Cryotherapy for breast cancer: a feasibility study without excision

Cryotherapy in the Treatment of Early-Stage Breast Cancer

Breast cancer is one of the most common malignancies, affecting millions of people worldwide annually. The treatment paradigm for early-stage breast cancer is in flux. The focus is now on opportunities to de-escalation treatment to minimize morbidity and maximize patients' quality of life. Recently, percutaneous minimally invasive ablative techniques have been explored. Early trials in small population of patients demonstrated cryoablation to be effective, safe, and well-tolerated in an outpatient setting. Subsequent surgical resection was performed and the ablation success rate was the highest if the tumor was less than 1.5 cm and with < 25% ductal carcinoma in situ component. ACOSOG Alliance Z1072, a phase II trial with curative intent, demonstrated 100% ablation in all tumors smaller than 1 cm and 92% success in lesions without multifocal disease and less than 2 cm in size. There are ongoing prospective clinical trials to investigate the efficacy of cryoablation without surgical excision for treatment of early-stage breast cancer. FROST (Freezing Instead of Removal Of Small Tumors) started in 2016 is ongoing, ICE3 (Cryoablation of Low Risk Small Breast Cancer) started in 2014 just released 5 years results, and COOL-IT: Cryoablation vs Lumpectomy in T1 Breast Cancers is also ongoing. These prospective trials will expand our knowledge on the safety and value of cryoablation. It is crucial to understand the indications, technical nuances, and distinctive imaging findings for cryoablation as it has potential to revolutionize standard surgical practice.

Defining Breast Cryoablation Treatment Success: A Guide for the Curative and Palliative Treatment of Breast Cancer

RATIONALE AND OBJECTIVES

Recent ICE3 trial of breast cryoablation for breast cancer demonstrated 98% success rate, similar to breast-conserving surgery. However, ICE3 and other published studies did not differentiate curative from palliative treatment nor define patient-specific treatment objectives. We sought to define treatment success of curative and palliative breast cryoablation for breast cancer in meeting procedure objectives and patient-specific treatment objectives.

MATERIALS AND METHODS

We conducted a retrospective analysis of breast cancer patients who underwent breast cryoablation during 2021-2024. Breast radiologists performed outpatient cryoablation using local anesthesia and argon gas cryoprobes under ultrasound or MRI guidance. Patient demographics, referral indications, tumor characteristics, procedure details, and imaging follow-up findings were analyzed. Cryoablation was categorized as curative or palliative. Treatment success was defined as achievement of both procedure and patient-specific treatment objectives.

RESULTS

Breast cryoablation was performed for 34 lesions in 29 patients with N0M0 (n = 25), N1M0 (n = 2), N2M0 (n = 1), and N0M1 (n = 1) disease. Most tumors were invasive ductal carcinoma (IDC), low to intermediate grade, estrogen receptor (ER) and progesterone receptor (PR) positive and HER2 negative (23 tumors, 68%). Tumor size ranged from 0.4-1.9 (median 0.8) cm for curative cryoablation and 0.6-6.0 (median 1.3) cm for palliative cryoablation. For 27 patients with follow-up imaging, ablation was curative in 14 patients, 14 tumors and palliative in 13 patients, 18 lesions. Imaging follow-up time ranged from 3 to 26 (median 16) months, > 12 months in 22 of 27 patients and 25 of 32 tumors. Complications were limited to 2 cases of skin frost injury, 1 mild and 1 moderate. Treatment success was achieved in 13 of 14 patients with curative and all 13 patients with palliative cryoablation.

CONCLUSION

Our study defines treatment success for curative and palliative breast cryoablation, demonstrates breast cryoablation achieves not only procedure (technical) but also patient-specific treatment objectives without significant complications, and may serve as guide for integrating breast cryoablation in the treatment of breast cancer patients.

Percutaneous ultrasound-guided cryoablation for early-stage primary breast cancer: a follow-up study in Japan

BACKGROUND

Ultrasound-guided percutaneous cryoablation (PCA) for early-stage breast cancer (ESBC) can be performed under local anesthesia in an outpatient clinic. This study continues a pilot stage to examine local control, safety, patient quality of life (QoL), satisfaction and cosmetic outcomes of cryoablation for ESBC.

METHODS

PCA was performed under local anesthesia for patients with primary ESBC, followed by radiation and endocrine therapies. Oncologic outcomes were examined by imaging (mammography, ultrasound, MRI) at baseline and 1, 6, 12, 24, 36, and 60 months post-cryoablation. EQ-VAS, EQ-5D-5L, subjective satisfaction and Moiré topography were used to measure health-related QoL outcomes.

RESULTS

Eighteen patients, mean aged 59.0 ± 9.0 years, mean tumor size 9.8 ± 2.3 mm, ER + , PR + (17/18), HER2-, Ki67 < 20% (15/18), underwent PCA and were followed for a mean of 44.3 months. No serious adverse events were reported, and no patients had local recurrence or distant metastasis in the 5-year follow-up. Cosmetic outcomes, satisfaction level, and QoL all improved post-cryoablation. Five-year average reduction rates of the cryolesion long, short, and depth diameters, on US, were 61.3%, 42.3%, and 22.8%, respectively, compared to the 86.2% volume reduction rate on MRI. The correlation coefficient between MRI and US measurement criteria was highest for the long diameter. During follow-up, calcification of the treated area was observed in 13/18 cases.

CONCLUSION

Cryoablation for ESBC is an effective and safe procedure with excellent cosmetic outcomes and improved QoL. This study contributes to the growing evidence supporting cryoablation as a potential standard treatment for ESBC, given compliance to pre-defined patient selection criteria.

CT-Guided Percutaneous Cryoablation of Breast Cancer: A Single-Center Experience

This study shall retrospectively evaluate the efficacy and safety of liquid-nitrogen based CT-guided cryoablation (CA) as a minimal-invasive technique for the curative treatment of primary breast cancer. A total of 45 female patients with 56 tumors were treated by CT-guided CA in analgosedation as an outpatient procedure. We used a liquid-nitrogen based system with a single cryoprobe and performed two freeze cycles with an intermediate thawing. The mean tumor diameter was 1.6 ± 0.7 cm. Follow-up was conducted via contrast-enhanced MR images of the breast. No complications were observed in all 56 ablations. Initial complete ablation was achieved in 100% of cases. Four cases of local tumor progression were reported, resulting in a rate of 8.9%, and 6 cases of intramammary distant recurrence at a rate of 13.3%. The extramammary tumor progression was observed in 7 patients at a rate of 15.6%. The mean overall survival was 4.13 years (95% CI: 3.7-4.5). The mean overall progression-free survival was 2.5 years (95% CI: 1.8-3.2) and the mean local progression-free survival was 2.9 years (95% CI: 2.3-3.6). Cryoablation is a safe and effective treatment for primary breast cancer tumors, which can be performed in analgosedation and as an outpatient procedure. However, potential for improvement exists and further evidence is necessary.

