Use of autologous fat grafting for reconstruction postmastectomy and breast conserving surgery: a systematic review protocol

Upper Extremity Functional Outcomes After Breast Cancer Treatment: An Analysis of DASH Score in Breast Reconstruction Patients

BACKGROUND

Patients undergoing postoncologic breast reconstruction can experience upper extremity (UE) functional deficits.

OBJECTIVES

In this study, we utilized the disabilities of the arm, shoulder, and hand (DASH) questionnaire to identify patient factors that impacted UE functional recovery.

METHODS

Patients who underwent oncologic followed by reconstructive surgery by a single surgeon from 2014 to 2019 and completed the DASH survey were included. A DASH score was calculated for each patient, with values ranging from 0 (no impairment) to 100 (severe impairment). Regression analysis was conducted to identify significant predictors for DASH score with a significance level for entry and stay set at P = .15.

RESULTS

Among 289 patients who underwent breast reconstruction, 157 completed the questionnaire. The average patient age was 52.6yrs ± 8.6 at the time of reconstruction. A total of 111 had implant-based reconstruction, 15 had autologous reconstruction, and 24 had a combination of both. Average DASH score was 7.7 (range 0.0-52.5), with 74.1% of patients having a score greater than 0. Regression analysis showed 5 variables associated with significantly higher DASH scores: age between 50 and 60 years (P = .13), history of radiation (P = .01), placement of a subpectoral implant (P = .06), postoperative complications (P = .10), and lymphedema (P < .01). Autologous breast reconstruction (P = .04) was associated with a significantly lower DASH score.

CONCLUSIONS

Implant-based reconstruction, radiation history, postoperative complications, and age at reconstruction were associated with increased UE functional impairment in patients who underwent breast reconstructive surgery. Identification of these factors can inform areas for potential practice changes and improve patient counseling regarding postoperative expectations.

LEVEL OF EVIDENCE: 3

The effect of obesity on adipose-derived stromal cells and adipose tissue and their impact on cancer

The significant increase in the incidence of obesity represents the next global health crisis. As a result, scientific research has focused on gaining deeper insights into obesity and adipose tissue biology. As a result of the excessive accumulation of adipose tissue, obesity results from hyperplasia and hypertrophy within the adipose tissue. The functional alterations in the adipose tissue are a confounding contributing factor to many diseases, including cancer. The increased incidence and aggressiveness of several cancers, including colorectal, postmenopausal breast, endometrial, prostate, esophageal, hematological, malignant melanoma, and renal carcinomas, result from obesity as a contributing factor. The increased morbidity and mortality of obesity-associated cancers are attributable to increased hormones, adipokines, and cytokines produced by the adipose tissue. The increased adipose tissue levels observed in obese patients result in more adipose stromal/stem cells (ASCs) distributed throughout the body. ASCs have been shown to impact cancer progression in vitro and in preclinical animal models. ASCs influence tumor biology via multiple mechanisms, including the increased recruitment of ASCs to the tumor site and increased production of cytokines and growth factors by ASCs and other cells within the tumor stroma. Emerging evidence indicates that obesity induces alterations in the biological properties of ASCs, subsequently leading to enhanced tumorigenesis and metastasis of cancer cells. As the focus of this review is the interaction and impact of ASCs on cancer, the presentation is limited to preclinical data generated on cancers in which there is a demonstrated role for ASCs, such as postmenopausal breast, colorectal, prostate, ovarian, multiple myeloma, osteosarcoma, cervical, bladder, and gastrointestinal cancers. Our group has investigated the interactions between obesity and breast cancer and the mechanisms that regulate ASCs and adipocytes in these different contexts through interactions between cancer cells, immune cells, and other cell types present in the tumor microenvironment (TME) are discussed. The reciprocal and circular feedback loop between obesity and ASCs and the mechanisms by which ASCs from obese patients alter the biology of cancer cells and enhance tumorigenesis will be discussed. At present, the evidence for ASCs directly influencing human tumor growth is somewhat limited, though recent clinical studies suggest there may be some link.

