Abstract P4-06-20: Delivering tumour antigens survivin and mucin-1 on virus-like particles for breast cancer immunotherapy

Breast cancer is the most frequently diagnosed cancer in women worldwide. Although there are a variety of treatment options available, breast cancer is a difficult disease to treat and many patients experience recurrence following treatment. We have previously shown that tumour antigens delivered on virus-like particles (VLP) induce a targeted anti-cancer immune response. In this study we investigated whether combining the two tumour antigens survivin and mucin 1 as vaccine targets can induce a superior anti-cancer immune response for breast cancer immunotherapy. VLP were designed to recombinantly express the murine survivin epitope. Following expression of Survivin-VLP, aberrantly glycosylated mucin 1 (MUC1) peptide was conjugated onto the Survivin-VLP using intracellular cleavable bis-arylhydrazone linking strategy. Western Blot analysis and electron microscopy confirmed Survivin-VLP expression and UV absorption confirmed conjugation of the MUC1 peptide to the Survivin-VLP. C57mg.MUC1 breast cancer cells were injected into the mammary fat pad of C57Bl/6 and MUC1 transgenic mice. Once tumours were palpable, mice were vaccinated with the Survivin-MUC1-VLP and controls of DPBS, VLP without antigen or VLP delivering either survivin or MUC1 antigen. Tumour growth and mouse survival were monitored for 80 days. Mice vaccinated with Survivin-MU1-VLP delivering both antigens showed enhanced survival (D78) compared to mice vaccinated with VLP delivering only one of the antigens (D66) and controls (D53). Delivery of two tumour antigens induced an enhanced anti-tumour immune response compared to delivery of single tumour antigens. The induction of multiple immune responses against different tumour antigens may apply additional evolutionary pressure upon tumours, prolonging the ability for tumours to develop resistance, or escape through the proliferation of a resistant subpopulation. The use of VLP for the delivery of multiple antigens and adjuvants represents a promising approach to improve cancer immunotherapy for breast cancer.

Citation Format: Kramer K, Braeden D, Young VL, Walker GF, Ward VK, Young SL. Delivering tumour antigens survivin and mucin-1 on virus-like particles for breast cancer immunotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-20.

Changes in gene expression in the permissive larval host lightbrown apple moth (Epiphyas postvittana, Tortricidae) in response to EppoNPV (Baculoviridae) infection

Host cell and virus gene expression were measured five days after per os inoculation of 3rd instar lightbrown apple moth (LBAM) larvae with the Epiphyas postvittana nucleopolyhedrovirus (EppoNPV). Microarray analysis identified 84 insect genes that were up-regulated and 18 genes that were down-regulated in virus-infected larvae compared with uninfected larvae. From the 134 viral open reading frames represented on the microarray, 81 genes showed strong expression. Of the 38 functionally identifiable regulated insect genes, 23 coded for proteins that have roles in one of five processes; regulation of transcription and translation, induction of apoptosis, and maintenance of both juvenility and actin cytoskeletal integrity. Of the 34 functionally identifiable viral genes that were most strongly expressed, 12 had functions associated with these five processes, as did a further seven viral genes which were expressed at slightly lower levels. A survey of the LBAM-expressed sequence tag library identified further genes involved in these processes. In total, 135 insect genes and 38 viral genes were analysed by quantitative polymerase chain reaction. Twenty-one insect genes were strongly up-regulated and 31 genes strongly down-regulated. All 38 viral genes examined were highly expressed. These data suggest that induction of apoptosis and regulation of juvenility are the major 'battlegrounds' between virus and insect, with the majority of changes observed representing viral control of insect gene expression. Transcription and translational effects seem to be exerted largely through modulation of mRNA and protein degradation. Examples of attempts by the insect to repel the infection via changes in gene expression within these same processes were, however, also noted. The data also showed the extent to which viral transcription dominated in the infected insects at five days post inoculation.

The effect of cyclic swelling (octamethylcyclotetrasiloxane) on the physical properties of silicone breast implant shells

Changes in the physical and mechanical properties of silica filled silicone elastomeric films were studied as a function of repeated sorption extraction cycling. The sorption of octamethylcyclotetrasiloxane (D4) on the properties of three silicone filled elastomeric films was analyzed. Two of the films, SILASTIC I and SILASTIC II, were shells of explanted breast implants and the third, a calendered film, prepared with similar composition to the elastomer used for the breast prosthesis were studied. The as-received (AR) SILASTIC I and II films contained 20 and 26.5 wt% non-cross-linked material that was removed by extraction with hexane. The failure properties of the extracted films are significantly higher than those of the AR films. The amount of swelling, weight gain, volumetric change, and the stress- and strain-to-fail of the films were measured in the as-received condition, and after a series of extractions and swellings. Repeated cycling (up to 5 cycles) of extraction-swelling had essentially no effect on the failure properties of films when all the diluent was removed. The effect of diluent on the failure properties of all three films was quite large. The stress-to fail of the swollen film was reduced a factor of 6 compared to baseline extracted samples while the corresponding strain values were reduced a factor of 5. The energy to fail of the swollen compared to baseline films was reduced almost a factor of 50. However, the overall mechanical properties of the films are restored when the diluent was removed. The mechanical forces involved in the swelling process do not degrade the polymer even when cycled through five swell-extract cycles.