Breast cryoablation for the palliative treatment of indolent subtype of multicentric triple-negative breast cancer

Breast cryoablation for palliative and curative treatment of breast cancer has been performed for decades. Although there is a recent resurgence of interest in breast cryoablation with curative intent for unifocal, hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, this report highlights the essential role that cryoablation can play in the palliative treatment of multicentric oestrogen and progesterone receptor-negative and human epidermal growth factor receptor 2-negative (triple-negative) breast cancer, meeting the select pretreatment objectives such as breast or nipple pain relief and prevention of tumour erosion through the skin or nipple in patients who have failed or cannot tolerate the standard of care treatment.

Breast Tomographic Ultrasound: The Spectrum from Current Dense Breast Cancer Screenings to Future Theranostic Treatments

This review provides unique insights to the scientific scope and clinical visions of the inventors and pioneers of the SoftVue breast tomographic ultrasound (BTUS). Their >20-year collaboration produced extensive basic research and technology developments, culminating in SoftVue, which recently received the Food and Drug Administration's approval as an adjunct to breast cancer screening in women with dense breasts. SoftVue's multi-center trial confirmed the diagnostic goals of the tissue characterization and localization of quantitative acoustic tissue differences in 2D and 3D coronal image sequences. SoftVue mass characterizations are also reviewed within the standard cancer risk categories of the Breast Imaging Reporting and Data System. As a quantitative diagnostic modality, SoftVue can also function as a cost-effective platform for artificial intelligence-assisted breast cancer identification. Finally, SoftVue's quantitative acoustic maps facilitate noninvasive temperature monitoring and a unique form of time-reversed, focused US in a single theranostic device that actually focuses acoustic energy better within the highly scattering breast tissues, allowing for localized hyperthermia, drug delivery, and/or ablation. Women also prefer the comfort of SoftVue over mammograms and will continue to seek out less-invasive breast care, from diagnosis to treatment.

Role of Interventional Radiology in Managing Primary and Metastatic Breast Cancer

Percutaneous image-guided locoregional therapies are emerging in the treatment of primary and metastatic breast cancer. Cryoablation has emerged as the dominant ablative approach as an alternative to surgery for primary breast cancer in patients who do not wish to have surgery or are poor surgical candidates. Cryoablation is well tolerated and provides excellent local control and cosmesis. Thermal ablation may also be used in the treatment of oligometastatic breast cancer, allowing patients to achieve long disease-free intervals. Transarterial therapies have been studied in the treatment of oligoprogressive hepatic metastasis, though further supportive data would be helpful to demonstrate its efficacy.

Treatment Options for Early Stage Inoperable Breast Cancer: Cryoablation or Radiotherapy?

Background

Surgical removal of the tumour is the gold standard treatment for early stage invasive breast cancer. However, with a global ageing population, a larger number of diagnoses are occurring in women with comorbidities that render them unsuitable for surgery. Hence, it is of interest to explore alternative treatment strategies for this group of women.

Summary

Our narrative review aims to explore two such techniques, cryoablation and external beam radiotherapy, providing a brief summary of the evidence behind each technique. Following this, we discuss which groups of patients would gain the most benefit from each technique. Factors favouring the use of radiotherapy include patients with larger tumours, more superficial tumours, and those with less well-demarcated tumours where there is uncertainty regarding tumour extent. Meanwhile, patients who may benefit more from cryoablation include those who desire a smaller number of treatment sessions, have concerns regarding cosmesis and skin pigmentation, or who have relative contraindications to radiotherapy such as scleroderma, systemic lupus erythematosus, reduced lung function, or cardiac comorbidities.

Key Messages

Continued advancements in both cryoablation and radiotherapy technologies are taking place, in tandem with imaging technologies enabling greater certainty in tumour detection and delineation. These factors will help increase local control rates in this group of non-operable early stage breast cancer patients. Through this review, we hope to aid in the clinical decision-making process regarding the selection and referral of patients for each treatment.

Non-surgical ablation for breast cancer: an emerging therapeutic option

Non-surgical ablation is emerging as an alternative local therapy option for patients with early-stage breast cancer and encompasses two main types of percutaneous therapeutic procedures: radiofrequency ablation and cryoablation. Both techniques involve obliteration of a spherical lesion and feasibility studies have shown that complete tumour ablation is achievable with good or excellent cosmetic results. Although few clinical studies have directly compared non-surgical ablation with conventional surgical resection, observational studies indicate that clinical outcomes are favourable with acceptable rates of local control and no detriment to long-term survival. There remain outstanding issues with these percutaneous ablative techniques that require resolution before they could be incorporated into routine clinical practice. Hence, a consensus meeting was convened to discuss the challenges of non-surgical ablation and clarify indications for its use alongside clinical management pathways. In this Policy Review we will address some of the broader biological aspects of non-surgical ablation, including immune-modulatory effects and potential novel applications for the future.

Modern cancer therapy: cryoablation meets immune checkpoint blockade

Cryoablation, as a minimally invasive technology for the treatment of tumors, destroys target tumors with lethal low temperatures. It simultaneously releases a large number of tumor-specific antigens, pro-inflammatory cytokines, and nucleoproteins, known as "danger signals", activating the body's innate and adaptive immune responses. However, tumor cells can promote the inactivation of immune effector cells by reprogramming immune checkpoints, leading to the insufficiency of these antigens to induce an immune response capable of eradicating the tumor. Immune checkpoint blockers rejuvenate exhausted T cells by blocking immune checkpoints that induce programmed death of T cells, and are therefore considered a promising therapeutic strategy to enhance the immune effects of cryoablation. In this review, we provide a detailed explanation of the immunological mechanisms of cryoablation and articulate the theoretical basis and research progress of the treatment of cancer with cryoablation combined with immune checkpoint blockers. Preliminary data indicates that this combined treatment strategy exhibits good synergy and has been proven to be safe and effective.

Cryoablation for the treatment of breast cancer: immunological implications and future perspectives. Utopia or reality?

Cryoablation is a minimally invasive technique currently employed in breast cancer care, that uses freeze and thaw cycles to treat benign breast lesions, small breast cancers or focal sites of metastatic disease in patients not eligible for surgery. The final goal of this procedure is to destroy breast cancer cells using extreme cold. In addition, several studies have shown that this technique seems to have an enhancing effect on the immune response, especially by increasing the expression of tumor neoantigens specific to tumor cells, which are then attacked and destroyed. Exploiting this effect, cryoablation in combination with immunotherapy could be the key to treating early-stage breast cancers or patients who are unsuitable for surgery. According to some recent studies, there are other potential tools that could be used to enhance the therapeutic effect of cryoablation, such as FE3O4 nanoparticles or the manipulation of aquaporin expression. The aim of this narrative review is to summarize the current evidence regarding the use, indications, advantages and disadvantages of cryoablation in the treatment of breast cancer.

The Role of Contrast-Enhanced Mammography After Cryoablation of Breast Cancer

Image-guided cryoablation is an emerging therapeutic technique for the treatment of breast cancer and is a treatment strategy that is an effective alternate to surgery in select patients. Tumor features impacting the efficacy of cryoablation include size, location in relation to skin, and histology (e.g., extent of intraductal component), underscoring the importance of imaging for staging and workup in this patient population. Contrast-enhanced mammography (CEM) utilization is increasing in both the screening and diagnostic settings and may be useful for follow-up imaging after breast cancer cryoablation, given its high sensitivity for cancer detection and its advantages in terms of PPV, time, cost, eligibility, and accessibility compared with contrast-enhanced MRI. This Clinical Perspective describes the novel use of CEM after breast cancer cryoablation, highlighting the advantages and disadvantages of CEM compared with alternate imaging modalities, expected benign postablation CEM findings, and CEM findings suggestive of residual or recurrent tumor.

