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Egyptian Journal of Surgery Vol 28, No 3, July, 2009
ORIGINAL ARTICLE
TETRACYCLINE SCLEROTHERAPY IN TREATING POSTMASTECTOMY
SEROMA: A SIMPLE SOLUTION FOR A FREQUENTLY OCCURRING
PROBLEM
Emad Hokkam, Sherif Farrag, Soliman El Kammash
Department of General Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
Correspondence to: Emad Hokkam, Email: [email protected]

Aim: Seroma is the most common complication occurring after breast surgery. Its management usually involves repeated
aspiration and drain insertion. Tetracycline sclerotherapy appeared successful for treating many chronic fluid collections
e.g. pleural effusions, hydrocele, liver cysts, renal cysts….etc. The present study aimed to evaluate the efficacy of topical
tetracycline (TCN) sclerotherapy in treating postmastectomy seroma.
Methods: Forty nine female patients with resistant post mastectomy seroma were enrolled in the study. All patients
were subjected to aspiration of the seroma and instillation of 2g tetracycline dissolved in 100 ml sodium chloride 0.9% +
10 ml Lidocaine. After 24 hours, the solution is re-aspirated and a crepe bandage is applied to the chest wall. Each
patient is asked to record her pain using the Visual Analogue Scale (VAS). The procedure is repeated in patients who had
experienced seroma recollection.
Results: Thirty six patients (73.4%) were successfully treated with one sclerotherapy session while nine patients (18.4%)
needed two sessions and four patients (8.2%) needed three sessions. The majority of the patients (85.7%) had no
complications after the technique.
Conclusion: the topical application of tetracycline is effective and feasible method in the management of refractory post
mastectomy seroma.
Keywords: Breast, lymphocele, seromadesis.


INTRODUCTION
a tendency towards less extensive and rather more conservative interventions.(1) Breast cancer is the most common cause of cancer deaths among women worldwide. Incidence rates are high in Seroma formation is the most frequent postoperative more developed countries, whereas, rates in developing complication after breast cancer surgery. Its incidence countries and Japan are low but are lately increasing.(1) In after breast surgery is (15-81%).(3) It occurs in most Egypt, breast cancer is the most common cancer in patients after mastectomy and is increasingly being females constituting 33% of all female cancers.(2) considered as a side effect of surgery rather than a complication, however not all patients are clinically For a long period, surgery was the main line of treatment of breast cancer. Application of new techniques in the treatment of cancer such as radiotherapy, hormonal Seroma is defined as a serous fluid collection that therapy, and chemotherapy allowed better management develops under skin flaps after mastectomy or in the of the advanced cases. Although other therapeutic axillary dead space after axillary dissection (as a modalities competed with surgery in the treatment of the consequence of both, lymphatic disruption and oozing of loco-regional primary tumor, nevertheless, surgery is still the major diagnostic and therapeutic mean, but with Although seroma is not life threatening, it can lead to 3. Patients prepared for reconstructive surgery. significant morbidity e.g. infection, flap necrosis, wound 4. Chronic medical illness (diabetes mellitus, end stage dehiscence, predisposes to sepsis, prolonged recovery renal disease and chronic liver disease). period, multiple physician visits and may delay adjuvant therapy. Fluid collection is ideally managed by repeated Forty nine patients were eligible for the study. All needle aspiration to seal the skin flaps against chest patients were reviewed to evaluate the method, timing, and outcome of TCN sclerotherapy. Indication for sclerotherapy was based on recurrent seroma despite of Several interventions have been reported with the aim of three consecutive sessions of aspiration and crepe reducing seroma formation including the use of bandaging. All sclerotherapy sessions were conducted in ultrasound scissors in performing lymphadenectomy,(7) the one-day operative room using local anaesthesia. The using fibrin glue,(8,9) bovine thrombin application,(10) and technique involves inserting wide bore canula (14 or 16 altering surgical technique to close the dead space.(11) gauge) to aspirate seroma fluid which is calculated and recorded for every patient (Fig. 1). Then, instillation of 2g Despite numerous trials of new techniques which have of TCN in 100 ml of 0.9% of NaCl + 10 ml Lidocaine was attempted to reduce the incidence of seroma formation, done. The instillated amount remains in the cavity for 24 no single method appears to be uniformly effective. hours after which it is aspirated and a crepe bandage is Topical sclerotherapy with Tetracycline (TCN) has long applied to the chest wall. Pain is recorded according the been used successfully in the treatment of malignant Visual Analogue Scale (VAS) which was classified as pleural effusions to cause obliteration of the pleural mild (1-4), moderate (5-6) and severe (7-10). The first report of TCN sclerotherapy for treating seromas after mastectomy was in 1983 by Sitzmann and his colleagues,(13) who instilled 2 g of TCN in 150 ml of 0.9% NaCl following aspiration of seromas in 5 patients. All patients had a marked decrease in the size of seromas within 48 hrs. In the same year Nichter and his team,(14) demonstrated efficacy of TCN in 4 patients with persistent postoperative seromas. Numerous reports described the use of TCN sclerotherapy in a diverse range of conditions. TCN was used in the past for the treatment of malignant pleural effusions,(12) hydroceles of the testes,(15) endometrial cysts,(16) hepatic cysts,(17) pericardial effusions,(18) and even the gallbladder lumen.(19) PATIENTS AND METHODS
