Percutaneous image-guided ablation of breast tumors: an overview

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.

Interventional Techniques for Bone and Musculoskeletal Soft Tissue Tumors: Current Practices and Future Directions - Part I. Ablation

Musculoskeletal (MSK) image-guided oncologic intervention is an established field within radiology. Numerous studies have described its clinical benefits, safety, cost effectiveness, patient satisfaction, and improved quality of life, thereby establishing image-guided oncologic intervention as a preferred pathway in treating patients presenting with specific benign MSK tumors. But there is a paradigm shift on the horizon because these techniques may also support established pillars (surgery, systemic treatment, radiotherapy) in the treatment of malignant MSK tumors. Unlike benign tumors, where they are used as primary therapy lines with curative intent, such interventions can be selected for malignant tumors as adjuvant treatment in painful or unstable bone or soft tissue lesions or as more palliative therapy strategies. Using examples from our clinical practices, we elaborate on the benefits of applying a multidisciplinary approach (traditionally involving MSK radiologists, oncologists, orthopaedic surgeons, microbiologists, pathologists, physiotherapists, and pain management experts), ideally within a sarcoma treatment center to deliver a patient-specific therapy plan and illustrate methods to assess the benefits of this model of care.In this article, we review the current repertoire of ablation techniques, demonstrate why such procedures offer value-based alternatives to conventional treatments of specific tumors, and reflect on future directions. Additionally, we review the advantages and limitations of each technique and offer guidance to improve outcomes.

Safety and Efficacy of Ultrasound-Guided Cryoablation for Benign Breast Fibroepithelial Lesions

OBJECTIVE

The purpose of this study is to evaluate the safety and efficacy of cryoablation for benign breast fibroepithelial lesions (FELs) that otherwise warrant surgical excision, including symptomatic fibroadenomas, growing fibroadenomas, and cellular FELs.

METHODS

All patients from 2016-2018 who had ultrasound-guided cryoablation of a symptomatic and/or growing fibroadenoma or cellular fibroepithelial lesion were reviewed. The electronic medical record was reviewed for any procedure-related complications and reduction in mass volume by ultrasound and was recorded to assess for efficacy. Patients were surveyed using a seven-point Likert scale to assess satisfaction with the procedure and a ten-point visual analog pain scale to assess level of discomfort.

RESULTS

Twenty-four women (average age 37.1 years, range 19-57 years) with 26 FELs were treated with no adverse events and 100% technical success. Thirteen cellular FELs and 13 symptomatic and/or growing fibroadenomas were ablated. Twenty-two patients had an average imaging follow-up of 11.7 months (range 5-23 months), and 18 patients completed the follow-up survey. There was 92% (22/24) clinical success, defined as a greater-than-50% reduction in mass volume. Average reduction in mass volume was 86% overall. Eighty-five percent (17/20) would recommend the procedure to others and reported pain during the procedure to be minimal (average 2.4 out of 10) with overall satisfaction rating of 6.2 out of 7. Twelve symptomatic masses demonstrated a significant reduction in pain after cryoablation (P = 0.01).

CONCLUSION

Cryoablation is a safe and efficacious minimally invasive nonsurgical alternative for the treatment of benign breast FELs.

Initial Institutional Experience With Cryoablation Therapy for Breast Fibroadenomas: Technique, Molecular Science, and Post-Therapy Imaging Follow-up

Cryoablation is a safe and effective nonsurgical treatment for breast fibroadenomas (FAs). The treatment response is inversely related to the tumor size, with lesions less than 2 cm showing an optimal response. Ultrasound (US) imaging follow-up of the ablated tumor is recommended at 6-month intervals for 2 years at our institution. Although a decrease in the size of the FA clinically and on US imaging is the expected treatment response, variations can be seen. Knowledge of typical US changes over time is imperative to prevent unnecessary rebiopsy or excision in patients who have undergone cryoablation. We will review the initial patient selection criteria, cryoablation technique, and US findings at regular follow-up intervals after cryoablation of FAs through a series of cases treated at our institution.

Clinical application of ultrasound-guided percutaneous microwave ablation for benign breast lesions: a prospective study

BACKGROUND

Background: Benign breast lesions are the most common diseases in adult women, which have been treated with minimally invasive therapies in recent years. Little is known about the feasibility of Microwave ablation (MWA) for benign breast lesion treatment. The primary aim of this prospective study was to evaluate the safety and efficiency of MWA as a potential therapeutic option for benign breast lesions in a single-center cohort study.

METHODS

Women with possibly benign breast lesions based on an ultrasound (US) assessment who were scheduled to undergo MWA between November 2014 to July 2018 were included in the study. The patients underwent conventional US to measure the size of the lesion, Doppler US to assess the vascularity of the lesion, elastography to evaluate the stiffness of the mass, core needle biopsy of suspicious lesions, contrast-enhanced US to help determine the treatment plan and eventually MWA of the lesion. Lesions were followed at one, three, six, twelve and eighteen months after treatment to with the same imaging modalities.

