Pilot Trial of Cryoprobe-Assisted Breast-Conserving Surgery for Small Ultrasound-Visible Cancers

Reducing the Risk of Needle Tract Seeding or Tumor Cell Dissemination during Needle Biopsy Procedures

PURPOSE

Many women fear that breast needle biopsies increase the risk of cancer spread. The purpose of this review article is to discuss the breast cancer literature regarding the risk of needle-biopsy-induced cancer cell displacement and its impact on local and regional recurrence and breast cancer survival.

METHODS

A literature review is performed to discuss the risks and mitigation of needle-biopsy-induced cancer cell displacement.

RESULTS

Needle-biopsy-induced cancer cell displacement is a common event. The risk is influenced by the biopsy technique and the breast cancer type. Evidence suggests that the risk of needle-biopsy-induced cancer cell displacement may potentially increase the odds of local recurrence but has no impact on regional recurrence and long-term survival.

CONCLUSIONS

Technical modifications of needle biopsy procedures can reduce the risk of breast needle-biopsy-induced cancer cell displacement and potentially reduce the risk of local recurrence, especially in patients for whom whole breast radiation is to be omitted.

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.

Optimal localization strategies for non-palpable breast cancers –A network meta-analysis of randomized controlled trials

Purpose

Mammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of non-palpable breast cancer localization.

Methods

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

Results

24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079–0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069–0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050–0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001–0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods.

Conclusion

USGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for re-operation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.

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Ultrasound-guided (USGL) and anchor-guided (AGL) localization had optimal outcomes.

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These methods significantly lowered margin positivity (odds ratio: 0.192 & 0.229).

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However, small sample sizes in trials evaluating USGL and AGL limit these results.

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Operation duration, complications, or specimen data were comparable for all methods.

Novel wire-free techniques for localization of impalpable breast lesions-A review of current options

Localization methods for breast lesions including cancers have changed and advanced since their inception. Currently, the most widely used technique in the United Kingdom is the image-guided hook wire localizer developed in the 1970s. It remains as the gold standard for localization of impalpable breast tumors. Besides its advantages, there are some disadvantages associated with this technique. In recent years, novel wire-free techniques (eg, Magseed^® , SCOUT^® , and LOCalizer™) have been developed to not only localize impalpable breast lesions but also negate the disadvantages of wire localization. This article reviews the variety of techniques from their origins to the most recent advancements that are used to localize breast lesions. The future is heading toward non-wire technology and wire localization may then be reserved for special cases.

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.

Minimally invasive ablative techniques in the treatment of breast cancer: a systematic review and meta-analysis

PURPOSE

Breast-conserving surgery is effective for breast cancer treatment but is associated with morbidity in particular high re-excision rates. We performed a systematic review and meta-analysis to assess the current evidence for clinical outcomes with minimally invasive ablative techniques in the non-surgical treatment of breast cancer.

METHODS

A systematic search of the literature was performed using PubMed and Medline library databases to identify all studies published between 1994 and May 2016. Studies were considered eligible for inclusion if they evaluated the role of ablative techniques in the treatment of breast cancer and included ten patients or more. Studies that failed to fulfil the inclusion criteria were excluded.

RESULTS

We identified 63 studies including 1608 patients whose breast tumours were treated with radiofrequency (RFA), high intensity focussed ultrasound (HIFU), cryo-, laser or microwave ablation. Fifty studies reported on the number of patients with complete ablation as found on histopathology and the highest rate of complete ablation was achieved with RFA (87.1%, 491/564) and microwave ablation (83.2%, 89/107). Short-term complications were most often reported with microwave ablation (14.6%, 21/144). Recurrence was reported in 24 patients (4.2%, 24/570) and most often with laser ablation (10.7%, 11/103). The shortest treatment times were observed with RFA (15.6 ± 5.6 min) and the longest with HIFU (101.5 ± 46.6 min).

CONCLUSION

Minimally invasive ablative techniques are able to successfully induce coagulative necrosis in breast cancer with a low side effect profile. Adequately powered and prospectively conducted cohort trials are required to confirm complete pathological ablation in all patients.

Cryosurgery for Breast Cancer

As the majority of breast cancers present as small non-palpable lesions, alternatives for surgical lumpectomy come into consideration. Breast tumor ablation without surgical excision may be a less morbid procedure without sacrificing cancer control. Cryosurgery is one of several ablative options for the treatment of small unifocal breast cancer. The potential advantages include avoidance of a surgical procedure, less overall discomfort, improved cosmesis, quicker recovery and the prospect of overall cost benefits. Clinical experience in 29 patients is reviewed demonstrating effectiveness in properly chosen patients. A comparison of ablation methods is discussed. Finally, future research of the role of cryosurgery in the management of breast cancer is described.

