When a 39-year-old woman from Tanzania with an infected cavity in her armpit and an advanced tumour in her breast came to Mumbai looking for medical help, her ailment put Dr Indoo Ambulkar, senior medical oncologist at HCG Cancer Centre, Mumbai, in a quandary.
The woman had third-stage breast cancer, which means it was advanced and growing rapidly. The lesion in her armpit had ulcerated into a foul-smelling, pus-filled mass that needed immediate attention. Despite the obstacles, the patient’s condition made Dr Ambulkar more determined than ever to find the best treatment plan for her.
“The patient had visited many hospitals in Tanzania and consulted specialists without much success,” says Dr Ambulkar. “After six months of running from pillar to post, she met a surgeon in her country who suggested a biopsy [removal of a tissue sample from the body and testing it for presence of disease]. The test revealed that her breast lump was cancerous. By then, the lump in her armpit had turned into a ‘fungating mass’. That’s when she decided to fly to India for treatment and came to our centre. We treat many complex cancers on a daily basis but some cases, like this one, really put us in a spot.”
When a cancer becomes infected
A fungating mass or lesion develops when cancer present inside the body becomes infected and breaks out of the skin forming a wound. The wound may be filled with pus and has a foul odour because of necrosis (when tissue starts dying). As the wound deepens it can be quite difficult to treat.
According to the World Health Organization, breast cancer is the most commonly occurring cancer in the world. Globally, around two million women were diagnosed with breast cancer in 2020. When detected early, breast cancer can be effectively treated with a combination of different therapies, including surgery, to remove the tumour, radiation, chemotherapy and targeted therapy. The aim is to totally remove the cancer cells to prevent recurrence and save the life of the patient.
Sustained therapy
When Dr Ambulkar first examined the woman, the cavity in her armpit was 15cm deep and was filled with pus. The infection was getting worse, and a foul smell was emanating from the wound. A battery of tests was done — including biopsy and PET — and initially the diagnosis looked quite bleak. The medical oncologist and her team were in a dilemma as to what they should tackle first: the lesion in the armpit or the cancerous growths.
“In the normal course, we initially give chemotherapy after the necessary investigations or we proceed with surgery depending on the extent and type of cancer,” says Dr Ambulkar. “But here we had to bring the infection under control and could not delay treatment of the wound in her armpit. Even though it looked like the infection may not clear, I didn’t lose hope. Our team stayed positive, and the aim was to treat the wound and get the patient ready for cancer therapy as soon as possible. The cavity was continuously oozing pus, and the nursing team was constantly cleaning the wound and dressing it. We were removing 300–400 ml of pus every day. It took the infection about 10 days to fully heal, as the patient responded well to the medications and daily dressing.”
After that the Tanzanian woman was ready for therapy. It was decided to administer a combination of chemotherapy and targeted therapy for both the lump in the breast and the mass in the armpit. The treatment was done in weekly sessions. Targeted therapy is a type of precision cancer treatment that is able to pinpoint certain genes or enzymes that may be causing the cancer to spread. The precise nature of targeted therapy ensures that the treatment targets cancerous cells and does not cause damage to healthy cells. Through genetic testing and other diagnostic tools, oncologists are able to track the changes in the body that prompt cancer growth and use specific drugs to stop the spread.
Post-chemo
The doctor evaluated her progress after 12 cycles of chemotherapy and the progress was encouraging. “She responded well to the chemo,” says Dr Ambulkar. “By the end of the sessions, her armpit had become near normal, and the damaged skin and tissues were growing back normally. The patient underwent surgery for removal of the rest of the breast lump. Then, we gave radiation therapy for about two weeks. She also got reconstruction surgery for her armpit at our hospital. It’s to her credit that she withstood the treatment well.”
Concerted efforts by Dr Ambulkar and her team and the cancer surgeons for almost eight months ensured the patient was able to beat the odds. Based on the doctor’s advice, she is continuing maintenance therapy in Tanzania. It is now almost two years since the treatment for her cancer was done.
“Necrotic tumours are often difficult to treat and can pose a major challenge to doctors,” she says. “But staying positive and not losing hope is important for both the doctor and the patient. The disease may seem impossible or too advanced to treat and the scenario may look bleak, but that does not mean we give up. We try harder, look for a breakthrough. Because every patient deserves the right treatment.”
