Increased risk of recurrence associated with certain risk factors in breast cancer patients after DIEP-flap reconstruction and lipofilling-a matched cohort study with 200 patients

Oncologic safety of autologous fat grafting in primary breast reconstruction after mastectomy for cancer

INTRODUCTION

Autologous fat transfer (AFT) is widely used to improve results of breast reconstructive surgery, but its safety is controversial. Our objective was to evaluate the oncologic safety of AFT in a homogeneous population of patients who underwent a total mastectomy with immediate reconstruction for breast cancer.

METHODS

We performed a retrospective cohort study by identifying all patients who underwent immediate breast reconstruction after mastectomy for breast cancer from 2007 to 2015 in our center. A patient group with AFT performed in the 24 months after mastectomy was compared to a control group.

RESULTS

Five hundred fifty cases were included, of whom 136 (24.7%) underwent at least one fat graft transfer. Median age was 51 years. Reconstruction was performed in 465 (84.5%) with an implant reconstruction. The median time from mastectomy to AFT was 13.8 months. The median follow up was 55.2 months. A total of 53 events were observed, including 10 (7.4%) in the AFT group and 43 (10.4%) in the control group. There was no difference in 5-year recurrence-free survival (RFS) between the groups. In the subgroup analysis, only lymph node involvement in patients who underwent AFT in the first 24 months after oncologic surgery appeared as a risk factor of recurrence. Among the 104 patients with lymph node involvement, 5-year RFS was 69.2% in patients with lipofilling vs 92.5% in patients without it (p = 0 0.0351).

CONCLUSION

Performing early lipofilling in primary breast reconstruction after mastectomy for cancer seems to be oncologically safe. Lymph node involvement increases the risk of recurrence in this population.

[Lipofilling in the management of breast cancer: An update based on a literature review and national and international guidelines]

BACKGROUND

Lipomodelling (LM) is an increasingly used technique to reconstruct or correct an aesthetic defect linked to a loss of substance. In France, the Haute Autorité de santé (HAS) published recommendations in 2015 and 2020 concerning the conditions of use of LM on the treated and contralateral breast. These appear to be inconsistently followed.

METHODS

Twelve members of the Senology Commission of the Collège national des gynécologues-obstétriciens français (French College of Gynecologists and Obstetricians) reviewed the carcinological safety of LM and the clinical and radiological follow-up of patients after breast cancer surgery, based on French and international recommendations and a review of the literature. The bibliographic search was conducted via Medline from 2015 to 2022, selecting articles in French and English and applying PRISMA guidelines.

RESULTS

A total of 14 studies on the oncological safety of LM, 5 studies on follow-up and 7 guidelines were retained. The 14 studies (6 retrospective, 2 prospective and 6 meta-analyses) had heterogeneous inclusion criteria and variable follow-up, ranging from 38 to 120 months. Most have shown no increased risk of locoregional or distant recurrence after LM. A retrospective case-control study (464 LMs and 3100 controls) showed, in patients who had no recurrence at 80 months, a subsequent reduction in recurrence-free survival after LM in cases of luminal A cancer, highlighting the number of lost to follow-up (more than 2/3 of luminal A cancers). About follow-up after LM, the 5 series showed the high frequency after LM of clinical mass and radiological images (in ¼ of cases), most often corresponding to cytosteatonecrosis. Most of the guidelines highlighted the uncertainties concerning oncological safety of LM, due to the lack of prospective data and long-term follow-up.

DISCUSSION AND PERSPECTIVES

The members of the Senology Commission agree with the conclusions of the HAS working group, in particular by advising against LM "without cautionary periods", excessively, or in cases of high risk of relapse, and recommend clear, detailed information to patients before undergoing LM, and the need for postoperative follow-up. The creation of a national registry could address most questions regarding both the oncological safety of this procedure and the modalities of patient follow-up.

Meta-Analysis of the Oncological Safety of Autologous Fat Grafting After Breast Cancer on Basic Science and Clinical Studies

BACKGROUND

The purpose of the present study was to comprehensively evaluate the oncological safety of autologous fat grafting after breast cancer by combining experimental and clinical studies.

