Hyperbaric oxygen therapy for a refractory skin ulcer after radical mastectomy and radiation therapy: a case report

Background: Radiation therapy is performed as an adjuvant therapy when indicated following surgical resectionof malignant tumors. However, radiation exposure induces acute or chronic dermatitis, depending on theradiation dose, interval, tissue volume, or irradiated area of the body. Radiation-induced skin ulcers andosteomyelitis of the underlying bone are intractable late-stage complications of radiation therapy, and oftenrequire reconstructive surgery to cover exposed tissue. Hyperbaric oxygen therapy has been suggested as atreatment for delayed radiation injury with soft tissue and bony necrosis.Case presentation: A 74-year-old Japanese female underwent left radical mastectomy for breast cancer(T3N3M0, stage IIIB) in 1987. Radiation therapy was initiated 6 weeks after the surgery. She receivedtelecobalt-60 in a total dose of 50 Gy with 25 fractions to the left supraclavicular, parasternal and left axillaryregions, and electron treatment (9 MeV) in a total dose of 50 Gy in 25 fractions to the left chest wall. Afterirradiation, her skin became thinner and more fragile on the left chest wall, but no severe infections wereobserved. She noticed a small ulcer that repeatedly healed and recurred in 2000. She visited the hospitalwhere she received radiation therapy and was treated for a skin ulcer on the left chest wall in December2012. A fistula developed and then pus was discharged in January 2013. She was referred to the hyperbaricmedical center in February 2013, and the fistula (1.5 × 3 cm) with pus discharge was observed. She wasdiagnosed with a late-onset radiation-induced skin ulcer that developed 25 years after radical mastectomy.HBO2 (2.5 atmospheres absolute with 100% oxygen for 60 minutes) was indicated for the refractory ulcer andosteomyelitis of the ribs. The patient was treated with HBO2 a total of 101 times over the course of 1 yearand completely recovered.Conclusions: Hyperbaric oxygen therapy can be performed safely for even more than 100 sessions inpatients with radiation-induced skin ulcers and osteomyelitis. Hyperbaric oxygen therapy can be consideredas an alternative, conservative treatment when surgical resection for late-onset, radiation-induced skin ulcersis not indicated because of fragile skin in the irradiated areas.