Hi!

Do you really have ferret fur-babies? One of our kids is a ferret nut, but the critters don't seem to like me. Maybe because I'm scared to death of those sharp little teeth!

You're sure right that cellulitis is an infection. Nasty one. I'm really sorry you're dealing with it, and I hope you're already feeling a whole lot better. Not sure where to start to answer your questions, so I'll just jump in. Hope it won't be too disjointed.

The thought of this returning must be pretty discouraging. If it does, it'd be time to see an infectious disease specialist to help you keep that from happening over and over. Not good!

Cellulitis is not a form of lymphedema (LE), but it is perhaps the major complication of LE. It occurs because stagnant lymph fluid is a bacteria magnet. It's protein-rich and it's warm, so they thrive in it. Any cut, scrape, abrasion, or even a dry skin micro-crack can allow bacteria to enter, and sometimes cellulitis can even show up even though no external cause can be found.

So, the swelling you described under your arm suggests lymph fluid accumulation, which you want to avoid. The medical professionals who deal with moving lymph fluid are well-trained LE therapists. If you see one s/he can help you learn ways to reduce any residual swelling and keep it that way, so you lower the risk of spontaneous cellulitis infection.

On the other hand, seroma and hematoma formation post-surgery is currently suspected of being indicative of future LE development, and it's certainly possible that you already have some LE in your breast and underarm (truncal LE). An experienced LE therapist will be able to determine that by simple physical exam, and she'll go on to treat it (with massage and exercises and instruction in skin care), which will also greatly reduce your risk of continuing cellulitis bouts.

Win/win!!

Finding a good therapist can be a bit of a trick, though. You can find well-trained ones near you by checking all the links at the Therapist Locator, www.mylymphedema.com and at the Lymphology Association of North America, www.clt-lana.org.

As I'm sure your doctors have told you, cellulitis can spread quickly and become systemic, because it travels through the lymph system. So those of us at risk for recurring cellulitis generally keep a filled antibiotic prescription on hand to start immediately when an infection threatens. Quick treatment often means the difference between getting better at home and ending up in the hospital on IV antibiotics. So you might want to talk to your doctor about that. Of course if we need to resort to our antibiotic stash we call our docs at the earliest possible moment to let them know, and then follow up with them to assure we're acting wisely.

I hope that answers some of your questions and didn't just confuse things. Please let us know what you discover.

Gentle (((hugs!)))

Binney 

Hi ferretmom,

Awe, I've always been amazed by ferrets. They are such wonderful little creatures. We humans sometimes do more harm than good--especially when it comes to living with "wild" critters, whether they are small or large!

I wanted to jump in here because I developed an infection in my breast right after lumpectomy SNB (3 nodes--all clear), and radiation. I got caught in a catch-22 situational mess. My breast surgeon was willing to refer me to the LE Clinic in our area (only one on the central coast of CA) but they were understaffed and couldn't see me for almost 3 months! On top of that the Rad Onc said go see your breast surgeon and by the way, "my equipment doesn't cause that." So, I finally got in to see someone, but it was after 2 plane trips (and told I didn't need to worry about LE).

The antibiotics seemed to clear up the breast, but I still had lots of pain. I didn't have the gray skin and other symptoms you describe. I was told it was seroma or hematoma and that would clear up over time. By the time I returned to the surgeon (after the LE Clinic did what they could for me), I decided that having a mastectomy would solve the problem--NOT!

So, in a way, for me, what Binney says about it possibly moving into other areas--that's what happened to me. With the mast, I decided to do immediate reconstruction--TRAM-flap.

I now have LE in my upper trunk, and right arm and hand. The surgery did not make it go away.

Don't want to worry you, but just be aware that lopping off the breast does not necessarily solve the problem if it ends up being LE. Of course, each of our bodies are different, and we each respond to treatment differently. But, if I had it to do over, I don't think I would have had the reconstruction. Oh well, I carry on and try to share my experience in the hope I will help other women not end up with truncal LE! It's no party at times!

I wish you all the best, and I know what you mean abut walk in the park--I was told it would be a piece of cake (not one I'd ever like to sample again).

If you have any questions about my experience with breast infection and LE, please don't hesitate to ask.