METHODS

All studies published before August 2021 were collected by searching PubMed, Cochrane, Embase, Web of Science, SINOMED, and China National Knowledge Infrastructure. After screening the research and extracting the data, RevMan was used to perform the meta-analysis.

RESULTS

Five basic science studies and 26 clinical studies, involving a total of 10,125 patients, were eventually included. In the basic science studies, adipose-derived stem cells promoted breast cancer growth, but fat grafting and adipose-derived stem cells plus fat grafting were not associated with breast cancer growth. An overall analysis of clinical studies showed that autologous fat grafting does not increase the risk of breast cancer recurrence. Subgroup analyses indicated that autologous fat grafting did not increase the risk of breast cancer recurrence in Asian or Caucasian patients, in patients undergoing breast-conserving surgery or modified radical mastectomy, in patients with in situ carcinomas or invasive carcinomas, or in patients undergoing postoperative radiotherapy.

CONCLUSION

This study combined experimental and clinical studies to conclude that autologous fat grafting does not increase the risk of breast cancer recurrence. However, the experimental results suggest that adipose-derived stem cells should be used with caution after breast cancer surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

SINGLE-CENTER ONCOLOGIC OUTCOME OF FAT TRANSFER FOR BREAST RECONSTRUCTION FOLLOWING MASTECTOMY IN 1000 CANCER CASES - A MATCHED CASE-CONTROL STUDY

BACKGROUND

Autologous fat transfer (AFT) has an important role in breast reconstructive surgery. Nevertheless, Some concerns remain with regards to its oncological safety. We present a single center case-matching study analysing the impact of AFT in cumulative incidence of local recurrences (LR).

MATERIALS AND METHODS

From a prospectively maintained database, we identified 902 patients who underwent 1025 breast reconstructions from 2005 to 2017. Data regarding demographics, tumor characteristics, surgery details and follow-up were collected. Exclusion criteria were patients with distant metastases at diagnosis, recurrent tumor or incomplete data regarding primary tumor, patients who underwent prophylactic mastectomies and breast-conserving surgeries. Statistical analysis was done to evaluate the impact of the variables on the incidence of LR. A p-value < 0.05 was considered statistically significant.

RESULTS

After 1:n case-matching, we selected 919 breasts, out of which 425 (46.2%) patients received at least one AFT session vs 494 (53.8%) control cases. LR had an overall rate of 6.8% and we found LR in 14 (3.0%) AFT cases and 54 (9.6%) controls. Statistical analysis showed that AFT did not increase risk of LR: HR 0.337 (CI 0.173-0.658), p=0.00007. Multivariate analysis identified IDC subtype and lymph node metastases to have an increased risk of local recurrences (HR > 1). Conversely, positive hormonal receptor status was associated with a reduced risk of events (HR < 1).

CONCLUSIONS

AFT was not associated with a higher probability of locoregional recurrence in patients undergoing breast reconstruction therefore it can be safely used for total breast reconstruction or aesthetic refinements.LEVEL OF EVIDENCE: 3.

Systematic review: Oncological safety of reconstruction with fat grafting in breast cancer outcomes

BACKGROUND

Autologous fat grafting (AFG) has become a commonly used procedure for breast reconstruction (BR) after cancer removal. Nevertheless, oncological considerations remain for AFG after breast cancer surgery.

OBJECTIVES

This article aims to evaluate the oncological safety of AFG in BR and its effect on disease-free survival (DFS) and local-regional recurrences (LRR).

METHODS

A systematic review regarding the use of AFG in BR to identify a difference in incidence rates of LRR and DFS between patients who had AFG and controls was performed using PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov, Scopus, and Cochrane databases. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews-Protocols (PRISMA-P) guidelines. The included studies had to match predetermined criteria according to the PICOS approach.

