Malignant Ulcer of the Axilla

Tor Svensjö MD, PhD, Department of Surgery, Central Hospital Kristianstad Sweden


Nine years earlier the patient had undergone a partial left sided mastectomy  with axillary lymph node dissection due to a15mm invasive lobular carcinoma, Nottingham grade II, hormone receptor positive, with1 out of 12 lymph nodes positive for tumor. Patient received radiation therapy 50 Grey in 25 fractions and Tamoxifen for 5 years. The patient later terminated her Tamoxifen treatment due to side effects. The patient also had well controlled Type 2 Diabetes, hypertension and hypothyroidism. She presented with an ulcer of the right axilla of 8 months duration. The ulcer had not improved in spite of various local treatments.


77 year old woman with a 6×2 cm ulcer in the left axilla. The ulcer showed what appeared to be hyper granulation.

Fig.1. Left armpit showing central ulcer surrounded by nodular skin lesions, highly suspicious of representing recurrent breast cancer.




Pathology report on punch biopsies showed recurrence of Invasive lobular carcinoma with multiple skin metastasis, hormone receptor positive, Ki67 25%.

Differential Diagnoses:

Radiation ulcer or radiation induced Sarcoma, Basal cell carcinoma or Squamous cell carcinoma.

Workup Required:

Tissue biopsy was done at the first visit and confirmed recurrent breast cancer. CT scan of upper body was negative. Tumor Board recommended wide local excision.


Wide local excision and closure with fascio-cutaneous flap.

Expertise Needed:

Plastic Surgeon or surgeon with experience with local flaps.


Wide local excision and closure with a fascio-cutaneous transposition flap incorporating thoracodorsal perforators marked with a hand held doppler.
Fig.2. A Preoperative markings. 3 thoracodorsal perforators identified with doppler and marked with dots.
B Wound defect after wide local excision. Pectoralis major muscle (upper part of wound) and latissimus muscle (lower part of wound) are visible.
C Flap raised and transposed into defect.
D End of procedure. Flap healed at 2 week follow up without necrosis or infection.

Follow Up:

Patient was completely healed at 2 weeks follow up. Pathology demonstrated invasive lobular carcinoma with tumor free margins. Patient was recommended prolonged antihormonal treatment. Radiotherapy was not considered due to previous radiation. A small local recurrence was radically excised 15 months later. At 10 year follow up patient was alive without further recurrence.
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