Following research committee approval and informed Fig 1. Aspiration of seroma
patient consent, our study was designed as prospective research that was carried on female patients presented with postmastectomy seroma at surgery outpatient VAS is a measurement instrument that tries to measure a clinic, Suez Canal University Hospital in the period characteristic or attitude that is believed to range across a between December 2007 and July 2008. All patients continuum of values and cannot easily be directly fulfilling the following inclusion criteria were enrolled in measured. VAS is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end. The patients mark on the line the point that they feel 1. All females with resistant postmastectomy seroma. represents their perception of their current state. The VAS score is determined by measuring the millimeters Any type of mastectomy operations (modified radical mastectomy, radical mastectomy, simple from the left hand end of the line to the point that the mastectomy and breast conservative technique). All Patients were followed up every 2 weeks for the 4. Any time of presentation (post operatively). development of complications like fever, infection and flap necrosis. Patients, who experienced seroma Patients with the following criteria were excluded from recollection, were subjected to reaspiration of the collected seroma, recording its amount and TCN sclerotherapy. The subsequent sclerotherapy sessions were performed using the same volume and concentration of previously used formula. The sessions were repeated till the seroma disappeared. postoperative chemotherapy; half of them had seroma before starting chemotherapy sessions and the other half Data were collected through history of the surgical operations, clinical examination of the wound and seroma cavity, investigations like ultrasound to measure In the first session; the amount of aspirated fluid was the precise size of the seroma and all details about <100cc in 10 patients (20.4%), 100-150cc in 22 patients sclerotherapy sessions for every patient. Data were (44.9%), and >150cc in 17 patients (34.7%). In the second analyzed by Statistical Package for Social Science (SPSS) session; the amount of aspirated fluid was <100cc in 10 version 13.0. Quantitative data were expressed as mean patients (76.9%), 100-150cc in 3 patients (23.1%), and no and stander deviation (SD), and qualitative data were patients had >150cc. In the third session; the amount of expressed as number & percentage of the total. Student t aspirated fluid was <100cc in 3 patients (75%), 100-150cc test was used to test the significance of the difference in one patient (25%), and no patients had >150cc Table 3. between quantitative variable while chi square test was The mean aspiration volume across all patients in the first session was 120.9±3.6 ml while it was 100.0±25.2 ml and 75.0±35.4 ml in the second and third sessions respectively. The amount of aspirated seroma was significantly decrease in the second and third session The study was conducted on 49 female patients with compared with the first one (t-test, P = 0.006, P = 0.003 mean age 48.5±7.7 years. Modified radical mastectomy was the most frequent operation done to the patients (71.4%), while the frequencies of simple mastectomy and The majority of the patients had no pain during or/and breast conservative technique operations were 18.4% and after instillation (91.8% & 89.8% of the patients 10.2% respectively. The amount of aspirated seroma was respectively), the rest of the patients experienced mild to significantly high in the modified radical mastectomy moderate pain and no patients had severe pain during operations rather than other types of operations (chi or/and after instillation (as assessed by the Visual square test, P<0.05). The relation between the type of the Analogue Scale) Table 4. The majority of the patients had operation and the aspirated fluid in the first session is no complications after instillation (85.7%), 3 patients (6.1%) suffered from low grade fever and 4 patients (8.2%) had infections in the wound site. Five out of the Thirty seven patients (75.5%) presented as early as ≤ 4 seven patients (71.4%) who experienced complications weeks postoperatively, while 12 patients (24.5%) were treated in the outpatient clinic by broad spectrum presented late (> 4 weeks), with the mean time of antibiotics and antipyretics while two patients needed presentation 3.3±0.9 weeks. Thirty six patients (73.4%) hospitalization for treatment with intravenous had only one instillation, 9 patients (18.4%) had 2 antibiotics. All the seven patients who experienced instillations, and 4 patients had 3 instillations (8.2%), complications were subjected to multiple with the mean of 1.3±0.6 instillations. Table 2 correlates aspiration/injection sessions (4 patients had two sessions between amount of aspirated fluid in the first session while 3 patients had three sessions). Complications developed in (53.8%) of patients who underwent multiple aspiration/injection sessions while no patient As regards chemo and radiotherapy, none of the patients (0%) developed complications in the single had history of previous radiation to the affected side aspiration/injection group; it was significantly high in while 5 patients (10%) had received neoadjuvant patients who underwent multiple aspiration/injection chemotherapy. Twelve patients had received Table 1. The relation between the type of the operation and the aspirated fluid in the first session.