The transport of octamethylcyclotetrasiloxane (D4) and polydimethylsiloxane (PDMS) in lightly cross-linked silicone rubber

The transport of octamethylcyclotetrasiloxane (D4), one of the major constituents of silicone fluids and rubbers, and low viscosity polydimethylsiloxane oil into a silica filled cross-linked silicone elastomeric rubber was measured as a function of temperature, cross-link density of the rubber, and concentration of the D4 in methanol solution. A small amount of material, approximately 3 wt%, is extracted from the rubber with hexane. The extraction process has a large effect upon D4 solubility in the rubber, increasing from approximately 160 to 180 wt% after extraction. The heats of solution for both penetrants into the rubber are essentially zero and the activation energies for diffusion are small, approximately 8 and 15 kJ molt(-1) for D4 and PDMS, respectively. The diffusion process is Fickian and the diffusion coefficient of D4 into silicone/silica rubbers is essentially independent of concentration over the concentration investigated, i.e. from 1 to 100 vol% D4 in methanol. The permeability, i.e. the product of the diffusion coefficient and the solubility, decreases rapidly for D4 concentrations less than 50 vol% (0.1 mol fraction). This suggests that the permeation of D4 out of any encapsulation device, such as a silicone breast implant, is linearly dependent upon the concentration of D4 in the prosthesis. Swelling is isotropic and was measured by dimensional changes in rectangular samples and correlates well with the volume of D4 sorbed.

Variability in the properties of silicone gel breast implants

Several generations of silicone gel breast implants have been produced by implant manufacturers. The primary material usually viewed as the base material in the manufacture of implants is polydimethylsiloxane. Polymeric reactions are notorious for their variability and nonuniformity. The elastomer used in different types of implants can have vastly different properties. Furthermore, the material properties associated with a particular type of implant can vary considerably from one lot to the next. Considering the various designs, styles, and manufacturing techniques associated with silicone gel implants, knowledge of the original properties of the implants before implantation is important in determining the effects of aging in vivo. This study was conducted to investigate differences in key mechanical and chemical properties of silicone gel breast implant materials. The two types of implants chosen for analysis were Silastic I and Silastic II control implants. Material property data were determined for both types of controls and significant differences were found in their values. Lot-to-lot variability was also investigated and found to be significant.

Scanning electron microscopy characterization of surgical instrument damage to breast implants

In this article, mechanisms of breast-implant failure caused by surgical instruments commonly used to perform implantation, breast biopsies, needle localization procedures, cyst aspirations, and explantation are described. Failure was artificially induced in breast-implant shells using various types of surgical instruments, including scalpels, suture needles, hypodermic needles, hemostats, and Adson forceps. Field-emission scanning electron microscopy (SEM) was used to document the morphology of the failure sites produced by these instruments. Micrographs were used to categorize failure according to a specific type of surgical instrument. SEM micrographs were also obtained on explants that failed in situ, and the morphology of the corresponding failure sites was examined. The study was designed to document a range of failure mechanisms associated with gel-filled, saline-filled, double-lumen (saline-gel), and soybean oil-filled implants. The results of the study also demonstrate that SEM can often be used to determine the cause of breast-implant failure.

Breast implant research: where we have been, where we are, where we need to go

This article summarizes the current state and future needs of research into saline-filled and silicone gel breast implants. The authors describe recent investigations into possible causes and potential risk factors for silicone gel and saline implant failure. Also discussed are local complications of breast implantation and the need for revisional operations in augmentation and reconstruction patients. In addition, the effects that surgical, implant, and patient variables have on the aesthetic outcome of surgery are addressed. The last portion of the article lays out future research needs, such as determining the incidence rate of implant failure, reducing the frequency of revisional surgery, and the difficulty of designing better breast implants in the current strict regulatory climate.

Effect of surgical insertion on the local shell properties of SILASTIC II silicone gel breast implants

The reasons for the failure of silicone gel breast implants are unclear. One potential failure mechanism is the weakening of the implant shell during its insertion into the breast. Such local weakening could eventually lead to implant failure. We recently reported on the effect of implant surgery on the overall mechanical properties of SILASTIC II gel-filled implants. In the earlier study, the mechanical properties of 34 Dow Corning SILASTIC II gel-filled breast implants from the same manufacturing lot were measured. Twenty of the thirty four implants were not implanted but were evaluated to establish a baseline of control data. The other fourteen lot-matched implants were inserted into a subglandular pocket through an inframammary incision in a cadaver breast and then removed. The experimental augmentation scenario was designed to represent actual breast implantation as closely as possible. The mechanical properties of the anterior and posterior sides of the control implants (not implanted) and explants (implanted in a cadaver) were measured and compared to determine whether differences existed between the explant and control groups. We found that the implantation surgery process did slightly reduce the average tensile strength. Although not as statistically significant, other mechanical properties such as breaking energy and moduli were less for the explants than the controls. The reduction was a relatively small percentage in the context of overall shell properties. Elongation and tear resistance were unaffected. Our findings suggested that the surgical act of implanting a breast implant has a small but detectable weakening effect on the average tensile strength, breaking energy and moduli of the elastomeric shell of the device. The present study is an extension of the previous investigation. Here we have analyzed the explant shell region where the surgeon's fingers forced the implant through the incision. Our results indicate that the implant shell can be locally damaged due to the implantation process.

