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.     

Cryoablation of Early-Stage Breast Cancer: Work-in-Progress Report of a Multi-Institutional Trial

Background With recent improvements in breast imaging, our ability to identify small breast tumors has markedly improved, prompting significant interest in the use of ablation without surgical excision to treat early-stage breast cancer. We conducted a multi-institutional pilot safety study of cryoablation in the treatment of primary breast carcinomas.Methods Twenty-nine patients with ultrasound-visible primary invasive breast cancer 2.0 cm were enrolled. Twenty-seven (93%) successfully underwent ultrasound-guided cryoablation with a tabletop argon gas-based cryoablation system with a double freeze/thaw cycle. Standard surgical resection was performed 1 to 4 weeks after cryoablation. Patients were monitored for complications, and pathology data were used to assess efficacy.Results Cryoablation was successfully performed in an office-based setting with only local anesthesia. There were no complications to the procedure or postprocedural pain requiring narcotic pain medications. Cryoablation successfully destroyed 100% of cancers <1.0 cm. For tumors between 1.0 and 1.5 cm, this success rate was achieved only in patients with invasive ductal carcinoma without a significant ductal carcinoma-in-situ (DCIS) component. For unselected tumors >1.5 cm, cryoablation was not reliable with this technique. Patients with noncalcified DCIS were the cause of most cryoablation failures.Conclusions Cryoablation is a safe and well-tolerated office-based procedure for the ablation of early-stage breast cancer. At this time, cryoablation should be limited to patients with invasive ductal carcinoma 1.5 cm and with <25% DCIS in the core biopsy. A multicenter phase II clinical trial is planned.     

Incidence and Detection of Contralateral Breast Cancer

Abstract: In this study we estimated the efficacy of contralateral breast biopsy as a subsidiary method of early detection of bilateral breast cancer. We performed blind biopsies in the upper outer quadrant of the opposite breast in 195 patients undergoing surgical treatment for primary breast cancer. The histologic examination of the biopsy specimens showed 12 malignant lesions, which accounts for an incidence of 6.1%. In detail, we had two infiltrating ductal cancers, two infiltrating lobular cancers, three ductal in situ cancers, and five lobular in situ cancers. The overall incidence of invasive disease was 2.05%. We concluded that contralateral breast biopsy should be reconsidered as a method for enhancing early detection of contralateral breast cancer in high-risk groups, especially when it meets the emotional needs of patients. Permission given, it is included in the main surgical treatment of patients, avoiding the cost and complications of anesthesia, and it is cosmetically acceptable, without being an emotional burden for the woman.     

Management of screen-detected breast cancer: audit of the first 100 cases in the Southampton and Salisbury breast screening programme.

With the natural history and optimal treatment of a high proportion of screen-detected breast cancers yet to be determined, treatment poses the management team with a number of therapeutic dilemmas. This study surveys the management policy and treatment of a consecutive series of 100 screen-detected cancers treated in a single breast unit. The problems encountered are discussed. There were 87 women with stage Tis or T1 tumours, including 26 women with in situ cancers, four with invasive cancers less than 5 mm in size, and seven with tubular cancers. Sixty-six women were managed with breast-conserving surgery and 36 women underwent localisation biopsy as the sole surgical treatment of the breast. With selection bias for high-grade and lateral tumours, only 2/13 cancers up to 10 mm in size were lymph node positive on axillary clearance. All lymph node positive women received adjuvant therapy. No adjuvant therapy was given in 43 cases, including those with in situ cancer. Thirty-six had extensive intraductal component (EIC). Patient and surgeon choice tends to be a major factor both in type of surgery and adjuvant therapy for screen-detected breast cancer. The optimal treatment for tumours detected by breast cancer screening is debatable and randomised trials on their management need to be expedited.     

Renal cancer: what can we expect from emerging new technologies: radiofrequency and cryoablation?