RESULTS

A total of 11 studies were included. Seven studies reported LRR, and 5 studies reported DFS in 5,886 patients. Our systematic review showed that AFG was not associated with increased LRR and DFS. Pooled hazard ratios (HRs) (95% confidence intervals [CIs]) for LRR and DFS were 1.26 (0.90-1.76) and 1.27 (0.96-1.69), respectively.

CONCLUSIONS

AFG can, therefore, be performed safely in BR after breast cancer. Further, randomized controlled trials and related systematic reviews, as well as evidence-based medicine (EBM) studies of level 1, are required to consolidate the results of the studies identified in this systematic review.

Oncological safety of reconstruction with autologous fat grafting in breast cancer patients: a systematic review and meta-analysis

To evaluate the oncological safety of autologous fat grafting and its effect on disease-free survival and local recurrence in breast cancer patients with autologous fat grafting (AFG) reconstruction. A literature search was performed using the Pubmed, Medline, Web of Science, and Cochrane libraries from January 2011 to March 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to identify all relevant studies involving the application of autologous fat grafting in breast cancer reconstruction procedures. The primary outcome of the meta-analysis was a difference in incidence rates of locoregional recurrence and disease-free survival (DFS) between patients who had autologous fat grafting and controls. A total of 11 studies were included. Eight studies reported local-regional recurrences (LRR) and five studies reported disease-free survival (DFS) in 5,886 patients. Our meta-analysis of all included studies about survival outcomes showed AFG was not associated with increased LRR and DFS. Pooled hazard ratios (HRs) (95% CIs) for LRR and DFS were 1.26 (0.90-1.76) and 1.27 (0.96-1.69), respectively. According to the published literature, autologous fat grafting did not result in an increased rate of LRR and DFS in patients with breast cancer. Autologous fat grafting can, therefore, be performed safely in breast reconstruction after breast cancer.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction: A Meta-analysis Based on Matched Cohort Studies

BACKGROUND

Autologous fat grafting has become a commonly used procedure for breast reconstruction after breast cancer surgical treatment. Nevertheless, oncological considerations remain concerning autologous fat grafting after breast cancer surgery.

OBJECTIVE

This meta-analysis aimed to summarize the current matched cohort studies and provide high-quality evidence-based conclusions on the oncological safety of fat grafting in breast reconstruction.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. A literature search was performed on August 1, 2021, using PubMed. All relevant matched cohort studies of patients undergoing autologous fat grafting after breast cancer surgery were included. After independently screening the studies and extracting the data, pooled estimates for local and regional recurrence as well as distant metastases were conducted using Review Manager software (RevMan, version 5.3). Outcomes were expressed as odds ratios and 95% confidence intervals.

RESULTS

Seventeen studies involving 7494 patients were included. The observed outcomes indicated that no significant differences existed in the risks of local and regional recurrence or distant metastases between autologous fat grafting and control groups. Also, there was no significant heterogeneity among the studies.

CONCLUSION

This study provided evidence-based conclusions that support the use of autologous fat grafting in breast reconstruction.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The oncological safety of autologous fat grafting: a systematic review and meta-analysis

Objective

To present a systematic review of the literature and a meta-analysis evaluating the oncological safety of autologous fat grafting (AFG).

Summary background data: AFG for breast reconstruction presents difficulties during follow-up radiological exams, and the oncological potential of grafted fat is uncertain. Previous studies confirmed that the fatty tissue could be transferred under a good condition suitable would not interfere with mammographic follow-up, although the issue of oncological safety remains.

Methods

We reviewed the literature published until 01/18/2021. The outcomes were overall survival (OS), disease-free survival (DFS), and local recurrence (LR). We included studies that evaluated women with breast cancer who undergone surgery followed by reconstruction with AFG. We synthesized data using the inverse variance method on the log-HR (log of the hazard ratio) scale for time-to-event outcomes using RevMan. We assessed heterogeneity using the Chi² and I² statistics.

