Hrev_master Emergency Care Journal 2024; volume 20:12016 [Emergency Care Journal 2024; 20:12016] [page 3] Painful burning lesions on the chest wall of a patient with advanced breast cancer Erika Poggiali,1 Etilda Braho,2 Raffaella Bertè3 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Vita-Salute San Raffaele University and Emergency Department, San Raffaele IRCCS Hospital, Milan; 3Palliative Care Unit, Guglielmo da Saliceto Hospital, Piacenza, ItalyRaffaele IRCCS Hospital, Milan, Italy A 90-year-old woman presented at our emergency department complaining of dyspnea (sO2 88% on room air, respiratory rate 24/min) and severe (NRS 8/10) burning chest pain. Ten years earlier, she had undergone a bilateral radical mastectomy and radio-chemotherapy for breast cancer. In September 2023, she developed some nodules on her chest skin treated with elec- trochemotherapy, multiple liver lesions, and a bilateral paraneo- plastic pleural effusion. Question Given the patient’s history, what is the most likely diagnosis? 1. Atopic dermatitis 2. Necrotizing fasciitis 3. Iatrogenic necrotic ulcers 4. Stevens-Johnson syndrome Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523303044. E-mail: poggiali.erika@gmail.com Key words: skin lesions; electrochemotherapy; palliative care; pain management; breast cancer. Contributions: EP and EB collected details of the case, cared for the patient, and drafted the manuscript. RB critically revised the manu- script. All the authors approved the final version to be published. Conflict of interest: EP is a member of the editorial board of Emergency Care Journal. This work was not supported by any grant. The other authors declare no potential conflict of interest. Availability of data and materials: all data underlying the findings are fully available upon reasonable request to the corresponding author. Ethics approval and consent to participate: as this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board guide- lines. Informed consent: the patient provided consent for access to medical records at the time of admission. Received: 21 October 2023. Accepted: 31 October 2023. Early view: 5 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12016 doi:10.4081/ecj.2023.12016 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. Non -co mmerc ial us e o nly Images in Emergency [page 4] [Emergency Care Journal 2024; 20:12016] Answer The patient developed iatrogenic necrotic ulcers after being treated with electrochemotherapy (ECT). ECT is a possible thera- peutic option for primary skin cancer or cutaneous metastases unresponsive to conventional chemo/radiotherapy or unsuitable for surgery, including melanoma, basal cell, and squamous cell carci- noma, Kaposi's sarcoma, and breast cancer.1-3 ECT is based on the local application of pulses of electric current to tumor tissue to ren- der the cell membranes permeable to otherwise impermeant or poorly permeant anticancer drugs, such as bleomycin, allowing for a potent localized cytotoxic effect.4 The first use of ECT with bleomycin in humans was by Mir et al. in 1991.5 All cancer types are sensitive to ECT with bleomycin; however, their anatomic location may preclude the application of an electroporation cur- rent. ECT is generally safe, well-tolerated, repeatable, and associ- ated with brief hospitalization, with a favorable cost-benefit ratio. ECT is nowadays indicated as a palliative treatment in cases of bleeding metastases, or to reduce mass-related symptoms.6 After the administration of the electric pulses, the overlying skin can blanch due to reflex vasoconstriction called “vascular lock” medi- ated by the sympathetic nervous system that occurs across the tumor and immediately nearby tissues for 1 to 2 minutes.7 Because the cytotoxic effects are confined to the region of tumor tissue cov- ered by the electrical field, ECT can cause local pain and ulcers. Considering our patient’s advanced age, the poor prognosis of her relapsed breast cancer, and her severely reduced quality of life due to pain and respiratory discomfort, we discussed the case with pal- liative care colleagues and decided to start IV morphine infusion (20 mg) with an elastomeric pump 24 hours a day with complete control of her suffering and dyspnea.8 The patient was transferred to the hospice and died 72 hours later. References 1. Choromańska A, Szwedowicz U. Electrochemotherapy of melanoma: What we know and what is unexplored? Adv Clin Exp Med 2023;32:5-8. 2. de Bree R, Wessel I. Electrochemotherapy in the head and neck area: an addition to the treatment armamentarium. Curr Opin Otolaryngol Head Neck Surg 2020;28:112-7. 3. Łapińska Z, Saczko J. Novel electroporation-based treatments for breast cancer. Adv Clin Exp Med 2022;31:1183-6. 4. Tasu JP, Tougeron D, Rols MP. Irreversible electroporation and electrochemotherapy in oncology: State of the art. Diagn Interv Imaging 2022;103:499-509. 5. Mir LM, Belehradek M, Domenge C, et al. L'électrochimiothérapie, un nouveau traitement antitumoral: premier essai clinique [Electrochemotherapy, a new antitumor treatment: first clinical trial]. C R Acad Sci III 1991;313:613- 8. [French]. 6. Lebar AM, Sersa G, Kranjc S, et al. Optimisation of pulse parameters in vitro for in vivo electrochemotherapy. Anticancer Res 2002;22:1731-6. Non -co mmerc ial us e o nly