Type of operation
Amount/ cc
Modified radical mastectomy
Simple mastectomy
Breast conserving therapy
Table 2. Correlation between amount of aspirated fluid in the first session and number of aspiration/injections.
Number of instillations
Amount/ cc
Table 3. Amount of aspirated fluid in different sessions of injections.
Aspirate fluid
1st session of injection (n=49)
2nd session of injection (n=13)
3rd session of injection (n=4)
* Statistically significant difference versus 1st session value (t-test, p-value < 0.05). Table 4. Severity of pain as measured by visual analogue scale (VAS) among the studied patients during and after
instillation of TCN.
During instillation of TCN
After instillation of TCN
Severity of pain
DISCUSSION
administered topically to the chest wall and skin flaps prior to skin closure. The control group received an Postmastectomy seroma can pose a significant and time- equal volume of normal saline. Patients were monitored consuming problem to the surgeon and often resulting in for the development of postoperative wound seroma repeated out-patient attendance and aspiration.(21) every 2 weeks. There were no significant differences Treatment usually involves needle aspiration or drain between groups regarding total volume of closed suction replacement. The rare patient requires return to the drainage. Seroma formation 2 weeks postoperatively was operating room for excision of the seroma capsule, which greater in the TCN group than the control group (53% vs. 22%, P = 0.01). There were no differences between groups regarding the degree of postoperative pain, The use of sclerosant in the management of seroma is not wound infection, or seroma formation 1 month new. Various agents have been investigated, including postoperatively. They concluded that topical TCN is not marine mussel proteins and the Gram-positive anaerobe effective at preventing post-mastectomy wound seromas. Corynebacterium parvum in rat models.(23) In humans, seromadesis has been reported with erythromycin,(24) The results of our study disagree with that of the povidone iodine,(22) talc(25) and hypertonic saline.(26) The previous study in which TCN was instillated most commonly reported sclerosant in the literature is intraoperatively and in a lower concentration (1g TCN in tetracycline, and there are reports that found it 100cc 0.9% NaCl) which may be low to produce proper useful(13,14,27) and those that did not.(28,29) reaction that enhance tissue adhesion. Also the researchers performed the technique once with no trials Tetracycline sclerotherapy can be administrated in two ways. The first is to administrate it topically to the chest wall and skin flaps prior to skin closure.(28) while the McCarthy et al,(29) designed a randomized controlled second is to aspirate seroma postoperatively and instill trial to study the effect of topical tetracycline on patients tetracycline after its dilution in 0.9% NaCl.(13) The present with post-mastectomy seroma. The trial was aborted as study aimed to evaluate the efficacy of topical TCN he found that tetracycline was painful and not effective. sclerotherapy when used in the second way in treating In the present study, we avoid the development of severe pain by adding 10 cc Lidocaine to the used formula. The results of the current work revealed that the topical We suggest that post operative tetracycline sclerotherapy use of TCN is highly efficient in treating post-operative is a feasible treatment for refractory seroma after seroma as most of the patients (73.4%) responded well to mastectomy. It is effective and without serious this technique from the first session. This result agrees with that obtained by Sitzmann and his colleagues,(13) who treated five patients with seromas following REFERENCES
mastectomy and axillary clearance by aspiration and instillation of a sclerosant solution containing Contesso G, Omar S. Breast Cancer, 4th edition, National tetracycline. He reported that all seromas had resolved Cancer Institute, Cairo University. 2001. promptly without infection, flap necrosis or recurrence. The same was also reported by Nichter and his team,(14) El Bolkainy MN. Topographic Pathology of Cancer. who used the previous technique on only 4 patients, he National Cancer Institute, Cairo University. 