BREAST trial study protocol: evaluation of a non-invasive technique for breast reconstruction in a multicentre, randomised controlled trial

INTRODUCTION

Pioneers have shown that it is possible to reconstruct a full breast using just autologous fat harvested by liposuction or autologous fat transfer (AFT). This study describes the first multicentre randomised study protocol to thoroughly investigate the effectiveness of AFT to reconstruct full breasts following mastectomy procedures (primarily and delayed).

METHODS AND ANALYSIS

This study is designed as a multicentre, randomised controlled clinical superiority trial with a 1:1 allocation ratio. A total of 196 patients (98 patients per treatment arm) are aimed to be included. Patients who wish to undergo breast reconstruction with either one of the two techniques are randomly allocated into the AFT group (intervention) or the tissue-expander/prosthesis group (control). The primary outcome measure for the quality of life is measured by the validated BREAST-Q questionnaire.

ETHICS AND DISSEMINATION

Approval for this study was obtained from the medical ethics committee of Maastricht University Medical Centre/Maastricht University; the trial has been registered at ClinicalTrials.gov. The results of this randomised controlled trial will be presented at scientific meetings as abstracts for poster or oral presentations and published in peer-reviewed journals.

TRIAL STATUS

Enrolment into the trial has started in October 2015. Data collection and data analysis are expected to be completed in December 2021.

TRIAL REGISTRATION NUMBER

NCT02339779.

Adipose tissue-derived mesenchymal stem cells for breast tissue regeneration

With an escalating incidence of breast cancer cases all over the world and the deleterious psychological impact that mastectomy has on patients along with several limitations of the currently applied modalities, it's plausible to seek unconventional approaches to encounter such a burgeoning issue. Breast tissue engineering may allow that chance via providing more personalized solutions which are able to regenerate, mimicking natural tissues also facing the witnessed limitations. This review is dedicated to explore the utilization of adipose tissue-derived mesenchymal stem cells for breast tissue regeneration among postmastectomy cases focusing on biomaterials and cellular aspects in terms of harvesting, isolation, differentiation and new tissue formation as well as scaffolds types, properties, material-host interaction and an in vitro breast tissue modeling.

Pure fat grafting for breast reconstruction: An alternative autologous breast reconstruction

Plastic surgeons offer various options for breast reconstruction based on patient preference, underlying disease, and comorbidities. An alternative form of breast reconstruction exists, which includes tissue expansion with tissue expander and subsequent fat grafting without the use of implant or flap. We retrospectively reviewed the breast cancer patients who underwent breast reconstruction at our institution to identify those with pure fat grafting. Demographic information, complications, operative details, and BREAST-Q scores were abstracted. From 2010-2015, 10 patients were identified. Patients with unilateral or bilateral mastectomy followed by pure fat grafting had a median of 3.5 or 4 sessions and a total median fat grafting volume of 380 or 974.5 cc, respectively. Patients were followed for 12 months, and no complications or breast cancer recurrences were noted. Finally, BREAST-Q scores at the 12-month follow-up were comparable to the preoperative values.

Endothelial Differentiated Adipose-Derived Stem Cells Improvement of Survival and Neovascularization in Fat Transplantation

Background

Adipose-derived stem cells (ASCs) assisted lipotransfer have been considered to facilitate the survival of fat grafts. However, emerging evidence of insufficient vascularization is another obstacle for fat graft survival in cell-assisted lipotransfer.

Objectives

This study evaluated if endothelial phenotype ASCs with fat lipoaspirate improves survival and neovascularization in fat transplantation.

