A Hirbe

AR Chapelier

Christoph Johann Heuck

F Fehlauer

G Liljegren

H Bartelink

H Letur-Könirsch

Holger Gerullis

JJ Pavy

LF Fajardo

M Deutinger

M Koc

M Krohn

P Rubin

Paul Schneider

S Delanian

S Johansson

Journal of Medical Case Reports

English

PubMed

Crossref

Breast pseudotumoral radionecrosis as a late radiation-induced injury: a case report

Springer - Publisher Connector

BioMed CentralJournal of Medical Case Reports
ssOpen AcceCase report
Breast pseudotumoral radionecrosis as a late radiation-induced 
injury: a case report
Holger Gerullis*1,2, Christoph Johann Heuck3 and Paul Schneider1
Address: 1Department for General and Thoracic Surgery, DRK Clinics, Drontheimer Strasse, Berlin 13359, Germany, 2West German Cancer Center 
(WTZ), University of Essen, 45122 Essen, Germany and 3Montefiore Medical Center, Department of Medical Oncology, The Albert Einstein Cancer 
Center, Bronx, NY 10467, USA
Email: Holger Gerullis* - holger.gerullis@gmx.net; Christoph Johann Heuck - cheuck@montefiore.org; Paul Schneider - chirurgie@drk-
kliniken-markbrandenburg.de
* Corresponding author    
Abstract
Introduction: New therapies and treatment protocols have led to improved survival rates in
many cancers. The improved rates are such that patients are now living long enough to experience
some negative long-term side effects of the initial therapy.
Case presentation: We report the case of a 65-year-old Caucasian woman who presented with
a rare case of pseudotumoral radionecrosis, a late radiation-induced injury, after combined surgical
and cobalt radiation therapy for the treatment of adenocarcinoma of the right breast. The patient
underwent resection of this benign, yet progressively growing and painful tumor. A cosmetically
satisfying result was achieved by reconstruction of the thoracic wall with a polypropylene mesh and
a latissimus dorsi muscle flap.
Conclusion: With improved overall survival, new management strategies for late side effects of
therapy are becoming of crucial importance for affected patients. In the future, improving toxicity-
free survival will be as important as achieving disease-free survival or local tumor control.
Introduction
With the increasing number of long-term survivors who
have been treated with newer anticancer therapy strate-
gies, we encounter increasing numbers of sequelae from
earlier therapeutic approaches. These long-term side
effects are an important factor in the patient's quality of
life, both psychologically and somatically, and must be
addressed in the treatment of the underlying disease.
Radiation-induced fibroatrophy (RIF) is a rare late sequela
of high-dose radiation therapy. It is localized to the radia-
tion field and is usually irreversible. The pathologic man-
ifestation of this entity can be limited to skin dryness,
hyperpigmentation or telangiectasia. This superficial
damage, however, may also be combined with underlying
fibronecrotic lesions affecting the pleura and lungs result-
ing in pulmonary fibrosis, neurological disorders second-
ary to the development of perineural fibrosis, or
spontaneous rib fractures due to osteoradionecrosis [1-3].
We report the excellent cosmetic and functional results
after surgical treatment in a particular clinical setting of
pseudotumoral radionecrosis as a late radiation-induced
injury after initial anticancer treatment.
Published: 8 October 2009
Journal of Medical Case Reports 2009, 3:71 doi:10.1186/1752-1947-3-71
Received: 22 April 2008
Accepted: 8 October 2009
This article is available from: http://www.jmedicalcasereports.com/content/3/1/71
© 2009 Gerullis et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Journal of Medical Case Reports 2009, 3:71 http://www.jmedicalcasereports.com/content/3/1/71Case presentation
We report the case of a 65-year-old Caucasian woman
who presented with a subcutaneous inflammatory tumor
of the right breast, which had been progressively growing
over a period of 10 years (Figure 1). The patient had a past
history of a multifocal adenocarcinoma of the right breast,
which was resected 23 years earlier. Further treatment
included chemotherapy with six cycles of fluorouracil,
doxorubicin and cyclophosphamide in combination with
cobalt radiation with a total dose of 60 Gy, followed by
tamoxifen for a total of 12 years. The first local signs were
observed seven years after the radiation treatment with the
loss of irradiated skin elasticity followed by increasing
induration and telangiectasia. Over the 10 years before
presentation, the mass had significantly increased in size
and become increasingly painful, restricting the patient
psychologically and functionally in her daily activities.
The patient's other past medical history included high
blood pressure and hypercholesterolemia. Her only addi-
tional surgery was an appendectomy during childhood.
Diagnostic work-up (bone scintigraphy, abdominal ultra-
sound, thoracic computed tomography (CT) scan)
revealed no local or distant metastases (Figure 2). As there
was no suspicion for a progressive malignant disease, we
did not perform a pre-operative biopsy. We offered the
patient resection of the thoracic wall, reconstruction by a
Premilene® mesh and switching of an ipsilateral latissimus
dorsi muscle flap. Intra-operatively, we observed multiple
retromammarial adhesions without macroscopic tumor
infiltration. Pathological fractures of costae 3/4/5 were
also observed. The tumor could be removed in its entirety.
Reconstruction of the thoracic wall was performed with a
