Breast transplanted to replace cancerous one in 'world first' operation

BBC News

5 hours ago

Five months into a pregnancy for a much wanted second child in 2024, Nicola Purdie found a lump in her right breast.It is a nightmare scenario for anyone. But for Nicola this was not a new experience.She had already had a double mastectomy, chemotherapy and breast reconstruction after being diagnosed with cancer in 2020.But a radical idea which she suggested to her surgeon has led to what is believed to be a pioneering world first procedure - transplanting a healthy reconstructed breast to replace a cancerous one.
In September 2020, Nicola had just finished with breastfeeding her first child and was returning to work as a geography teacher in her home town of Swansea when she found a lump.By October it was diagnosed as cancer and she started five months of chemotherapy at Singleton Hospital, followed by the double mastectomy.Nicola, now 38, said: "Even though I only had cancer in the one breast, my maternal aunty and maternal grandmother also had had breast cancer previously. I thought 'I'm young, let's just get rid of everything and do as much as we can'."She had reconstructive surgery using skin and tissue from her abdomen in a procedure known as a DIEP (deep inferior epigastric perforator) flap. "It meant I had natural breasts which would grow and shrink with my bodyweight over time and I wouldn't need implants that would need changing in 10 or 15 years," she said.Because the cancer was oestrogen-fuelled, she was placed on hormone suppression therapy for at least two years.
'This is not a coincidence. This is cancer'
"We knew at the time I was diagnosed that we wanted to have another baby eventually, so we waited for two-and-a-half years actually."All the oncologists we saw were of the same opinion that I was at no increased risk, because I'd had a complete pathological response [no sign of cancer post-treatment]."Then lump number two appeared. Nicola explained: "This time it was in the skin of the breast because that was the only tissue that was remaining really from the first surgery. There must have been some cancer cells there."I knew straight away as soon as I found the lump, this is not a coincidence. This is cancer again."
Apart from family and a close friend, Nicola did not tell anyone about the cancer this time. Partly it was to shield her daughter from knowing but she had another reason."I wanted to protect the baby. I wanted him to come into the world and it to be all about him. I didn't want it to be focusing on 'oh gosh Nicky, you OK?'."She attributes this mindset to helping her "shut the door" on thinking about it until her son was born.Because of pregnancy, she could not begin chemotherapy, or have the usual scans to establish if the cancer had spread.She had some chest X-rays and an ultrasound of her stomach and liver, which gave a degree of certainty, although not "100%", that it remained contained in the breast. She also had a lumpectomy to remove the lump from the breast skin.
The plan was to deliver the baby at 32 weeks, at the end of August, but even in the midst of the urgency for treatment, she had an eye to her son's future."I think it was 26 August and I said 'can I put my teacher's hat on now and push it to the week after'. "My husband was like 'what?' But I said 'I've got to give him the best chance'. "So we waited until the first Monday in September and he was born at 32 weeks and six days."Fraser was in the neonatal unit for three weeks. "He went from strength to strength and that made things easier as well because of what I was dealing with. "I don't know how I would have been if he was poorly as well."Nicola started chemotherapy two weeks after giving birth and would go from the baby unit upstairs to have her treatment and then straight back down to her son.She had 16 rounds of chemo which took her all the way through to the beginning of February.
Initially the oncology team had not been sure what operation to suggest as Nicola had multiple cancer sites in the right breast area and a tumour in one lymph node. The most likely option was removal and an LD (latissimus dorsi) flap, which involves swinging a muscle and skin from the back to cover the area left behind by the removed breast, but leaving the area flat in her case.Reconstruction using an implant on the right side instead would not have been possible as so much skin had to be removed, there would not be enough to cover it, or to withstand damage from subsequent radiation treatment.However, Nicola's aunt had had the LD flap operation and she knew it came with an arduous recovery process and possibly reduced range of movement - not an option for her as the mother of two small children.She also knew she wanted "symmetry" - either two breasts or none.It was while talking to her sisters she initially had the idea that, if she did end up having both breasts removed, why not use the skin from the healthy left breast to cover the larger affected area on the right.But it was only once she was in the consulting room with consultant plastic, reconstructive and breast surgeon Reza Arya, that the idea of moving the whole breast intact dawned.
She realised it would allow her to create a right breast and have reconstructive surgery on the left side using an implant because there was enough skin left in situ from the first operation in 2020.When she put this to Reza - "could we rob Peter to pay Paul?" - she "could literally see the cogs whirring" in his head.He recalled being speechless at the idea. "I had never seen or heard of such a procedure being talked about or published. "I wasn't even sure at that stage whether I would be adding to Nicola's care or taking away from it."Reza said it was very unusual to have a patient come up with such a radical idea."Kudos to Nicola because she's amazing. "I had extensive discussions with colleagues all over the UK who are all experts in flap reconstruction from the abdomen. The conclusion was maybe it is possible and just go ahead with it."This is not run of the mill mastectomy we're talking about," he said. "We're removing the whole of the footprint of the breast [on the right]. It is a very, very large area of skin and to be able to close it you have to borrow from somewhere, some skin and tissue, that can withstand future radiotherapy."Left is a side that's easy to reconstruct in future, because it's not subject to radiotherapy and all other treatments, and the cancer itself."
When Nicola went into the surgery, she knew she could wake up to very different outcomes - a successful left to right transplant, or an LD flap reconstruction on her right side after all if he decided the transfer would not work, with the left breast removed anyway at her request.She gave Reza her blessing for any outcome. And her outrageous gamble paid off."What makes it a world first is that the tissue has been ported to two different sites," she said. "We didn't know if that would be possible or probable, the microsurgery of actually sewing the vessels together - if it would work or if it would be so scarred that it would be completely impossible."She is starting a few weeks of radiotherapy, and around Christmas time will have reconstructive surgery on the left side using a saline implant.
She will be on hormone therapy for the next 10 years to manage the risks of recurrence but has been given the all-clear in terms of this treatment cycle.For someone who has been through such gruelling experiences, she is remarkably upbeat. How does she stay positive?"If I am having those moments when I feel 'oh my god this is awful, why has this happened to us?' "I let myself think about it for a minute and then move on to the next thing. If you don't allow yourself to think about it, it won't get you down."I have to sit back and think 'this is life. Worse things can happen'. I'm lucky that I've had incredible treatment from the word go, and an amazing team who I trust."She added: "Both the kids were just the best distraction ever. It's hope isn't it? When you see little children. You think there's hope for the future."