Locoregional Therapies for Primary and Metastatic Breast Cancer: AJR Expert Panel Narrative Review

Minimally invasive locoregional therapies have a growing role in the multidisciplinary treatment of primary and metastatic breast cancer. Factors contributing to the expanding role of ablation for primary breast cancer include earlier diagnosis, when tumors are small, and increased longevity of patients whose condition precludes surgery. Cryoablation has emerged as the leading ablative modality for primary breast cancer owing to its wide availability, the lack of need for sedation, and the ability to monitor the ablation zone. Emerging evidence suggests that in patients with oligometastatic breast cancer, use of locoregional therapies to eradicate all disease sites may confer a survival advantage. Evidence also suggests that transarterial therapies-including chemoembolization, chemoperfusion, and radioembolization-may be helpful to some patients with advanced liver metastases from breast cancer, such as those with hepatic oligoprogression or those who cannot tolerate systemic therapy. However, the optimal modalities for treatment of oligometastatic and advanced metastatic disease remain unknown. Finally, locoregional therapies may produce tumor antigens that in combination with immunotherapy drive anti-tumor immunity. Although key trials are ongoing, additional prospective studies are needed to establish the inclusion of interventional oncology in societal breast cancer guidelines to support further clinical adoption and improved patient outcomes.

Cryogenic Media in Biomedical Applications: Current Advances, Challenges, and Future Perspectives

This paper explores the crucial role of cryogenic mediums in driving breakthroughs within the biomedical sector. The objective was to investigate, critically discuss, and present the current knowledge and state-of-the-art practices, along with the challenges and perspectives of the most common applications. Through an extensive literature review, this work aims to supplement existing research, offering a comprehensive and up-to-date understanding of the subject. Biomedical research involving cryogenic mediums is advancing on multiple fronts, including the development of advanced medical technologies, clinical treatments for life-threatening conditions, high-quality biospecimen preservation, and antimicrobial interventions in industrial food processing. These advances open new horizons and present cutting-edge opportunities for research and the medical community. While the current body of evidence showcases the impressive impact of cryogenic mediums, such as nitrogen, helium, argon, and oxygen, on revolutionary developments, reaching definitive conclusions on their efficiency and safety remains challenging due to process complexity and research scarcity with a moderate certainty of evidence. Knowledge gaps further underline the need for additional studies to facilitate cryogenic research in developing innovative technological processes in biomedicine. These advancements have the potential to reshape the modern world and significantly enhance the quality of life for people worldwide.

Cryoablation for the Treatment of Breast Cancer: A Review of the Current Landscape and Future Possibilities

Breast cancer is one of the most common malignancies worldwide. Traditional treatment options for breast cancer include surgery, radiation therapy, and chemotherapy. However, cryoablation, a minimally invasive technique, has emerged as a promising alternative for the treatment of early-stage breast cancer. This article aims to provide an overview of cryoablation, focusing on incorporation into practice, patient selection, procedural technique, imaging follow-up, post-treatment radiopathological findings, and current and ongoing research in the field. The current evidence suggests that cryoablation offers a safe and effective treatment option for selected patients, providing comparable oncological outcomes to traditional treatments while minimizing invasiveness and preserving breast aesthetics.

Cryoablation Allows the Ultimate De-escalation of Surgical Therapy for Select Breast Cancer Patients

BACKGROUND

Widespread use of screening mammography has allowed breast cancer to be detected at earlier stages. This allows for increased customization of treatment and less aggressive management. De-escalation of therapy plays an important role in decreasing treatment burden and improving patient quality of life. This report examines cryoablation as the next step in the surgical de-escalation of breast cancer.

METHODS

Women with a diagnosis of clinically node-negative, estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor receptor 2-negative (HER2 -) infiltrating ductal carcinomas 1.5 cm or smaller underwent ultrasound-guided cryoablation. Either the Visica 2 treatment system (before 2020) or the ProSense treatment system (since 2020) was used to perform the cryoablation. Patients received mammograms and ultrasounds at a 6 months follow-up visit, and magnetic resonance images at baseline, then at 1 year follow-up intervals. Adjuvant therapy decisions and disease status were recorded.

RESULTS

This study enrolled 32 patients who underwent 33 cryoablation procedures (1 patient had bilateral cancer). One patient had a sentinel node biopsy in addition to clinical staging of the axilla. For all the patients, adjuvant endocrine therapy was recommended, and six patients (18.75%) received adjuvant radiation. Of the 32 patients, 20 (60.6%) have been followed up for 2 years or longer, with no residual or recurrent disease at the site of ablation.

CONCLUSION

Cryoablation of the primary tumor foregoing sentinel node biopsy offers an oncologically safe and feasible minimally invasive office-based procedure option in lieu of surgery for patients with early-stage, low-risk breast cancer.

Cryoablation Therapy for Early-Stage Breast Cancer: Evidence and Rationale

Recent advances in breast cancer research and treatment propel a paradigm shift toward less aggressive and less invasive treatment for some early-stage breast cancer. Select patients with small, low-risk tumors may benefit from a less aggressive approach with de-escalated local therapy. Cryoablation of breast cancer is an emerging nonsurgical treatment alternative to breast-conserving surgery. Advantages of cryoablation over surgery include the use of local anesthesia, faster recovery, improved cosmesis, and cost savings. Proper patient selection and meticulous technique are keys to achieving successful clinical outcomes. The best candidates for cryoablation have unifocal invasive ductal carcinoma tumors that are low grade, hormone receptor positive, and ≤1.5 cm in size. In this review, we outline the current evidence, patient selection criteria, procedural technique, pre- and postablation imaging, and the advantages and limitations of cryoablation therapy.

The Evolving Role of Cryosurgery in Breast Cancer Management: A Comprehensive Review

Breast cancer is the most commonly diagnosed type of cancer, accounting for approximately one in eight cancer diagnoses worldwide. In 2020, there were approximately 2.3 million new cases of breast cancer globally, resulting in around 685,000 deaths. Consequently, there is an ongoing need to develop innovative therapeutic approaches that can improve both clinical outcomes and patient quality of life. The use of ultra-low cryogenic temperatures, facilitated by cryogenic media such as liquid nitrogen, has revolutionized the biomedical field and opened up new possibilities for advanced clinical treatments, including cryosurgery. Cryosurgery has demonstrated its feasibility as a minimally invasive technique for destroying breast tumors and eliciting a significant antitumor immune response in the host. This feature sets cryosurgery apart from other ablative techniques. It has been shown to be well tolerated and effective, offering several advantages such as simplicity, the avoidance of general anesthesia, minimal pain, low morbidity, short recovery time, cost-effectiveness, and notably, improved aesthetic outcomes. The reviewed studies indicate that cryosurgery holds promise in the management of early-stage breast cancer and metastatic disease, especially in triple-negative and Her2-positive molecular subtypes in conjunction with checkpoint inhibitors and anti-Her2 antibodies, respectively. Furthermore, the effectiveness of cryosurgery in the management of ductal carcinoma in situ should be investigated as an alternative modality to surgery or surveillance. The minimally invasive nature of cryosurgery has the potential to significantly enhance the quality of life for patients.

