LAUSR

We present the case of a 70-year-old female from a high-level care nursing home, who presented to the emergency department of a regional base hospital in New South Wales, Australia with a large fungating left breast tumour which had significant ulceration and active bleeding. This is on the background of functional decline, decreased mobility and cachexia, although she remained cognitively intact. The lesion was first seen on computed tomography (CT) scan 2 years prior as a 36 21-mm left breast mass, on which core biopsy demonstrated a fibroepithelial lesion. The left breast mass rapidly progressed in size over this period to the point of requiring elective tumour debulking surgery for symptom relief. However, in the month leading up to this admission she had two hospital presentations with symptomatic anaemia (hypotension and tachycardia) and a significant haemoglobin drop from 127 to 70 g/L requiring blood transfusion, but was otherwise managed conservatively while awaiting planned definitive surgery. On her third presentation, she had progressive ulceration and significant active bleeding from the tumour, not controlled with bedside pressure or dressings. A staging CT scan of her chest, abdomen and pelvis was performed which showed the lesion had substantially increased to 150 190 210 mm in size, and was a highly vascular mass abutting the chest wall. There was no deeper muscle or bone invasion, or distant metastases seen. She was consented for an emergency left mastectomy. In the operating theatre, significant bleeding from a spurting vessel was noted upon removal of dressings prior to surgical preparation which required suture haemostasis (Fig. 1). Mastectomy was performed with excision of the left breast mass enbloc with part of pectoralis major muscle at the deep margin. The specimen weight was 3.5 kg and was sent to anatomical pathology for analysis. The size of the defect was reduced with a purse-string suture to achieve an approximate 40% reduction of overall wound area and topical negative pressure wound therapy (TNPWT) was applied. She was well following surgery and was discharged from hospital on post-operative day 3 for ongoing TNPWT in the community, and proceeded to elective split skin grafting of wound 2 weeks later. Her wound was reviewed and the skin graft had successfully taken. The histopathology was mostly consistent with a borderline phyllodes tumour with foci of malignant phyllodes. Superficial areas of ulceration were noted. The surgical resection margins were clear. Discussion