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Poster Presentation by Ray Ortega, MD

Introduction

A 32-year-old Haitian woman underwent local high-dose radiation following a modified radical mastectomy for a locally aggressive breast cancer that involved her lymph nodes. Initially, she received 2 cycles of neoadjuvant Adriamycin and Cytoxan with no response. She was then switched to Lupron and Tamoxifen, she had undergone left modified radical mastectomy with axillary node dissection previously. She later received 4 cycles of Taxol, which had to be discontinued due to an allergic reaction. The radiation resulted in a full thickness tissue injury, which measured over 200 sq cm, to the skin of the left anterior chest wall that measured over 200 sq cm. She underwent hyperbaric oxygen therapy for the radiation injury. However, the tissue loss progressed.

Discussion

On August 17, 2005, she underwent debridement of the chest wall in preparation for bilayered living cell therapy (Apligraf^®*) placement. The bilayered living cell therapy (Apligraf^®*) barrier function initially provided stable coverage to some parts of the injury, but the full thickness lost worsened in some areas.

On November 18, 2005, she underwent a resection of the involved tissues by a thoracic surgeon. The plastic surgery team performed a latissimus dorsi muscle flap with skin graft coverage of her chest. The extent of the injury was underestimated by initial resection. This required an additional resection of ulcers and the flap periphery on the medial chest wall and axilla.

On March 13, 2006, the 2 persistant ulcers of the chest wall and axilla were excised. Bilayered living cell therapy (Apligraf^®*) was placed in an effort to stimulate wound healing in a compromised environment. One of the chest wall ulcers closed, but 2 persisted. The chest wall ulcers measured 2.0 cm x 1.0 cm and 2.5 cm x 2.0 cm. In the axilla, the ulcer measured 2.5 cm x 1.1cm.

The ulcers were not healing and required further intervention. On July 7, 2006, the radiation ulcers of the left chest wall and the left axilla were debrided, and bilayered living cell therapy (Apligraf^®*) was applied in the axilla and chest wall areas.

Conclusions

All ulcers were healed at 1 year. Although off-label, this author chose to use Apligraf^®* for wound healing because of the hyperproliferative capacity of the product in a wound with a highly compromised healing capacity.

Apligraf^®* is indicated for use with standard therapeutic compression for the treatment of noninfected partial and full-thickness skin ulcers due to venous insufficiency of greater than 1 month duration and which have not adequately responded to conventional ulcer therapy. Apligraf^®* is also indicated for use with standard diabetic foot ulcers of greater than 3 weeks duration that have not adequately responded to conventional ulcer therapy and that extend through the dermis but without tendon, muscle, capsule or bone exposure.

Reference

Organogenesis, Inc. information on file Canton, MA.

*Apligraf^® is a registered trademark of Novartis, Inc., East Hanover, NJ © 2004 Organogenesis, Inc., Canton, MA

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