Breast Cancer Cryoablation in the Multidisciplinary Setting: Practical Guidelines for Patients and Physicians

Breast cancer cryoablation has emerged as a minimally invasive alternative to lumpectomy for treating early-stage breast cancer. However, no consensus exists on what should be considered the standard of care for the multidisciplinary management of patients treated with breast cancer cryoablation. In lieu of national guidelines, this review of the literature provides a multidisciplinary framework and an evidence-based discussion of the integration of "standard of care practices" in the comprehensive management of breast cancer cryoablation patients.

Endophytic upper tract urothelial carcinoma in a solitary kidney treated by cryotherapy: an unorthodox case for successful management

BACKGROUND

Nephroureterectomy remains the gold standard treatment for upper tract urothelial carcinoma (UTUC). Considering the high risk of developing renal function impairment after surgery, the rationale for nephron sparing approaches in treatment of UTUC has been raised. In this case, renal cryoablation was able to achieve successful oncologic control while preserving renal function during 5 years of follow up without intraoperative or post operative complications.

CASE PRESENTATION

A 79 year old male presents after three months of macroscopic hematuria. Imaging revealed a 3.6 × 3.1 × 2.7 cm endophytic mass in the interpolar region of the left kidney and an atrophic right kidney. After weighing the lesion's location with the patient's of complex medical history, he was counselled to undergo a minimally invasive percutaneous cryoablation as treatment for his solitary renal mass. A diagnostic dilemma was encountered as imaging suggested a diagnosis of renal cell carcinoma. However, the pre-ablation biopsy established an alternative diagnosis, revealing UTUC. Percutaneous cryoablation became an unorthodox treatment modality for the endophytic component of his UTUC followed by retrograde ureteroscopic laser fulguration. The patient was followed in 3 months, 6 months, then annually with cross sectional imaging by MRI, cystoscopy, urine cytology and renal function testing. After five years of follow-up, the patient did not encountered recurrence of UTUC or deterioration in renal function, thereby maintaining a stable eGFR.

CONCLUSION

Although evidence for nephron-sparing modalities for UTUC is mounting in recent literature, limited data still exists on cryotherapy as a line of treatment for urothelial carcinoma. We report successful management of a low-grade UTUC using cryoablation with the crucial aid of an initial renal biopsy and long-term follow-up. Our results provide insight into the role of cryoablation as a nephron-sparing approach for UTUC.

Measurement Analysis of Ice Ball Size during CT-Guided Cryoablation Procedures for Better Prediction of Final Ice Ball Size and Avoidance of Complications

Introduction Cryoablation is the destruction of living tissue by the application of extreme freezing temperature. There has been an increase in the use of cryoablation in the management of musculoskeletal lesions, in particular fibromatosis.

Aim This study aimed to measure the average and relative increase in size of the cryoablation ice ball after the first (10 minutes) and second freeze cycles (20 minutes) to accurately predict the size of the ice ball between first and second freezes to help prevent any unwanted damage of the nearby skin and neurovascular structures. This is especially important when ablating in relatively small body parts such as in the appendicular skeleton.

Material and Methods Eight patients treated with cryoablation over a 12-month period for fibromatosis were, included in the study. The size and volume of the ice ball were measured during the first and second cycle of cryoablation.

Results The average patient age of the cohort was 35.6 years old (min 28 and max 43). There was female predominance in the study (3:2, F:M). There was a significant increase (26%) in the linear dimensions and almost doubling in the volume of the ice ball between freeze cycles (p-value = 0.0037 for dimensions and p-value = 0.0002 for volumes).

Conclusion This pilot study is a preliminary attempt to predict the eventual size of the ice ball during cryoablation procedures when treating cases of fibromatosis. This should help in planning cryoablation to ensure decrease morbidity by preventing injury to adjacent critical structures (neurovascular bundle and skin).

In-situ cryo-immune engineering of tumor microenvironment with cold-responsive nanotechnology for cancer immunotherapy

Cancer immunotherapy that deploys the host's immune system to recognize and attack tumors, is a promising strategy for cancer treatment. However, its efficacy is greatly restricted by the immunosuppressive (i.e., immunologically cold) tumor microenvironment (TME). Here, we report an in-situ cryo-immune engineering (ICIE) strategy for turning the TME from immunologically "cold" into "hot". In particular, after the ICIE treatment, the ratio of the CD8+ cytotoxic T cells to the immunosuppressive regulatory T cells is increased by more than 100 times in not only the primary tumors with cryosurgery but also distant tumors without freezing. This is achieved by combining cryosurgery that causes "frostbite" of tumor with cold-responsive nanoparticles that not only target tumor but also rapidly release both anticancer drug and PD-L1 silencing siRNA specifically into the cytosol upon cryosurgery. This ICIE treatment leads to potent immunogenic cell death, which promotes maturation of dendritic cells and activation of CD8+ cytotoxic T cells as well as memory T cells to kill not only primary but also distant/metastatic breast tumors in female mice (i.e., the abscopal effect). Collectively, ICIE may enable an efficient and durable way to leverage the immune system for combating cancer and its metastasis.

Ablative Therapies for Breast Cancer: State of Art

Breast cancer (BC) is the most frequently diagnosed malignancy among women. In the past two decades, new technologies and BC screening have led to the diagnosis of smaller and earlier-stage BC (ESBC). Therefore, percutaneous minimally invasive techniques (PMIT) were adopted to treat patients unfit for surgery, women who refuse it, or elderly patients with comorbidities that could make surgery a difficult and life-threatening treatment. The target of PMIT is small-size ESBC with the scope of obtaining similar efficacy as surgery. Minimally invasive treatments are convenient alternatives with promising effectiveness, lower morbidity, less cost, less scarring and pain, and more satisfying cosmetic results. Ablative techniques used in BC are cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused ultrasound (US), and laser ablation. The aim of our study is to discuss the current status of percutaneous management of BC, evaluate the clinical outcomes of PMIT in BC, and analyze future perspectives regarding ablation therapy in BC.

Breast cancer cryoablation with radiologic-pathologic correlation

Breast cryoablation has become a viable option for the treatment of breast cancer in properly selected patient populations. With the increase in the use of cryoablation, post-treatment follow-up imaging and pathology has also gained increased importance. By using the proper imaging combination of diagnostic mammography, ultrasound and MRI, physicians are able to detect residual or recurrent malignancy and differentiate it from expected post-treatment findings. If suspicious imaging findings are seen, prompt biopsy and pathological diagnosis are essential. The pathologist must also be able to differentiate the expected post-procedural histological findings from those of recurrent or residual malignancy. These imaging and pathological findings must also be compared in order to ensure concordance and appropriate patient treatment.

