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Lani · 06-07-2014, 07:22 PM

Recurrence of an Invasive Ductal Breast Carcinoma 4 Months after Autologous Fat Grafting
Chaput, Benoit M.D.; Foucras, Lionel M.D.; Le Guellec, Sophie M.D.; Grolleau, Jean Louis M.D.; Garrido, Ignacio M.D., Ph.D.
Author Information
Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil (Chaput, Foucras)
Pathology Department, Institut Claudius Regaud (Le Guellec)
Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France (Grolleau, Garrido)
Correspondence to Dr. Chaput, Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, 1 Avenue Jean Poulhès, 31059 Toulouse, France benoitchaput@aol.com

Sir:

Autologous fat grafting is widely used in reconstructive breast surgery but, more recently, is also being used in breast augmentation. For 20 years, the cautious recommendation of the American Society of Plastic and Reconstructive Surgeons was a real obstacle.1 Nevertheless, for a few years, we have witnessed a strong increased confidence in this procedure.

Graphic Figure. No caption a...
A patient aged 34 years was admitted for two breast nodules. Initially, a tumorectomy had been performed with insufficient exeresis margins. Thus, a mastectomy with axillary node dissection had been performed followed by chemotherapy and radiotherapy. Twenty-four months later, a reconstructive operation was started, the first step of which consisted of autologous fat grafting. At 4 months, during the expander's setting, the mastectomy scar was excised (Fig. 1). Discrete lumps and papular lesions had been noticed. Histologic analysis confirmed local recurrence of the carcinoma. Currently, the patient presents a metastatic invasion of the sternum.

Graphic Fig. 1
Radiographically, the studies in favor of a slight modification of the parenchyma are numerous, and a trained radiologist finds little difficulty in interpretation. The cancer issue is different. In vitro, the promotion of cancer recurrence and metastases has been demonstrated through the action of the adipose-derived stem cells, the neoangiogenesis, and aromatase.2–5 Nevertheless, these relations have never been highlighted in vivo. This can be explained by the actual rupture between the laboratory studies and those in humans.

We are attempting to authenticate not a real causal link but the possibility of a synchronous recurrence to autologous fat grafting that may have been masked. Nonetheless, the risks of promoting a latent cancer or metastases are not excluded. Moreover, this patient very quickly presented metastases. Histologically, it is interesting to note that the tumor cells were displayed along the trenches created during autologous fat grafting (Fig. 2). It is possible that either the cancer recurrence was already present and the cannula went in the tumor, participating in local dissemination, or the quiescent tumor cells resumed their development along the graft trenches. The extension to the sternum could also result either from the dissemination through the cannula or from the metastatic development of the tumor.

Graphic Fig. 2
On the international level, the behavior is not homogenous. In 2009, the American Society of Plastic Surgeons Fat Graft Task Force had concluded that no reliable study confirmed the absence of risk of cancer. In 2011, the French Society of Plastic and Reconstructive Surgery, which had strictly advised against breast autologous fat grafting since 2007, changed their position. The French Society is now suggesting autologous fat grafting as part of a clinical protocol. Currently, a prospective study is ongoing in France [Adipose Tissue Transfer for Moderate Breast Cancer Conservative Treatment Sequella (GRATSEC); http://clinicaltrials.gov/show/NCT01035268] in an attempt to provide answers with a high level of evidence regarding the uncertainties between autologous fat grafting and breast neoplasia.2

This case, atypical in its chronology and histology, enables us to raise the questions once more regarding this procedure and of its controversial characteristics on breast cancer. The absence of scientific evidence must lead us to remain vigilant, even nowadays. Information and regular patient follow-up remain essential in the long term with, if possible, a national compulsory registry to centralize the data.

Benoit Chaput, M.D.

Lionel Foucras, M.D.

Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil

Sophie Le Guellec, M.D.

Pathology Department, Institut Claudius Regaud

Jean Louis Grolleau, M.D.

Ignacio Garrido, M.D., Ph.D.

Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

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REFERENCES

1. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg. 2007;119:775–785; discussion 786–787. [Context Link]

2. Mojallal A, Saint-Cyr M, Garrido I. Autologous fat transfer: Controversies and current indications for breast surgery. J Plast Reconstr Aesthet Surg. 2009;62:708–710. Bibliographic Links [Context Link]

3. Pearl RA, Leedham SJ, Pacifico MD. The safety of autologous fat transfer in breast cancer: Lessons from stem cell biology. J Plast Reconstr Aesthet Surg. 2012;65:283–288. Bibliographic Links [Context Link]

4. Petit JY, Lohsiriwat V, Clough KB, et al.. The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: A multicenter study—Milan-Paris-Lyon experience of 646 lipofilling procedures. Plast Reconstr Surg. 2011;128:341–346. [Context Link]

5. Dirat B, Bochet L, Dabek M, et al.. Cancer-associated adipocytes exhibit an activated phenotype and contribute to breast cancer invasion. Cancer Res. 2011;71:2455–2465. Bibliographic Links [Context Link]

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GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

* Text—maximum of 500 words (not including references)

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We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