Surgical treatment of nonpalpable primary invasive and in situ breast cancer

Breast cancer is the most-common cancer among women worldwide, and over one-third of all cases diagnosed annually are nonpalpable at diagnosis. The increasingly widespread implementation of breast-screening programmes, combined with the use of advanced imaging modalities, such as magnetic resonance imaging (MRI), will further increase the numbers of patients diagnosed with this disease. The current standard management for nonpalpable breast cancer is localized surgical excision combined with axillary staging, using sentinel-lymph-node biopsy in the clinically and radiologically normal axilla. Wire-guided localization (WGL) during mammography is a method that was developed over 40 years ago to enable lesion localization preoperatively; this technique became the standard of care in the absence of a better alternative. Over the past 20 years, however, other technologies have been developed as alternatives to WGL in order to overcome the technical and outcome-related limitations of this technique. This Review discusses the techniques available for the surgical management of nonpalpable breast cancer; we describe their advantages and disadvantages, and highlight future directions for the development of new technologies.

Percutaneous Image-Guided Cryoablation of Breast Cancer: A Systematic Review

A systematic review of the clinical safety and efficacy of percutaneous breast cancer cryoablation was performed. Of 202 papers screened, seven matched the inclusion criteria. Cryoablation was mainly performed under ultrasound guidance, and on average two cryoprobes were used. Complete local tumor control was noted in 73% of patients (mean follow-up, 8 mo). No major complications were noted. The cosmetic outcome was satisfactory. Breast cancer cryoablation is safe, although local tumor control is suboptimal. The best results are achieved with small (<15 mm) ductal tumors treated by application of multiple cryoprobes.

Cryosurgery in the treatment of women with breast cancer-a review

Cryoablation could be an alternative to surgical excision of breast cancer. The cytotoxic potential of cryosurgery has been shown in both animal models and studies conducted on humans. There are several advantages to be gained from ablation performed at very low temperatures and these include the method's simplicity, lack of pain, low morbidity, cost-effectiveness, and potential for positive cryo-immunologic effects. This manuscript reviews data concerning the use of cryoablation in the treatment of breast cancer.

Cryotherapy for breast cancer: a feasibility study without excision

PURPOSE

To assess the feasibility of percutaneous multiprobe breast cryoablation (BC) for diverse presentations of cancers that remained in situ after BC.

MATERIALS AND METHODS

After breast magnetic resonance (MR) imaging and thorough consultation, patients underwent BC after giving informed consent. This study was approved by the institutional review board. In 12 BC sessions, 22 breast cancer foci (stages I-IV) were treated in 11 patients who refused surgery by using multiple 2.4-mm cryoprobes. Five patients had recurrent disease and six had new diagnoses. With use of only local anesthesia, six patients were treated with ultrasonographic (US) guidance and five were treated with both computed tomographic (CT) and US guidance. Saline injections and warming bags were used to protect the skin. Procedure success was defined as 1 cm visible ice beyond all tumor margins. MR imaging and/or clinical follow-up were available for up to 72 months after BC.

RESULTS

US produced sufficient ice visualization for small tumors, whereas CT helped confirm overall ice extent. The mean pretreatment breast tumor diameter was 1.7 cm +/- 1.2 (range, 0.5-5.8 cm), and an average of 3.1 cryoprobes produced 100% procedural success with mean ice diameters of 5.1 cm +/- 2.2 (range, 2.0-10.0 cm). No significant complications, retraction, or scarring were noted. Biopsies at the margins of the cryoablation site immediately after BC and at follow-up were all negative. No local recurrences have been noted at an average imaging follow-up of 18 months.

CONCLUSIONS

In conjunction with thorough pre- and postablation MR imaging, CT/US-guided multiprobe BC safely achieved 1 cm visible ice beyond tumor margins with minimal discomfort, good cosmesis, and no short-term local tumor recurrences.

Pathologic evaluation of cryoprobe-assisted lumpectomy for breast cancer

Cryoprobe-assisted lumpectomy is a relatively new technique that converts nonpalpable carcinomas into well-defined, palpable ones by creating an ice ball under ultrasonographic guidance, thus eliminating the need for preoperative needle localization. We evaluated the effect of cryoprobe-induced freezing on tumor tissue, peritumoral tissue, and margin status in 6 cases of cryoprobe-assisted lumpectomy performed for infiltrating ductal carcinoma. Immunohistochemical stains for estrogen and progesterone receptors and the proliferation marker Ki-67 were performed on 4 cases and results compared with those of the pretreatment biopsy specimens. Although it was possible to recognize the tumor as infiltrating carcinoma in all cases, the alteration in tumor morphology interfered with tumor grading, distinguishing in situ and invasive components, and assessment of mitoses and lymphovascular invasion. The expression of estrogen and progesterone receptors was greatly reduced, whereas the Ki-67 staining was not significantly different when compared with pretreatment biopsy specimens. The "cryoprobe effect" did not interfere with evaluation of the margins and surrounding breast tissue.