Radiofrequency and cryoablation are both minimally invasive techniques applied to the treatment of renal cell carcinoma. These techniques allow in situ destruction of neoplasm. Although cryotherapy is the most studied, radiofrequency is the most currently used technique. Indications mostly accepted as elective indication are the less than 4 cm in diameter exophytic tumors. Radiofrequency and cryoablation can also be proposed in patients with solitary kidney, multiple bilateral tumors and patients with contraindication for surgical resection. The radiofrequency parietal tract can be coagulated at the time of radiofrequency electrode withdrawal reducing the rare risk of parietal tumor dissemination. Preliminary oncological results in exophytic small renal tumors are promising with only few complications. A longer follow-up is however mandatory to better define the place of these two new technologies in the treatment of renal cancer.     

Imaging technologies in breast diagnosis and surgical treatment

The diagnostic and surgical management of breast cancer has changed dramatically over the past 2 decades. All facets in the multidisciplinary management of breast cancer are rapidly evolving and being driven forward by technological advances. Conventional imaging techniques are now being augmented with advances in molecular imaging that probe biological properties of tissue to create images, and optical imaging which reflects physical properties of normal and diseased tissues. Automated computer assisted biopsy techniques are being developed to sample breast tissue with a higher degree of accuracy and patient comfort. As the trend toward minimally invasive breast surgery continues ablative techniques such as radiofrequency ablation, cryoablation, interstitial laser ablation and focused ultrasound ablation are being explored to potentially avoid the need for surgery all together. New intraoperative lesion localization techniques such as 3-dimensional ultrasonographic tumor models, magnetic resonance imaging (MRI)-guided projection and reproduction, radioguided occult lesion localization and optical imaging techniques are being developed to improve surgical guidance. Evaluation of advanced imaging and intraoperative guidance techniques requires more comprehensive histopathological examination of surgical specimens, prompting the development of techniques aimed at to improving upon the current limitations in breast pathology. This review will describe the development of new technologies in breast imaging, tumor ablation, intraoperative surgical guidance and tissue processing aimed at advancing minimally invasive diagnosis and treatment of breast cancer.     

Male breast cancer: report of 2 cases and review of the literature

Male breast cancer is rare and accounts for 1% of all breast cancers. The authors report two cases of male breast cancer at Stage III and review the literature. A Madden mastectomy with axillary clearance was performed. Patients were given adjuvant chemotherapy and started on tamoxifen. At one year follow-up the patients are alive and free from disease. Modified radical mastectomy is the preferred surgical approach for localized disease. Adjuvant hormonal therapy with tamoxifen is recommended as first-line treatment. Adjuvant chemotherapy has a role in node-positive cancer and locally advanced disease. Men should be made more aware of the disease and multicentric clinical trials encouraged to ensure an appropriate treatment on the basis of prospectively collected data.     

Surgical management of invasive breast cancer: a 5-year prospective study of treatment in the Australian Capital Territory and South-Eastern New South Wales

BACKGROUND: Breast cancer is a major health problem in Australia. The aim of the present report is to evaluate the surgical management of invasive breast cancers in our region. METHODOLOGY: As part of a multidisciplinary quality assurance project, data were collected for the majority of breast cancers treated in our region between July 1997 and June 2002. Participants included surgeons, medical and radiation oncologists, pathologists and general practitioners. RESULTS: Over the 5-year period, 1069 invasive breast cancers were treated. Mastectomy (52%) was more common than breast conservation. For cancers less than 2 cm in diameter (61%), breast conservation was achieved in 62%. High nuclear grade cancers (27%) resulted in mastectomy in 60%. This treatment pattern was the same for patients living in urban and rural areas and in all age groups. Those patients requiring two or more operations (30%) to achieve surgical clearance still had a 33% rate of breast conservation. Over the last 5 years there has been an increase in sentinel node biopsies (16 sentinel node biopsies during 1998-1999; 64 during 2001-2002) and axillary dissections started to decrease. A small group has had no axillary node biopsy or dissection, mainly patients over 70 years of age. Multimodality treatments increased over the 5-year period of our study with the use of postoperative radiotherapy increasing from 60% to 65% and chemotherapy from 36% to 55%. CONCLUSIONS: The project has mapped treatment trends for breast cancer in our region and documented the implementation of new treatment methods as well as the increasing use of multidisciplinary management, multimodality treatment and the implementation of best practice guidelines.     