Results

Fifteen studies evaluating 8541 participants were included. The hazard ratios (HR) could be extracted from four studies, and there was no difference in OS between the AFG group and control (HR 0.9, 95% CI 0.53 to 1.54, p = 0.71, I² = 58%, moderate certainty evidence), and publication bias was not detected. The HR for DFS could be extracted from six studies, and there was no difference between the AFG group and control (HR 1.01, 95% CI 0.73 to 1.38, p = 0.96, I² = 0%, moderate certainty evidence). The HR for LR could be extracted from ten studies, and there was no difference between the AFG group and control (HR 0.86, 95% CI 0.66 to 1.12, p = 0.43, I² = 1%, moderate certainty evidence).

Conclusion

According to the current evidence, AFG is a safe technique of breast reconstruction for patients that have undergone BC surgery and did not affect OS, DFS, or LR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09485-5.

Oncologic safety of breast reconstruction with autologous fat grafting: A systematic review and meta-analysis

BACKGROUND

Autologous fat grating has become increasingly popular as a breast reconstructive procedure. Nevertheless, preclinical studies show that fat transfer to a previous breast cancer site could activate latent cancer cells, creating a favourable environment for disease recurrence. A systematic review and meta-analysis was performed to investigate whether fat grafting increases the risk of locoregional recurrence in patients formerly treated for breast cancer.

METHODS

Based on PRISMA guidelines, a systematic review searching for randomised clinical trials and matched cohorts on the topic was performed in the electronic databases Pubmed, Embase, Web of Science, and Cochrane. The date of the last search was July 20, 2021. The meta-analysis assessed the comparison of locoregional recurrence between groups.

RESULTS

From a total of 558 publications, data from nine matched cohorts (1.6%) reporting on 4247 subjects (1590 and 2657 subjects, respectively, in lipofilling and control groups) were suitable for inclusion in the meta-analysis. Neither of the outcomes had a statistically significant difference for disease recurrence. For the primary outcome, comparing locoregional recurrence rates between groups, the incidence rate ratio was 0.92 (95% CI: 0.68-1.26; P = 0.620).

CONCLUSION

The present meta-analysis, which comprises the outcomes of the individual studies with the best current evidence on the topic so far, strengthens the evidence favouring the oncologic safety of lipofilling for breast reconstruction.

Oncologic Safety of Autologous Fat Grafting after Breast Cancer Surgical Treatment: A Matched Cohort Study

BACKGROUND

Autologous fat grafting has been an increasingly popular procedure for remodeling the breast of patients undergoing breast cancer surgery. This study's objective was to investigate whether autologous fat grafting is associated with a higher risk of disease recurrence in the context of late breast reconstruction for patients diagnosed with breast cancer who have undergone either breast-conserving surgery or mastectomy.

METHODS

A retrospective matched cohort study was performed in a single tertiary health care center. Data were collected from 42 patients formerly treated for breast cancer who underwent the first session of autologous fat grafting between August of 2007 and June of 2016. A total of 126 patients with similar features, who did not undergo autologous fat grafting, were individually matched at a 1:3 ratio with the autologous fat grafting group. The primary endpoint was locoregional recurrence. Secondary outcomes were rates of local and distant recurrences, disease-free survival, and overall survival.

RESULTS

At a mean follow-up of 65 months after fat grafting, no significant differences were found between the lipofilling and control groups for locoregional recurrence (7.1 percent versus 6.3 percent; p = 0.856), local recurrence (7.1 percent versus 5.6 percent; p = 0.705), distant recurrence (14.3 percent versus 7.9 percent; p = 0.238), disease-free survival (21.4 percent versus 19.0 percent; p = 0.837), and overall survival (14.3 percent versus 7.1 percent; p = 0.181).

CONCLUSIONS

No evidence of increased risk in any of the survival outcomes was identified. Lipofilling seems to be a safe procedure for breast reconstruction after surgical treatment of breast cancer.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Long-term Follow-up of Autologous Fat Transfer vs Conventional Breast Reconstruction and Association With Cancer Relapse in Patients With Breast Cancer

Importance

Autologous fat transfer (AFT or fat grafting) has become an invaluable tool for the correction of disfiguring deformities after breast cancer surgery. However, clinical and animal studies have shown conflicting results regarding its oncologic safety.

