Stage IIB breast cancer with severe radiation recall after abemaciclib

What happened, in summary

This 41-year-old premenopausal woman was diagnosed in March 2024 with right breast invasive ductal carcinoma, initially staged cT2N1M0, Stage IIB. Biopsy showed strongly hormone receptor-positive disease, with estrogen receptor positivity at 90%, progesterone receptor positivity above 90%, and HER2 1+, considered HER2-negative. Ultrasound showed multicentric breast lesions, and axillary lymph-node puncture confirmed nodal metastasis. She completed 6 cycles of neoadjuvant TEC chemotherapy, but the response was poor. Because breast-conserving surgery was not feasible, she underwent subcutaneous total mastectomy with nipple-areolar complex resection, immediate prepectoral tissue expander and TiLoop patch placement, and axillary lymph-node dissection. Pathology showed Miller-Payne grade I response and 12 of 14 lymph nodes involved, reported as ypT2N3M0. She then started ovarian suppression with goserelin plus an aromatase inhibitor. From November 27 to December 31, 2024, she received adjuvant radiotherapy to the right chest wall, regional nodes, and supraclavicular fossa, 50 Gy in 25 fractions. Five days after radiation, she developed pain near the expander injection port, and 1 month later the port was exposed. The wound remained stable with dressings until March 14, 2025, when abemaciclib 150 mg twice daily was started. Within 1 week, the incision opened rapidly into a 10 by 10 centimeter defect with exposed expander and patch, consistent with severe radiation recall dermatitis. Infection was considered less likely because she had no fever, normal blood counts, and no obvious pus at the wound. Abemaciclib was stopped, and she underwent expander/patch removal with debridement and closure on April 23, 2025. The flap healed well afterward, while her future systemic treatment and reconstruction decisions remained unresolved.