Patient 1

Patient 1 (date of birth: 9 June 1957) had a tumour resected from the right breast without mastectomy on 12 December 2000. The post-operative disease stage was T1N0 (15 nodes negative) M0, grade unknown. She received neither chemotherapy nor hormonal therapy.

Radiotherapy was started on 22 January 2001. Initially, a treatment consisting of 4 MV X rays in a total dose of 50 Gy (25 fractions of 2 Gy, 2 Gy fractions daily, five times per week) was delivered to the whole breast via two tangential fields. Then, a local boost with 8 MeV electrons in 2.5 Gy fractions was begun. The planned field size was 11 cm × 7 cm and exposure was set for 155 MU. The accidental exposure occurred on 27 February 2001 during delivery of the second fraction. The total dose to the chest wall was therefore 50 Gy with fractionated 4 MV X rays and one 2.5 Gy fraction of 8 MeV electrons plus that attributable to the accidental exposure.

A few hours after the accidental exposure, Patient 1 reported development of slight erythema in the exposed area. She was treated with the topical ointment Linomag (complex of linolic acid, linolenic acid and arachidonic acid) for three weeks (until 19 March). On 28 February topical treatment with Solcoseryl began. Erythema remained for six weeks and on 7 March an area of moist desquamation measuring 2 cm × 2 cm was noted. An X ray of the chest taken on 19 March revealed no pathological signs in the lung.

Tumour markers administered on 23 March were as follows: CA 125 -12.31 mIU/ml, CEA - 1.88 mIU/ml, CA 15-3 - 4.58 mIU/ml. At the end of March, the patient noted some limitation of movement of the right shoulder.

Systemic treatment with Panthenol (vitamin PP) and vitamin B1 began and topical Panthenol spray and ointment were used, which led to relief of the symptoms of pain, itching and limitation of movement of the right shoulder. On 27 March she was admitted to the BOC for treatment of an increasing area of desquamation in the irradiated field. She was discharged from the hospital on 6 April.

On 7 May, examination revealed superficial ulceration located at the surgical scar in the centre of the irradiated field and a 3 cm white border just inside the edges of the field. As the patient refused to be hospitalized, she was provided with a Neomycin spray and sterile gauze covered with Linomag for

topical treatment at home. An examination performed in June showed that the ulcerated area measured 4.5 mm × 18 mm (Fig. 12).

During topical treatment at home, the size of the ulcerated area remained unchanged up until July. Bacteriological culture taken from the ulcer on 11 July revealed Staphylococcus pyocyaneus +++, sensitive to Gentamycin, Amikacin, Vibramycin, Ciprofloxacin, Biseptol, Vancomycin and Netilmycin. On 1 August, Patient 1 was hospitalized in the Centre of Oncology (Warsaw), having been diagnosed as having cancer of the right breast, status post-tumorectomy, with right axillary lymph node dissection and post-radiotherapy lesion. She was admitted for rehabilitation, the treatment consisting of systemic Tocopherol and Pentoxyfylline, and local topical therapy with Argosulfan ointment.

Staphylococcus aureus infection was present and was treated with topical Gentamycin. By 2 September small areas of necrosis had appeared in the irradiated field. Cancer markers were normal. HBO therapy was started on 6 November. After three weeks, the ulcerated area was reduced in size and severity.

Examination by the IAEA expert medical team on 30 November and 1 December revealed a 3.5 cm × 1.5 cm ulcerated lesion along the axis of the surgical scar (Fig. 13). The centre of the ulcer was 6 cm superior and lateral to

FIG. 12. Patient 1 on 4 June 2001: Ulcerated subaxillary area (4.5 mm × 18 mm).

the nipple. There was a 1 cm border of induration surrounding the ulcer and there were minor areas of telangiectasia in the axilla.

The IAEA expert medical team concluded that the condition of the patient did not appear to be serious at the time of examination and that surgery was not necessary. However, surgery may be required in the future. It was recommended that administration of Pentoxyfylline (800–1200 mg/d) and Tocopherol (400–500 mg/d) therapy be continued for a total treatment time of at least one year. On the basis of this regimen, the lesions of the patient could be expected to heal completely. Secondary cosmetic rehabilitation needs to be considered and made available at a later phase.

Patient 1 completed HBO therapy on 21 December 2001. In mid-January 2002, two small ulcerations with a diameter of about 1 cm were detected along the axis of her surgical scar. On 27 August 2002, the patient was admitted to the Oncological Surgery Ward in the Holy Cross Cancer Centre in Kielce. She was suffering from post-radiation fibrosis with superficial necrosis at the scar on her right breast. She underwent a one step operation on 30 August.¹¹ The operation

11 Performed by Prof. A. Kułakowski.

FIG. 13. Patient 1 in December 2001: Ulcerated lesion (3.5 cm × 1.5 cm) along the axis of the surgical scar.

involved making a wide excision of all the necrotic, prenecrotic and fibrotic tissues (distinctly identified by MRI and CT) and covering the wound with an omentum flap through a ‘tunnel’ prepared below the skin between the abdomen and the thoracic wall. The patient also underwent subcutaneous mastectomy of her right breast and skin grafts were positioned over the wound.

The skin grafts were taken from the patient’s thigh and thoracic wall at the right side. At the end of the operation a thin skin graft was positioned over the flap with skin that had been removed from the thigh.

At the end of October 2002, Patient 1 was still in the Oncological Surgery Ward of the Holy Cross Cancer Centre, as the healing of her post-operative wound, although satisfactory, was not complete.