Objective

To determine whether exposure to AFT vs conventional breast reconstruction is associated with increased rates of cancer relapse in patients with breast cancer.

Design, Setting, and Participants

This matched cohort study involved retrospective medical record review to identify all patients in a local patient database receiving AFT between 2006 and 2014. Each AFT case was matched with a nonexposed control patient with similar baseline characteristics. The mean (SD) follow-up of patients receiving AFT was 9.3 (4.9) years including 5.0 (1.7) years following AFT. Control patients were followed up for a mean (SD) of 8.6 (1.8) years from the primary surgery. Patients were identified through the local patient database of the Tergooi Hospital in Hilversum, the Netherlands. A total of 287 patients with breast cancer (300 affected breasts) who received AFT for breast reconstruction after cancer were included in the intervention group. Each AFT case was matched with a respective control patient based on age, type of oncologic surgery, tumor invasiveness, and disease stage. In addition, individual AFT-control pairs were selected to have the same locoregional recurrence-free interval at baseline. Data were analyzed between 2016 and 2017.

Exposures

Reconstruction with AFT vs conventional breast reconstruction or none.

Main Outcomes and Measures

Primary end points were the cumulative incidences of oncologic events in AFT and control patients and their respective hazard ratios.

Results

Of the 587 total patients, all were women and the mean age was 48.1 years for the patients undergoing AFT and 49.4 years for the control patients. Eight locoregional recurrences were observed in the treatment group (287 patients) and 11 among the control group (300 patients), leading to an unadjusted hazard ratio of 0.63 (95% CI, 0.25-1.60; P = .33). No increased locoregional recurrence rates were seen in relevant subgroups based on the type of oncological surgery, tumor invasiveness, or pathological stage. In addition, no increased risks with AFT were detected with respect to distant recurrences or breast cancer-specific mortality.

Conclusions and Relevance

No significant differences in the locoregional recurrence rates between the AFT and control groups were observed after 5 years of follow-up. These findings confirm the results of previous studies; therefore, clinical evidence suggesting that AFT is associated with increased risk for cancer relapse is still lacking.

Adipose-Derived Stem Cells in Cancer Progression: New Perspectives and Opportunities

Growing importance has been attributed to interactions between tumors, the stromal microenvironment and adult mesenchymal stem cells. Adipose-derived stem cells (ASCs) are routinely employed in regenerative medicine and in autologous fat transfer procedures. To date, clinical trials have failed to demonstrate the potential pro-oncogenic role of ASC enrichment. Nevertheless, some pre-clinical studies from in vitro and in vivo models have suggested that ASCs act as a potential tumor promoter for different cancer cell types, and support tumor progression and invasiveness through the activation of several intracellular signals. Interaction with the tumor microenvironment and extracellular matrix remodeling, the exosomal release of pro-oncogenic factors as well as the induction of epithelial-mesenchymal transitions are the most investigated mechanisms. Moreover, ASCs have also demonstrated an elective tumor homing capacity and this tumor-targeting capacity makes them a suitable carrier for anti-cancer drug delivery. New genetic and applied nanotechnologies may help to design promising anti-cancer cell-based approaches through the release of loaded intracellular nanoparticles. These new anti-cancer therapies can more effectively target tumor cells, reaching higher local concentrations even in pharmacological sanctuaries, and thus minimizing systemic adverse drug effects. The potential interplay between ASCs and tumors and potential ASCs-based therapeutic approaches are discussed.

Comparison of survival outcomes of locally advanced breast cancer patients receiving post-mastectomy radiotherapy with and without immediate breast reconstruction: a population-based analysis

Objective

To compare the survival outcomes in locally advanced breast cancer (LABC) patients receiving post-mastectomy radiotherapy (PMRT) with and without immediate breast reconstruction.