Analysis of periprosthetic capsular tissue from women with silicone breast implants by magic-angle spinning NMR

The amount of silicone (polydimethylsiloxane [PDMS]) in capsular tissue surgically removed from women with breast implants was measured by using (29)Si and (1)H magic-angle spinning solid-state NMR spectroscopy. Twelve women having smooth surface silicone gel-filled implants, including a subject with "low-bleed" double-lumen implants, had detectable levels of PDMS ranging from 0. 05 to 9.8% silicon in wet tissue (w/w). No silicon-containing compounds other than PDMS were detected. No correlation was found between the amount of PDMS measured in the capsular tissue and the length of implantation time (Pearson correlation coefficient, r = 0. 22). The results showed no relationship between higher amounts of PDMS and capsular contracture (p = 0.74) or other symptoms (p = 0. 53). Magn Reson Med 42:436-441, 1999.

Silicone gel-filled breast and testicular implant capsules: a histologic and immunophenotypic study

The immunophenotypic characteristics of silicone gel-filled breast and testicular implant capsules have not been well described. Therefore, we studied 17 paraffin-embedded tissue sections from 9 breast implant patients and 1 testicular implant patient to assess the type and extent of inflammatory responses present. Immunohistochemical analyses were performed on paraffin-embedded tissue sections for expression of CD20, CD45RO, betaF1, CD68, CD44, kappa and A immunoglobulin light chains, and bcl-XL (a member of the bcl-2 family of proteins involved in apoptosis). The most common histologic features included prominent T-cell and foamy macrophage reactions with foreign body giant cells and granulomas in a dense fibrovascular connective tissue. Foci of polyclonal plasma cells and acute inflammatory cells were variably present. In one case, there was reactive germinal center formation, a novel finding. A "pseudosynovium" at the implant capsule interface was present in the majority of cases as previously described; it showed reactivity with CD68. Thin strands of highly refractile, nonpolarizable material, consistent with silicone, were regularly noted in intra- and extracellular locations. The immunohistochemical results included reactivity of the majority of lymphocytes with CD45RO and/or betaF1 (confirming an anamnestic reactive T-cell phenotype), and reactivity of the macrophages, giant cells, and "pseudosynovium" with the macrophage/histiocyte marker, CD68. The reactive germinal centers were positive for CD20. Reactivity for CD44, an activation and intracellular adhesion marker, was frequently observed in the foamy macrophages and foreign body giant cells and has not been previously reported. The plasma cells demonstrated polyclonal immunoglobulin light-chain reactivity, consistent with a reactive process. These findings suggest that silicone implants induce chronic inflammatory responses in many adjacent capsules, which consist of anamnestically responding T cells, reactive B-lymphocytes, and macrophages.

Report from the conference on ultrasound-assisted liposuction safety and effects

The authors report on the Ultrasound-Assisted Liposuction (UAL) Safety and Effects conference held in St. Louis, Missouri, in November 1998. The meeting was convened to discuss how internal UAL works (its physics and mechanisms of action), gain a basic knowledge of the interaction between acoustic energy and tissue, identify safety concerns potentially related to thermal effects and free radical production, and define future research questions. Those attending represented multiple scientific disciplines: plastic surgery, physics, lipid chemistry, cancer biology, and medical biophysics. Participants agreed that scientists do not yet understand the mechanisms of UAL action, although multiple mechanisms are probably involved, such as mechanical forces, cavitation, and thermal effects. Additional research has revealed that long-term complications or negative bioeffects--including DNA damage and oxidation-free radical attack--are probably not serious safety concerns with UAL. Several areas deserving future investigation were proposed.

Vilray P. Blair, his surgical descendants, and their roles in plastic surgical development

Perhaps one of the most historically well-known plastic surgeons is Vilray P. Blair. As commander of the U.S. Army corps of head and neck surgeons during World War I, he became well known for his work in posttraumatic reconstruction. Blair's efforts in the early part of this century helped to develop plastic surgery as a distinct surgical subspecialty in the United States. His prowess as a surgeon allowed him to build one of the largest plastic surgery centers in the country and to train many of the top young American surgeons. Blair excelled as a teacher. He produced academic surgeons such as James Barrett Brown and Bradford Cannon, who took the lead in the care of wartime injuries during World War II. At Valley Forge General Hospital, Blair's trainees dedicated themselves to the reconstruction of injured patients and trained other young plastic surgeons in the care of postwar trauma. This exceptional level of patient care resulted in the U.S. government recognizing plastic surgery as a subspecialty following World War II. Since that time, Blair's surgical descendants at Washington University have led the country in the development of new training concepts and ideals and have gone on to become leaders in plastic surgery worldwide.

Factors associated with breast implant rupture: pilot of a retrospective analysis

This pilot study's goal was to test the feasibility of a data collection form which will be used in a scale-up study analyzing multiple surgeons' records. The goal of this expanded study will be to develop identifying factors for women who are at greater risk for having ruptured implants and, if necessary, target them for screening, surveillance, or intervention. In the pilot study, we compared factors associated with implant rupture in women with and without rupture. Similar studies have considered one or a few factors at a time and, generally, have given little attention to implant generation. We developed a data collection form after reviewing records of three surgeons. A total of 92 records was collected and analyzed. An important feature in the pilot was to compare the results of patients whose implants the surgeons had both implanted and explanted (n = 34) with those of patients whose implants the surgeons had only explanted (n = 55) (unknown = 3). This comparison could show if including all explantation patients in a surgeon's practice would bias the sample; however, based on this pilot data, concerns regarding this type of bias seem to be minimal. Similar amounts of data (e.g., implant information, history of capsular contracture, etc.) were collectable on patients whose surgeons both implanted and explanted them (87%) and who had different surgeons for implantation and explantation (84%). Though the data from this limited sample cannot offer firm conclusions on rupture associations, a few factors stood out: size of implants (38. 3% of ruptured versus 15.9% of intact implants were 100-200 cm3), history of mammography (46.8% of ruptured versus 24.4% of intact had mammograms, which is likely due to older women with older implants having more mammograms), and history of closed capsulotomy (85.1% of ruptured versus 68.9% of intact). Interestingly, additional procedures performed on the breast (e.g., scar revision, wound repair, etc.) did not affect rupture: both the ruptured and the intact groups had an average of 1.7 procedures performed. The data collection form tested very well in this pilot study. Also, including all patients in the study sample, instead of excluding those who received their implants elsewhere, did not change the results. Though there are not enough data to draw any firm conclusions regarding rupture factors, the collection instrument was rigorously tested and should perform well in an expanded study.