2000. stated that tetracycline sclerotherapy provides a rational non-operative alternative treatment and a rapid Woodworth PA, McBoyle MF, Helmer SD, Beamer RL. Seroma formation after breast cancer surgery: resolution of persistent seromas as it is simple and incidence and predicting factors. Am Surg. without major complications. However, these two studies are carried on a small sample of patients. Harris JR, Lippman ME, Morrow M, Osborne C. Diseases Widgerow et al,(27) performed another study on a larger of breast, 3rd edition, Philadelphia; Lippincott Williams & population (69 patients) and he demonstrated the efficacy of tetracycline in tissue adhesion. However, this study was carried in diverse clinical situations involving Pogson CJ, Adwani A, Ebbs SR. Seroma following breast non-healing wounds and seroma-prone areas. cancer surgery. Eur J Surg Oncol. 2003;29:711-7. On the other hand, Rice and his associates,(28) performed Aitken DR, Minton JP. Complications associated with mastectomy. Surg Clin North Am. 1983;63:1331-52. a prospective, randomized, trial to examine the effect of intraoperatively administered topical TCN on the Lumachi F, Brandes AA, Burelli P, Basso SM, Iacobone M, occurrence of postoperative mastectomy seromas. Thirty- Ermani M. Seroma prevention following axillary two women were randomized to the control arm (normal dissection in patients with breast cancer by using saline) and 30 women to the TCN arm. In the treatment ultrasound scissors: a prospective clinical study. Eur J group, TCN solution (1g TCN in 100cc 0.9% NaCl) was Gilly FN, Francois Y, Sayag-Beaujard AC, Glehen O, 19. El-Mufti M. Sclerotherapy of the human gallbladder using Brachet A, Vignal J. Prevention of lymphorrhea by means ethanol and tetracycline hydrochloride. Br J Surg. of fibrin glue after axillary lymphadenectomy in breast cancer: prospective randomized trial. Eur Surg Res. 1998;30:439-43. 20. Hyun MS, Lee JL, Lee KH, Shin SO, Kwon KY, Song HS, et al. Pain and Its Treatment in Patients with Cancer in Jain PK, Sowdi R, Anderson AD, MacFie J. Randomized Korea: Clinical study. Oncology. 2003;3:237-44. clinical trial investigating the use of drains and fibrin sealent following sugery of breast cancer. Br J Surg. 21. Kopelman D, Klemm O, Bahous H, Klein R, Krausz M, Hashmonai M. Postoperative Suction Drainage of the Axilla: for How Long? Prospective Randomised Trial. Eur 10. Burak WE, Goodman PS, Young DC, Farrar WB. Seroma formation following axillary dissection for breast cancer: risk factors and lack of influence of bovine thrombin. J 22. Throckmorton AD, Askegard-Giesmann J, Hoskin TL, Bjarnason H, Donohue JH, Boughey JC, et al. Sclerotherapy for the treatment of postmastectomy 11. McCaul JA, Aslaam A, Spooner RJ, Louden I, Cavanagh T, Purushotham AD. Aetiology of seroma formation in patients undergoing surgery for breast cancer. Breast. 23. Tekin E, Kocdor MA, Saydam S, Bora S, Harmancioglu O. Seroma prevention by using Corynebacterium parvum in a rat mastectomy model. Eur Surg Res. 2001;33:245-8. 12. Hausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusions. Semin Oncol. 1980;12:54-75. 24. Kafali H, Yurtseven S, Atmaca F, Ozardali I. Management of non-neoplastic ovarian cysts with sclerotherapy. Int J 13. Sitzmann JV, Dufresne C, Zuidema GD. The use of sclerotherapy for treatment of postmastectomy wound seromas. Surgery. 1983;11:233-6. 25. Saeb-Parsy K, Athanassoglou V, Benson JR. Talc seromadesis: a novel technique for the treatment of 14. Nichter LS, Morgan RF, Dufresne CR. Rapid mangement chronic seromas following breast surgery. Breast J. of persistent seromas by sclerotherapy. Ann Plast Surg. 26. Gruver DI. Hypertonic saline for treatment of seroma. 15. Breda G, Giunta A, Gherardi L, Xausa D, Silvestre P, Tamai A. Treatment of hydrocele: Randomized prospective study of simple aspiration and sclerotherapy 27. Widgerow AD, Song C, Ritz M, Potgieter E. Wound with tetracycline. Br J Urol. 1992;70:76-77. modulation via sclerotherapy and tissue adhesion. Observations and discussion. S Afr J Surg. 1997;35:88-92. 16. Chang CC, Lee HF, Tsai HD, Lo HY. Sclerotherapy-An adjuvant therapy to endometriosis. Int J Gynaeol Obstet. 28. Rice DC, Morris SM, Sarr MG, Farnell MB, van Heerden JA, Grant CS, et al. Intraoperative topical tetracycline sclerotherapy following mastectomy: a prospective, 17. Davies CW, Mclntyre AS. Treatment of a symptomatic randomized trial. J Surg Oncol. 2000;73:224-7. hepatic cyst by tetracycline hydrochloride instillation sclerosis. Eur J Gastroenterol Hepatol. 1996;8:173-5. 29. McCarthy PM, Martin JK, Wells DC, Welch JS, Ilstrup DM. An aborted, prospective, randomized trial of 18. Celermajer DS, Boyer MJ, Bailey BP, Tattersall M H. sclerotherapy for prolonged drainage after mastectomy. Pericardiocentesis for symptomatic malignant pericardial effusion: A study of 36 patients. Med J Aust. 1991;154:19-22.

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