CASE REPORT OPEN ACCESS

International Journal of Surgery Case Reports 11 (2015) 2428

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journal homepage: www.casereports.com

Forequarter amputation for recurrent breast cancer

Krishna N. Pundi, Yazan N. AlJamal, Raaj K. Ruparel, David R. Farley
Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, United States

a r t i c l e

i n f o

Article history:
Received 9 February 2015
Received in revised form 27 March 2015
Accepted 12 April 2015
Available online 15 April 2015
Keywords:
Amputation
Breast
Advanced cancer
Forequarter
Metastatic
Recurrent cancer

a b s t r a c t
INTRODUCTION: Localized excision combined with radiation and chemotherapy represents the current
standard of care for recurrent breast cancer. However, in certain conditions a forequarter amputation
may be employed for these patients.
PRESENTATION OF CASE: We present a patient with recurrent breast cancer who had a complicated treatment history including multiple courses of chemotherapy, radiation, and local surgical excision. With
diminishing treatment options, she opted for a forequarter amputation in an attempt to limit the spread
of cancer.
DISCUSSION: In our patient the forequarter amputation was utilized as a last resort to slow disease
progression after she had failed multiple rounds of chemotherapy and received maximal radiation. Unfortunately, while she had symptomatic relief in the short-term, she had cutaneous recurrence of metastatic
adenocarcinoma within 2 months of the procedure. In comparing this case with other reported forequarter amputations, patients with non-metastatic disease showed a mean survival of approximately two
years. Furthermore, among patients who had signicant pain prior to surgery, all patients reported pain
relief, indicating a signicant palliative benet. This seems to indicate that our patients unfortunate outcome was anomalous compared to that of most patients undergoing forequarter amputation for recurrent
breast cancer.
CONCLUSION: Forequarter amputation can be judiciously used for patients with recurrent or metastatic
breast cancer. Patients with recurrent disease without evidence of distant metastases may be considered
for curative amputation, while others may receive palliative benet; disappointingly our patient achieved
neither of these outcomes. In the long term, these patients may still have signicant psychological
problems.
2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Historically, forequarter amputations have been used for management of bone and soft-tissue sarcomas of the shoulder girdle,
although more recently it has been employed in the treatment
and palliation of recurrent breast cancer. Axillary tumor recurrence can be very problematic for patients, causing signicant
pain, lymphedema, limb dysfunction, and/or skin ulceration. In
cases of isolated recurrence, management using localized surgery,
chemotherapy, and radiation is the preferred approach. However,

for patients who have more signicant invasion without the possibility of local excision, a radical approach may be necessary for
removal of the tumor in those patients desiring aggressive oncologic treatment. In these cases, the forequarter amputation offers
the possibility of stopping the spread of the tumor while also palliating the pain and other morbidities often associated with invasion.
We report the case of a forequarter amputation attempting to palliate a patient for axillary recurrence of breast cancer and provide
a review of the literature on this controversial subject.
2. Presentation of case

Abbreviations: ALND, axillary lymph node dissection; BCT, breast conserving therapy; CA, cancer antigen; ER, estrogen receptor; MRA, magnetic
resonance angiography; OR, operating room; PET/CT, positron emission tomography/computed tomography; PR, progesterone receptor; RT, radiotherapy; SLN,
sentinel lymph nodes.
Corresponding author at: Department of Surgery, Mayo Clinic, 200 First Street
SW, Rochester, MN 55905, United States. Tel.: +1 507 284 2095; fax: +1 507 284
5196.
E-mail address: [email protected] (D.R. Farley).