Incidence of second cancers among women with in situ carcinoma of the breast

A population-based cohort of 371 women with carcinoma in situ (CIS) of the breast, collected by the Tuscany Cancer Registry, has been analysed for further invasive cancers. All cases, diagnosed between 1985 and 1997, have been followed up to the end of 1997. During 1707 person-years of follow-up, 27 further invasive cancers were diagnosed while 13.7 were expected (Observed/Expected=2.0, P<0.05). The relative risk for invasive breast cancers was 3.7 (P<0.05). According to the surgical treatment for CIS and the site of further invasive breast cancer, no side specific difference was evident. No significant increase was evident for other cancer sites; only non-melanomatous skin cancers occurred more frequently than expected (O/E=4.2). The cumulative risk of developing an invasive cancer after CIS was 13.2% at 10 years. There were also two deaths due to breast cancer (O/E=8.3; P<0.05) corresponding to a cumulative mortality risk of 2% at 10 years. We have quantified the risk of developing an invasive breast cancer among women with CIS of the breast as four times that of the general population.     

Effect of screening mammography on the surgery of breast cancer in Finland: a population-based analysis during the years 1985-2004

A nationwide mammographic screening of women aged 50 to 59 years commenced in Finland in January 1987. We studied the effect of screening on surgical diagnosis, treatment, and survival of breast cancer in one geographic area in Finland. We reviewed the medical records, survival data from Finnish Cancer Registry, and screening data from the Finnish Mammogrphic Working Group of 1049 women who underwent surgery for breast cancer in our hospital between the years 1985 and 2004. Altogether, 35 parameters including diagnostic procedures, operative data, and staging were recorded. The results of tumors detected by mammographic screening (n=156) and interval cancers (n=148) were compared with the tumors detected outside of screening (n=745). The incidence of breast cancer increased from 35 to 72 cases per 100,000 inhabitants, and the percentage of nonpalpable cancers increased from 12 to 33. Approximately 30 women per 100,000 inhabitants were annually referred from mass screening for surgical biopsies, in 60 per cent of which cancer was detected. Breast lump was still a first sign of cancer in 60 per cent of patients. The mammographic screening detected 20 per cent of new breast cancers. The cancers detected by screening were smaller, found at an earlier stage, and their 10-year-survival was better (90% vs 70%) than those detected by other means (P = 0.003). Overall mortality of interval cancers was worse (27%) than screening cancers (6%, P < 0.0001). Mammographic screening detects up to 20 per cent of new breast cancers in a well-defined population area. The prognosis of screening cancers is better than the cancers found outside of screening.     

Survival rates for breast cancers detected in a community service screening mammogram program

BACKGROUND: This single-institution long-term prospective study was performed in the setting of community service screening mammography to evaluate the association between the methods of breast cancer detection and survival rates. METHODS: From 1994 through 2001, data on 1237 patients with breast cancer were collected concurrent with definitive surgical treatment and entered into a comprehensive database. RESULTS: Mammography was the sole method of detection for 517 (44%) of 1179 Tis-T2 breast cancers. Fifty-seven percent of invasive cancers detectable by mammography alone were less than 1 cm in diameter. For 1049 patients with invasive cancers, the 5-year overall observed survival rates were 94% for 372 whose cancers were detectable by mammogram alone and 87% for 677 whose cancers were detectable by palpation (alone or in combination with mammography) (P = .0002). CONCLUSIONS: Most of the contribution to breast cancer mortality reduction is from the detection of small nonpalpable cancers, not from adjuvant therapy.     

Salvage prostate cryoablation after primary interstitial brachytherapy failure: a feasible approach

Salvage treatment for recurrent prostate cancer remains a very difficult and challenging field in urologic oncology. The introduction of minimally invasive surgical procedures such a targeted cryoablation brings some hope with its feasibility and efficacy to become a potentially curable treatment. We present the case of a 75-year-old male with prostate cancer treated primarily by brachytherapy, who developed late locally recurrent disease that was successfully treated with targeted salvage cryoablation.     

