Stage IIIB ER/PR-positive breast cancer: emergency mastectomy for infected fungating tumor

What happened, in summary

This 71-year-old woman came to the emergency department with a painful, oozing right breast lesion after more than 50 years without health care or screening mammography. The lesion had started as a rash 4 months earlier, then became a bleeding, draining mass. On arrival she was septic, with a large malodorous fungating breast mass, purulent drainage, extensive redness tracking across the chest wall and flank, severe electrolyte abnormalities, and a CT showing a necrotic ulcerated breast mass with soft-tissue abscesses, subcutaneous gas, and a large fluid collection. Because infection control was urgent, she was taken for emergency right toilet mastectomy with extensive debridement of the breast, axilla, flank, and necrotic tissue; some pectoralis major tissue was also removed. Cultures grew methicillin-sensitive Staphylococcus aureus, consistent with type 1 necrotizing soft-tissue infection. Her recovery required 7 days in the ICU, vasopressors, renal replacement therapy for acute kidney injury, 5 additional debridements, negative-pressure wound therapy, and later wound closure. Pathology showed high-grade invasive ductal carcinoma with skin involvement, 2 tumor foci measuring 12 cm and 15 cm, ER >75%, PR >75%, and HER2 0. The cancer was staged pT4b(m)N0MX, Stage IIIB. A positive posterior margin required re-excision. Later PET/CT findings in mediastinal nodes decreased over time, while chest-wall uptake remained difficult to separate from inflammation or residual disease. Because of her prolonged recovery, severe complications, colectomy with ileostomy after colitis, and repeated hospitalizations, the tumor board did not recommend chemotherapy, axillary dissection, or radiation at that time. Treatment centered on anastrozole. As of May 2025, recovery was slow but progressing, though oncology follow-up had become inconsistent.