A 49-year-old woman presented to our institution with a history

of recurrent breast cancer. On her initial presentation two years
earlier, she detected a mass in her right breast and presented to
her primary care physician for further work-up. Prior surgical history included a gastric bypass but no breast-related procedures.
The family history was signicant for bilateral breast cancer in her
mother. The patient was on no medications and was otherwise
healthy. The physical examination detected a mobile, palpable, rm

http://dx.doi.org/10.1016/j.ijscr.2015.04.018
2210-2612/ 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

CASE REPORT OPEN ACCESS

K.N. Pundi et al. / International Journal of Surgery Case Reports 11 (2015) 2428

25

Fig. 1. (A) Horizontal sections on PET/CT indicating axillary recurrence of the cancer prior to surgery, and (B) post-surgical scan indicating removal of the affected lymph
nodes and subsequent reduction in PET/CT signal.

mass in the central right breast. No worrisome lymphadenopathy

was appreciated. Mammography detected a probable right-sided
breast cancer.
An ultrasound-guided ne needle aspiration identied an invasive ductal carcinoma, and the patient was advised to have surgery.
The patient opted for a right simple mastectomy to remove the
2.5 cm mass; margins were free. Two axillary sentinel lymph nodes
(SLN) were negative. The mass was a Nottingham grade III invasive
ductal carcinoma that was estrogen receptor (ER), progesterone
receptor (PR), and HER-2/neu negative (triple negative). The nipple,
skin, and chest wall were free of involvement. She was subsequently treated with dose-dense adjuvant chemotherapy using
Adriamycin and cyclophosphamide for four cycles followed by four
cycles of Taxol given every two weeks followed by external beam
radiation to the chest wall and lower right axilla (50 Gy in 25 fractions).
Despite a negative BRCA genotype, the patient sought aggressive management of her oncologic risks and underwent bilateral
oophorectomy for known polycystic ovaries and a rising cancer
antigen (CA) 125 level. She was t and seemingly well for one year.
Thirteen months after the simple mastectomy and SNL removal,
she noticed right axillary lymphadenopathy which was conrmed
by positron emission tomography/computerized tomography
(PET/CT) as shown in Fig. 1A. There was no evidence of systemic
metastatic disease. A ne-needle aspiration indicated this was
metastatic poorly differentiated adenocarcinoma, and subsequent
axillary dissection found 2 of 10 lymph nodes involved with tumor
(Fig. 1B indicates PET/CT following axillary dissection). Postoperatively the patient received an additional 50 Gy of radiation to the
axilla. She started adjuvant chemotherapy with gemcitabine and
carboplatin, completing ve cycles over the next ve months.
A month after conclusion of her chemotherapy a PET scan indicated some nonspecic uptake in the right axilla, but no treatment
was recommended at that time. Six months later, there was a palpable, rm node in the right axilla. An ultrasound-guided biopsy
revealed metastatic adenocarcinoma. At this time, she was referred
to our institution.
With concerns radiation was no longer an option, the patient and
her oncologists desired lymph node removal in hopes of analysis
to devise a better chemotherapy regimen. With a full understanding that more surgery would unlikely be curative, the patient and

surgeon agreed on a third axillary operation; the procedure was difcult with dense, irradiated scar tissue throughout the axilla (Fig. 2
shows the intraoperative ultrasound). The node and surrounding
tissue was removed en bloc, but resection of the axillary vein and
pectoralis muscle was avoided. Histologic analysis revealed poorly
differentiated adenocarcinoma involving the lymph node consistent with a primary breast source. Magnetic resonance angiography
(MRA) performed three months later showed an ill-dened 4.5 cm
soft tissue mass in the right axilla consistent with recurrent tumor
or adenopathy and possible involvement of the axillary vein and
chest wall (Fig. 3). At this time there was no evidence of distant
metastatic disease. In consulting with her medical team, the patient
was presented the options of continuing with observation, further
chemotherapy, or a forequarter amputation. In order to attempt a

Fig. 2. Intraoperative ultrasound of the axilla indicating dense, woody tissue with
diffuse scarring from radiation therapy.

CASE REPORT OPEN ACCESS

26

K.N. Pundi et al. / International Journal of Surgery Case Reports 11 (2015) 2428

Fig. 3. (A) Coronal MRA showing axillary recurrence of a 4.5 cm mass abutting the chest wall and axillary vein with possible involvement; (B) and (C) demonstrate the tumor
in horizontal sections.