06-07-2014, 07:22 PM	#12
Lani Senior Member Join Date: Mar 2006 Posts: 4,778	Re: Fat Grafting Recurrence of an Invasive Ductal Breast Carcinoma 4 Months after Autologous Fat Grafting Chaput, Benoit M.D.; Foucras, Lionel M.D.; Le Guellec, Sophie M.D.; Grolleau, Jean Louis M.D.; Garrido, Ignacio M.D., Ph.D. Author Information Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil (Chaput, Foucras) Pathology Department, Institut Claudius Regaud (Le Guellec) Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France (Grolleau, Garrido) Correspondence to Dr. Chaput, Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, 1 Avenue Jean Poulhès, 31059 Toulouse, France benoitchaput@aol.com Sir: Autologous fat grafting is widely used in reconstructive breast surgery but, more recently, is also being used in breast augmentation. For 20 years, the cautious recommendation of the American Society of Plastic and Reconstructive Surgeons was a real obstacle.1 Nevertheless, for a few years, we have witnessed a strong increased confidence in this procedure. Graphic Figure. No caption a... A patient aged 34 years was admitted for two breast nodules. Initially, a tumorectomy had been performed with insufficient exeresis margins. Thus, a mastectomy with axillary node dissection had been performed followed by chemotherapy and radiotherapy. Twenty-four months later, a reconstructive operation was started, the first step of which consisted of autologous fat grafting. At 4 months, during the expander's setting, the mastectomy scar was excised (Fig. 1). Discrete lumps and papular lesions had been noticed. Histologic analysis confirmed local recurrence of the carcinoma. Currently, the patient presents a metastatic invasion of the sternum. Graphic Fig. 1 Radiographically, the studies in favor of a slight modification of the parenchyma are numerous, and a trained radiologist finds little difficulty in interpretation. The cancer issue is different. In vitro, the promotion of cancer recurrence and metastases has been demonstrated through the action of the adipose-derived stem cells, the neoangiogenesis, and aromatase.2–5 Nevertheless, these relations have never been highlighted in vivo. This can be explained by the actual rupture between the laboratory studies and those in humans. We are attempting to authenticate not a real causal link but the possibility of a synchronous recurrence to autologous fat grafting that may have been masked. Nonetheless, the risks of promoting a latent cancer or metastases are not excluded. Moreover, this patient very quickly presented metastases. Histologically, it is interesting to note that the tumor cells were displayed along the trenches created during autologous fat grafting (Fig. 2). It is possible that either the cancer recurrence was already present and the cannula went in the tumor, participating in local dissemination, or the quiescent tumor cells resumed their development along the graft trenches. The extension to the sternum could also result either from the dissemination through the cannula or from the metastatic development of the tumor. Graphic Fig. 2 On the international level, the behavior is not homogenous. In 2009, the American Society of Plastic Surgeons Fat Graft Task Force had concluded that no reliable study confirmed the absence of risk of cancer. In 2011, the French Society of Plastic and Reconstructive Surgery, which had strictly advised against breast autologous fat grafting since 2007, changed their position. The French Society is now suggesting autologous fat grafting as part of a clinical protocol. Currently, a prospective study is ongoing in France [Adipose Tissue Transfer for Moderate Breast Cancer Conservative Treatment Sequella (GRATSEC); http://clinicaltrials.gov/show/NCT01035268] in an attempt to provide answers with a high level of evidence regarding the uncertainties between autologous fat grafting and breast neoplasia.2 This case, atypical in its chronology and histology, enables us to raise the questions once more regarding this procedure and of its controversial characteristics on breast cancer. The absence of scientific evidence must lead us to remain vigilant, even nowadays. Information and regular patient follow-up remain essential in the long term with, if possible, a national compulsory registry to centralize the data. Benoit Chaput, M.D. Lionel Foucras, M.D. Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil Sophie Le Guellec, M.D. Pathology Department, Institut Claudius Regaud Jean Louis Grolleau, M.D. Ignacio Garrido, M.D., Ph.D. Plastic and Reconstructive Surgery Unit, CHU Toulouse Rangueil, Toulouse, France Back to Top DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Back to Top REFERENCES 1. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg. 2007;119:775–785; discussion 786–787. [Context Link] 2. Mojallal A, Saint-Cyr M, Garrido I. Autologous fat transfer: Controversies and current indications for breast surgery. J Plast Reconstr Aesthet Surg. 2009;62:708–710. Bibliographic Links [Context Link] 3. Pearl RA, Leedham SJ, Pacifico MD. The safety of autologous fat transfer in breast cancer: Lessons from stem cell biology. J Plast Reconstr Aesthet Surg. 2012;65:283–288. Bibliographic Links [Context Link] 4. Petit JY, Lohsiriwat V, Clough KB, et al.. The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: A multicenter study—Milan-Paris-Lyon experience of 646 lipofilling procedures. Plast Reconstr Surg. 2011;128:341–346. [Context Link] 5. Dirat B, Bochet L, Dabek M, et al.. Cancer-associated adipocytes exhibit an activated phenotype and contribute to breast cancer invasion. Cancer Res. 2011;71:2455–2465. Bibliographic Links [Context Link] Back to Top GUIDELINES Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: * Text—maximum of 500 words (not including references) * References—maximum of five * Authors—no more than five * Figures/Tables—no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.