Breast cancer in the elderly,in men and during pregnancy

Female breast cancer is the most common tumour diagnosed worldwide and is one of the leading causes of cancer-related death. The management of elderly, male and pregnant patients with breast cancer requires some additional considerations which are reviewed in this chapter. Breast screening is routinely offered to women aged between 50 and 70 years in England. There are substantial regional variations among UK hospitals in the clinical management of elderly breast cancer patients. Primary endocrine therapy is used in the treatment of ER-positive elderly breast cancer patients not fit for surgical intervention. Male breast cancer is rare, accounting for less than 1% of all breast cancers. It is more common in elderly men and tends to behave like post-menopausal breast cancer. Although breast cancer is one of the most frequently diagnosed malignancies among pregnant women, breast cancer during pregnancy is a rare condition and has been associated with more aggressive, high-grade, poorly differentiated tumours and with a predominance of more aggressive molecular subtypes such as triple negative, HER-2-positive and lower rates of ER and PR expression.     

Primary Chemotherapy of Resectable Breast Cancer

Abstract: Primary chemotherapy (the administration of chemotherapy prior to definitive locoregional therapy) of breast cancer has numerous potential advantages and several identified disadvantages. While primary chemotherapy has been used widely in the treatment of locally advanced and inflammatory breast cancers, interest is now turning to its use in resectable breast cancers. Within the last five years, several trials of primary chemotherapy in the treatment of resectable breast cancer, both randomized and non-randomized, have been published. Although preliminary reports suggest that primary chemotherapy may be advantageous, the results from definitive randomized trials are not yet available. Until they are, this approach, although promising, remains in the investigational stages.     

超声引导细刀头氩氦刀经皮冷冻治疗乳腺纤维腺瘤的临床研究

目的：探讨细刀头氩氦刀靶向冷冻治疗乳腺纤维腺瘤的临床应用价值。方法：在彩色超声引导下应用Cryo-Hit氩氦刀对23例乳腺纤维腺瘤经皮靶向冷冻治疗。结果：23例冷冻治疗后无感染、休克、血小板减少等并发症发生。术后随访6～24月,彩超检查19例病灶消失,4例病灶缩小约60％,再次治疗后病灶消失;23例乳腺皮肤均无瘢痕存留。结论：彩色超声引导细刀头氩氦刀经皮靶向冷冻治疗乳腺纤维腺瘤是安全、有效、操作简便的一种方法,可以避免常规手术切除遗留瘢痕的缺点。     

Conservative treatment in cancer of the breast

Conservative treatment combining breast saving surgical procedures and radiotherapy, is considered as the best treatment for small breast cancers. The purpose of the study is to define the most appropriate surgical technique in order to reach both the complete resection of the primary and the best cosmetic result. Terms corresponding to the type of resection will be define in order to facilitate the comparison between the different studies on tumorectomies for breast cancer. Technical problems will be analyzed in the light of our experience of the conservative treatment especially in what concerns the cosmetic results.     

Cryoablation treatment of benign breast lesions with 12-month follow-up

OBJECTIVE: Eighty percent of all breast biopsies reveal benign findings. The most common benign tumor is a fibroadenoma. Despite their benign nature, many women eventually choose to have their bothersome lumps surgically removed. We report the use of cryoablation to treat these benign breast lesions with minimum 12-month follow-up. METHODS: After receiving Institutional Review Board approval, a prospective nonrandomized trial was initiated in June 2000. Ultrasound-guided cryoablation of core biopsy-proven benign fibroadenomas, other benign breast nodules, or nodular fibrocystic change was performed on 78 lesions in 63 patients. Eighty-five percent of lesions treated were benign fibroadenomas. The cryoablation procedure consisted of a double freeze-thaw cycle that lasted between 6 and 30 minutes and was performed most often in an office setting. Each patient was serially evaluated for treatment efficacy, complications, and patient satisfaction. RESULTS: Sixty-four of 78 lesions (mean size 2.0 cm [range 0.8 to 4.2]) were followed-up for at least 12 months after cryoablation per protocol, which included 53 fibroadenomas. At 1 year, ultrasound tumor volume resorption was 88.3% overall (87.3% for fibroadenomas), and 73% of the entire group became nonpalpable to both clinician and patient (75% for fibroadenomas). Two of the fibroadenoma patients had their palpable residual nodule excised, both revealing necrotic debris and no viable tumor in the treated volume. Serial mammograms showed resorption of the lesion leaving minimal residual density without calcifications. Cosmesis was excellent with only a small scar remaining at the probe insertion site. There was no report of visual or palpable volumetric deficit. Patient satisfaction was good to excellent in 92% of cases. CONCLUSIONS: Cryoablation was successful in treating core biopsy-proven benign breast lesions in 63 patients. At 12 months, we found gradual resorption of treated tissue with no cosmetic deficit. Ultrasound-guided cryoablation is an effective and safe treatment for benign breast lesions, as seen at 12-month follow-up, and offers an office-based, minimally invasive alternative to surgical excision.     

