Image-guided surgery of small breast cancers

Presented at the Second Annual Meeting of the American Society of Breast Surgeons, La Jolla, California, May 3–6, 2001.
https://doi.org/10.1016/S0002-9610(01)00730-9Get rights and content

Abstract

Background: Widespread screening mammography has resulted in detection of many breast cancers smaller than one cm. Image-guided percutaneous needle sampling provides accurate diagnostic and prognostic information for adjuvant therapy. Less invasive methods based on imaging techniques are emerging as an alternative to wire localization and lumpectomy.

Data Sources: Information presented in this overview was provided by seven investigators from five medical centers in the United States. These researchers are currently developing various techniques of image-guided percutaneous therapy of small (Tis, 1) breast cancers.

Conclusions: Several percutaneous treatment modalities for treatment of early breast cancer, either excisional or in-situ ablative, are described in this overview and their potential applications are discussed.

Section snippets

Tumor size: image/pathologic assessment

The most important factor in predicting outcome of patients with invasive breast carcinoma is the size of the primary tumor as assessed by the pathologist. Most pathologists measure the maximal tumor size based on gross examination and then adjust the measurement following review of the microscopic slides. Studies by Tresserra et al [3] and Abner et al [4] showed that the tumor size assessed microscopically was larger than that measured grossly in 16% and 34% of their cases, respectively. The

Pathologic margins

One of the most important decisions prior to percutaneous treatment of early breast cancer, whether excisional or by using an in-situ ablation technique, will be to determine the extent of the tumor and thus define the area to treat. Based on our current standards this will not be easy, since experience with excisional biopsy has shown that surgical margins of resection are frequently involved by tumor [9]. Alternative techniques will need to be developed to aid the surgeon in delineating the

Removal of breast cancer with vacuum-assisted stereotactic breast biopsy

Vacuum-assisted breast biopsy has become a well established diagnostic tool equal in sensitivity and specificity to open needle-localized procedures for the diagnosis of mammographically detected lesions. Thus far, however, this technology has not been used for the definitive surgical treatment of early breast cancer. Two observations suggest that it may be possible to use vacuum-assisted tumor removal to treat early breast cancer. Jewell, in a personal series, noted that in approximately 25%

Stereotactic large core cannulae for conservation treatment of breast cancer

Large core cannulae employed in conjunction with stereotactic table (Avanced Breast Biopsy Instrumentation [ABBI]) were originally introduced in 1996 as a diagnostic tool. Nonpalpable mammographic breast lesions could be removed as a nonfragmented single large core specimen. Pathological examination was equivalent to that of a needle localization excisional breast biopsy, allowing not only for determination of histology but also tumor size and margins. Evaluation of margins was noted in an

Radiofrequency ablation of breast tumors

Destruction of solid tumors by radiofrequency ablation (RFA) results from the frictional heat generated by intracellular ions moving in response to an alternating current. The current flows from an uninsulated electrode implanted in the tumor to a grounding pad applied externally to the skin. Hyperthermia from RFA is thought to induce cell death by affecting cell membrane fluidity, cytoskeletal protein and nuclear structure, including disruption of DNA replication [21].

The physics of the

Cryosurgery of breast cancer

Cryotherapy as an in-situ technique of destroying tumors has been extensively applied to patients with liver and prostate cancers [26], [27]. Staren et al [28] were first to report their experience with cryoablation of carcinogen-induced mammary tumors in rats and mice and tested the effect on sheep and dog mammary tissues. They then treated a patient with two adjacently located (0.8 cm and 0.5 cm) infiltrating lobular carcinoma. The cryoprobe was directed to the target area either under direct

Laser therapy of small breast tumors

In-situ ablation of mammographically detected, well-defined breast tumors by laser is a potential alternative to lumpectomy. The photobiologic mechanisms of laser-induced tissue injury can be separated into three categories: photochemical, photothermal, and photomechanical [29]. The photothermal effect is the principal mechanism used in the interstitial laser therapy (ILT) of the breast cancer. The laser light energy may be precisely directed to a target in the breast by stereotactic technique

Summary

As outlined in this overview, several excisional and in-situ ablative techniques are emerging for percutaneous treatment of mammographically detected breast cancer. The technical details, safety, and efficacy of each one will be the subject of further investigation and ensuing clinical trial. It is estimated that between 60,000 and 90,000 patients who have undergone a small core biopsy of a circumscribed infiltrating carcinoma or a cluster of microcalcifications no more than 1.5 cm. in diameter

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