double layer polypropylene mesh (Premilene®, Braun,
Melsungen), fixed with Ethibond® (Ethicon, Norderstedt)
sutures. A flap of the latissimus dorsi muscle was then
mobilized and switched to the thoracic wall. The muscle
was fixed circularly, subcutaneously and cutaneously.
Two thoracic drains were placed (Figure 3). The whole
operation time was 210 minutes, and blood loss
remained minimal at 50 ml.
The thoracic drains were removed on postoperative days 4
and 8, and the patient left our institution on postoperative
day 18. Microscopic examination of the resected specimen
showed a wide, almost scarred, radionecrosis and fibrosis
of fat, muscle and bone (Figure 4). Also noted were
extended dystrophic calcifications corresponding to a
radiation-induced vasculopathy. Histologically, there was
no evidence of malignancy. Within a follow-up of 14
months, the cosmetic result remained satisfactory without
any disturbance in healing.
Discussion
In the majority of cases, cancer is an aggressive disease
which is often fatal and requires consequential therapeu-
tic approaches with agents that provide a narrow thera-
peutic window. The toxicity of the therapy and the
acceptable risk of complications have to be balanced
against the risk of recurrence of the malignancy. Radiation
therapy has been one of the pillars of cancer therapy for
many years. Many technological advances have been
made to improve radiation delivery to the targeted area
while reducing damage to the surrounding normal tissue.
However, with improving survival of our patients, we are
now able to observe the long-term effects of earlier thera-
pies, which, at the time they were applied, were in accord-
ance with the best knowledge available.
The spectrum of late radiation-induced injuries is quite
heterogeneous but the injuries are usually benign. They
may manifest themselves as breast edema, fibrosis, tel-
angiectasia, pulmonary fibrosis, chronic ulceration, rib
fractures, fat necrosis or osteonecrosis [4]. The main dif-
ferential diagnosis is malignant radiation-induced sar-
coma (RIS), which has a very poor prognosis [5].
Fajardo differentiates between epithelial and/or parenchy-
mal, stromal and vascular lesions as delayed injuries from
ionizing radiation [6]. Epithelial and/or parenchymal
lesions include atrophy, necrosis, metaplasia, cellular aty-
pia, dysplasia, and neoplasia. Fibrosis, fibrinous exudates,
necrosis and atypical fibroblasts are considered to be com-
mon stromal lesions. Vascular lesions affect the microves-
sels producing lethal and sublethal damage to the
endothelial cells, with capillary rupture or thrombosis,
and may present as telangiectasia [6].
Pre- and postoperative macroscopic presentationFigure 1
Pre- and postoperative macroscopic presentation. 
(A) Calcific subcutaneous, painful, progressively growing 
tumor on the right breast 23 years after 60 Gy cobalt radia-
tion before the corrective operation. (B) Post-corrective 
surgery: after reconstruction of the thoracic wall with a dou-
ble layer polypropylene mesh and switching of a flap of latis-
simus dorsi muscle to the thoracic wall.Page 2 of 5
(page number not for citation purposes)
Journal of Medical Case Reports 2009, 3:71 http://www.jmedicalcasereports.com/content/3/1/71These changes may occur in any organ. The incidences of
complications involving tissues that have a slow turnover
increase with time after radiation while most acute reac-
tions are observed in epithelial tissues. Therefore, a long
follow-up is necessary in order to fully understand the tox-
icity of the treatment. The increasing number of long-term
survivors allows us to observe these important late side
effects more frequently.
In the future, the ability to provide toxicity-free survival
may be as important an outcome as achieving a disease-
free survival or local tumor control [7]. Perception of a
long-term injury from prior treatment as a burden may be
very different for the patient and the doctor, in particular,
if the morbidity is irreversible, protracted, uncontrollable,
painful or socially disabling.
In order to evaluate the most effective therapeutic strategy
and to permit quantification of late effects on normal tis-
sue, all patients should be systematically monitored using
a scoring system such as the LENT-SOMA (late effects nor-
mal tissues - subjective, objective, management, and ana-
lytic) scale, as proposed by The European Organization
Pre-operative imaging studies of the tumorFigure 2
Pre-operative imaging studies of the tumor. Computed tomographic scan of the thorax (A) and respective 3-D image 
(B) exhibiting a large area of costal and muscular radionecrosis. The pleura was not affected.
Intra-operative situs and steps in the surgical procedureFigure 3
Intra-operative situs and steps in the surgical procedure. (A) Operative field; (B) placement of two thoracic drains 
after resection of the tumor; (C, D) reconstruction of the thoracic wall with a double layer polypropylene mesh; (E) mobiliza-
tion and switching of the latissimus dorsi flap to the thoracic wall; (F) wound closure.Page 3 of 5
(page number not for citation purposes)
Journal of Medical Case Reports 2009, 3:71 http://www.jmedicalcasereports.com/content/3/1/71for Research and Treatment of Cancer and the Radiation
Therapy Oncology Group (EORTC/RTOG) [5,7,8].
A variety of conservative strategies have been evaluated in
order to manage radiation-induced fibroatrophic proc-
esses. Treatment approaches include superoxide dis-
mutase or combined pentoxifylline-tocopherol
application, underlining the importance of an antioxidant
