Seroma formation after axillary dissection is a common problem in breast cancer surgery. We report the case of a 68-year- old female with breast cancer who underwent a wide local excision and axillary clearance due to stage III breast cancer. Patient received post-operative whole breast irradiation therapy and developed a painful, infected seroma one month after surgery. This was treated with antibiotic therapy after which the infection subsided. One year after surgery patient pre- sented with a painful persisting seroma in the left axilla. We decided to surgically treat the seroma by removing the ﬁbrous seroma capsula and closing of the dead space with a latissimus dorsi ﬂap. Six weeks after surgery, patient was pain and ser- oma free and was happy with the surgical result. Latissimus dorsi ﬂap harvesting is an ideal way to treat persisting ﬁbrous encapsulated seroma pockets after axillary clearance in the treatment of breast cancer. ﬁbrous encapsulated seromas. Most articles are case reports, INTRODUCTION none of which describe ﬁlling of the dead space with ﬂap har- Seroma formation after breast cancer surgery is deﬁned as a vesting [7, 8]. collection of serous ﬂuid containing blood plasma and/or lymph ﬂuid under the skin ﬂaps or in the axilla. The reported incidence of seroma varies greatly, ranging from 3% to more CASE PRESENTATION than 90% [1–3]. Seroma formation can lead to patient discom- fort, repeated seroma aspirations with the risk of infection, pro- A 68-year-old female was referred to our breast clinic by her pri- longed hospital stay, delayed wound healing, skin ﬂap necrosis, mary care physician after undergoing screening mammography. delay in commencing adjuvant therapies and higher surgical Upon mammography, a breast mass was visualized in the left expenditures [2, 4, 5]. upper quadrant, measuring 13 mm × 8 mm. Ultrasonography of The pathophysiology of seroma formation has been exten- the left axilla revealed two suspicious lymph nodes with cortical sively analysed. The extent of axillary lymph node involvement, thickening. The breast mass and a suspicious lymph node were type and extent of breast surgery and the use of electrocautery biopsied. Pathology revealed a hormone positive ductal breast have all been related to seroma formation. In recent years there carcinoma and a lymph node metastasis in the left axilla. Patient have been many publications on effective techniques to prevent was planned for wide local excision and axillary clearance under seroma formation. These techniques all appear to have one general anaesthesia. Routine pathology examination revealed a common denominator: reduction of the dead space . There 1.1 cm grade 1 ductal carcinoma with clear resection margins and are however very few publications on (surgical) treatment of 18 lymph nodes, one containing a macro metastasis (pT1cN1 (1/ Received: November 1, 2017. Accepted: February 13, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy032/4924369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 J. van Bastelaar et al. Figure 1: Fibrous seroma capsula of the left axilla after axillary clearance and Figure 2: After surgical excision of seroma pocket and ﬁlling of the dead space radiotherapy. with a latissimus dorsi skin-muscle ﬂap. 18)). Patient was discussed postoperatively in the multidisciplin- ary breast cancer meeting and adjuvant Tamoxifen and breast radiotherapy were instituted (16 fractions in a total dose of 42.56 Gy). One month after surgery patient presented to our breast clinic with a fever and swelling and redness of the skin in the left axilla. Under suspicion of an infected seroma, seroma aspiration was performed and sent for culture. Antibiotic treat- ment was instituted for one week and she remained free of symptoms for a couple of months. One year after surgery and radiotherapy, our patient was seen in the breast clinic for follow up. Mammography was unremarkable. Upon physical examination there was an appar- ent ﬁbrotic seroma pocket that had persisted (Fig. 1). The over- lying skin was sensitive to touch and displayed radiation dermatitis. Her arm and shoulder function were impaired. Range of motion was limited to 110° when abducting her arm. This case was discussed with our reconstructive breast team and after informed consent was obtained a surgical excision of the ﬁbrous seroma pocket and the overlying skin was performed. The dead space was closed with a latissimus dorsi skin and mus- cle ﬂap. Low suction drains were left in place. The drains were removed on the second day post-surgery. Six weeks after surgery patient was evaluated in the out- patient clinic. The pain had subsided and there was no clinical seroma. Movement of her shoulder had improved greatly and abduction of the right arm was now possible up to 160° (Fig. 2). Figure 3: Lateral view after surgical excision of seroma pocket and ﬁlling of the dead space with a latissimus dorsi skin-muscle ﬂap. DISCUSSION Seroma formation occurs frequently after mastectomy or axil- drains) causing seroma formation. The key to reducing seroma lary clearance in breast cancer surgery. Seroma has signiﬁcant formation and its sequelae seems to lie in reduction of the impact on patients’ quality of life and could delay the initiation dead space . Previous retrospective studies have proven that of adjuvant treatment. It is well known that seroma occurs and reduction of the dead space after mastectomy is beneﬁcial in causes complaints in the early weeks post-surgery and/or seroma formation and that it furthermore reduces complica- radiotherapy. In the literature, a great number of articles can be tions associated with seroma formation. There are no studies found on seroma formation, its risk factors, consequences, and to date describing the surgical treatment of ﬁbrous encapsu- early treatment. Reported treatment options are limited, mostly lated seromas after axillary clearance. This case demonstrates consisting of repeated aspirations and treatment of infection that ﬁlling the dead space with skin/muscle ﬂap harvesting where necessary. is an ideal technique to combat seroma formation. As seen Many factors are held responsible (surgical technique, instru- in many studies analysing ﬂap ﬁxation after mastectomy, ments used for dissection, obliterating the dead space, use of closing of the axilla can be troublesome. As published by Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy032/4924369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Surgical removal of ﬁbrous axillary seroma pocket and closure of the dead space 3 Van Bemmel et al. in a systematic review, closing of the axillary REFERENCES dead space leads to reduction of seroma formation. Ten Wolde 1. Carless PA, Henry DA. 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Journal of Surgical Case Reports – Oxford University Press
Published: Mar 1, 2018
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