Managing Necrotizing Soft-Tissue Infection in Breast Cancer: A Case of Emergency Toilet Mastectomy

Introduction

Necrotizing soft-tissue infections (NSTIs) are characterized by the depth of tissue involvement, and carry an overall mortality rate of 34% [1,2]. Immediate medical attention and emergency surgical intervention, if needed, can prevent progression to sepsis and septic shock, potentially leading to organ dysfunction and death if not promptly recognized and treated [1,3].

While NSTIs can occur in various settings, their manifestation in the context of advanced breast cancer presents a unique and challenging clinical scenario. Globally, 60–70% of newly diagnosed breast cancers are locally advanced, and even in countries with advanced healthcare systems like the United States, surgeons still encounter cases with extensive locoregional progression into the chest wall or skin [4]. However, the progression of breast malignancy to NSTI is exceptionally uncommon [5].

The management of such complex cases requires a delicate balance between oncologic principles and the urgent need for infection control. Current guidelines offer limited direction, likely due to the scarcity of reported advanced neoplasms in Western medicine [6]. This has necessitated individualized treatment approaches, with toilet mastectomy emerging as a potential palliative intervention in severe cases. The procedure involves extensive debridement of the affected tissue, allowing surgeons to visualize deeper structures and collect specimens for culture to guide antibiotic selection [7]. Importantly, toilet mastectomy serves multiple purposes: it provides crucial source control to prevent further septic complications while simultaneously enhancing patient quality of life by improving wound management and alleviating distressing symptoms [6].

This case report presents a unique instance of NSTI superimposed on breast cancer, highlighting the critical importance of emergency surgical intervention, sepsis management, and the indications for toilet or palliative mastectomy.

Case Report

MANAGEMENT OF INVASIVE DUCTAL CARCINOMA:

Specimens taken during right-sided toilet mastectomy revealed invasive ductal carcinoma (IDC) of the right breast with skin involvement, grade 3, with 2 foci measuring 12 cm and 15 cm, and ulceration of the skin (Figure 5). Immunohistochemistry demonstrated the tumor was ER/PR-positive and HER2-negative (ER >75%, PR >75%, HER2 0). Posterior margins were positive, requiring re-excision to achieve negative margins. PET/CT showed an FDG-avid aortopulmonary lymph node and left hilar lymph node. The patient’s disease was staged as pT4b(m)N0MX, with future metastatic evaluation planned.

Due to her complicated postoperative course, evaluation for 18F-fluorodeoxyglucose (FDG) -avid mediastinal nodes on a repeat PET/CT was delayed nearly 5 months after her initial presentation. The scan revealed an interval decrease in tracer uptake in these nodes. However, moderately intense tracer uptake was observed in the superficial soft tissues of the parasternal right anterior chest wall, approximately 4 cm medial to a skin defect in the anterior chest wall. This finding was suspicious for an infectious or inflammatory process, or recurrent or residual malignancy.

The patient’s case was presented to the Institutional Oncology Tumor Board for comprehensive evaluation. Given her prolonged recovery and complex medical history, the board determined that aggressive treatments such as systemic chemotherapy, axillary lymph node dissection, and radiation therapy were not appropriate at this time. Instead, a more conservative approach was adopted, focusing on hormonal therapy with anastrozole, an aromatase inhibitor, as the primary treatment modality. In the months following this decision, the patient experienced additional complications, including a partial small-bowel obstruction and ostomy-related issues, necessitating further hospitalizations. These setbacks have impacted her ability to maintain consistent follow-up care, and she has not returned to the hematology-oncology clinic for several months.

Given the patient’s stage 3B ER+/PR+ HER2− disease, prediction models estimate her 5-year survival rate with treatment to be between 66% and 98%. However, without treatment, this rate drops significantly to 31.9% [8,9]. Unfortunately, as the patient has discontinued follow-up care with medical oncology, her prognosis is likely to be less favorable than these estimates suggest.

Discussion

We presented a rare case of a patient with early signs of sepsis in the context of NSTI and underlying breast malignancy. The uniqueness of our case is further accentuated by the urgent toilet mastectomy performed in the setting of a life-threatening condition, which in the current era is an uncommon and controversial oncologic surgical procedure [6]. This case report provides key insights into the interplay between infection and malignancy. First, NSTI of the breast can serve as the initial presentation in patients with advanced malignancy, underscoring the need to maintain a high index of suspicion for this rare but serious condition. Second, there is a critical need for prompt diagnosis and aggressive treatment of NSTI, regardless of its association with an underlying malignancy, to reduce morbidity and mortality. Lastly, the report demonstrates the potential role of toilet mastectomy as a palliative surgical option in carefully selected cases, providing symptom relief and infection control in patients with advanced breast cancer complicated by severe infection.

Invasive ductal carcinoma (IDC) commonly presents as a palpable breast lump or mass, often accompanied by changes in breast shape, skin texture (eg, dimpling or puckering), or nipple appearance. Advanced IDC may involve the skin, presenting as erythema or ulceration. Complications of IDC include local progression with skin necrosis or infection, lymphatic spread, and distant metastases [10]. In our patient, the lesion progressed rapidly over 4 months from a “rash” to an overtly infected and necrotic mass, exemplifying the aggressive nature of IDC.