Breast Surgery Techniques: Preoperative Bracketing Wire Localization by Surgeons

With the development of expertise in image guidance for breast surgery, many surgeons now perform preoperative wire localization themselves. Use of a single wire versus multiple wires to bracket a radiographic breast abnormality has previously been described, although benefits of this technique based on clinical outcomes such as margin status, tissue volume removed, and re-excision rates have not been established. This study is a retrospective analysis of wire-localized breast biopsies performed by 14 surgeons over 29 months; stereotactic and ultrasound guidance were used. During this time, 489 wire localizations were done, of which 159 used multiple wires. Two hundred eleven of these biopsies were done for malignant disease, 86 using multiple wires. After controlling for tumor node metastases stage, single and multiple wire placements were compared using endpoints of margin status, need for re-excision, and total volume of tissue removed. Neither margin status nor re-excision was related to the number of wires placed. However, the number of wires placed was significantly related to the total volume of tissue removed. Use of more than one localizing wire was associated with greater volume of tissue removal (measured in centimeters cubed) in benign disease (46 vs 25, P < 0.001), equivalent volumes in stage 0 disease (73 vs 67), less volume in stage 1 disease (113 vs 164), and less volume in stages 2 through 4 (158 vs 207, P = 0.03). Outcomes based on surgeon case volume during the study period demonstrated that low- (1–40), medium- (41–80), and high-volume (>80) surgeons did not differ in the type or stage of breast pathology treated. Surgeons with high case volumes were more likely to place multiple localizing wires ( P < 0.001) and were more likely to do a breast-conserving procedure if re-excision was performed ( P < 0.018). Surgeons with low case volumes were more likely to perform a re-excision ( P < 0.025). Surgeon experience has a positive impact on quality outcome measures such as performance of a definitive procedure at the time of initial surgery and use of breast-conserving procedures at the time of re-excision. Multiple wire localization can be used to significantly reduce the volume of breast tissue removed in malignant disease without sacrificing margin status or increasing the need for future re-excision.

Use of Ultrasound in Breast Surgery

The use of ultrasound has grown tremendously since it was introduced in 1951. This article describes use of this modality in patients who have breast disease.

Breast interventions: a primer for interventional radiologists

Breast cancer is the second leading cause of cancer related deaths in the United States. The area of breast interventions has benefited from recent advances in devices and imaging quality. Ultrasound, MRI, and stereotactic guided vacuum assisted and mechanical rotating stick freeze biopsy are the preferred methods for histologic diagnosis of breast lesions. Ablation techniques are available for the treatment of benign and malignant breast disease. The MammoSite balloon catheter can be placed percutaneously for delivering high dose short term brachytherapy. Interventional Radiologists can and should perform all of these procedures to improve the quality of women's health.

Locoregional therapy of breast cancer: maximizing control, minimizing morbidity

The goal of locoregional therapy in breast cancer has remained unchanged for a century: the eradication of all malignant cells from the breast and draining lymph nodes, hopefully prior to them having spread to distant organs. However, how we accomplish this goal has changed dramatically over this time period and our success in achieving this goal has been greatly enhanced by improvements in breast imaging and systemic therapies. The therapeutic importance of surgery and radiation has been underestimated in recent years and is thought to have minimal impact on long-term outcome. More recent data have reputed this contention and the relationship between local control and survival in breast cancer is becoming increasingly apparent. This article will review the importance of attaining optimum local control with minimum morbidity and examine where the future of locoregional therapy of breast cancer may lie.

Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors

BACKGROUND

This study compared the surgical results of 2 localization methods-cryo-assisted localization (CAL) and needle-wire localization (NWL)-in patients undergoing breast lumpectomy for breast cancer.

METHODS

A total of 310 patients were treated in an institutional review board-approved study with 18 surgeons at 17 sites. Patients were randomized 2:1 to undergo either intraoperative CAL or NWL. A cryoprobe was inserted under ultrasound guidance in the operating room and an ice ball created an 8- to 10-mm margin around the lesion. The palpable ice ball then was dissected. NWL was placed according to institutional practice and resection was performed in a standard fashion. Surgical margins, complications, re-excisions, tissue volume, procedure times, ease of localization, specimen quality, and patient satisfaction were evaluated. Positive margins were defined as any type of disease present 1 mm or less from any specimen edge.