RESULTS

A total of 314 women aged 17 to 69 years old (mean = 36.9 ± 9.9 years) with 725 benign breast lesions (mean of maximum diameter = 10.86 ± 5.40 mm) were included. The frequency of palpable mass, pain and nipple discharge significantly decreased after treatment. Complete ablation rate was 97.8%, immediately after ablation, which increased to 100% after supplementary ablation of the 15 cases with incomplete ablation. Blood flow classification and lesion's volume also showed a significant decrease, while both volume reduction ratio and disappearance rate significantly increased following treatment. The elasticity score of the lesions showed fluctuations across different follow-up intervals. None of the patients experienced major complications and the 1% who had mild symptoms were successfully treated.

CONCLUSION

MWA treatment is shown to be safe and efficient and has the potential to be considered as an alternative first line treatment for benign breast lesions.

Microwave ablation of benign breast tumors: a prospective study with minimum 12 months follow-up

PURPOSE

This prospective study was to evaluate clinical outcomes of microwave ablation (MWA) of benign breast tumors with minimum 12 months follow up.

METHODS

With approval of the institutional ethics committee and written informed consent, 56 patients with 107 biopsy-proved breast benign tumors were recruited from November, 2013 to April, 2017. MWA with ultrasound (US) guidance was performed under local anesthesia. During the procedure, pull-back technique was used for tumors larger than 1.0 cm in diameter and hydro-dissection technique was used for tumors adjacent to skin, pectoralis and areola. Clinical outcomes were followed up by physical examination and medical images including US, contrast enhanced US and MR.

RESULTS

The maximum diameter of these tumors was 1.6 ± 0.8 cm. MWA was successfully performed with the median 120 s of duration (ranging 20-1100 s). Technical success was achieved in all patients. At the median follow-up of 20.5 months (ranging 12-53 months), the mean volume reduction ratios (mVRRs) of tumors were 77.1 ± 8.2%, 84.3 ± 10.6%, 93.3 ± 8.2% at follow-up of 12, 18, 24 months (p < .0001), respectively. Compared with 92% of masses were palpable before ablation, mass palpabilities were 40%, 11%, 5% at follow-up of 12, 18, 24 months (p < .001), respectively. Cosmetic satisfaction was reported excellent or good in 100% of patients.

CONCLUSIONS

As a safe and effective minimally invasive modality for inactivating benign breast tumors in situ, MWA achieved optimistic clinical outcomes on volume reduction and cosmetic satisfaction after minimum 12 months follow-up.

Can Incidental Vascular Calcifications at Mammography be Used as a Screening Biomarker for Heart and Kidney Disease?

Mammography is a screening test with extensive international application and financial infrastructure promoting accessibility and affordability. Designed specifically to detect microcalcifications, mammography is powered to detect calcifications in vessel walls. Breast arterial calcifications (BAC) are one of the most common incidental findings documented by mammography. This review considers the literature regarding BAC in relation to cardiovascular disease (CVD) and its risk factors. The aim is to assess the possibility of using BAC as an early surrogate imaging biomarker of CVD.

Successful cryoablation of breast cancer

The current standard of care for screen-detected breast cancers is surgical excision. Cryotherapy is a promising non- surgical alternative treatment for these cancers and is performed under local anesthesia as an outpatient, circumventing the risks that come with an operation. New research also shows promising results for the treatment of breast cancer when cryotherapy is combined with immune modulation as it may help prevent tumor recurrence. We herein report a case of breast cancer treated successfully with cryoablation. A brief literature review of cryoablation as a treatment for breast cancer is added.

Ultrasound-guided percutaneous microwave ablation for benign breast lesions: evaluated by contrast-enhanced ultrasound combined with magnetic resonance imaging

Background

Minimally invasive ablative techniques in the treatment of breast tumor has become popularly in recent years.

Methods

We analyzed gray-scale and contrast-enhanced ultrasound (CEUS) features of 205 microwave ablated breast benign lesions from 182 consecutive patients, compared with magnetic resonance imaging (MRI) and histopathology findings. The follow-up was implemented at 3, 6 and 12 months after the ablation treatment.

Results

Before the MWA, the mean of largest diameter and volume of the lesions were 14.41±6.54 and 3,224±961 mm³, respectively. However, those of the lesions respectively were 8.48±6.30 and 2,116±732 mm³ one year after the treatment. The longest diameter and the volume of the ablative lesions were gradually decreased 3, 6 or 12 months after the MWA. 44 (/205, 21.5%) ablative lesions were disappeared one year after the MWA. One hundred and forty-two (/205, 69.3%) ablative lesions presented a hypoechoic halo surrounding it on gray-scale US after the MWA. The success rate of the MWA treatment in the benign breast lesion was 87.32% and 82.93% evaluated by CEUS and enhanced MRI, respectively. During the ablation, no patient had serious complications, such as hemorrhage, serious pain and fat necrosis, etc.

