An estimated 1 in 8 women in the U.S. will develop breast cancer in her lifetime. While treatment options have improved and survival rates have dramatically increased, many patients still require invasive surgery, chemotherapy and/or radiation, which can have unpleasant side effects.

As a plastic surgeon who regularly performs breast reconstruction, I have seen first-hand the impact that traditional treatments have on a patient’s body and quality of life. My patients handle these challenges beautifully, but it matters personally to me that breast cancer treatment options continue to improve, and I follow this area of study closely.

One newer treatment option called immunotherapy harnesses a patient’s own immune system to destroy cancer cells—and scientists recently developed a new type of immunotherapy using TILs (tumor-infiltrating lymphocytes), which may have the power to reverse or even cure some of the deadliest forms of cancer.

This article in Forbes reports on a case in which TILs eradicated all tumors in a patient with metastatic breast cancer who had previously been told she would be dead within months. Nearly 2 years after receiving the treatment, the patient is cancer-free.

Immunotherapy using a patient’s own immune cells, called tumor-infiltrating lymphocytes, may have the power to reverse or even cure some of the deadliest forms of cancer.

How does TIL immunotherapy work?

Tumor-infiltrating lymphocytes, or TILs, are immune cells that the body generates to attack tumors. The key is getting the right TILs in a large enough quantity to overpower the cancer and heal the body—the body can’t produce enough of these cells to overtake the tumors on its own.

During this particular type of immunotherapy, doctors extracted TILs from the patient’s own tumors, identified which particular TILs had the right “data” to target the mutated proteins in the cancerous cells, and then grew them in a lab. Once they had enough TILs, they injected them back into the patient, unleashing them on the tumor. At the same time, the patients took medications that prevented the body from interfering with these TILs. It worked.

Could immunotherapy using TILs mean the end of invasive cancer treatments?

One huge benefit of immunotherapy is that it usings the body’s own natural cells to defeat cancer without surgery or toxic chemicals, which dramatically reduces the risk for side effects and adverse reactions. For breast cancer patients, this may be a way to avoid mastectomy.

That TILs may also be able to completely treat metastasized tumors and more aggressive forms of cancer is enormous; should this new immunotherapy option continue to prove effective, patients who previously were considered untreatable may have a new lease on life.

It’s important to keep in mind that while promising, cancer is a moving target, and that makes successful immunotherapy is a very complex endeavor. To work, the TILs have to be able to respond to the specific mutations occurring in a patient’s tumors—and those mutations can change. However, scientists are doing their best to address potential problems as they develop immunotherapy, and large-scale trials are underway to see if TIL immunotherapy proves as successful for other patients as it did for this breast cancer patient.

All in all, I am hopeful that immunotherapy and other less invasive breast cancer treatment options will become more mainstream in the future. As rewarding as it is to help my Fairfax breast reconstruction patients restore their bodies after mastectomy, I would much rather women have an option to beat breast cancer without any surgery at all.

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When Charlotte Ponce was a baby, a pet raccoon attacked her, destroying much of her face and taking her ear.  She has already had her nose, cheek, and upper lip reconstructed. The article reports that Charlotte is especially excited to wear “flashy earrings.”

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Autologous breast reconstruction

Using a national database, researchers assessed trends in breast reconstruction from 1998-2008. The rate of immediate reconstruction after mastectomy rose steadily each year — from about 21 percent to 38 percent by the end of the study.

While the number of breast reconstruction procedures without implants remained relatively unchanged, the rate of reconstructions with implants increased by an average of 11 percent per year.

The rise in reconstructions might be explained by the trend in more women opting for preventive mastectomies, particularly in high-risk cases. Rising awareness and acceptance of the Women’s Health and Cancer Rights Act (WHCRA) of 1998, which ensures coverage for breast reconstruction after mastectomy, was also cited as a contributing factor.

Reconstruction with implant

Determining the reason behind the preference for implants is less obvious. But maybe it’s as simple as the fact that most of the approximately 300,000 women who get breast implants each year are satisfied.

And breast reconstruction with implants after mastectomy is a well-trod, relatively safe and acceptable route to restoring a natural appearance and sense of wholeness.

It’s all about getting back to normal, as quickly as possible.

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“The war led surgeons to attempt ground-breaking procedures, which paved the way for modern plastic surgery,” said Dr. Andrew Bamji, former curator of the Gillies archive.