pathway [9,10]. However, in our particular case, surgery
was unavoidable. As the possibility of local recurrence or
persistence of the primary malignant tumor within the
radiated tissue exists, an adequate pre-operative diagnos-
tic work-up must be done before planning a resection
and/or reconstructive surgical strategy [11,12].
We report the excellent surgical result of performing an
ablatio mammae with resection of the thoracic wall, and
reconstruction with a synthetic mesh and a latissimus
dorsi muscle flap.
In our patient, the symptomatic pain in the right chest
decreased minimally postoperatively. This may have
resulted from the surgical trauma after the radical surgery,
which was performed in order to reduce as much of the
irradiated tissue as possible. Subjectively, the patient
reported high satisfaction with the cosmetic and func-
tional outcome. This corresponds to the reported phe-
nomenon that patients evaluate operative results less
critically [13,14].
Conclusion
Radiation-induced long-term side effects may have a
benign or malign nature. The aggressive and poor prog-
nostic nature of RIS is the main malignant differential
diagnosis for late radiation-induced alterations. Late radi-
ation-induced fibroatrophy (RIF) as a benign adverse
event is a rare, irreversible and unavoidable damage after
radiotherapy. It may adversely affect the functional and
esthetic outcome of patients. Besides conservative treat-
ment options including superoxide dismutase or com-
bined pentoxifylline-tocopherol, secondary radical
Histological characteristics of the specimenFigure 4
Histological characteristics of the specimen. Wide, almost scarred, radionecrosis and fibrosis of muscle, fat and bone, 
and extended dystrophic calcifications corresponding to a radiation-induced vasculopathy.Page 4 of 5
(page number not for citation purposes)
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surgery with exeresis of the necrotic defect and flap recon-
struction is the usual treatment in the case of combined
superficial RIF with spontaneous or trauma-induced
fibronecrotic lesions of the underlying irradiated tissue
and bones. It permits excellent cosmetic and functional
results.
Abbreviations
CT: computed tomography; EORTC: European Organiza-
tion for Research and Treatment of Cancer; LENT: late
effects normal tissues; RTOG: Radiation Therapy Oncol-
ogy Group; RIS: radiation-induced sarcoma; RIF: radia-
tion-induced fibroatrophic process; SOMA: subjective,
objective, management, and analytic
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
HG drafted the manuscript, performed the literature
review and participated in the surgery. PS performed the
surgery and supervised the preparation of this report. CJH
assisted in the preparation of this manuscript and in the
literature review. All authors read and approved the final
manuscript.
References
1. Koc M, Polat P, Suma S: Effects of tamoxifen on pulmonary
fibrosis after cobalt-60 radiotherapy in breast cancer
patients.  Radiother Oncol 2002, 64:171-175.
2. Johansson S, Svensson H, Denekamp J: Timescale of evolution of
late radiation injury after postoperative radiotherapy of
breast cancer patients.  Int J Radiat Oncol Biol Phys 2000,
48(3):745-750.
3. Hirbe A, Morgan EA, Uluçkan O, Weilbaecher K: Skeletal compli-
cations of breast cancer therapies.  Clin Cancer Res 2006, 12(20
Pt 2):6309s-6314s.
4. Fehlauer F, Tribius S, Höller U, Rades D, Kuhlmey A, Bajrovic A,
Alberti W: Long term radiation sequelae after breast-con-
serving therapy in women with early-stage breast cancer: an
observational study using the LENT-STOMA scoring sys-
tem.  Int J Radiat Oncol Biol Phys 2003, 55(3):651-658.
5. Chapelier AR, Bacha EA, de Montpreville VT: Radical resection of
radiation-induced sarcoma of the chest wall: report of 15
cases.  Ann Thorac Surg 1997, 63(1):214-219.
6. Fajardo LF: The pathology of ionizing radiation as defined by
morphologic patterns.  Acta Oncol 2005, 44(1):13-22.
7. Pavy JJ, Denekamp J, Letschert J, Littbrand B, Mornex F, Bernier J,
Gonzales-Gonzales D, Horiot JC, Bolla M, Bartelink H: Late effects
toxicity scoring: the SOMA Scale.  Int J Radiat Oncol Biol Phys
1995, 31:1043-1047.
8. Rubin P, Constine LS, Fajardo LF, Phillips TL, Wassermann TH: Late
effects of normal Tissues (LENT) scoring system.  Int J Radiat
Oncol Biol Phys 1995, 31(5):1041-1042.
9. Letur-Könirsch H, Guis F, Delanian S: Uterine restoration by radi-
ation sequelae regression with combined pentoxifylline-
tocopherol: a phase II study.  Fertil Steril 2002, 77(6):1219-1226.
10. Delanian S, Lefaix JL: The radiation-induced fibroatrophic proc-
ess: therapeutic perspective via the antioxidant pathway.
Radiother Oncol 2004, 73(2):119-123.
11. Deutinger M, Tairych G, Resch A, Biber E: Contour defects after
breast preserving therapy of breast carcinoma. Primary and
secondary possibilities of correction.  Strahlenther Onkol 1999,
175(11):577-582.
12. Krohn M, Drews C, Trams G: Esthetic and functional results
after BCT of breast cancer.  Onkologe 1996, 566:611-617.
13. Bartelink H, van Dam F, van Dongen E: Psychological effects of
breast conserving therapy in comparison with radical mas-
tectomy.  Int J Radiat Oncol Biol Phys 1985, 11(2):381-385.
14. Liljegren G, Homberg L, Westmann G, the Uppsala-Örebro Breast
Cancer Study Group: The cosmetic outcome in early breast
cancer treatment with sector resection with or without radi-
otherapy.  Eur J Cancer 1993, 29A(15):2083-2089.Page 5 of 5
(page number not for citation purposes)