Fig. 4. Photographs during the surgical procedure showing removal of the right arm, resection of the chest wall between ribs 25, resection of a lung nodule, placement of a
brachial plexus nerve catheter, and chest wall reconstruction.

more aggressive solution to the issue, the patient opted for a forequarter amputation, which was successfully performed one month
later. The surgery involved removal of the right arm, resection of
the chest wall from ribs 25, wedge resection of a 1 mm right lung
nodule (palpated during surgery but not seen on imaging), chest
wall reconstruction, and placement of a right brachial plexus nerve
catheter (Fig. 4). The total OR time was 4.5 h. Histology revealed
that the axillary mass and pulmonary nodule were both consistent with poorly differentiated adenocarcinoma with a primary
breast source; surgical resection margins were negative. Her postoperative course was generally uneventful save for a brief episode
of atrial brillation. The patient was discharged on postoperative
day 7 with referrals to physical therapy, occupational therapy, and
amputee service, as well as deep vein thrombosis prophylaxis with
acetylsalicylic acid for six weeks.
At six week follow-up, the patient had developed new skin nodules on the chest surrounding the surgical site. Biopsy of these
nodules was positive for ER/PR negative metastatic undifferentiated adenocarcinoma. Additionally, a PET scan showed that there
was now left axillary lymphadenopathy measuring 2 cm in diameter. She thus underwent three full cycles of eribulin treatment.
In the following months she was treated with further palliative
radiation and weekly cisplatin chemotherapy. Unfortunately, this
patient went on to suffer from further metastases to the lung
with deterioration of her health and consistent phantom pain. She
was also hospitalized multiple times for severe polymicrobial skin
ulcerations until her eventual passing several months later.
3. Discussion
Breast cancer represents the most common form of cancer
among women in the United States. The 5-year relative survival of

individuals with breast cancer in 2009 was reported to be 98.6% for

those with localized breast cancer at diagnosis, 84.4% with regional
spread, and 24.3% with distant metastasis [1]. Since the early 1990s,
the death rates have declined with the addition of new therapies
and earlier detection [2].
For patients who underwent a mastectomy as initial treatment
there is a 510% local recurrence rate within 10 years, although
up to 36% of patients with local recurrence may have simultaneous distant metastases [35]. For recurrence following BCT and RT,
mastectomy is the standard approach given there is no evidence
of distant metastasis; however, palliative mastectomy may still
be performed [6,7]. When axillary recurrence occurs, it has been
shown that multimodal treatment involving surgery, irradiation
and chemotherapy is the best approach to optimize disease-free
survival [8].
In the case of our patient, having received the maximum amount
of radiation and in an attempt to prevent further spread, radical
excision was performed using a forequarter amputation. While the
axillary recurrence had not caused any symptoms of pain or dysfunction yet, palliating these problems as well as delaying further
spread and recurrence made the forequarter amputation a more
viable option in the eyes of the patient.
The usage of forequarter amputation for recurrent breast cancer
is a rare practice, and Table 1 provides a summary of the outcomes
from published cases [920]. When patients sought surgery for
curative benet, they generally had good survival outcomes from
the procedure. For those who had locally recurrent cancer, 5 out of
9 survived to the time of published data with an average survival
among all patients of 23.4 14.6 months. While this is not enough
to determine that patients with locally recurrent breast cancer will
universally benet from a forequarter amputation, it provides better context for its usage. Meanwhile, patients who sought palliative

CASE REPORT OPEN ACCESS

K.N. Pundi et al. / International Journal of Surgery Case Reports 11 (2015) 2428
Table 1
Meta-analysis of patients who have undergone forequarter amputation for breast
cancer recurrence [920].

27

amputation. Palliatively, forequarter amputations can be used as

salvage therapy in patients with advanced axillary recurrence of
breast cancer and intractable pain [1114,16].