Use of Diagnostic Imaging Modalities in Modern Screening, Diagnostics and Management of Breast Tumours 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

Breast radiologists and nuclear medicine specialists updated their previous recommendation/guidance at the 4th Hungarian Breast Cancer Consensus Conference in Kecskemét. A recommendation is hereby made that breast tumours should be screened, diagnosed and treated according to these guidelines. These professional guidelines include the latest technical developments and research findings, including the role of imaging methods in therapy and follow-up. It includes details on domestic development proposals and also addresses related areas (forensic medicine, media, regulations, reimbursement). The entire material has been agreed with the related medical disciplines.

Argon-Helium Cryoablation for Cutaneous Squamous Cell Carcinoma in the Elderly

Cutaneous squamous cell carcinoma (cSCC) is a common type of malignant neoplasm in non-melanoma skin cancer (NMSC). Most cases of simple cSCC are considered curable by surgical removal of the lesion. However, clinical treatments for cSCC with medium- or large-sized lesions are difficult. Meanwhile, the effectiveness of the treatments is not guaranteed, especially for elderly patients, because of an intolerance to surgical resection or other adjuvant modalities. In such cases, safe and effective treatments with excellent aesthetic outcomes are urgently needed. In this study, we reported 6 elderly cSCC patients with medium- or large-sized lesions treated with argon-helium cryoablation. The average age of all 6 patients was 78 years (range 72-85 years). They were all diagnosed with cSCC with a median tumor size of 5.8 cm (range 2.5-15.5 cm) and dermal invasion. Complete ablation was achieved in all cases after a single ablation session (2 freeze-thaw cycles). Patients experienced mild pain and hemorrhage after ablation, but the symptoms were manageable. One patient developed infection and fever because of extensive necrosis of the tumor, which was eventually cured after treatment. All patients obtained good cosmetic outcomes, and their quality of life improved significantly. In the 5-year follow-up study, 4 patients were alive while 2 patients died of unrelated diseases 3 years after cryotherapy. None of the 6 patients had a recurrence. These results suggested the feasibility of argon-helium cryoablation as a novel therapeutic strategy for elderly cSCC with medium- or large-sized lesions.

Tumor-Infiltrating Lymphocytes (TILs) as a Biomarker of Abscopal Effect of Cryoablation in Breast Cancer: A Pilot Study

Background

Morphological evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer is gaining momentum as an immunological biomarker. This experiment evaluates the role of TILs in distant tumors as a measure of abscopal effect from cryoablation of breast cancer.

Methods

BALB/c mice underwent bilateral orthotopic transplant with 4T1-12B (triple-negative) cells. At 2 weeks, left tumors were treated by either resection (standard of care group) or cryoablation (intervention group) followed by resection of the distant right tumors 1 week posttreatment. TIL scores were calculated from hematoxylin and eosin-stained sections and phenotyped for cytotoxic T-lymphocyte (CTL) markers by immunofluorescence. Primarily resected tumors served as baseline (Tbaseline), whereas resected distant right-sided served as the readout for abscopal effect (AbsRes or AbsCryo). Mice were monitored for tumor recurrence and metastasis.

Results

The AbsCryo had a significant mean (SD) increase in stromal (2.8 [1.1]%; p = 0.015) and invasive margin TILs (50 [12]%; p = 0.02) compared with TBaseline (1.0 [0]% and 31 [4.9]%, respectively). CTL phenotyping revealed a significant increase in mean (SD) CD8+ T cells (15.7 [12.1]; p = 0.02) and granzyme B (4.8 [3.6]; p = 0.048) for the AbsCryo compared with TBaseline (5.2 [4.7] and 2.4 [0.9], respectively). Posttreatment, the cryoablation group had no recurrence or metastasis, whereas the resected group showed local recurrence and lung metastasis in 40% of the mice. Postprocedure increase in TIL score of distant tumors was associated with decrease in tumor relapse (p = 0.02).

Conclusions

Cryoablation induced a robust tumor-specific TIL response compared with resection, suggesting an abscopal effect leading to the prevention of cancer recurrence and metastasis.

Cryoablation Without Excision for Low-Risk Early-Stage Breast Cancer: 3-Year Interim Analysis of Ipsilateral Breast Tumor Recurrence in the ICE3 Trial

BACKGROUND

The ICE3 trial is designed to evaluate the safety and efficacy of breast cryoablation, enabling women older than 60 years with low-risk early-stage breast cancers to benefit from a nonsurgical treatment and to avoid the associated surgical risks.

METHODS

The ICE3 trial is a prospective, multi-center, single-arm, non-randomized trial including women age 60 years or older with unifocal, ultrasound-visible invasive ductal carcinoma size 1.5 cm or smaller and classified as low to intermediate grade, hormone receptor (HR)-positive, and human epidermal growth factor receptor 2 (HER2)-negative. Ipsilateral breast tumor recurrence (IBTR) at 5 years was the primary outcome. A 3-year interim analysis of IBTR was performed, and the IBTR probability was estimated using the Kaplan-Meier method.

RESULTS

Full eligibility for the study was met by 194 patients, who received successful cryoablation per protocol. The mean age was 75 years (range, 55-94 years). The mean tumor length was 8.1 mm (range, 8-14.9 mm), and the mean tumor width was 7.4 mm (range, 2.8-14 mm). During a mean follow-up period of 34.83 months, the IBTR rate was 2.06% (4/194 patients). Device-related adverse events were reported as mild in 18.4% and moderate in 2.4% of the patients. No severe device-related adverse events were reported. More than 95% of the patients and 98% of the physicians reported satisfaction with the cosmetic results at the clinical follow-up evaluation.

CONCLUSIONS

Breast cryoablation presents a promising alternative to surgery while offering the benefits of a minimally invasive procedure with minimal risks. Further study within a clinical trial or registry is needed to confirm cryoablation as a viable alternative to surgical excision for appropriately selected low-risk patients.

Image-guided Microinvasive Percutaneous Treatment of Breast Lesions: Where Do We Stand?

Treatment of breast lesions has evolved toward the use of less-invasive or minimally invasive techniques. Minimally invasive treatments destroy focal groups of cells without surgery; hence, less anesthesia is required, better cosmetic outcomes are achieved because of minimal (if any) scarring, and recovery times are shorter. These techniques include cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused US, laser therapy, vacuum-assisted excision, and irreversible electroporation. Each modality involves the use of different mechanisms and requires specific considerations for application. To date, only cryoablation and vacuum-assisted excision have received U.S. Food and Drug Administration approval for treatment of fibroadenomas and have been implemented as part of the treatment algorithm by the American Society of Breast Surgeons. Several clinical studies on this topic have been performed on outcomes in patients with breast cancer who were treated with these techniques. The results are promising, with more data for radiofrequency ablation and cryoablation available than for other minimally invasive methods for treatment of early-stage breast cancer. Clinical decisions should be made on a case-by-case basis, according to the availability of the technique. MRI is the most effective imaging modality for postprocedural follow-up, with the pattern of enhancement differentiating residual or recurrent disease from postprocedural changes. ^©RSNA, 2021.