A review of the literature on the etiology of capsular contracture and a pilot study to determine the outcome of capsular contracture interventions

The etiology of capsular contracture is unclear and probably multifactorial. This review covers the literature on several proposed contracture factors, including filler material, implant placement, surface texture, and bacterial infection. The pilot study's goal was to test the feasibility of a data collection form, which could be used in a scaled-up study analyzing multiple surgeon's records. The goal of the expanded version of this study will be to determine the efficacy of available interventions for capsular contracture, including surveillance. The Breast Implant Public Health Project, LLC (BIPHP), piloted a retrospective review of outcomes in women who had interventions to relieve capsular contracture or had chosen a wait-and-watch approach. An evaluation of the efficacy of various treatments can help women decide if they want to pursue treatment at all and, if so, which treatment might offer them the best solution. BIPHP researchers (E.E.A., M.E.) developed a data collection form after reviewing records of three surgeons (B.C., W.P., V.L.Y.). During the data collection using the same records, we tested a randomization process to identify women with capsular contracture who underwent various interventions, including a wait-and-watch strategy, and those who had no mention of any intervention or waiting approach. Data were gathered on a total of 90 breasts with capsular contracture (scored Baker I-IV or qualitatively), of which 45 underwent a total of 102 interventions for capsular contracture. Interventions were classified as "closed capsulotomy," "surgical," or "watchful waiting." Closed capsulotomy was performed most often (47%), followed by surgery (29%) and watchful waiting (21%). Presurgical Baker scores averaged higher in breasts that underwent surgery (3.1) than for watchful waiting (2.5) or closed capsulotomy (2.3). Though closed capsulotomies had 100% of outcomes scoring "improved" or "same," 58% of the breasts underwent the procedure more than once, suggesting that the favorable outcome was short-lived. The wait-and-watch approach resulted in scores of either "same" or "worse"; surgery (open capsulotomy, repositioning, or capsulectomy) resulted in 79% improved, 16% same, and 5% worse outcomes in breasts with outcomes listed. In all intervention procedure categories, outcomes were frequently unavailable; they were noted only 60% of the time (52/87). The missing 40% may have resulted from the doctor's failure to note it in the chart, satisfied patients not returning for additional treatment, or dissatisfied patients seeking treatment elsewhere. Generally, the data collection forms and procedures were workable; however, we uncovered issues to address in the scale-up of this pilot study: (1) the outcome report rate was 60%; (2) though Baker scores are commonly used to evaluate the degree of capsular contracture, it seems that grade I may have different meanings for different surgeons, which would need to be clarified; (3) participating surgeons will need to divulge standard-of-care items that they may not have included in medical records, but routinely performed (e.g., patient massage, use of prophylactic antibiotics); and (4) records were initially separated by "implant," then researchers realized that a more useful collection would be by "breast." The latter approach captures the history of the breast in one record, which may be more important to contracture than the differences in implants. With the modifications discussed, the study can be scaled up to encompass as many records as necessary to achieve robust statistical power. These data will add to the existing literature regarding factors associated with capsular contracture and identify factors that affect the successful outcome of capsular contracture interventions.

Analysis of breast implant capsular tissue for crystalline silica and other refractile phases

This study questions previous reports of the presence of micrometer-sized areas of crystalline silica in pathologic tissue sections that are based exclusively on polarized-light microscopy. By using optical principles, it can be argued that it is impossible to identify unambiguously or to detect the birefringence of crystalline silica in 5-microm-thin sections. To clarify whether silicone, amorphous silica, or crystalline silica occurs in micrometer-sized moieties in standard 5-microm-thick tissue sections, one needs to apply a structural means of analysis in addition to optical microscopy. This study recommends the use of the laser Raman spectroscopic technique, which is very well suited to clarify this highly controversial issue in future pathologic studies.

Elemental analysis and clinical implications of calcification deposits associated with silicone breast implants

Calcification of the fibrous capsule surrounding silicone breast implants is a well-recognized occurrence that increases with time following implantation. These mineralized deposits potentially confound mammographic breast cancer surveillance already made difficult by the obscuring effects of silicone breast implants. The authors performed elemental analysis of silicone breast implant-associated calcifications to define better their chemical composition as related to mammographic and clinical significance. Electron probe microanalysis and infrared spectroscopy revealed all of the calcification deposits to be calcium complexed with tribasic phosphate. No evidence of calcium oxalate, calcium carbonate, silicone, or talc was observed. Caution must be employed in interpreting mammograms in women with silicone breast implants as well as those who have had their silicone breast implants removed. High-density mammographic calcifications indicative of calcium phosphate associated with a silicone breast implant may represent an accepted consequence of implantation or nearby carcinoma. We recommend baseline mammography on women who have had their silicone breast implants removed to prevent unnecessary fine-needle aspiration or tissue biopsy of retained breast capsule calcifications during subsequent routine surveillance for carcinoma.