Patients (%)

Conicts of interest

Total number of cases

28 (100%)

Female

27 (96%)

Age

56.6 10.6 years

Pre-surgical diagnosis
Local recurrence only
Conrmed metastasis

16 (57%)
12 (43%)

Presenting symptoms
Pain
Edema
Limb dysfunction
Ulceration
Infection
Bleeding
Fungation
Necrosis
Blistering
Wound care
No symptoms

15 (71%)
12 (57%)
11 (52%)
10 (48%)
4 (19%)
3 (14%)
1 (5%)
1 (5%)
1 (5%)
1 (5%)
1 (5%)

Intention of surgery (n = 28)

Palliative
Curative

18 (64%)
10 (36%)

Surgical complications (n = 19)

Flap necrosis
Delayed healing
Pleural effusion

4 (21%)
1 (5%)
1 (5%)

Pain relief (n = 15)

15 (100%)

Funding
None.
Consent
Informed consent was obtained from the patient for publication
of the case report and accompanying images.
Author contributions
Study Design: Pundi, Farley.
Data Collection: Pundi.
Data Analysis: Pundi, Farley.
Writing: Pundi, AlJamal, Ruparel, Farley.
Edits: Pundi, AlJamal, Ruparel, Farley.
References

Survival
Recurrent, palliative (n = 7)
Recurrent, curative (n = 9)
Metastatic, palliative (n = 11)
Metastatic, curative (n = 1)

Alive
1 (14%)
5 (56%)
0 (0%)
1 (100%)

The authors have nothing to disclose and no conicts of interest.

Mean survival
13 8.1 mos.
23.4 14.6 mos.
13.3 16.3 mos.
23 mos.

therapy had a mean survival of 13 8.1 months if they had local

recurrence and 13.3 16.3 months with metastatic disease.
Upon initial presentation, the most common symptoms among
patients included pain (71%), edema (57%), limb dysfunction (52%),
and ulceration (48%). In patients who noted pain as a presenting
symptom, 100% reported relief following the procedure. Furthermore, immediate post-surgical complications were relatively
limited, with 4 patients (21%) experiencing ap necrosis and only
1 patient each (5.3%) having problems with pleural effusion and
delayed healing. As a result, there can be palliative benet from
this surgery with seemingly limited post-operative complications.
Our patient lacked any real issues with pain or limb dysfunction as noted in patients in other studies and unfortunately did not
garner benet from this procedure because of early recurrence and
progression of her cancer. We hope that her experience was atypical
given that many of the patients who underwent this procedure had
a much longer survival and received palliative benet long-term.
4. Conclusion
As suggested by previous authors, we would concur that there
are certain curative and palliative uses for the forequarter amputation with careful consideration. Our relatively asymptomatic
patient appreciated the efforts to eradicate her local tumor recurrence, but she did not gain long term benets. Patients who have
immobile, unresectable recurrent tumors in the axilla, with severe
pain with loss of function, are negative for distant metastasis,
and have any tumor-related complications including bleeding,
infection, or edema can be considered for curative forequarter