Inhibition of aquaporins as a potential adjunct to breast cancer cryotherapy

Cryoablation is an emerging type of treatment for cancer. The sensitization of tumors using cryosensitizing agents prior to treatment enhances ablation efficiency and may improve clinical outcomes. Water efflux, which is regulated by aquaporin channels, contributes to cancer cell damage achieved through cryoablation. An increase in aquaporin (AQP) 3 is cryoprotective, whereas its inhibition augments cryodamage. The present study aimed to investigate aquaporin (AQP1, AQP3 and AQP5) gene expression and cellular localization in response to cryoinjury. Cultured breast cancer cells (MDA-MB-231 and MCF-7) were exposed to freezing to induce cryoinjury. RNA and protein extracts were then analyzed using reverse transcription-quantitative PCR and western blotting, respectively. Localization of aquaporins was studied using immunocytochemistry. Additionally, cells were transfected with small interfering RNA to silence aquaporin gene expression and cell viability was assessed using the Sulforhodamine B assay. Cryoinjury did not influence gene expression of AQPs, except for a 4-fold increase of AQP1 expression in MDA-MD-231 cells. There were no clear differences in AQP protein expression for either cell lines upon exposure to frozen and non-frozen temperatures, with the exception of fainter AQP5 bands for non-frozen MCF-7 cells. The exposure of cancer cells to freezing temperatures altered the localization of AQP1 and AQP3 proteins in both MCF-7 and MDA-MD-231 cells. The silencing of AQP1, AQP3 and AQP5 exacerbated MDA-MD-231 cell damage associated with freezing compared with control siRNA. This was also observed with AQP3 and AQP5 silencing in MCF-7 cells. Inhibition of aquaporins may potentially enhance cryoinjury. This cryosensitizing process may be used as an adjunct to breast cancer cryotherapy, especially in the border area targeted by cryoablation where freezing temperatures are not cold enough to induce cellular damage.

Emerging photoacoustic and thermoacoustic imaging technologies for detecting primary and metastatic cancer and guiding therapy

In recent years, there has been a progressive trend towards less invasive technologies for detecting metastatic cancer and guiding therapy with the goal of lower morbidity, better outcomes, and superior cosmetic appearance than traditional methods. This mini-review examines three emerging noninvasive hybrid technologies for detecting primary cancer, metastasis and guiding thermal therapy. Real-time thermoacoustic imaging and thermometry potentially provides valuable and critical feedback for guiding focused microwave ablation therapy. Label-free photoacoustic monitoring of cancer cells is a promising clinical diagnostic and theranostic tool for detecting metastatic disease and monitoring the response to therapy. Finally, immunologically targeted gold nanoparticles combined with photoacoustic imaging is able to detect lymph node micrometastasis in mouse models of breast cancer. These emerging techniques have the potential to improve the decision to biopsy, provide more accurate prognosis, and enhance the efficacy of therapy for early and late stage cancers.

Cryoablation and Immunotherapy for Breast Cancer: Overview and Rationale for Combined Therapy

Cryoablation is a well-tolerated outpatient procedure that has been used to treat metastatic sites as well as small breast cancers in patients who are considered poor candidates for surgery. Recent studies suggest that cell disruption caused by cryoablation may increase the expression and immunogenicity of tumor neoantigens, which could enhance the ability of the immune system to recognize and attack cancer cells at both local and distant sites. Such an approach might broaden the role of immunotherapy for the treatment of breast cancer, which has previously demonstrated limited response to these agents, likely owing to the modest immunogenicity of most breast cancer subtypes. If cryoablation can induce a systemic tumor-specific response, it could enhance tumor susceptibility to immunotherapy agents. This review briefly summarizes the necessary components for generating an immune response against tumor cells, reviews the tumor microenvironment of breast cancer, describes the rationale for and limitations of immune checkpoint inhibition, highlights the potential for cryoablation to induce a systemic tumor-specific immune response, and describes the rationale for combining cryoablation and immune checkpoint inhibitors for the treatment of breast cancer. Keywords: Ablation Techniques, Breast, Neoplasms-Primary, Percutaneous, Tumor Microenvironment, Tumor Response, Ultrasonography © RSNA, 2021.

Breast Cancer Cryoablation: Assessment of the Impact of Fundamental Procedural Variables in an In Vitro Human Breast Cancer Model

INTRODUCTION

Breast cancer is the most prominent form of cancer and the second leading cause of death in women behind lung cancer. The primary modes of treatment today include surgical excision (lumpectomy, mastectomy), radiation, chemoablation, anti-HER2/neu therapy, and/or hormone therapy. The severe side effects associated with these therapies suggest a minimally invasive therapy with fewer quality of life issues would be advantageous for treatment of this pervasive disease. Cryoablation has been used in the treatment of other cancers, including prostate, skin, and cervical, for decades and has been shown to be a successful minimally invasive therapeutic option. To this end, the use of cryotherapy for the treatment of breast cancer has increased over the last several years. Although successful, one of the challenges in cryoablation is management of cancer destruction in the periphery of the ice ball as the tissue within this outer margin may not experience ablative temperatures. In breast cancer, this is of concern due to the lobular nature of the tumors. As such, in this study, we investigated the level of cell death at various temperatures associated with the margin of a cryogenic lesion as well as the impact of repetitive freezing and thawing methods on overall efficacy.

METHODS

Human breast cancer cells, MCF-7, were exposed to temperatures of -5°C, -10°C, -15°C, -20°C, or -25°C for 5-minute freeze intervals in a single or repeat freeze-thaw cycle. Samples were thawed with either passive or active warming for 5 or 10 minutes. Samples were assessed at 1, 2, and 3 days post-freeze to assess cell survival and recovery. In addition, the modes of cell death associated with freezing were assessed over the initial 24-hour post-thaw recovery period.

RESULTS

Exposure of MCF-7 cells to -5°C and -10°C resulted in minimal cell death regardless of the freeze/thaw conditions. Freezing to a temperature of -25°C resulted in complete cell death 1 day post-thaw with no cell recovery in all freeze/thaw scenarios evaluated. Exposure to a single freeze event resulted in a gradual increase in cell death at -15°C and -20°C. Application of a repeat freeze-thaw cycle (dual 5-minute freeze) resulted in an increase in cell death with complete destruction at -20°C and near complete death at -15°C (day 1 survival: single -15°C freeze/thaw = 20%; repeated -15°C freeze/thaw = 4%). Analysis of thaw interval time (5 vs 10 minute) demonstrated that the shorter 5-minute thaw interval between freezes resulted in increased cell destruction. Furthermore, investigation of thaw rate (active vs passive thawing) demonstrated that active thawing resulted in increased cell survival thereby less effective ablation compared with passive thawing (eg, -15°C 5/10/5 procedure survival, passive thaw: 4% vs active thaw: 29%).

CONCLUSIONS

In summary, these in vitro findings suggest that freezing to temperatures of 25°C results in a high degree of breast cancer cell destruction. Furthermore, the data demonstrate that the application of a repeat freeze procedure with a passive 5-minute or 10-minute thaw interval between freeze cycles increases the minimal lethal temperature to the -15°C to -20°C range. The data also demonstrate that the use of an active thawing procedure between freezes reduces ablation efficacy at temperatures associated with the iceball periphery. These findings may be important to improving future clinical applications of cryoablation for the treatment of breast cancer.