Guidelines and indications for breast implant capsulectomy

This article discusses indications for performing a capsulectomy in conjunction with explantation of breast implants. This issue has rarely been addressed in the literature, and there is no consensus on guidelines to assist surgeons in deciding whether a capsulectomy is warranted. The many factors that must be weighed when considering performance of a capsulectomy are outlined, and recommendations for the explantation contexts in which capsulectomy may be considered optional or should usually be performed are given. Capsulectomy may be indicated in the majority of instances when breast implants are removed or exchanged, but the potential risks of capsule removal must always be balanced against the potential benefits.

Long-term results of total penile reconstruction with a prefabricated lateral arm free flap

PURPOSE

We present 5-year followup results of patients who underwent total penile reconstruction with a prefabricated lateral arm free flap technique.

MATERIALS AND METHODS

We treated 3 female-to-male transsexuals and a man with penile amputation with a 2-stage technique of total penile reconstruction. In the first stage the neourethra is constructed as a tubed skin graft incorporated in the territory of the lateral arm flap. Three to 6 months later the lateral arm flap with its well epithelialized conduit is fashioned into a penis, an inflatable prosthesis is incorporated and the construction is transferred to the pubis with vascular, urethral and nerve repairs.

RESULTS

In addition to the 2 surgical procedures required to construct the penis, the patients have required an average of 3 revisions. There were no complications beyond the first year postoperatively. All 4 patients are able to void in the standing position and are free of fistulas or strictures. The inflatable prosthesis allows them to achieve penetration during sexual intercourse. All reconstructed penises have recovered erogenous and tactile sensibility. Patient satisfaction with the reconstructed penis is high. All transsexuals are married and fully integrated as men.

CONCLUSIONS

With the prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction. To our knowledge our series represents the first report of a technique for functional penile reconstruction with at least 5 years of followup.

Mammographic visualization of a nonpalpable breast mass through a radiolucent breast implant

We report a woman who underwent augmentation mammaplasty as part of a clinical trial of the Trilucent (soybean oil-filled) breast implant in Genoa, Italy. Five months after surgery a mammography was performed in response to the patient's complaints of pressure and tightness in the area of her left breast. The mammogram clearly demonstrated a 5-mm fibroadenoma of the left breast. This is the first documented case of a nonpalpable breast lesion that was detected by mammography through the new radiolucent, triglyceride-filled implant.

Microbial growth inside saline-filled breast implants

In vitro and in vivo experiments were conducted to determine whether intraluminal saline in breast implants can support the growth of common wound-infecting microorganisms over a prolonged period of time. The bacteria tested were Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Corynebacterium jeikeium, Enterobacter cloacae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Three fungal species also were tested: Aspergillus fumigatus, Paecilomyces variotii, and Candida albicans. In the in vitro study, four organisms survived in flasks of sterile saline for the 2 weeks in which serial cultures were performed: K. pneumoniae, C. albicans, A. fumigatus, and P. variotii. In the in vivo study, 61 white rabbits (122 implants) received both an experimental implant inoculated with one of the test organisms and a control implant containing only sterile saline. They were sacrificed at 1-, 3-, or 6-month scheduled endpoints. None of the control implants containing sterile saline had positive cultures. In contrast, the intraluminal saline was culture positive for 7 of the 10 inoculated organisms after varying lengths of time: S. epidermidis, E. coli, E. cloacae, K. pneumoniae, P. aeruginosa, A. fumigatus, and P. variotii. Samples of capsular tissue also were cultured. Of the 122 capsular tissue specimens, 21 (17 percent) had positive cultures and surrounded both inoculated and sterile implants. In most instances, capsules that were culture positive contained an organism different from the one that had been inoculated in the group. In only 3 cases was the same organism cultured from both the periprosthetic tissue and the intraluminal saline, and these may represent instances of the inoculated organism migrating through the implants filler valves. The data show that several types of bacteria (particularly gram-negative species) and fungi can grow and reproduce in a restricted saline environment for extended periods of time.

Development of alternative breast implant filler material: criteria and horizons

The introduction of the silicone gel-filled breast implant more than 30 years ago changed the nature of alloplastic breast augmentation and reconstruction. Over the last three decades, it is estimated that one million American women have undergone implantation with some variation of these devices. Recent medical, legal, and regulatory developments have forced a moratorium on the unrestricted uses of the silicone gel-filled implants, and it appears unlikely that its general use will return. However, there is a continued need for some type of breast implant in both aesthetic and reconstructive surgery. The Food and Drug Administration has proposed testing guidelines for the development of any new breast implant before unrestricted clinical use. These guidelines will direct the creation of new filler materials from their earliest stages, through long-term postimplantation follow-up studies. This article succinctly examines the central issues in the breast implant controversy in relation to the FDA's recommendations for the development of new implants, discusses breast implant filler materials currently under development, and offers guidelines fro the development of breast implant fillers that are safe and effective.