IDC can also present with subtle, non-specific symptoms that can lead to misdiagnosis. A case reported by Tahhan et al illustrates this challenge, describing a 43-year-old patient whose IDC manifested as diffuse pruritic lesions on the upper back and subclavian region [11]. Given the variable presentations, it is essential to rule out IDC as a differential diagnosis.

The differential diagnosis for breast abnormalities spans a broad spectrum, encompassing both benign and malignant conditions. Common benign infectious causes include mastitis, cellulitis, and abscesses, while benign neoplasms such as fibroadenoma and fibrocystic changes are also frequent considerations. Malignant causes include primary breast cancers, such as invasive ductal carcinoma and ductal carcinoma in situ, as well as skin malignancies like squamous cell carcinoma and melanoma, or metastatic disease from other primary sites [12].

Paget’s disease of the breast is another critical differential to consider. It typically presents with unilateral erythema, crusting, or scaling of the nipple and areola. In most cases, Paget’s disease is associated with an underlying malignancy, often ductal carcinoma in situ or invasive carcinoma. When an underlying mass is present, it is almost invariably invasive cancer [13]. Additionally, diffuse skin induration with an erysipeloid appearance – frequently without a palpable mass – should raise suspicion for inflammatory breast cancer (IBC). IBC is characterized by rapid onset of redness, swelling, peau d’orange (“orange peel”) texture, and warmth affecting at least one-third of the breast [14]. This aggressive presentation necessitates prompt biopsy and imaging to confirm the diagnosis and stage the disease. Given the overlapping clinical features of these conditions, timely evaluation using a combination of clinical examination, imaging (eg, mammography, ultrasound), and biopsy is essential to establish an accurate diagnosis and avoid delays in treatment [12].

NSTI of the breast is exceeding rare, without a clear precipitating event [15]. A systematic review by Konik et al identified only 25 cases of idiopathic breast NSTI, with most linked to triggers such as breast trauma, insect bites, infected cysts, or breast procedures. Risk factors such as uncontrolled diabetes, elevated BMI, peripheral vascular disease, alcoholic liver disease, and immunosuppression increase susceptibility to NSTI [2,15]. The case described by Islam et al demonstrates how a seemingly minor event, like an insect bite, can lead to severe NSTI in a high-risk patient [2]. Furthermore, the atypical presentation of our patient, and the one in Islam et al’s case report, underscore the importance of maintaining a high index of suspicion for severe infections in patients with complex medical histories. Although our patient exhibited signs of early sepsis, she did not meet the systemic inflammatory response syndrome (SIRS) criteria, as her uncontrolled diabetes and underlying malignancy may have suppressed her immune response [16].

The decision to perform an urgent toilet mastectomy before confirming a definitive diagnosis was pivotal in this case. Historically, this procedure was recommended for locally advanced breast cancer involving all breast quadrants. While not curative, it aimed to alleviate patient distress caused by large, painful, and oozing breast masses. The procedure presents unique challenges, including the need for wide resection to ensure clear surgical margins, which complicates primary closure [17]. Despite its potential life-saving role in emergency situations, the indications for this approach remain unclear, and evidence of its survival benefits is limited [6].

In developed nations, advancements in breast cancer detection, systemic therapy, and radiation therapy have all contributed to the de-escalation of radical breast cancer surgical intervention over time [18,19]. However, in our patient’s case, the urgent need for surgery to prevent sepsis progression necessitated immediate intervention, deviating from standard protocols. The toilet mastectomy served as a crucial life-saving measure by removing the primary source of infection. Nevertheless, the complexity of the case and the severity of the infection meant that a single surgical intervention was insufficient. The patient required multiple returns to the operating room for additional debridement and washout procedures. Her complex postoperative course also led to deferring standard cancer treatments in favor of hormone therapy alone, highlighting the need for individualized treatment plans tailored to both oncologic and infectious considerations.

This patient’s long-standing avoidance of healthcare likely contributed to her advanced presentation. In the state of Massachusetts, where healthcare access is available and health insurance is mandatory [20], it remains perplexing why this patient delayed seeking care. This case illustrates that there still may be locoregional heterogeneity in access to care, even in “healthcare rich states,” as well as other direct and indirect socioeconomic barriers to care. Furthermore, psychological factors, such as embarrassment or distress due to the nature of the disease, may have played a role in avoiding medical attention and contributed to her eventual loss to follow-up.

Conclusions

This case is notable for 3 key aspects: (1) although rare, NSTI and sepsis may be the first presentation of advanced breast cancer; (2) the critical importance of recognizing and promptly treating sepsis in the context of NSTI, regardless of its association with underlying malignancy; and (3) toilet mastectomy remains an essential procedure for select cases. It also highlights the ongoing necessity for healthcare providers to be prepared for managing advanced disease presentations, even in regions with well-developed healthcare systems. Furthermore, this patient’s experience shows the importance of addressing barriers to healthcare access, including psychological factors, and the need for public health initiatives to encourage regular screenings and early medical intervention.

By sharing our experience, we aim to contribute to the knowledge base for managing complex presentations of advanced breast cancer and inform clinicians on the appropriate applications of toilet or palliative mastectomy. This case report may prove valuable for future multidisciplinary, evidence-based decision-making in similar cases.