Real-time 3D thermoacoustic imaging and thermometry using a self-calibration technique

Thermoacoustic (TA) imaging is a modality where pulsed microwaves are used to generate ultrasound waves in tissue, which are highly correlated with temperature. This study uses a self-calibration approach to improve the estimation of temperature using 3D real-time TA thermometry in porcine tissue during localized heating. The self-calibration method estimated temperatures at eight embedded thermocouple locations with a normalized root-mean-square error of 3.25±2.08%. The results demonstrate that the method has the suitable accuracy and resolution to provide feedback control for breast cancer ablation therapy.

Cryoablation: A promising non-operative therapy for low-risk breast cancer

BACKGROUND

The aim of this study was to evaluate the feasibility of cryoablation for early-stage low-risk breast cancer without tumor resection.

METHODS

Women diagnosed with ER+, PR+, and HER2-infiltrating ductal carcinomas ≤1.5 cm were treated with cryoablation. The non-surgical procedure used a Visica® 2 Treatment System with ultrasound guidance for ablation of the tumor with a 1 cm margin. Patients were monitored at 6-month intervals by MRI, mammogram, and ultrasound.

RESULTS

Twelve patients with unifocal breast cancer were treated with cryoablation for local control without follow-up tumor resection. All patients received adjuvant endocrine therapy, and none had radiation. The median follow-up was 28.5 (range = 4-41) months with 11 patients having at least one six-month follow-up. All imaging modalities showed complete ablation of target zone 11/11 (100%). Four patients (33.3%) have been followed up for ≥ 2 years with no local failure or residual disease.

CONCLUSION

Cryoablation of early-stage low-risk (ER+, PR+, and HER2-) breast cancer is a safe alternative to surgery.

Fluorodeoxyglucose positron emission tomography/computed tomography findings after percutaneous cryoablation of early breast cancer

BACKGROUND

To document ¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings after percutaneous cryoablation for early breast cancer.

METHODS

Data of 193 consecutive patients who had undergone cryoablation for invasive ductal carcinoma or ductal carcinoma in situ ≤ 15 mm without a history of ipsilateral breast cancer, synchronous ipsilateral lesion, and with estrogen receptor positive/human epidermal growth factor 2 negative were enrolled. The imaging characteristics of the treated areas were evaluated and classified on CT images as one of two types: fatty mass or non-fatty mass type. The maximum standardized uptake value (SUVmax) of the initial post-cryoablation PET/CT, the CT type of the treated area and selected clinical factors (age, menopausal status, lesion area, breast density, timing of PET/CT) were retrospectively evaluated.

RESULTS

The median interval between cryoablation and the initial post-cryoablation PET/CT was 12 months. The median SUVmax of the treated area was 1.36. The CT findings of the treated area were classified as fatty mass type (n = 137, 71.0%) or non-fatty mass type (n = 56, 29.0%). The treated areas of patients with lower breast density, of older age, post-menopausal status, and lower radiation dose were significantly more likely to be of fatty mass type (P < 0.001). Non-fatty mass type averaged a significantly higher SUVmax than did fatty mass type.

CONCLUSIONS

Post-cryoablation PET/CT findings are of fatty or non-fatty mass type. A non-fatty appearance, which can show higher SUVmax, does not necessarily denote recurrence.

Liquid Metal Hybrid Platform-Mediated Ice-Fire Dual Noninvasive Conformable Melanoma Therapy

Cryoablation and photothermal therapy are anticancer therapeutic strategies that destroy tumors by external energy intervention of achieving extremely low temperature and very high temperature in a short time. Compared to traditional surgical resection, radiotherapy, and chemotherapy, they have the advantages of being minimally invasive and having less side effects. However, single cryoablation or photothermal therapy itself has limited therapeutic accuracy, which greatly restricts its clinical application. There is still a common phenomenon that the energy transport at the tumor target site cannot be accurately controlled in space and time dimensions, resulting in limited thermal effect and difficulty to form a conformable treatment area, which will result in low targeted killing efficiency, and tumor cells will become residual and undergo metastasis and recurrence. Herein, a multimodal therapy of cryoablation combined with photothermal therapy was proposed. To further enhance the therapeutic performance, a liquid metal hybrid platform, which is composed of a high-thermal-conductivity liquid metal paste and high-photothermal-conversion-efficiency liquid metal nanoparticles, is mediated for cryoablation and photothermal therapy. Cold and heat synergistic effects are realized through this multimodal therapy. Due to the liquid metal hybrid platform, enhanced antitumor efficacy is achieved in vitro and in vivo. More importantly, the liquid metal hybrid platform-mediated dual therapy is totally noninvasive and does not show obvious systemic toxicity. Collectively, this study has first realized ice (cryoablation)-fire (photothermal therapy) dual noninvasive therapy by one liquid metal platform and demonstrated superior antitumor effect for melanoma treatment. This work explores a new promising multimodal cancer therapy strategy based on the liquid metal platform, which has great potential application in cancer treatment in the future.

Implementing Breast Cryoablation in Practice

Breast cryoablation is becoming more commonplace as a minimally invasive percutaneous procedure that utilizes extreme cold to destroy targeted tissue and has been used to treat symptomatic fibroadenomas and early-stage breast cancer for over a decade with promising results. The practical considerations for implementing a breast cryoablation service include developing and communicating strategic and operational plans, training and privileging the proceduralist, selecting equipment, collaborating with referring clinicians, recruiting and navigating patients, and understanding billing considerations.

Cryoablation-activated enhanced nanodoxorubicin release for the therapy of chemoresistant mammary cancer stem-like cells

Anticancer nanodoxorubicin with targeting ability, thermal responsive and pH sensitive characteristic is fabricated. Nanodrug could realize controllable and enhanced drug release when cryoablation is applied at the target tumor site.

Cryoablation In The Management Of Breast Cancer: Evidence To Date

Cryoablation has been successfully used to treat various type of solid tumors, including breast carcinomas. This ablation method has the advantage of being a minimally invasive procedure useful in various clinical situations, including early breast cancer and metastatic breast cancer, when co-morbidities preclude the use of surgical treatment. However, due to the small sample size of the available studies, reliable and definitive conclusions on the usefulness of cryoablation in patients with breast cancer could not be drawn. In fact, many aspects necessitate to be elucidated, regarding technical issues, indications, efficacy, imaging follow-up, and possible advantages over other percutaneous ablative methods. This review article has the aim to clarify the current evidence supporting cryoablation of breast cancer, and discuss the future perspectives, including those arising from the new studies on immunological effects related to cryoablation.

Validation of a low-cost, carbon dioxide-based cryoablation system for percutaneous tumor ablation

Breast cancer rates are rising in low- and middle-income countries (LMICs), yet there is a lack of accessible and cost-effective treatment. As a result, the cancer burden and death rates are highest in LMICs. In an effort to meet this need, our work presents the design and feasibility of a low-cost cryoablation system using widely-available carbon dioxide as the only consumable. This system uses an 8-gauge outer-diameter needle and Joule-Thomson expansion to percutaneously necrose tissue with cryoablation. Bench top experiments characterized temperature dynamics in ultrasound gel demonstrated that isotherms greater than 2 cm were formed. Further, this system was applied to mammary tumors in an in vivo rat model and necrosis was verified by histopathology. Finally, freezing capacity under a large heat load was assessed with an in vivo porcine study, where volumes of necrosis greater than 1.5 cm in diameter confirmed by histopathology were induced in a highly perfused liver after two 7-minute freeze cycles. These results demonstrate the feasibility of a carbon-dioxide based cryoablation system for improving solid tumor treatment options in resource-constrained environments.