Hugs, 

Hi ferretmom,

I didn't have many side effects from the radiation. However, I did have some burning of the skin but no blisters just redness. The rad onc prescribed some rad salve to put on after treatment. It helped a lot. My infection occurred during radiation. After the antibiotics I still had the breast pain--like someone stabbing me with a skewer through the nipple--it was constant. That's when the rad onc sent me to the bs. He put me on Neurontin which helped some. Was told the sensations would stop eventually and that the breast needed to heal. I asked about a compression sleeve for the 2 plane trips I was taking--one to Hawaii the day after finishing rads. Was told I didn't need to worry about LE in arm as only took out 3 nodes. Flew w/my mom at end of September 04 back east w/out sleeve again. Was still having pain and seeing bs who kept telling me to give it time. Prescribed some Vicodin to take when pain at worst. About a month later, I asked bs about helping husband build floor with cement pavers weighing about 40 lbs each. Again was told by bs to go ahead and do whatever I felt like doing (initial surgery june04). Was still having pain off and on. I moved over 80 pavers from the back of the truck to the building site (we were having a shed built). Think the 2 trips and pavers was just too much. Pain so excruciating I had to take another med leave from work. And there began my struggle to get in to the LE clinic for treatment. Even with that, I did not have much improvement in the breast healing. Doc finally did ultrasound in Dec. and showed nothing. I asked for biopsy, and he did that. Showed a mixture of necrotic blood cells but no infection and no cancer (I learned then that the bc had been concerned about IBC--never crossed my mind). By January 05 I was back in his office asking that something be done. It was then we scheduled the mast for March 05. Returned to work in May 05 with continuing pain. Left work in Aug 05 and began seeing pain management doc. Still see him every three months. Still on pain meds that make brain fuzzy sometimes and I do have short term memory problems. Now medically retired and on permanent disability--SSI and unable to work at all. Life has changed big time. But I keep trying to look on the bright side. I am participating in a Lymphedema Patient Support Group and volunteer at the LE Clinic. I'm working on a book about my experience and believe that I have had this experience with bc and le in order to help other women who may at sometime be in my situation. I try to educate every medical professional I come across. The nurses at the outpatient surgery center where I have my neck injections (for pain) 2x a year have the hot pink Lymphedema Alert bracelets (free to LE patients from Peninsula Medical in Scotts Valley CA) for anyone with LE coming in for procedures. They have also asked if they can pass out my phone number to any patient that comes in whom they suspect might have LE and want to talk to someone with LE. I'm doing what I can, and I spend my free time with my family and pets or working in the garden, or trying out new recipes. Life is good--and would be even better if I could eliminate the pain!

Hugs, 

Wow!  I am so glad that they have a given a name to this condition.  In August 2003 I had a lumpectomy and 17 nodes removed, followed by 2 re-excissions to get clear margins.  I then had chemo and radiation.  Last month I  spent a week in the hospital hooked up to IV antibiotics to deal with cellilitus in my bad boob.  The same thing happen three years ago that also involved hospitalization with IV antibiotics.   I have lived with a seroma since my treatment, and now live in fear that it is going to happen again.  It was so unexpected and I cannot pinpoint a reason that it happened again.  No cuts, no insect bites. Everything was going well.  While I was in the hospital a oncology nurse looked at my breast and told me it looked like inflammatory breast cancer.  I was terrified.  My doctor did a punch biopsy and also aspirated the fluid from my seroma and did a biopsy of that as well.  Fortunately I was cancer free.  Just a lot of imflammation.  Ever since my last episode my breast looks more mishappen than ever and I am still seeing a little pinkish clear fluid leaking form my nipple when there is pressure on my breast.  I am due for my annual mammogram next month and I don't see anyway that I can allow them to do that to my poor breast. 

Debby

djs, OUCH! I sure hope things are 100% better by next month, because otherwise we're ALL gonna hurt just thinking about you! Are you seeing a lymphedema therapist for your breast? Besides the seroma, it sounds like there's a good chance you might have some lymphedema there too. Either way, a well-trained Lymphedema therapist should be able to help you move some of that fluid out of there gently and effectively, which cuts down on the infection risk. Are you using any kind of chest compression (bra or vest or even a cozy leo)?

Maura, I can sure understand your balking at being rushed into treatment. You've already got your plate full of stressful appointments! The fact is, though, that most of us have had to go to therapy five days a week for several weeks to get good results. So if you can do it in only three days a week that should make it at least a bit less of an imposition. Sigh! I hope she's making you comfortable with the massage -- ahhhhhh! Thank goodness lymphedema treatment isn't about more surgery or more drugs and their side effects! It sounds like your temps there are as bad as ours, but I'd guess the humidity where you are must make it even harder! Aaugh! This too shall pass -- and the sooner the better!