Das Mammakarzinom beim Mann

Male breast cancer (male BC) accounts for <1% of all cancers in men, showing an increasing incidence with a peak in the sixth decade. Overall, men experience a worse prognosis than women, probably due to an advanced stage together with the higher age at diagnosis of male patients. Major risk factors for developing male BC include clinical disorders involving hormonal imbalances (excess of estrogen or a deficiency of testosterone as seen in patients with Klinefelter syndrome) and a positive family history for breast cancer. About 90% of male BC are invasive ductal carcinomas. Standard treatment for localized cancer is surgical removal. Adjuvant radiation and systemic therapy are the same as in women with breast cancer. Male BC expresses hormone receptors in about 90% of cases; therefore, tamoxifen is a therapeutic option. A future challenge for the urologist or andrologist is to diagnose the disease at an early stage to improve prognosis.     

Effective follow-up for recurrence or a second primary cancer in patients with early gastric cancer

BACKGROUND: Patients with early gastric cancer have an excellent prognosis with low rates of recurrence, but may have an increased risk of developing a second primary cancer. Because the number of early gastric cancers has increased, clarification of both recurrences and second primary cancers is important for the development of effective postoperative follow-up programmes. METHODS: Data on 1070 patients with early gastric cancer were analysed retrospectively with respect to the clinicopathological features of both recurrence and second primary cancers after surgical treatment. RESULTS: Multivariate analysis showed that lymph node metastasis and older age were independent risk factors for recurrence of early gastric cancer. The incidence of second primary cancers was 5.0 per cent; lung and colorectal cancers were detected most frequently, followed by cancers in the oesophagus, breast and remnant stomach. CONCLUSION: Clinicopathological features of patients with early gastric cancer can be used to identify those most at risk of developing either recurrence or a second primary cancer.     

Nonpalpable breast cancer: needle-localized biopsy for diagnosis and considerations for treatment

Screening mammography as an adjunct to physical examination led to the discovery of 237 radiographically suspicious but nonpalpable breast lesions. Needle localization of the lesion preoperatively in the mammography suite followed by breast biopsy led to the diagnosis of 64 nonpalpable carcinomas, including 25 invasive, 16 minimally invasive, and 23 noninvasive cancers. Noninvasive and minimally invasive cancers were microscopic. Of the invasive lesions, 7 were 10 mm or less in diameter and 14 were 11 to 20 mm in diameter. Noninvasive and minimally invasive cancers tended to occur in younger women (average age 52 and 51 years, respectively), and almost uniformly appeared as clustered calcifications mammographically. Invasive cancers affected an older population (average age 65 years), and the mammographic appearance was that of a mass in the majority of cases. A variety of surgical procedures were carried out subsequent to biopsy to provide definite treatment of these nonpalpable breast cancers. A review of surgical specimens available from these procedures demonstrated a 27 percent incidence of residual disease at the biopsy site. In patients who underwent mastectomy, 34 percent had an unsuspected focus of cancer in another quadrant of the breast and an additional 14 percent had an unsuspected focus of epithelial atypia. No patient with either noninvasive or minimally invasive cancer was found to have axillary lymph node metastases. Twenty-nine percent of patients with invasive tumors demonstrated lymph node metastases in the axilla. Our results demonstrate the efficacy of preoperative needle localization to assist in the biopsy of nonpalpable breast lesions and the diagnosis of a significant number of early breast cancers. The treatment plan for patients with these cancers must address the high incidence of residual disease at the biopsy site, multicentricity, and the proved capacity for invasive lesions to metastasize to the axillary lymph nodes, regardless of the size of the primary tumor.