ABSTRACT

Lipofilling has gained increased confidence in both esthetic and reconstructive breast surgery. However, in breast carcinoma patients there are some doubts about the crosstalk between adipose tissue microenviroment and cancer tissue. In our case report, a 48-year-old female patient with a heterozygous pathogenic variant in the chromosome 17 BRCA 1 gene had a history of lipofilling after loss of breast prosthesis. The patient presented with the development of triple negative breast carcinoma 20 months after lipofilling application. This case again raises the question about the risk of lipofilling on breast cancer development.

Introduction

Lipofilling has gained popularity in breast surgery for esthetic and reconstructive purposes. It is efficent to correct volume defects with minimal scarring, improve esthetic results and lead to increase in patient satisfaction rate (1, 2). On the other hand, the oncologic safety of lipofilling in the context of breast reconstruction is still a matter of controversy (3). Adipose tissue is a rich source of adipose tissue derived stem cells and growth factors. As a result of lipofilling, inflammation and remodeling processes occur at the recipient tissue. Up to now, it remains unclear whether this adipose tissue-breast cancer interactions really have the ability to stimulate breast cancer progression. A careful oncological follow-up is recommended for breast cancer patients after lipofilling (4, 5).

In this article, we presented a case of a 48-year-old woman with triple negative breast cancer development in the left breast 20 months after lipofilling for esthetic reasons.

Case Report

A 48-year-old female patient applied to our clinic with a complaint of a palpable mass in her left breast.

On the physical examination of the patient, a hard mass of approximately 3 cm in the upper inner quadrant and widespread nodular lesions in the left breast were detected. No lymphadenopathy was present in the bilateral axilla.

Particularly in the patient’s medical history, she had bilateral augmentation mammoplasty surgery with breast implants in 1997. There was replacement of the left-side implant in 2012 due to implant complications. Removal of the left implant and lipofilling was done in January 2021. Breast ultrasound and magnetic resonance imaging scans performed at that time showed no suspicious findings for cancer in either breast.

The patient complained of palpable hardness in the left breast after six months after fat injection. The mammographic evaluation was consistent with fat necrosis in the middle inner quadrant of the left breast and superimposed on the pectoral muscle in the deep plane.

She noticed increase in the size of the mass in the left breast after one year. In the radiological evaluation performed in August 2022, there was a 27*16 mm sized, BIRADS 5 solid mass lesion in the upper inner quadrant of the left breast and lymphadenopathy, the largest of which was 19 mm in diameter and showed cortical thickening (5.5 mm) detected in the axilla (Figures 1, Figures 2).

Tru-cut biopsy results from the patient’s mass in the left breast were invasive breast carcinoma, grade 3, ER-, PR-, HER2-, Ki-67; 60-70%. The pathology results from the axillary lymph nodes were benign.

In genetic testing, a heterozygous pathogenic variant was detected in the chromosome 17 BRCA 1 gene (c.66dup-pGlu23Argfrester18). In her family history, her aunt had colectomy for colon carcinoma.

With those findings, the patient was evaluated at the oncology council and the patient underwent neoadjuvant chemotherapy. After chemotherapy, a radiological complete response was detected in the mass.

In May 2023, nipple skin sparing mastectomy, axillary sentinel lymph node sampling and breast reconstruction was performed for the left breast. The pathology results of the patient revealed no residual invasive carcinoma (complete response), and no metastasis in the axillary lymph nodes (0/4).

Discussion

Lipofilling has been used in the last century for filling defects and remodeling body shape. It is an extremely useful tecnique in esthetic and reconstructive breast surgery as well. The multipotent stem cells found in adipose tissue has regenerative potential. Patients are more satisfied with the appearance of their breast and showed an improved psychosocial, sexual, and physical well-being after breast surgery. They also have significantly lower implant complications, capsular contracture rate, and breast pain as a result of the regenerative potential of the fat tissue (1, 2, 6). In the previous studies conducted on healthy BRCA mutation carriers, lipofilling was regarded as an oncologicaly safe method after prophylactic mastectomy (7, 8).

However, fat tissue with its stem cells, adipokines and vascular-inducing factors may have pro-tumorigenic potential. Crosstalk between this mesenchymal stem cells and epithelial cells have the ability to participate in primary and metastatic tumor development and progression (9, 10). A remarkable role of adipose tissues in cancer development as increased breast cancer proliferation and enhanced agresiveness was shown in animal and in vitro studies (2, 11-13). On the other hand, there were no clearly demonstrated cancer recurrence risk increase in clinical studies (5, 14). One of the rare clinical studies showing an increased local event risk was reported by Petit et al. (4). They showed increased intraepithelial neoplasia risk. They took attention to increased risk of local recurrence in women <50 years, with high grade neoplasia, Ki-67 ≥14 who had undergone quadrantectomy. They reported that cancer recurrence happened generally three to four years after lipofilling (4). Similarly, Berti et al. (15) conducted a retrospective study on breast carcinoma patients and compared survival and local recurrence rates between patients with lipofilling and without lipofilling. They showed that, lipofilling was an independent predictive factor for local recurrence in invasive breast carcinoma patients (15).

The risk of inducing de novo carcinogenesis after lipofilling is a very rare circumstance. Cheng et al. (16) presented a case with musinous carcinoma, discovered 2 months after lipofilling. As invasive breast carcinoma development from carcinoma in situ was 3-5 years according to the literature, they took attention to the short time interval after lipofilling to breast carcinoma development (16).

Conclusion

In our case report, we presented a patient being BRCA1 heterozygous positive and de novo development of triple negative breast carcinoma shortly after fat injection. Although previous studies have reported that lipofilling is generally safe even in patients with BRCA mutation, we would like to emphasize once again that caution should be exercised in these procedures.