Methods

ASCs were isolated from human periumbilical fat tissue and cultured in endothelial growth medium for 2 weeks. Fat lipoaspirate was mixed with fresh adipose stroma vascular fraction (SVF), endothelial differentiated ASCs (EC/ASCs), and fat lipoaspirate alone. Three fat mixtures were subcutaneously injected into the adult male Sprague-Dawley rat's dorsum at 3 locations. At 8 weeks after transplantation, the grafted fat lipoaspirates were harvested, and the extracted fat was evaluated using photographic, survival weights measurements and histological examination. Neo-vascularization was quantified by immunofluorescence and real-time RT-PCR.

Results

Grafts from the EC/ASC assisted group had a higher survival rate, morphologic integrity, and most uniform lipid droplets. They also revealed less inflammation and fibrosis with increased number of vessels by histological and immunofluorescence analysis. Quantitative RT-PCR analysis indicated that the expression levels of EC-specific markers of CD31 and vWF were higher in the EC/ASC group compared with in the control and fat with SVF transplants.

Conclusions

These results indicated that co-implantation of fat lipoaspirate with ASCs differentiated toward an endothelial phenotype improves both survival and neovascularization of the transplanted fat lipoaspirate, which might provide benefits and represents a promising strategy for clinical application in autologous fat transplantation.

Current Therapeutic Strategies for Adipose Tissue Defects/Repair Using Engineered Biomaterials and Biomolecule Formulations

Tissue engineered scaffolds for adipose restoration/repair has significantly evolved in recent years. Patients requiring soft tissue reconstruction, caused by defects or pathology, require biomaterials that will restore void volume with new functional tissue. The gold standard of autologous fat grafting (AFG) is not a reliable option. This review focuses on the latest therapeutic strategies for the treatment of adipose tissue defects using biomolecule formulations and delivery, and specifically engineered biomaterials. Additionally, the clinical need for reliable off-the-shelf therapies, animal models, and challenges facing current technologies are discussed.

Effects of Collagenase Digestion and Stromal Vascular Fraction Supplementation on Volume Retention of Fat Grafts

OBJECTIVE

The use of autologous fat as a soft tissue filler has increased over the past decade in both reconstructive and aesthetic surgeries. Enhancement of autologous fat grafts with the addition of the stromal vascular fraction (SVF) has been reported to improve long-term volume retention. Stromal vascular fraction is most commonly isolated using enzymatic digestion, but it is unknown what effect the digestion process has on the adipocytes and SVF cells that comprise the graft. Some clinicians have reported use of enzymatically digested fat grafts to alter the physical properties of the tissue in specialized applications. We have previously reported that increasing collagenase digestion duration adversely affects the viability of adipocytes and SVF cells. Here, we aimed to determine if collagenase digestion of adipocytes before grafting is detrimental to long-term graft retention and if SVF supplementation can abrogate these potential deleterious effects.

METHODS AND RESULTS

We used a published xenograft model in which human lipoaspirate was implanted into the scalp of immunocompromised mice to study the effects of collagenase digestion on in vivo graft survival after 12 weeks. We used 4 experimental groups: grafts composed of collagenase-digested and nondigested adipocytes (50-minute digestion) and grafts with and without SVF supplementation. We used microcomputed tomography to serially and noninvasively quantify graft volume, in conjunction with hematoxylin-eosin staining of histological cross-sections of implanted and excised grafts to assess overall tissue viability. We found that adipocytes that were collagenase-digested before implantation had significantly lower retention rates at 12 weeks and poorer tissue health, which was assessed by quantifying the number of intact adipocytes, the number of cystic formations, and by scoring the degree of inflammation and fibrosis. Further, we found that SVF supplementation of the digested grafts improved graft survival, but not to the level observed in undigested grafts.

CONCLUSIONS

We conclude that collagenase digestion adversely affects the long-term volume retention of fat grafts, but that graft retention is improved by SVF supplementation. These experimental results can serve as an initial framework to further elucidate the reported efficacy and safety of using collagenase-digested fat grafts and SVF in the clinical setting.