Named after plastic surgery pioneer Sir Harold Gillies, the archives include medical documentation, paintings, plastic casts, instruments and more.

The artifacts tell a story about war injuries and the surgical techniques that were developed to treat them.

You can read more about Dr. Gillies’ work on Wikipedia:

“The Queen’s Hospital opened in June 1917 and with its convalescent units provided over 1,000 beds. There Gillies and his colleagues developed many techniques of plastic surgery; more than 11,000 operations were performed on over 5,000 men (mostly soldiers with facial injuries, usually from gunshot wounds).”

Photo: Sir Harold Gillies by Simon Harriyott, on Flickr

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During the ASPS meeting in in Denver this year, they were recognized and served as ambassadors for all Patients of Courage nominees. The 2011 honorees are Aaron Mankin, Dee Dee Ricks, Jamie Verdi and Dallas Wiens.

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In nipple-sparing mastectomy, the nipple and surrounding tissues are preserved for use in breast reconstruction, which is generally performed immediately after mastectomy.

From 1989 to 2010, plastic surgeon Scott Spear, MD and colleagues at Georgetown report their hospital’s experience with nipple-sparing mastectomy. They performed 162 nipple-sparing mastectomies in 101 women.

Thirty percent of the operations were performed for treatment of diagnosed breast cancer, while the remaining 70 percent of nipple-sparing mastectomies were performed on women at high risk of breast cancer undergoing preventive mastectomy.

Potential Benefits of the Nipple Sparing Mastectomy

Nipple-sparing mastectomy could offer important benefits for patient satisfaction and body image, as well as fewer procedures and complications. Plastic surgeons have been slow to adopt the technique because of perceived safety risks, especially the concern that the preserved breast tissue might contain cancerous cells. To address these concerns, Dr. Spear and colleagues sought to provide objective data on the risks and outcomes of nipple-sparing mastectomy.

They say that a biopsy is the key to detecting cancer cells. Before breast reconstruction, the doctors analyzed a sample of the tissue from under the nipple. In ten percent of the biopsies of the patients undergoing preventive mastectomy, evidence of breast cancer cells was detected. In these cases, the nipple was not used in breast reconstruction.

In other patients, biopsies detected no evidence of cancer, and the tissues were used for breast reconstruction. At an average follow-up of more than three years, there were no recurrent cancers of the nipple-areola complex in women undergoing therapeutic mastectomy, and no primary cancers in women undergoing preventive mastectomy.

According to the authors, these findings support the previous findings that the long-term risk of cancer developing in the nipple and surrounding tissues after nipple-sparing mastectomy is “zero or near-zero.”

Video: Who’s a Good Candidate for Nipple Sparing Mastectomy?

Surgical oncologist Dr. Richard Gray explains the nipple-sparing mastectomy procedure and which patients may be candidates for this procedure.

Read more

• ASPS: Nipple Sparing Mastectomy Does Not Increase Risk of Breast Cancer Recurrence
• Nipple Sparing Mastectomy an Outstanding Procedure for Some Patients

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According to the American Society of Plastic Surgeons, the results shown in this study “alleviate concerns that immediate reconstruction leads to increased complications” and make a strong argument for immediate breast reconstruction,

Reduced psychological trauma is one of the commonly cited benefits of immediate breast reconstruction, as the patient can go in for mastectomy and come out of surgery with the breast intact. Other benefits include decreased cost and shorter recovery time.

The 10-year study was based on the results of 170 women who had undergone breast reconstruction immediately after mastectomy. 13 of the patients had even undergone bilateral reconstruction to reconstruct both breasts. Surgeons primarily used a TRAM flap technique to compelte the surgery.

To determine if immediate reconstruction was justified, researchers analyzed the following outcomes:

• complication rates
• timing of other cancer treatments
• aesthetic appearance

They found a complication rate of 8.8 percent, which led to delays in further cancer treatments (chemotherapy/radiation) in eight patients. While fifteen patients experienced recurrence of the breast cancer, immediate reconstruction did not delay recognition of these recurrences.

Authors of the study say they hope these results will reassure breast cancer patients and plastic surgeons of the safety and efficacy of immediate breast reconstruction. They argue that it offers a safe and beneficial alternative to delayed breast reconstruction, which can involve waiting weeks or months for surgery.

Read more on plasticsurgery.org

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For patients and consumers, the most pertinent aspects of the document include the “Summary of key findings” and the “Recommendations for Patients Who Have or Who Are Considering Breast Implants.”