MRI Findings After Cryoablation of Primary Breast Cancer Without Surgical Resection

RATIONALE AND OBJECTIVES

To retrospectively evaluate findings on serial magnetic resonance imaging (MRI) after cryoablation for breast cancer lesions without subsequent surgical resection.

MATERIALS AND METHODS

This study was approved by the Institutional Review Board and the requirement to obtain informed consent waived. Ductal carcinoma in situ or invasive carcinoma ≤15 mm, nuclear grade 1 or 2, estrogen receptor positive/human epidermal growth factor 2 negative without lymph node metastasis were treated with cryoablation without subsequent excision. Two observers independently reviewed the first two postcryoablation MRIs for shape (none, focus-to-mass, or nonmass enhancement) and suspicion of residual disease (positive or negative). Fisher's exact or the Mann-Whitney U test was used to assess significance. Interobserver agreement on findings was evaluated by calculating κ values.

RESULTS

Fifty-four patients were enrolled. The first and second postcryoablation MRIs were performed 22-171 days and 82-487 days after cryoablation, respectively. Interobserver agreement ranged from fair to moderate (κ = 0.356-0.434). Observer 1 or 2 identified suspicious areas on the first postcryoablation MRI in seven cases (13.0%). These were significantly associated with focus-to-mass shape (vs non-focus-to-mass: nonmass enhancement or none) and residual disease or recurrence suspected by both observers (p < 0.001). There were no cases of both observers identifying suspicious findings on the second postcryoablation MRI.

CONCLUSION

Suspicious findings can be detected within the treated area at the first postcryoablation MRI. These can resolve during subsequent adjuvant therapies and follow-up.

Cryosurgery for primary breast cancers, its biological impact, and clinical outcomes

Recently, a number of new minimally invasive image-guided percutaneous ablation treatments, including cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused ultrasound, laser ablation, and irreversible electroporation have been developed. Several studies have shown the feasibility and safety of these cryoablation therapies for the treatment of benign breast tumors and small invasive breast cancer. Although the complete response rate of cryoablation for breast cancer is reported to be relatively good, most studies enrolled a small number of patients, and so reliable conclusions could not be drawn. In this review, we introduce the mechanisms of action of cryoablation, and summarize the current literature on the efficacy and safety of cryoablation for breast cancer. Cryoablation also induces an immunomodulatory effect, which is an interesting topic of research in the era of immune checkpoint inhibitors. Cryoablation for primary tumor may enhance the treatment effect of immune checkpoint inhibitors in patients with breast cancer. Further investigations of this new therapeutic strategy are needed.

The Evolving Role of Ultrasound Guided Percutaneous Laser Ablation in Elderly Unresectable Breast Cancer Patients: A Feasibility Pilot Study

Background and Objectives

Breast-conserving surgery represents the standard of care for the treatment of small breast cancers. However, there is a population of patients who cannot undergo the standard surgical procedures due to several reasons such as age, performance status, or comorbidity. Our aim was to investigate the feasibility and safety of percutaneous US-guided laser ablation for unresectable unifocal breast cancer (BC).

Methods

Between December 2012 and March 2017, 12 consecutive patients underwent percutaneous US-guided laser ablation as radical treatment of primary inoperable unifocal BC.

Results

At median follow-up of 28.5 months (range 6-51), no residual disease or progression occurred; the overall success rate for complete tumor ablation was therefore 100%. No significant operative side effects were observed, with only 2 (13.3%) experiencing slight to mild pain during the procedure, and all patients complained of a mild dull aching pain in the first week after procedure.

Conclusions

Laser ablation promises to be a safe and feasible approach in those patients who are not eligible to the standard surgical approach. However, longer follow-up results and larger studies are strongly needed.

Advances in breast intervention: where are we now and where should we be?

In the past four decades, a variety of methods for minimal or non-invasive diagnosis and treatment of breast cancer have been introduced. Although breast imaging has become more and more specific for diagnosis, specimen biopsy with histopathological confirmation is still necessary. Core-needle biopsy under ultrasound guidance is the appropriate first choice for the diagnosis of most lesions. Fine-needle aspiration is of interest for identification of the presence of metastatic disease in abnormal lymph nodes. For microcalcifications, vacuum-assisted biopsy is recommended, especially with stereotactic guidance. In recent years different therapeutic techniques have been developed for the treatment of solid lesions, including breast cancer. Certainly, with the improvement of technology and medical scientific progress, it is becoming more common to use minimal- or non-invasive therapies. The proposed minimally invasive techniques may offer complete treatment of breast cancer, with better cosmetic results, less psychological stress, and shorter hospital stays. In this article, the strengths and weaknesses of the different diagnostic and therapeutic techniques are presented, and promising techniques for the future are discussed.

Cryoablation of Abdominal Wall Endometriosis: A Minimally Invasive Treatment

OBJECTIVE

The objective of this study is to present cryoablation as a minimally invasive definitive treatment for abdominal wall endometriosis. We describe our experience with the outpatient application of cryoablation to treat symptomatic abdominal wall endometriosis in three patients.

CONCLUSION

This feasibility study shows that minimally invasive cryoablation treated abdominal wall endometriosis in three patients and provided a prompt clinical response.

Characterization of the cryoablation-induced immune response in kidney cancer patients

Cryoablation is one of treatment modalities for kidney cancer and is expected to induce strong local immune responses as well as systemic T-cell-mediated immune reactions that may lead to the regression of distant metastatic lesions. Thus, the characterization of T cell repertoire and immune environment in tumors before and after treatment should contribute to the better understanding of the cryoablation-induced anticancer immune responses. In this study, we collected tumor tissues from 22 kidney cancer patients, before cryoablation and at 3 mo after cryoablation. In addition, blood samples were collected from 14 patients at the same time points. We applied a next generation sequencing approach to characterize T cell receptor β (TCRB) repertoires using RNAs isolated from tumor tissues and peripheral blood mononuclear cells. TCRB repertoire analysis revealed the expansion of certain T cell clones in tumor tissues by cryoablation. We also found that proportions of abundant TCRB clonotypes (defined as clonotypes with ≥ 1% frequency among total TCRB reads) were significantly increased in the post-cryoablation tissue samples than those of pre-cryoablation tumor samples. Some of these TCRB clonotypes were found to be increased in peripheral blood. Expression analysis of immune-related genes in the tissues of pre- and post-cryoablation showed significantly elevated transcriptional levels of CD8⁺ , CD4⁺ , Granzyme A (GZMA), and CD11c along with a high CD8/FOXP3 ratio in the post-cryoablation tissue samples. Our findings revealed that cryoablation could induce strong immune reactions in tumors with oligoclonal expansion of antitumor T cells, which circulate systemically.