Adipose-Derived Stem Cells in Novel Approaches to Breast Reconstruction: Their Suitability for Tissue Engineering and Oncological Safety

Adipose-derived stem cells (ADSCs) are rapidly becoming the gold standard cell source for tissue engineering strategies and hold great potential for novel breast reconstruction strategies. However, their use in patients with breast cancer is controversial and their oncological safety, particularly in relation to local disease recurrence, has been questioned. In vitro, in vivo, and clinical studies using ADSCs report conflicting data on their suitability for adipose tissue regeneration in patients with cancer. This review aims to provide an overview of the potential role for ADSCs in breast reconstruction and to examine the evidence relating to the oncologic safety of their use in patients with breast cancer.

Peri-foci adipose-derived stem cells promote chemoresistance in breast cancer

Background

Mesenchymal stem cells in tumor microenvironment can influence therapeutic responses in various types of cancers. For triple negative breast cancer, chemotherapy remains the mainstay of standard treatment. Our aim was to investigate the correlation between human adipose-derived stem cells (hAdSCs) and chemoresistance in triple negative breast cancer.

Method

Conditioned medium was collected from hAdSCs, which was isolated from breast cancer patients who had had breast mastectomy. The expression of selected CD markers was evaluated by flow cytometry to characterize hAdSCs. By array analyses of the secreted cytokines and chemokines of hAdSCs, we identified CXCL1 that mediated doxorubicin resistance and the expression of ATP-binding cassette transporters ABCG2 in TNBC. By microRNA microarray, the association between hAdSC-mediated doxorubicin resistance in TNBC was also revealed.

Results

Conditioned medium collected from hAdSCs elicited doxorubicin resistance and enhanced the expression of ABCG2, which is a transporter responsible for the efflux of doxorubicin. CXCL1 secreted by hAdSCs downregulated miR-106a expression in triple negative breast cancer, and resulted in ABCG2 upregulation and doxorubicin resistance.

Conclusions

Our findings suggest that CXCL1 secreted by hAdSCs elicits doxorubicin resistance through miR-106a-mediated ABCG2 upregulation in triple negative breast cancer. These findings provide a better understanding of the importance of adipose-derived stem cells in breast cancer microenvironment regarding to the development of chemoresistance and reveal the potential of discovering novel therapeutic strategies to overcome drug resistance in TNBC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13287-017-0630-2) contains supplementary material, which is available to authorized users.

Intratissular expansion-mediated, serial fat grafting: A step-by-step working algorithm to achieve 3D biological harmony in autologous breast reconstruction

BACKGROUND

Breast reconstruction involves the use of autologous tissues or implants. Occasionally, microsurgical reconstruction is not an option because of insufficient donor tissues. Fat grafting has become increasingly popular in breast surgery. The challenge with this technique is how to reconstruct a stable and living "scaffold" that resembles a breast.

METHODS

Breast reconstruction (n = 7) was performed using intratissular expansion with serial deflation-lipofilling sessions. Mean age of the patients was 41 years (22-53). The expander generated a vascularized capsule at 8 weeks, which demarcated a recipient site between the skin and the capsule itself, and functioned as a vascular source for angiogenesis. Serial sessions of deflation and lipofilling were initiated at 8 weeks with removal of the expander at the completion of the treatment. An average of 644 ml (range, 415 ml-950 ml) of lipoaspirate material was injected to reconstruct the breast mound. An average of 4 (range, 3 to 5) fat-grafting sessions with a 3-month interval was needed to achieve symmetry with the contralateral breast. The average follow-up was 14 months (range, 9-29 months). MRI examination was performed at 8 months to analyze tissue survival and the residual volume.

RESULTS

MRI examination retained tissue survival and the mean reconstructed breast volume was 386 ml (range, 231 ml-557 ml). An aesthetically pleasant breast mound was created, with a high satisfaction rate.

CONCLUSION

We could reconstruct an aesthetically pleasant and stable breast mound in a selected group of patients by using intratissular expansion and fat grafting.