Some of the silicone implant safety findings are as follows:

• When used as labeled, silicone implants “have a reasonable assurance of safety and effectiveness.”
• No association has become evident between silicone implants and connective tissue disease, breast cancer, or reproductive problems.
• An MRI is still the recommended method for detecting silicone implant ruptures.
• The longer you have silicone implants (or saline implants), the more likely it is that you will experience a complication or adverse outcome. Choosing breast augmentation or implant-based breast reconstruction means monitoring your implants for a lifetime. “Between 20 to 40 percent of augmentation patients and 40 to 70 percent of reconstruction patients had reoperations during the first 8 to 10 years after they received their implants,” the FDA reports. Although “routine replacement is not necessary,” a revision is necessary for many women.
• Patients who have breast implants have a very small, but increased likelihood of receiving diagnosis of analplastic large cell lymphoma.

The FDA continues to monitor the safety and effectiveness of silicone implants. For updates on the latest findings, visit www.fda.gov/breastimplants.

ASPS Responds to FDA White Paper on Silicone Implant Safety

Today, the American Society of Plastic Surgeons responded to the white paper. An email to member surgeons stated that ASPS

1. Agrees that “silicone gel-filled breast implants have a reasonable assurance of safety and effectiveness when used as labeled,”
2. Accepts the Agency’s position that women who receive silicone gel-filled breast implants for reconstructive or cosmetic purposes will need to monitor the devices over their lifetime.
3. Believes that the FDA white paper is informative and will be a good resource for plastic surgeons and patients
4. Shares the FDA’s view in the white paper that more than 90 percent of patients are satisfied with their outcomes from breast implant surgery.
5. Will continue to collaborate with the FDA to ensure that science forms the basis for all decision-making on breast implants

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“Radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure,” concludes study author Dr. Michaël Veber, of University of Lyon-Léon Bérard Cancer Center in France

An article about this research was published in the March issue of Plastic and Reconstructive Surgery journal.

During fat grafting for breast surgery, a surgeon removes small amounts of fat from one part of the body (such as the hips or thighs via liposuction) and then transfers it to the breasts.

To determine if fat grafting for breast augmentation, what the authors call “lipomodeling,” caused any problems with mammogram screenings for breast cancer, the researchers reviewed mammograms performed 16 months (on average) after lipomodeling in 31 women.

In over half of the cases, the mammograms showed no abnormalities. Some women’s mammograms showed small calcifications or cysts that were thought to be caused by the fat transfer procedure, and a few women had other abnormalities related to scarring from their breast surgery. However, the authors concluded none of these changes were considered likely to raise suspicions of breast cancer on routine mammograms.

In 20 women, researchers evaluated mammograms performed before and after fat transfer. They found no significant differences in the mammographic results from before to after breast surgery. Overall, breast density remained stable over time and “radiographic follow-up was not more difficult after lipomodeling.”

The authors suggest that women undergoing lipomodeling have a complete evaluation — including mammograms — before and after the procedure.

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According to a new study out of Istanbul, Turkey, the role of a plastic surgeon is becoming increasingly important in the ER. The authors looked back on over 10,000 patients who had been admitted for emergency plastic surgery operations at a single Hospital. Factors such as patient age, gender and reason for treatment were evaluated.

According to the study, plastic surgery was most useful in cases of injury to the head, neck, upper extremities, lower extremities and soft tissues.

The authors find that upper extremity injuries were the most common indication for emergency plastic surgery, followed by head/neck injury and lower body injury. They write:

Among the 10,732 cases admitted to our emergency outpatient clinic between 2000 and 2004, upper extremity injuries were present in 64% of the patients. Twenty-five percent of the patients admitted to emergency plastic surgery clinics had head-and-neck injuries, and 37% had tissue defects of the lower extremities and trunk.

The patients, mostly young adult males, were often admitted to the ER because of an accident of some kind. Traffic accidents, burns, glassware cuts and other incidents were among the reasons.

You might assume that an American plastic surgeon working in the ER would have a slightly different focus, but according to the ASPS statistics, the most common emergency treatments look very similar. In 2010, some of the most frequently performed reconstructive surgeries included:

• Laceration repair (355, 601 procedures)
• Dog bite repair (32, 961 procedures)
• Burn Care (19,369 procedures)
• Hand surgery (105, 711 procedures)

You can read the entire study referenced here, “The practice of plastic surgery in emergency trauma surgery” through Pubmed.

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