Hang in there -- it get's better, honest!

Binney 

Review Article | August 01, 2003 | Breast Cancer, Cancer Complications, Oncology JournalBy Deborah A. Frassica, MD, Gopal K. Bajaj, MD, and Theodore N. Tsangaris, MD

Reviews

Commentary (Mendenhall): Treatment of Complications After Breast-Conservation Therapy

Commentary (Deutsch): Treatment of Complications After Breast-Conservation Therapy

ABSTRACT: Over the past 2 decades, breast-conservation therapy with lumpectomy and whole-breast radiotherapy has become a standard option for the majority of women with newly diagnosed breast cancer. Long-term local control is achieved in approximately 85% of patients, and the therapy is generally well tolerated. There can, however, be long-term effects on the breast and other nearby tissues that may range from asymptomatic findings on examination to severe, debilitating problems. Infection, fat necrosis, and severe musculoskeletal problems such as osteoradionecrosis or soft-tissue necrosis are uncommon, affecting less than 5% of patients. However, changes in range of motion, mild-to-moderate musculoskeletal pain, and arm and breast edema are much more common. As more women choose breast-conservation therapy for management of their breast cancer, physicians will encounter these problems, as well as in-breast tumor recurrence, with greater frequency. This review will focus on the incidence, contributing factors, and management of the late problems of infection, fat necrosis, musculoskeletal complications, and local recurrence following breast-conservation therapy.

Breast-conserving therapy with lumpectomy, axillary dissection, and radiotherapy, has been associated with a variety of side effects and complications. It is important to have a good understanding of the frequency and severity of treatment- related problems in order to adequately counsel patients about their treatment options. In addition, continual assessment of techniques and other factors that may influence the incidence of complications is necessary to develop safer treatment approaches. In general, the best way to manage a treatment-related problem is to avoid its occurrence. This is especially important in patients who undergo irradiation, because the options for treatment of late effects may be limited.

This review will focus on some of the less commonly discussed side effects and complications of breast-conserving surgery and radiotherapy for early-stage breast cancer such as infection, fat necrosis, musculoskeletal effects, and pain. In addition, the options for management of in-breast tumor recurrence will be reviewed.

Infection

The incidence of cellulitis or breast abscess after breast-conserving therapy is low, ranging from 1% to 5% in most case series, with an annual risk for the development of delayed cellulitis of 0.8%.[1-3] Patients may present with cellulitis or abscess in the perioperative period, or at any time before, during, or after radiation therapy.[2,4] The majority of cases present with pain, erythema, axillary swelling, and warmth in the involved breast, whereas a breast abscess or seroma may present as suspicious mammographic changes or a clinically palpable breast mass.[5] The median latency period for the development of delayed cellulitis is 3 to 5 months postradiotherapy, and it may even occur many years after the completion of therapy.[1-3,6,7]

Risk Factors

Although the clinical scenario in which delayed breast cellulitis commonly occurs points to a multifactorial etiology, specific risk factors have been evaluated. Brewer et al[1] performed a matched case-control study to statistically associate potential risk factors with the development of breast cellulitis in a cohort of patients treated with breast-conserving therapy. Their analysis of 17 cases revealed that arm lymphedema was the most prominent risk factor for the development of delayed breast cellulitis. Other trials have also identified the potential role of clinical or subclinical lymphedema of the breast secondary to alteration of vascular and lymphatic flow from surgery and radiotherapy as a potential predisposing factor for the development of breast infection.

It is believed that lymphedema results in stasis within the lymphatic channels, serving as a medium for bacterial growth. Similarly, microvasculature injury or skin desquamation may play an etiologic role.[2,4,7] It is felt that in this anatomically altered setting, microtrauma to the breast may precipitate cellulitis. In addition, many reports have implicated posttreatment breast seroma and aspiration of seroma fluid with the development of cellulitis.[1,4]

Mertz et al[7] found that radiographically demonstrable fluid collections at the lumpectomy site were present in 75% of a small cohort of patients treated for cellulitis after breast-conserving therapy. This finding may point to the presence of these fluid collections as a predisposing factor for the development of later infections.