Efficacy and Safety of Cell-Assisted Lipotransfer: A Systematic Review and Meta-Analysis

BACKGROUND

The main drawback of autologous fat grafting, which is commonly used for soft-tissue augmentation, is the high resorption rate. Cell-assisted lipotransfer has been used to improve fat graft survival; however, evidence for its efficacy and safety is still lacking.

METHODS

The authors searched PubMed, Cochrane Library, EBSCO, and EMBASE for clinical studies on cell-assisted lipotransfer published from 2008 through 2014. A meta-analysis was conducted to pool the estimated fat survival rate. Incidence of complications and incidence of multiple operations were calculated.

RESULTS

Seventeen articles involving 387 cases were included in the systematic review. The pooled fat survival rate was significantly higher in the cell-assisted lipotransfer group than in the nonlipotransfer group (60 percent versus 45 percent, p = 0.0096). Complication incidence was similar in the two groups. Cell-assisted lipotransfer significantly improved fat survival in the face (by 19 percent) and reduced the incidence of multiple operations (by 13.6 percent). In breast fat grafting, however, fat survival was improved by only 9 percent, which was not statistically significant. Meanwhile, lipotransfer in breast cases was associated with a higher complication incidence compared with face cases (p < 0.001).

CONCLUSIONS

This study demonstrates that cell-assisted lipotransfer has better efficacy than conventional fat grafting (non-cell-assisted lipotransfer). It is more applicable to face cases than to breast cases. Until now, there has not been enough evidence of the superiority of cell-assisted lipotransfer over conventional fat grafting for reducing complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Autologous fat grafting for cosmetic breast augmentation: a systematic review

BACKGROUND

Breast augmentation is one of the most popular aesthetic surgical procedures. The only potential alternative is autologous fat grafting (AFG), which is not new in principle. This procedure has been used on native breasts since 2009, following the recommendations of some learned societies.

OBJECTIVES

We performed a systematic review to determine the current worldwide status of fat grafting for aesthetic breast augmentation.

METHODS

A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria was conducted using the PubMed, EmBASE, and Cochrane library databases. This protocol was registered at the National Institute for Health Research, Prospective Register of Systematic Reviews.

RESULTS

A total of 42 articles published between 1987 and July 2014 were included. Most of the studies had a low level of evidence, with only one level 2 study, published by Spear (2014), a prospective cohort study which included 10 patients. The publications were from North America, Europe, and Asia. The indications were aesthetic augmentation (92.4%) and congenital malformation (7.6%). Two cases of cancer were reported among the 2023 patients included (0.09%), with a mean follow-up of 22 months, although the follow-up was insufficient for medium- and long-term cancer diagnoses.

CONCLUSIONS

AFG seems to be a major tool in this field, but we must remain cautious about its systematization for this indication. Preoperative patient selection is essential but underreported. AFG appears particularly relevant in breast malformations. We believe that this method should be practiced within the scope of a national or international registry with proper follow-up of patients.

Adipose-derived stem cells in radiotherapy injury: a new frontier

Radiotherapy is increasingly used to treat numerous human malignancies. In addition to the beneficial anti-cancer effects, there are a series of undesirable effects on normal host tissues surrounding the target tumor. While the early effects of radiotherapy (desquamation, erythema, and hair loss) typically resolve, the chronic effects persist as unpredictable and often troublesome sequelae of cancer treatment, long after oncological treatment has been completed. Plastic surgeons are often called upon to treat the problems subsequently arising in irradiated tissues, such as recurrent infection, impaired healing, fibrosis, contracture, and/or lymphedema. Recently, it was anecdotally noted - then validated in more robust animal and human studies - that fat grafting can ameliorate some of these chronic tissue effects. Despite the widespread usage of fat grafting, the mechanism of its action remains poorly understood. This review provides an overview of the current understanding of: (i) mechanisms of chronic radiation injury and its clinical manifestations; (ii) biological properties of fat grafts and their key constituent, adipose-derived stem cells (ADSCs); and (iii) the role of ADSCs in radiotherapy-induced soft-tissue injury.