Alberti W: Long term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-STOMA scoring system.

de Montpreville VT: Radical resection of radiation-induced sarcoma of the chest wall: report of 15 cases. Ann Thorac Surg

Delanian S: Uterine restoration by radiation sequelae regression with combined pentoxifyllinetocopherol: a phase II study. Fertil Steril

E: Contour defects after breast preserving therapy of breast carcinoma. Primary and secondary possibilities of correction. Strahlenther Onkol

E: Psychological effects of breast conserving therapy in comparison with radical mastectomy.

Esthetic and functional results after BCT of breast cancer. Onkologe

Late effects toxicity scoring: the SOMA Scale. Int J Radiat Oncol Biol Phys

Lefaix JL: The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol

Skeletal complications of breast cancer therapies. Clin Cancer Res

Suma S: Effects of tamoxifen on pulmonary fibrosis after cobalt-60 radiotherapy in breast cancer patients. Radiother Oncol

TH: Late effects of normal Tissues (LENT) scoring system.

The pathology of ionizing radiation as defined by morphologic patterns. Acta Oncol

the Uppsala-Örebro Breast Cancer Study Group: The cosmetic outcome in early breast cancer treatment with sector resection with or without radiotherapy.

Timescale of evolution of late radiation injury after postoperative radiotherapy of breast cancer patients.

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Breast pseudotumoral radionecrosis as a late radiation-induced injury: a case report

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