[1] SEER Cancer Statistics Review, 1975-2010, in: N. Howlader, A.M. Noone, M.
Krapcho, J. Garshell, N. Neyman, S.F. Altekruse, C.L. Kosary, M. Yu, J. Ruhl, Z.
Tatalovich, H. Cho, A. Mariotto, D.R. Lewis, H.S. Chen, E.J. Feuer, K.A. Cronin
(Eds.), National Cancer Institute, Bethesda, MD, 2013, based on November
2012 SEER data submission, posted to the SEER web site
http://seer.cancer.gov/csr/1975 2010/
[2] C. DeSantis, R. Siegel, P. Bandi, A. Jemal, Breast cancer statistics, 2011, CA
Cancer J. Clin. 61 (2011) 409418.
[3] S.H. Yang, K.H. Yang, Y.P. Li, et al., Breast conservation therapy for stage I or
stage II breast cancer: a meta-analysis of randomized controlled trials, Ann.
Oncol. 19 (2008) 10391044.
[4] J.A. van Dongen, A.C. Voogd, I.S. Fentiman, et al., Long-term results of a
randomized trial comparing breast-conserving therapy with mastectomy:
European Organization for Research and Treatment of Cancer 10801 trial, J.
Natl. Cancer Inst. 92 (2000) 11431150.
[5] C.L. Buchanan, P.L. Dorn, J. Fey, et al., Locoregional recurrence after
mastectomy: incidence and outcomes, J. Am. Coll. Surg. 203 (2006) 469474.
[6] A. Katz, E.A. Strom, T.A. Buchholz, et al., Locoregional recurrence patterns
after mastectomy and doxorubicin-based chemotherapy: implications for
postoperative irradiation, J. Clin. Oncol. 18 (2000) 28172827.
[7] B. Fowble, L.J. Solin, D.J. Schultz, J. Rubenstein, R.L. Goodman, Breast
recurrence following conservative surgery and radiation: patterns of failure,
prognosis, and pathologic ndings from mastectomy specimens with
implications for treatment, Int. J. Radiat. Oncol. Biol. Phys. 19 (1990) 833842.
[8] S. Galper, E. Blood, R. Gelman, et al., Prognosis after isolated axillary nodal
recurrence following conservative surgery and radiotherapy for early-stage
breast carcinoma, Int. J. Radiat. Oncol. Biol. Phys. 54 (Suppl) (2002) 56.
[9] M. Ayvaz, C. Yilgor, M.U. Mermerkaya, et al., Simultaneous forequarter
amputation and radical mastectomy for metastatic breast carcinoma in a
male patient: a case report, J. Korean Surg. Soc. 81 (Suppl. (1)) (2011) S6S11.
[10] J.C. Wittig, J. Bickels, Y. Kollender, et al., Palliative forequarter amputation for
metastatic carcinoma to the shoulder girdle region: indications, preoperative
evaluation, surgical technique, and results, J. Surg. Oncol. 77 (2001) 105113,
discussion 114.
[11] M.D. Goodman, B. McIntyre, E.A. Shaughnessy, A.M. Lowy, S.A. Ahmad,
Forequarter amputation for recurrent breast cancer: a case report and review
of the literature, J. Surg. Oncol. 92 (2005) 134141.
[12] A.I. Holleb, J.C. Lucas Jr., Palliative interscapulothoracic amputation in the
management of the breast cancer patient, Cancer 12 (1959) 643647.
[13] R.D. Mussey, Palliative forequarter amputation for recurrent breast
carcinoma, AMA Arch. Surg. 73 (1956) 154156.
[14] R. Sakamura, K. Nohira, M. Shibata, T. Sugihara, Coverage of a large soft-tissue
defect of the chest with a free llet forearm and hand ap, J. Reconstr.
Microsurg. 17 (2001) 229231.
[15] J. Rickelt, H. Hoekstra, F. van Coevorden, et al., Forequarter amputation for
malignancy, Br. J. Surg. 96 (2009) 792798.
[16] N. Fanous, M.S. Didolkar, E.D. Holyoke, E.G. Elias, Evaluation of forequarter
amputation in malignant diseases, Surg. Gynecol. Obstet. 142 (1976) 381384.
[17] O. Merimsky, Y. Kollender, M. Inbar, et al., Is forequarter amputation justied
for palliation of intractable cancer symptoms, Oncology 60 (2001) 5559.

CASE REPORT OPEN ACCESS

28

K.N. Pundi et al. / International Journal of Surgery Case Reports 11 (2015) 2428

[18] F.P. French, P.M. Murray, G. Perdikis, Extensive cutaneous metastatic breast
carcinoma of the hand and upper extremity: a case report, J. Hand Surg. [Am].
32 (2007) 252255.
[19] P. Nierlich, P. Funovics, M. Dominkus, et al., Forequarter amputation
combined with chest wall resection: a single-center experience, Ann. Thorac.

Surg. 91 (2011) 17021708.

[20] M.E. Puhaindran, J. Chou, J.A. Forsberg, E.A. Athanasian, Major upper-limb
amputations for malignant tumors, J. Hand Surg. [Am]. 37 (2012) 12351241.

Open Access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which
permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are
credited.