Evaluation of the patient presenting with a painful wrist

Wrist pain secondary to injury or disease is a common cause of morbidity and disability. The results of treatment are influenced strongly by promptly determining a correct diagnosis. We have found that a systematic, structured approach consisting of a detailed history and a thorough physical examination supplemented by the proper use of a variety of imaging modalities will establish accurately the diagnosis in almost all patients. Using such an algorithmic approach can greatly minimize medical costs and time lost from work as well as assist the surgeon in diagnosing the cause of wrist pain as quickly as possible. Even when this type of systematic approach is used in the evaluation of patients presenting with wrist pain, it is important for surgeons to remember that several imaging modalities, such as bone scans and arthrography, frequently demonstrate abnormal or atypical findings for which no pathologic correlate exists. If a firm diagnosis cannot be made even after a positive test result, it is unwise to perform surgery based solely on the findings of a test in the hope that wrist pain will thereby be relieved. In such cases, a trial of immobilization for 3 weeks is perhaps the best and most cost-effective way to verify that the pain is caused by an actual bone or joint abnormality that will respond to surgery.

Cumulative trauma disorders

The relationship between work activities and the diagnostic entities discussed in this article is poorly understood, but their development is probably multifactorial. The enormous cost to industry and society is driving many investigators to study the causes and pathologic manifestations of CTDs, and this research should lead to improved strategies for treating and preventing work-related injuries. Prevention, however, will work only if both management and labor participate in preventive efforts. When a task force approach can be implemented and senior management gives it the power to make effective changes, CTDs often can be reduced dramatically, as has been shown in numerous studies illustrating the success of this approach. It is unfortunate that many in senior management are reluctant to permit such task forces due to fear of increased injury claims. Our worry is that, in the end, the solution to problems believed to be associated with repetitive trauma at work may be shaped more by regulatory bodies and attorneys rather than scientists. Hand surgeons, who see patients with complaints that are perceived to be work related, often find themselves in the middle of this complicated problem, being asked to determine whether a patient's symptoms are caused by the performance of job tasks. To treat our patients with hand and wrist symptoms, we must stay abreast of the current understanding of CTDs and be familiar with the diagnosis and management of recognized disease entities such as those reviewed in this article. In most cases, a diagnosis of a specific clinical condition can be established that is based on strict criteria. If this is not possible and the picture is unclear, it is important not to guess at a diagnosis. Labeling a patient with a diagnosis such as thoracic outlet syndrome or nonspecific tendonitis without clear-cut and objective clinical signs can have lasting economic and employment consequences. For this reason, diagnosis of a specific clinical entity should be made only when the findings of the history, physical examination, and ancillary tests firmly support it.

Bleed of and biologic response to triglyceride filler used in radiolucent breast implants

Radiolucent breast implants filled with triglyceride oil have recently entered limited clinical trials. To investigate the questions of oil bleed and the fate of triglycerides that might escape from ruptured breast implants, experiments reported here used peanut oil labeled with radioisotopes so that it could be traced in the urine, feces, and organs of two groups of rabbits. In one experiment, 18 rabbits were implanted with peanut oil-filled implants labeled with tritium to determine whether triglycerides diffuse across silicone elastomer shells. In another experiment, 19 rabbits were injected with 14C-labeled peanut oil to study what might happen to the oil if an implant ruptures. At the end of the follow-up period, we measured radioisotope levels in tissue samples taken from the periprosthetic capsule or injection site of each rabbit, as well as from major organs and the subcutaneous fat on the dorsum opposite the experimental site. One experiment revealed that triglycerides do bleed across the implant shells. Tritium levels were highest in the implant capsule, the omentum, the aorta, and the subcutaneous fat on the nonexperimental side. In the experiment simulating implant rupture, 14C levels were above the background radiation count at the injection site and in the same tissue sites as in the bleed experiment. Both in vivo radiolabeling studies indicate that triglycerides freed from implants by means of bleed or rupture would be absorbed, metabolized, and either excreted or redistributed to the body's normal fat storage sites if they are not needed for energy. In a third in vitro experiment, triglyceride oil specimens were inoculated with various microorganisms associated with wound infections: Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Staphylococcus epidermidis, and diphtheroids. The data demonstrate that neutral triglycerides used as a breast implant filler do not support growth of common infection-producing bacteria and suggest that triglycerides may have bactericidal properties.

Chemical, physical and mechanical analysis of explanted breast implants

The chemical and biomechanical properties of explanted implants whose time of implantation ranged from zero to 21 years were measured. The properties appear to decrease with time. However it is important to note that proper controls have yet to be tested. The consistency of the gel varied considerably with manufacturer and date of manufacture. The data will be correlated with control samples when they become available. The data are consistent with the hypothesis that in some instances, the gel does affect the cross-linking, i.e., strength, of the silicone rubber shell. At the present time only a limited number of samples have been tested in this on-going program. One of our major objectives, to determine the influence of the physiological environment of the human body on the durability of the silicone implant, has yet to be quantified.

HLA typing in women with breast implants

Since the 1970s, anecdotal reports have described a relatively small number of women who received silicone gel breast implants and later developed either a recognized rheumatologic disease or unexplained symptoms suggestive of an autoimmune disorder. The study reported here examined whether there is any association between the symptoms seen in implant patients and HLA molecules. One-hundred and ninety-nine subjects were evaluated by HLA typing: symptomatic patients with implants (group I, n = 77), asymptomatic women with implants (group II, n = 37), healthy female volunteers without implants (group III, n = 54), and fibromyalgia patients without implants (group IV, n = 31). A statistically significant 68 percent of group I were positive for HLA-DR53, compared with 35 percent of group II and 52 percent of group III. The fibromyalgia patients were strikingly similar to group I women in terms of HLA-DR molecules, with 65 percent of group IV being positive for DR53. Group I also had a statistically significant increased frequency of HLA-DQ2. Asymptomatic women with implants (group II) had an increased frequency of DR1 and DQ1. In addition, 42 percent of symptomatic patients with implants formed autoantibodies to their own B cells; of these, 81 percent were DR53-positive. Although frequencies of capsular contracture and implant rupture were not significantly different in the two groups with implants, there were statistically significant associations in group I between contractures and ruptures and the presence of DR53 and B-cell autoantibodies. These data suggest that symptomatic patients with implants share important genetic characteristics (primarily HLA-DR53 positivity) that differentiate them from their asymptomatic counterparts. DR53 may be a marker of women who are predisposed by their HLA genotype to develop symptoms following exposure to silicone gel breast implants.