Methods

We used the Surveillance, Epidemiology, and End Results program to include LABC patients who were treated/not treated with immediate breast reconstruction followed by PMRT between 2003 and 2010. Statistical analysis was performed using the chi-squared test, Kaplan–Meier survival analysis, and Cox regression analysis. A 1:1 propensity score matching method was performed to decrease the selection bias.

Results

We identified 1,732 patient-pairs that were completely matched. In the unmatched population, 8,198 and 1,802 patients received mastectomy only and immediate breast reconstruction, respectively. Patients who received immediate breast reconstruction had better breast cancer-specific survival (BCSS) (hazard ratio [HR] 0.880, 95% CI 0.783–0.989, P = 0.032) and overall survival (OS) (HR 0.846, 95% CI 0.758–0.943, P = 0.003) than patients who underwent mastectomy alone. However, in the matched population, there was comparable BCSS and OS between patients who received immediate breast reconstruction and mastectomy alone. Subset analysis in the matched population found that immediate breast reconstruction was associated with better BCSS (HR 0.750, 95% CI 0.614–0.917, P = 0.005) and OS (HR 0.779, 95% CI 0.644–0.942, P = 0.010) compared to patients aged <50 years who received mastectomy alone.

Conclusion

There are comparable survival outcomes in LABC patients who received immediate breast reconstruction or mastectomy alone followed by PMRT. However, patients aged <50 years had a survival advantage after immediate breast reconstruction.

Survival and risk of breast cancer recurrence after breast reconstruction with deep inferior epigastric perforator flap

BACKGROUND

Women who undergo autologous breast reconstruction have been reported to have an increased risk of breast cancer recurrence compared with those who have mastectomy alone. It has been suggested that more extensive surgery possibly activates dormant micrometastases. The aim of this study was to evaluate whether delayed unilateral deep inferior epigastric perforator (DIEP) flap reconstruction after mastectomy increases the risk of breast cancer recurrence or affects mortality among women previously treated for breast cancer.

METHODS

This was a matched retrospective cohort study including women with a previous unilateral invasive breast cancer who received a delayed DIEP flap breast reconstruction and a control cohort of individually matched women with unilateral breast cancer who underwent mastectomy but no autologous breast reconstruction. Matching criteria comprised: year of diagnosis (+/-3 years), age at diagnosis (+/-5 years), type of cancer and demographic region. The primary endpoints were local recurrence or distant metastasis, and overall mortality was a secondary endpoint. Absolute risk of recurrent disease and mortality was analysed, and relative risks were estimated using Cox proportional hazards analysis.

RESULTS

There were 225 women in the DIEP cohort and 450 in the no-DIEP cohort. The median follow-up time was 125 months. There was no difference in absolute risk of recurrence between the cohorts. The hazard ratio for breast cancer recurrence in DIEP versus no-DIEP cohorts was 0·76 (95 per cent c.i. 0·47 to 1·21).

CONCLUSION

There is no increased risk in breast cancer recurrence after delayed DIEP flap reconstruction compared with mastectomy alone.

Breast cancer recurrence after reconstruction: know thine enemy

Breast reconstruction proceeding cancer treatment carries risk, regardless of the type of surgery. From fat grafting, to flap placement, to implants, there is no guarantee that reconstruction will not stimulate breast cancer recurrence. Research in this field is clearly divided into two parts: scientific interventional studies and clinical retrospective evidence. The reconstructive procedure offers hypoxia, a wound microenvironment, bacterial load, adipose derived stem cells; agents shown experimentally to cause increased cancer cell activity. This is compelling scientific evidence which serves to bring uncertainty and fear to the reconstructive procedure. In the absence of clinical evidence, this laboratory literature landscape is now informing surgical choices. Curiously, clinical studies have not shown a clear link between breast cancer recurrence and reconstructive surgery. Where does that leave us? This review aims to analyze the science and the surgery, thereby understanding the oncological fear which accompanies breast cancer reconstruction.

Meta-analysis of the oncological safety of autologous fat transfer after breast cancer

Lipofilling ok