnoses, such as bone metastasis^[18^]. One of the helpful imaging modalities in this regard is a positron emission tomography (PET) scan. In the early stages, decreased uptake may help differentiate osteoradionecrosis from metastasis. However, in the later stages, when there is an increased uptake in osteoradionecrosis, other features such as permeative bone loss and the absence of solid or cystic masses become more suggestive of this condition^[18^]. Chest computed tomography scan with contrast is another imaging modality that has been used in the diagnosis of osteoradionecrosis of the chest, which might reveal sclerotic changes in the affected bones, as well as calcification in the adjacent muscles^[16^]. Once diagnosed, surgical debridement, surgical reconstruction, and infection management are the cornerstones of treatment for patients with osteoradionecrosis of the chest wall^[19,20^].

This case report had several limitations worth mentioning. First, the follow-up duration was relatively short, and we have no information on the patient’s long-term outcomes or potential complications. Second, the patient was referred to our center at a late stage of the disease, so we lack information about the earlier clinical course, when symptoms were likely milder. Third, we did not assess any patient-related outcomes, such as satisfaction with the treatment or quality of life after treatment, which is another limitation of the study.

Conclusion

Osteoradionecrosis can develop in any area of the body exposed to radiotherapy and may occur in unusual sites such as the chest. A history of radiotherapy accompanied by symptoms like pain, ulceration, or hemorrhage should raise clinical suspicion for osteoradionecrosis and prompt appropriate investigations, including imaging studies such as PET scans. Early diagnosis and management are crucial, as delayed intervention may lead to extensive necrosis and poor aesthetic outcomes.

Ethical approval

The Ethics Committee of Tehran University of Medical Sciences approved the study protocol.

Consent

We obtained written informed consent from the patient to prepare this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

Not applicable.

Author contributions

H.A.: Conceptualization; Investigation; Resources; Data curation; Writing – original draft; Visualization. A.Y.: Investigation; Data curation. O.R.: Methodology; Validation; Writing – review & editing; Supervision; Project administration.

Conflicts of interest disclosure

The authors have no conflict of interest to declare.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Omid Rezaei.