Paecilomyces variotii contamination in the lumen of a saline-filled breast implant

This report describes a case of gross contamination with the filamentous fungus P. variotii cultured from an intraluminal saline breast implant removed from a patient 14 months after implantation because of severe capsular contracture. We suspect the fungal contamination occurred when a container of saline was left open in the operating room prior to filling and placement of the implant. This case may be the first documented report of microbial growth and reproduction in the internal environment of a saline implant. We assume that organisms such as P. variotii can survive--and accumulate biomass--on the minute amounts of substrates that diffuse across an implant envelope.

Effects of work and rest on upper extremity signs and symptoms of workers performing repetitive tasks

The temporal relationship between work and signs and symptoms of upper extremity musculoskeletal disorders among workers at risk is relatively unexplored. The study focused on changes in upper extremity circumference, volume, sensory threshold, and reported symptoms after work and rest. All workers (N=50) performed a repetitive poultry processing task and had exhibited upper extremity signs and symptoms in baseline testing prior to this study. These workers manifested significantly increased upper extremity circumference following a period of rest, with circumferences decreasing during work. Upper extremity volume and reported swelling also decreased during work. Reports of tenderness were significantly greater after work than after rest, while reports of pain were greatest after a short rest interval. Results show that the signs and symptoms observed in these workers were manifestations of occupational cumulative trauma and that further study of the relationship between work and signs and symptoms is needed.

Early active mobilization for flexor tendons repaired using the double loop locking suture technique

Current suture techniques limit the postoperative management for flexor tendons. A double loop locking suture (DOLLS) technique has been described that provides sufficient in vitro strength (average 4,400 g) for early active mobilization of the flexor tendon. This paper details four cases in which the flexor digitorum profundus (FDP) tendons were repaired using the DOLLS technique. Early active mobilization was initiated 3 to 7 days postoperatively. Results were classified according to Strickland's formula. Two patients achieved excellent results, one a good result, and one a fair result. One rupture of a flexor digitorum superficialis (FDS) tendon, which had been repaired with a modified Kessler technique, occurred. Although this FDS tendon ruptured, the FDP tendon, which had been repaired with the DOLLS technique, remained intact. With the use of a protective splint, early active mobilization of tendons repaired by the DOLLS technique appears to be an effective method for postoperative management.

Facial reconstruction with prefabricated induced expanded (PIE) supraclavicular skin flaps

The prefabricated induced expanded (PIE) supraclavicular flap refers to the staged transfer of an expanded supraclavicular skin with a fascia flap used as the carrier. In three patients, we utilized PIE supraclavicular flaps to successfully reconstruct a total forehead and two major nasal defects. Our first PIE flap confirmed the feasibility of the method but necessitated two microvascular free flaps. In the ensuing two patients, we reduced the need for microvascular anastomoses by using simple pedicled flap transfers in either or both stages. Whenever feasible, the preferred method consists of transferring a temporoparietal fascia flap to a subcutaneous pocket in the ipsilateral supraclavicular fossa and simultaneously placing a skin expander under both the fascia flap and the supraclavicular skin. After adequate expansion, the fascia becomes incorporated within the capsule of the expander, and the composite capsulofasciocutaneous flap can be safely transferred to the facial defect as the PIE flap. These patients show that supraclavicular PIE flaps can provide ample amounts of vascularized cutaneous tissue for the reconstruction of major facial defects. The necessary tissue is generated by expanding the most desirable tissue type available, and a selected vascular pedicle is induced to perfuse and carry that generated tissue. Compared with conventional expansion and adjacent flap transfers, PIE flaps allow the transfer of expanded skin to distant sites as island or free flaps perfused by the induced vascular pedicles.

Detecting cumulative trauma disorders in workers performing repetitive tasks

On-site testing of 157 poultry processors disclosed that 50% had three or more abnormal upper extremity findings out of a total of 22 possibles. The average worker had five to six abnormal findings. Impaired pinch strength, decreased vibration sensitivity in the fingertips, and reports of current numbness were the most prevalent. Of workers with signs, 25% reported no symptoms, whereas only 8% of workers reported symptoms but had no signs. The investigators concluded that this measurement method has utility for assessments of worker populations to determine prevalence of CTDs and, potentially, for preclinical detection of these disorders to permit early intervention, reduce medical costs, and minimize disability. The need for accurate measurement to enhance early detection and prevention is discussed.

The efficacy of breast augmentation: breast size increase, patient satisfaction, and psychological effects

In this study designed to quantify the degree of breast enlargement produced by augmentation mammaplasty, 112 women who underwent breast augmentation were interviewed. The size increase that typically resulted from various implant volumes was measured by comparing preoperative and postoperative bra sizes. For the study group as a whole, the average increase was two bra sizes (either increased cup size or a combination of increased cup size and chest circumference), regardless of the implant volume inserted. Patients also were asked a series of questions to evaluate the impact of the surgery on various psychological parameters, including body image, feelings of self-confidence, and interpersonal relationships. Along with having a very positive body image, the group reported decreased self-consciousness (86 percent) and heightened self-confidence (88 percent); in addition, 95 percent said they felt better about themselves after surgery. The women's satisfaction with the results of augmentation and the success of surgery in meeting their expectations also were measured. Eighty-six percent reported being completely or mostly satisfied with the postoperative results, 86 percent felt the operation was a complete success, and 95 percent said that augmentation met their expectations.