Treatment

As with a variety of other cellulitis syndromes, bacterial pathogens are often not recovered, and procedures such as aspiration of the leading edge of a lesion and blood cultures, in the absence of other systemic symptoms of infection, usually produce a low yield.[4,6] Hence, treatment is generally empiric, and choice of antibiotic treatment is influenced primarily by clinical presentation. The most frequently cultured organisms are Staphylococcus aureus or beta-hemolytic streptococci species.[4,6]

Initial treatment for mild cases consists of empiric therapy with oral antibiotics to cover normal skin flora. Penicillinase-resistant penicillins, including nafcillin and oxacillin, and first-generation cephalosporins, including cefazolin and cephalexin, are commonly selected.[6] If S aureus is suspected, a beta-lactamase-inhibiting penicillin such as amoxicillin/ clavulanate (Augmentin) or ampicillin/ sulbactam (Unasyn) may be used.[4] For persistent cases or for patients with leukocytosis and fever, hospital admission for a course of intravenous antibiotics may be warranted.[2]

Although many patients will experience a relatively quick response to empiric therapy, clearance of breast changes may be gradual and may persist for extended periods (Figure 1).[6] Cultures of abscesses or seroma aspirates may be obtained prior to the initiation of therapy to facilitate later revision of therapy as needed for patients without a clinical response. The recommended period of treatment is usually 10 to 14 days.

Incision and drainage should be considered for persistent abscess after completion of therapy. For nontoxic patients who do not respond to antibiotic therapy, a 7- to 14-day trial of nonsteroidal anti-inflammatory agents or topical corticosteroids may be warranted to treat potential dermatitis.[6] Skin biopsy to rule out cancer recurrence should be considered in all patients who fail to respond to conservative therapy.[8]

In addition to antibiotics, other preventive techniques to decrease lymphedema may be employed, such as compression therapy, skin care, and exercise. Patients with axillary or breast seromas should be counseled on the signs, symptoms, and treatment of cellulitis because they may be at higher risk of developing the problem.

Breast Cellulitis as a complication of surgery and radiation

by patoco » Sun Sep 24, 2006 3:07 pm

Not only are breast cancer patients not informed by their oncologists on the possibilities of lymphedema as a result of node removal and/or radiation, but they are not information either of the possibilities of cellulitis of the breast as a possible complication of breast-conserving surgery and radiotherapy.

This is important to be aware of because cellulitis, in and of itself can damage the lymphatics sufficiently to be a triggering event for lymphedema as well.

Here are case study abstracts.

...................

Cellulitis of the breast as a complication of breast-conserving surgery and irradiation.

Hughes LL,
Styblo TM,
Thoms WW,
Schwarzmann SW,
Landry JC,
Heaton D,
Carlson GW,
Wood WC.
Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia, USA.

Breast-conserving therapy (BCT) has become a standard treatment option for patients with early-stage breast cancer. We have observed cellulitis of the treated breast as a complication occurring before, during, and after breast irradiation. The cases of five women (median follow-up, 28 months; range, 24-65 months) who developed cellulitis before (n = 1), during (n = 2), or after (n = 2) breast irradiation were reviewed. A consecutive series of BCT patients at Emory University was reviewed to determine the incidence of this complication. Four of five women had an axillary dissection, yielding a median of 14 negative lymph nodes (range, 6-22 nodes).

Two of four patients developed axillary seromas requiring aspiration. In these four patients, only the breast was irradiated. A fifth patient had no axillary dissection and had breast and supraclavicular/axillary irradiation. The median whole breast dose was 50 Gy (range, 46-50.4 Gy). The clinical features of cellulitis included erythema, edema, tenderness, and warmth in all patients. Cellulitis was a relapsing problem for four of the five patients. The incidence of this complication in our series of BCT patients was approximately 1%. Cellulitis in the ipsilateral breast can be a relapsing complication of BCT and can be seen before, during, or after breast irradiation. Axillary seromas and aspiration seem to indicate a subset of patients at risk of early cellulitis.

Late cellulitis may be caused by a variety of factors related to modifications of vascular and skin integrity by surgery and radiotherapy. Prompt diagnosis and appropriate antibiotic therapy is recommended. This problem need not interrupt a course of breast irradiation, and does not necessarily lead to a poor cosmetic result.

PMID: 9256885 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/quer ... med_docsum

Read up on breast lymphedema and delayed breast cellulitis on my LymphActivist's Site at http://www.lymphactivist.org/breast_lymphedema_for_therapists.pdf

Aw, jdfly, I'm so sorry for all this mess you've been facing. The IV antibiotics should definitely help clear things up, but the whole process sure is discouraging, no? Hugs, and prayers for quick healing,
Binney