RESULTS

Positive margin status did not differ between the 2 groups (28% vs. 31%). The volume of tissue removed was significantly less in the CAL group (49 vs. 66 mL, P = .002). Re-excisions were similar in both groups. CAL was superior in ease of lumpectomy, quality of specimen, acute surgical cosmesis, short-term cosmesis, patient satisfaction, and overall procedure time for the patient. CAL had a lower invasive positive margin rate (11% vs. 20%, P = .039) but a higher observed ductal carcinoma in situ-positive margin rate (30% vs. 18%, approaching statistical significance, P = .052).

CONCLUSIONS

CAL is a preferred alternative to standard wire localization because it provides a palpable template, removes less tissue and improves cosmesis, decreases overall procedure time, and is more convenient for the patient and surgeon.

Ablative therapies for the treatment of malignant diseases of the breast

BACKGROUND

Because widespread screening for breast cancer is detecting more women at younger ages and earlier stages, the need for minimally invasive, cosmetically preferable approaches to its treatment is growing. Ablative techniques are now being applied to the treatment of primary breast tumors, perhaps offering an alternative to surgical excision. Techniques available for breast cancer treatment include radiofrequency ablation, cryoablation, interstitial laser ablation, microwave thermotherapy, and focused ultrasound ablation.

DATA SOURCES

Literature searches for breast and cryoablation, focused ultrasound ablation, interstitial laser ablation, microwave thermotherapy, and radiofrequency ablation were performed. Over 30 articles were identified and analyzed.

CONCLUSIONS

It is cautiously optimistic that these therapies can be used as a routine adjunct in the treatment of selected breast cancers. The challenge will lie in the ability to identify multifocal disease and in situ carcinoma as well as to ensure complete and effective eradication of the breast cancer.

Issues in breast cancer screening

This paper will review the use of screening mammography in the United States, with an emphasis on its limitations as currently practiced. It will then emphasize several areas where breast cancer imaging practice can be improved, namely in reducing overtreatment of potentially nonlethal cancers, in monitoring the effectiveness of nonsurgical therapies, and in guiding noninvasive therapies. Any new modality that is to have an impact on breast cancer mortality must perform comparably to screening mammography to become widely utilized. While mammography is not perfect, it has set a high threshold that other modalities must reach before they will be widely utilized for screening or diagnosis.

Ablative Approaches to the Minimally Invasive Treatment of Breast Cancer

With the improvements in imaging techniques that have allowed the earlier detection of smaller breast cancers and the desire for improvements in cosmetic outcome, a number of minimally invasive techniques for the treatment of early stage breast cancers are being investigated. Ablative therapies, including laser ablation, focused ultrasound, microwave ablation, radiofrequency ablation, and cryoablation, have been described. All of these techniques have shown promise in the treatment of small cancers of the breast; however, additional research is needed to determine the efficacy of these techniques when they are used as the sole therapy and to determine the long-term local recurrence rates and survival associated with these treatment strategies.

Cryoablation and cryolocalization in the management of breast disease

Cryotechnology is currently used for both treatment and diagnosis of breast disease. Due to the natural analgesic effect of cold, cryoablation is potentially more patient-friendly than other technologies which raise tissue temperature. Freezing produces a predictable volume of necrosis and is easily observed and controlled during treatment. Recent studies have demonstrated that, as a primary therapy for breast fibroadenoma, cryoablation is safe and effective with durable results that can be reproduced in community practices. Certain barriers do exist before cryoablation, or any other in situ ablation, can become a standard therapy for the treatment of localized breast malignancy. Investigations are underway to refine patient selection criteria and develop valid confirmatory assays so that clinical trials can begin. Cryolocalization, which creates a well-delineated, palpable mass of frozen tissue encompassing a tumor, is a relatively new application of cold in medicine. This strategy promises to reduce positive margin rates during lumpectomy of non- or barely-palpable tumors. Finally, cryotechnology now also aids in the collection of tissue for histological analysis.

Updates in breast ultrasound

Ultrasound is becoming an indispensable tool for the surgeon in the diagnosis and treatment of a variety of breast problems. Hands-on ultrasound education for surgeons and the ongoing improvements in imaging technology have made surgeon-performed breast ultrasound an effective method of identifying and diagnosing breast lesions and have increased the surgeon's ability to perform ultrasound-guided interventional procedures. This article reviews the current state of surgeon-performed breast ultrasound.