Surgical removal of fibrous axillary seroma pocket and closing of dead space using a lattisimus dorsi flap

Surgical removal of fibrous axillary seroma pocket and closing of dead space using a lattisimus... 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 [6]. 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 journals.permissions@oup.com 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 [9]. 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. Systematic review and meta-analysis et al. retrospectively evaluated 27 patients undergoing axillary of the use of fibrin sealant to prevent seroma formation lymph node dissection with and without quilting. In the non- after breast cancer surgery. Br J Surg 2006;93:810–9. quilting group, seroma was present in 75% and in the quilting 2. Kumar S, Lal B, Misra MC. Post-mastectomy seroma: a new group 36.4%. There were however no significant differences in look into the aetiology of an old problem. J R Coll Surg Edinb number of seroma aspirations [10]. 1995;40:292–4. Given the large burden that this is causing to patients and 3. Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. the varying chance of success, an important role is dedicated to Seroma formation after breast cancer surgery: incidence preventing seroma formation. We expect that the rate of and predicting factors. Am Surg 2000;66:444–50. chronic seroma is underestimated and generates high rates of 4. Tadych K, Donegan WL. Postmastectomy seromas and local discomfort, and limitations in shoulder function, espe- wound drainage. Surg Gynecol Obstet 1987;165:483–7. cially in axillary seroma. In the literature, some refer to treating 5. Almond LM, Khodaverdi L, Kumar B, Coveney EC. Flap persisting seroma by reinserting drains, talcage or surgical anchoring following primary breast cancer surgery facili- intervention and application of the quilting technique. Since tates early hospital discharge and reduces costs. Breast Care the seroma pocket is covered with fibrous tissue, these techni- (Basel) 2010;5:97–101. ques are inadequate in chronic seroma. Collaboration with a 6. Van Bemmel AJ, van de Velde CJ, Schmitz RF, Liefers GJ. reconstructive surgeon therefore seems favourable in order to Prevention of seroma formation after axillary dissection in breast remove the fibrous capsule and close the dead space with a cancer: a systematic review. Eur J Surg Oncol 2011;37:829–35. latissimus dorsi flap (Fig. 3). 7. Stanczyk M, Grala B, Zwierowicz T, Maruszynski M. Surgical resection for persistent seroma, following radical mastec- tomy. World J Surg Oncol 2007;5:104. LEARNING POINTS 8. Matsui Y, Yanagida H, Yoshida H, Imamura A, Kamiyama Y, Kodama H. Seroma with fibrous capsule formation � Reducing the dead space is pivotal in preventing seroma requiring surgical resection after a modified radical mastec- formation. tomy: report of a case. Surg Today 1998;28:669–72. � Little is known about the best way to treat encapsulated sero- 9. van Bastelaar J, van Roozendaal L, Granzier R, Beets G, Vissers ma pockets in the axilla. Y. A systematic review of flap fixation techniques in reducing � Removal of encapsulated axillary seroma pockets and closing seroma formation and its sequelae after mastectomy. Breast the dead space with latissimus dorsi flap seems to be a suc- Cancer Res Treat 2017;doi:10.1007/s10549-017-4540-x. cessful surgical procedure. 10. Ten Wolde B, van den Wildenberg FJ, Keemers-Gels ME, Polat F, Strobbe LJ. Quilting prevents seroma formation fol- lowing breast cancer surgery: closing the dead space by CONFLICT OF INTEREST STATEMENT quilting prevents seroma following axillary lymph node dis- None declared. section and mastectomy. Ann Surg Oncol 2014;21:802–7. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy032/4924369 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Surgical removal of fibrous axillary seroma pocket and closing of dead space using a lattisimus dorsi flap

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Abstract

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 [6]. 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 journals.permissions@oup.com 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 [9]. 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. Systematic review and meta-analysis et al. retrospectively evaluated 27 patients undergoing axillary of the use of fibrin sealant to prevent seroma formation lymph node dissection with and without quilting. In the non- after breast cancer surgery. Br J Surg 2006;93:810–9. quilting group, seroma was present in 75% and in the quilting 2. Kumar S, Lal B, Misra MC. Post-mastectomy seroma: a new group 36.4%. There were however no significant differences in look into the aetiology of an old problem. J R Coll Surg Edinb number of seroma aspirations [10]. 1995;40:292–4. Given the large burden that this is causing to patients and 3. Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. the varying chance of success, an important role is dedicated to Seroma formation after breast cancer surgery: incidence preventing seroma formation. We expect that the rate of and predicting factors. Am Surg 2000;66:444–50. chronic seroma is underestimated and generates high rates of 4. Tadych K, Donegan WL. Postmastectomy seromas and local discomfort, and limitations in shoulder function, espe- wound drainage. Surg Gynecol Obstet 1987;165:483–7. cially in axillary seroma. In the literature, some refer to treating 5. Almond LM, Khodaverdi L, Kumar B, Coveney EC. Flap persisting seroma by reinserting drains, talcage or surgical anchoring following primary breast cancer surgery facili- intervention and application of the quilting technique. Since tates early hospital discharge and reduces costs. Breast Care the seroma pocket is covered with fibrous tissue, these techni- (Basel) 2010;5:97–101. ques are inadequate in chronic seroma. Collaboration with a 6. Van Bemmel AJ, van de Velde CJ, Schmitz RF, Liefers GJ. reconstructive surgeon therefore seems favourable in order to Prevention of seroma formation after axillary dissection in breast remove the fibrous capsule and close the dead space with a cancer: a systematic review. Eur J Surg Oncol 2011;37:829–35. latissimus dorsi flap (Fig. 3). 7. Stanczyk M, Grala B, Zwierowicz T, Maruszynski M. Surgical resection for persistent seroma, following radical mastec- tomy. World J Surg Oncol 2007;5:104. LEARNING POINTS 8. Matsui Y, Yanagida H, Yoshida H, Imamura A, Kamiyama Y, Kodama H. Seroma with fibrous capsule formation � Reducing the dead space is pivotal in preventing seroma requiring surgical resection after a modified radical mastec- formation. tomy: report of a case. Surg Today 1998;28:669–72. � Little is known about the best way to treat encapsulated sero- 9. van Bastelaar J, van Roozendaal L, Granzier R, Beets G, Vissers ma pockets in the axilla. Y. A systematic review of flap fixation techniques in reducing � Removal of encapsulated axillary seroma pockets and closing seroma formation and its sequelae after mastectomy. Breast the dead space with latissimus dorsi flap seems to be a suc- Cancer Res Treat 2017;doi:10.1007/s10549-017-4540-x. cessful surgical procedure. 10. Ten Wolde B, van den Wildenberg FJ, Keemers-Gels ME, Polat F, Strobbe LJ. Quilting prevents seroma formation fol- lowing breast cancer surgery: closing the dead space by CONFLICT OF INTEREST STATEMENT quilting prevents seroma following axillary lymph node dis- None declared. section and mastectomy. Ann Surg Oncol 2014;21:802–7. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/3/rjy032/4924369 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Mar 1, 2018

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