Conclusions

Microwave ablation was a safe and efficient method in the treatment of the benign breast tumors. CEUS and enhanced MRI could accurately assess whether the MWA treatment is effective.

Interventional radiology in breast cancer

Molecular profiling of metastatic disease may greatly influence the systemic therapy recommended by oncologists and chosen by patients, allowing treatment to be more targeted. Comprehensive care of patients with advanced breast cancer now includes percutaneous image-guided biopsy if this has the potential to influence systemic treatment [1]. Interventional radiologists can contribute significantly to the care of patients affected by breast cancer, in diagnostic and supportive procedures and importantly also in treatment. Interventional radiologists carry out image guided percutaneous biopsies not only of the primary tumour but also of metastases. They insert percutaneous ports and tunnelled central venous catheters. They ablate painful bone metastases, and can treat or prevent pathological fractures. Most importantly they can ablate liver metastases in patients with limited or oligometastatic disease. The inhomogeneity and variety of cell populations in metastatic tumours from breast cancer, which is an important consideration in systemic therapy, is not an important consideration in the treatment of metastatic tumours using percutaneous ablative techniques, which are the major focus of this article. The treatment of primary tumours in the breast is also being explored, but is considered in its infancy at this stage.

Ultrasound guided percutaneous microwave ablation of benign breast lesions

The benign breast lesions (BBLs) share a high incidence for women and therapy methods with minimal invasion and better cosmetic outcome are thirsted for. In this study, 122 patients with 198 biopsy-proved BBLs were enrolled. Ultrasound (US)-guided microwave ablation (MWA) was performed with local anesthesia from November, 2013 to April, 2016. The mean longest tumor size assessed was 1.6±0.7 cm (ranging 0.7-4.9 cm). MWA was successfully performed in all cases including 85 lesions adjacent to the skin, pectoralis and areola. The mean ablation time was 3.2mins (ranging 0.5-18.3 mins). 99.5% of BBLs showed complete ablation when assessed by magnetic resonance imaging and 100% of them by US. At the median 14-month follow-up, the BBLs were not palpable in 45.9 % of the cases (palpable in 90.2 % of the cases before MWA) and the mean volume reduction ratio was 78.4±33.5% for total lesions and 89.3±20.8%, 84.7±27.6% and 55.9±32.9% for ≤1.0 cm, 1.1-2.0cm and >2.0 cm lesions in 12-month follow-up, respectively. Cosmesis were reported as good or excellent in 100 % by physician and patients. No side effect was found. The MWA of the BBLs proved feasible and effective, while showing meaningful reduction in volume, palpability and cosmetic satisfying outcomes.

Percutaneous image-guided cryoablation: current applications and results in the oncologic field

Percutaneous imaging-guided cryoablation (PICA) is a recently developed technique, which applies extreme hypothermia to destroy tumours under close imaging surveillance. It is minimally invasive, safe, repeatable, and does not interrupt or compromise other oncologic therapies. It presents several advantages over more established heat-based thermal ablation techniques (e.g. radiofrequency ablation; RFA) including intrinsic analgesic properties, superior monitoring capability on multi-modal imaging, ability to treat larger tumours, and preservation of tissue collagenous architecture. There has been a recent large increase in reports evaluating the utility of PICA in a wide range of patients and tumours, but systematic analysis of the literature is challenging due to the rapid pace of change and predominance of extensively heterogeneous level III studies. The precise onco-therapeutic role of PICA has not been established. This narrative review outlines the available evidence for PICA in a range of tumours. Current indications include curative therapy of small T1a renal tumours; curative/palliative therapy of small primary/secondary lung tumours where RFA is unsuitable; palliation of painful bone metastases; and urologic treatment of organ-confined prostate cancer. There is growing evidence to support its use for small hepatic tumours, and encouraging results have been obtained for breast tumours, extra-abdominal desmoid tumours, and management of higher-stage tumours and oligometastatic disease. However, the overall evidence base is weak, effectively restricting PICA to cases where standard therapy and RFA are unsuitable. As the technique and evidence continue to mature, the benefits of this emerging technique will hopefully become more widely available to cancer patients in the future.

Evidence-based medical oncology and interventional radiology paradigms for liver-dominant colorectal cancer metastases

Colorectal cancer metastasizes predictably, with liver predominance in most cases. Because liver involvement has been shown to be a major determinant of survival in this population, liver-directed therapies are increasingly considered even in cases where there is (limited) extrahepatic disease. Unfortunately, these patients carry a known risk of recurrence in the liver regardless of initial therapy choice. Therefore, there is a demand for minimally invasive, non-surgical, personalized cancer treatments to preserve quality of life in the induction, consolidation, and maintenance phases of cancer therapy. This report aims to review evidence-based conceptual, pharmacological, and technological paradigm shifts in parenteral and percutaneous treatment strategies as well as forthcoming evidence regarding next-generation systemic, locoregional, and local treatment approaches for this patient population.