Quantification of facial surface change using a structured light scanner

Three-dimensional surface changes that accompany facial surgical procedures were measured noninvasively and evaluated quantitatively. An optical three-dimensional surface scanner with 360-degree surface coverage of a subject's head and a subsecond data acquisition was used. The scanner employs six pairs of "white light" pattern projectors and digital TV cameras. A noncontact optical method to quantify facial surface morphology and objectively assess change resulting from reconstructive or cosmetic plastic surgery has been developed. This quantification technique was implemented and tested with the three-dimensional range scanner. This technique defines the entire surface of the head and face, as opposed to the conventional manual method of measuring surface points or facial landmarks. The method allows facial volume change assessment. The method was tested by repeatedly scanning a volunteer who was injected subcutaneously with known volumes of anesthetic solution. The measured and injected volumes were compared and showed little difference.

Diagnosis and treatment of accessory parotid gland masses

Accessory parotid glands are true parotid tissue lying distinctly separate from the parotid gland proper. They lie along and drain into Stensen's duct. Although literature describing the accessory parotid gland is limited, its anatomy and pathology have been described. Controversies exist in the literature regarding the diagnosis and management of pathological changes seen in these glands. We have found magnetic resonance imaging to be extremely helpful in their diagnosis and treatment. A review of the literature and an illustrative example are presented.

The impact of compliance on the rehabilitation of patients with mallet finger injuries

While patient compliance with hand therapy intuitively seems important to the outcome of treatment, no formal study has validated this assumption. The records of 44 patients who sustained mallet finger injuries were examined retrospectively. Compliance ratings were based on self-reports of performance with home programs and attendance at therapy appointments. Results of therapy were divided into excellent, good, or poor groups depending on the patient's final range of motion and final active extension lag at the distal interphalangeal joint. Statistical analysis reveals that compliant patients have excellent outcomes more often than do noncompliant patients (61.5% and 9.1%, respectively) in the treatment for mallet finger injuries. While increased age may negatively affect the final result of mallet finger injuries, an older individual can favorably influence his or her result by choosing to be compliant with treatment. Even patients who delay initiation of treatment can achieve favorable results.

Giant lipomas of the hand and forearm

Giant lipomas of the upper extremity are infrequently reported. They can alter function by restricting motion or producing compressive neuropathies. This report of four cases of giant lipoma in the hand and forearm illustrates these functional losses. The role of MRI and CT in preoperative evaluation of these lesions is discussed and a report of an anterior interosseous syndrome caused by a giant lipoma is presented.

How safe are silicone breast implants?

The Food and Drug Administration's recent decision to limit the use of silicone gel breast implants was surrounded by a great deal of misleading information in the popular press. This article outlines the most relevant information available in the literature on the most often raised safety issues, including the carcinogenicity of silicone, speculation on a possible connection between silicone and autoimmune disease, the significance of gel bleed, and the effect of implants on mammography. In this attempt to better educate primary care physicians, we explain what is known about silicone gel breast implants so physicians can more wisely counsel their patients, who may be needlessly frightened by inaccuracies they have heard.

Age-related differences in measures of upper extremity impairment

BACKGROUND

Upper extremity cumulative trauma disorders (CTDs) are among the most prevalent and costly occupational injuries. These disorders include nerve compression syndromes, tenosynovitis, epicondylitis, tendinitis, and arthritis. These have been related in the past to repetitive use of the upper extremity. The expected increase in the age of the American work force and the assumption that older workers are more susceptible to the disorders prompted this investigation of the relationship of age to signs and symptoms of upper extremity impairment.

METHODS

A battery measuring seven objective signs and four reported symptoms of upper extremity cumulative trauma disorders was administered to two stratified random samples of workers. One group (n = 157) processed cooked poultry and the second group (n = 118) performed data entry at VDT terminals. Workers were separated into three age groups (younger: 20-35 years, middle-aged: 36-50 years, and older: 51-71 years).

RESULTS

A series of analyses of variance were computed to determine whether the older workers were more impaired. No significant age differences were found for sign, symptom, or total scores in either sample, and no significant Age x Gender interaction was present. Older workers were more impaired for vibratory sensation, cutaneous pressure, and motor latency.

CONCLUSIONS

The results support the hiring of older workers for general tasks in the workplace without significant worry of increased susceptibility to CTDs.

The relative radiolucencies of breast implant filler materials

Breast implants in current use utilize silicone gel for filler material. One substantial drawback of silicone gel is its radiodensity, resulting in the obscuration of breast tissue on mammography. The relative radiolucencies of silicone gel, saline, breast tissue equivalent, triglycerides (peanut oil), and polyvinylpyrrolidone (Bio-Oncotic gel) were determined by using standard mammographic equipment. Visibility through these materials was compared by using a standard breast phantom as background. The x-ray dosage necessary to create each mammographic image was measured. Peanut oil provided the clearest image of the phantom artifacts, required the least radiation exposure, and was approximately four times more radiolucent than the saline or Bio-Oncotic gel and about 45 times more radiolucent than silicone gel. As improved implant filler materials are being sought, triglycerides maintain superior radiographic properties.