Breast cancer represents the most common cancer in females (1). With the application of screening mammography, many patients are now discovered in early stage of breast cancer with small tumors less than 2 cm (2). Therefore scientists and oncologists are trying to discover new non-surgical treatment for these small tumors, specially for old women to bypass surgical interventions and their side effects.
Many trials were designed to bypass surgery using chemotherapy or radiotherapy as a sole treatment but recurrence rates were very high comparing to surgical treatment. One randomized trial had gained popularity by using endocrine treatment (Tamoxifen) as a sole treatment to old females with ER+ for small tumors, but the local control was poor. However, it can be reserved for old or failed patients for temporary cancer control (3).
There is on the way a technique called cryoablation which is used by introducing a cryoprobe into the center of a tumor under ultrasound guidance in order to freeze the tissue to temperatures between –160 and –190 Celsius. Several small studies have now demonstrated the safety, feasibility, efficacy, and limitations of cryoablation in the treatment of early breast cancer. Successful cryoablation requires only moderate proficiency in ultrasound and percutaneous ultrasound guided placement of the probe within the center of the tumor, monitoring the formation of the ice ball and occasionally injecting saline between the ice ball and the skin to prevent thermal damage. Studies are now assessing the oncological outcome and the rate of recurrence of this technique. The cosmetic outcome of the cryotherapy is outstanding: as the scar after cryotherapy is not bigger than that of percutaneous core biopsy, and after leaving the frozen tissue in place which will be resorbed later by the body leaving natural size and shape, with no resultant volume loss or deformity (4-9).
Radiofrequency (RF) ablation is another technique that had succeeded in treatment of unresectable tumors of the liver. Therefore some studies had been applied on early breast cancer and showed as a promising non-invasive treatment. RF is produced by frictional heating. Electrode tips placed in the lesion produce a high-frequent current that flows into the surrounding tissue, initiating ionic agitation that causes heat followed by cell destruction. The RF probe is typically placed under ultrasound guidance and the tumor ablation is monitored by magnetic resonance imaging (MRI). One of the limitations of RF was assessment of the margins of the ablated tumor to show the marginal status, decrease local recurrence and to make sure that the tumors had been all ablated. Still follow-up data regarding local effects on the surrounding breast tissue or recurrence rates are hardly available. Further research will be necessary to establish the optimal technique, and to demonstrate the long-term oncological and cosmetic effects of RF ablation (10-14).
Important technique on the rise is the high-intensity focused ultrasound (HIFU) is a completely non-invasive technique. During HIFU, the ultrasound beam is focused into a small target volume to reach high focal power levels, resulting in temperature elevations causing cell death in a small target volume of tissue while surrounding structures are spared. HIFU can be guided by MRI (MR-HIFU) or by conventional diagnostic ultrasound (US-HIFU). Worldwide, thousands of patients with uterine fibroids, liver cancer, breast cancer, pancreatic cancer, bone tumors, and renal cancer have been treated by US-HIFU. Also studies are still needed for further evaluation of this technique (15-19).
An important drawback of the previous techniques is that the whole pathological assessment of the tumors, the marginal status can’t be assessed and also the patients need receive radiotherapy after using these techniques especially the HIFU.
Breast cancer management never stops at one management but always evolves to try to conserve the breasts and to decrease the morbidity of the surgical treatment.
The authors would like to thank the Foundation of Umberto Veronesi-Milan-Italy for their help to young researchers.
Disclosure: The authors declare no conflict of interest.
- Ferlay J, Shin HR, Bray F, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010;127:2893-917. [PubMed]
- Nerurkar A, Osin P. The diagnosis and management of pre-invasive breast disease: the role of new diagnostic techniques. Breast Cancer Res 2003;5:305-8. [PubMed]
- Mustacchi G, Ceccherini R, Pluchinotta A, et al. Results of adjuvant treatment in breast cancer women aged more than 70: Italian cooperative group experience. Tumori 2002;88:S83-5. [PubMed]
- Pfleiderer SO, Freesmeyer MG, Marx C, et al. Cryotherapy of breast cancer under ultrasound guidance: initial results and limitations. Eur Radiol 2002;12:3009-14. [PubMed]
- Staren ED, Sabel MS, Gianakakis LM, et al. Cryosurgery of breast cancer. Arch Surg 1997;132:28-33; discussion 34. [PubMed]
- Sabel MS, Kaufman CS, Whitworth P, et al. Cryoablation of early-stage breast cancer: work-in-progress report of a multi-institutional trial. Ann Surg Oncol 2004;11:542-9. [PubMed]
- Morin J, Traoré A, Dionne G, et al. Magnetic resonance-guided percutaneous cryosurgery of breast carcinoma: technique and early clinical results. Can J Surg 2004;47:347-51. [PubMed]
- Whitworth PW, Rewcastle JC. Cryoablation and cryolocalization in the management of breast disease. J Surg Oncol 2005;90:1-9. [PubMed]
- Edwards MJ. Office-based and intraoperative ultrasound enhance surgeon’s care of breast disease patients. Ann Surg Oncol 2003;10:201. [PubMed]
- Curley SA, Izzo F, Delrio P, et al. Radiofrequency ablation of unresectable primary and metastatic hepatic malignancies: results in 123 patients. Ann Surg 1999;230:1-8. [PubMed]
- Hayashi AH, Silver SF, van der Westhuizen NG, et al. Treatment of invasive breast carcinoma with ultrasound-guided radiofrequency ablation. Am J Surg 2003;185:429-35. [PubMed]
- Izzo F, Thomas R, Delrio P, et al. Radiofrequency ablation in patients with primary breast carcinoma: a pilot study in 26 patients. Cancer 2001;92:2036-44. [PubMed]
- Jeffrey SS, Birdwell RL, Ikeda DM, et al. Radiofrequency ablation of breast cancer: first report of an emerging technology. Arch Surg 1999;134:1064-8. [PubMed]
- Noguchi M, Earashi M, Fujii H, et al. Radiofrequency ablation of small breast cancer followed by surgical resection. J Surg Oncol 2006;93:120-8. [PubMed]
- LeBlang SD, Hoctor K, Steinberg FL. Leiomyoma shrinkage after MRI-guided focused ultrasound treatment: report of 80 patients. AJR Am J Roentgenol 2010;194:274-80. [PubMed]
- Köhler MO, Mougenot C, Quesson B, et al. Volumetric HIFU ablation under 3D guidance of rapid MRI thermometry. Med Phys 2009;36:3521-35. [PubMed]
- Mougenot C, Tillander M, Koskela J, et al. High intensity focused ultrasound with large aperture transducers: a MRI based focal point correction for tissue heterogeneity. Med Phys 2012;39:1936-45. [PubMed]
- Orsi F, Arnone P, Chen W, et al. High intensity focused ultrasound ablation: a new therapeutic option for solid tumors. J Cancer Res Ther 2010;6:414-20. [PubMed]
- Hynynen K. MRI-guided focused ultrasound treatments. Ultrasonics 2010;50:221-9. [PubMed]