Breast Surgery Past, Present

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Breast Surgery Past, Present Future

• Texas Tumor Registrars Association
• September 29, 2005
• Walton Taylor, MD
• Co-Director Presbyterian Allen Breast Center
• Co-Director Dallas Breast Center at Forest Park

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Basic Cancer Management

• Local Therapy
• Regional Therapy
• Systemic Therapy

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Past Interactions
Imager
Surgery
Medical Oncology
Radiation
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Past Surgical Breast Care

• Imaging Xeromammograms/Thermography
• Surgery - Mastectomy
• Adjuvant Therapy not much
• Breast surgery was relegated to general surgeons
  who did not like doing it!

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Current Interactions
Imager
Surgery
Medical Oncology
Radiation
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Breast Surgery Current Standard of Care
State of the Art

• Office Care
• Diagnostic Imaging
• Biopsy
• Coordination of BC Treatment
• Operative Care
• Lesion Targeting for lumpectomy
• Whole Breast Surgery
• Axillary Surgery
• Post-operative
• Radiation Therapy
• Chemotherapy and Hormonal Therapy

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Breast Surgery Current Standard of Care

• Office Care
• Diagnostic Imaging plain films/ultrasound

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Breast Surgery Current State of the Art

• Office Care
• Diagnostic Imaging plain films or digital
• 13MHz ultrasound

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Breast Surgery Current State of the Art

• Office Care
• Diagnostic Imaging plain films or digital
• 13MHz ultrasound MRI

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Breast Surgery Current State of the Art

• Imaging

• Office Care
• Diagnostic Imaging plain films or digital
• Ultrasound
• MRI
• PET
• PET Mammography

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Breast Surgery Current Standard of Care

• Office Care
• Biopsy - 14g core

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Stereotactic Biopsy
Breast Surgery Current Standard of Care
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Breast Surgery Current State of the Art

• Office Care
• Ultrasound Biopsy 8 or 11g Core Devices
• Larger cores, fewer indeterminant dxs
• EnCor
• Vacora
• Cassi
• Neothermia
• ATEC
• Mammotome

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Breast Surgery Current State of the Art

• Office Care
• Ultrasound (or Stereotactic) Biopsy
• 8 or 11g Core
• Ultrasound Visible Clip Placement

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Breast Surgery Current State of the Art

• US visible marker
• absorbable echogenic material plus wire marker
• placed at Stereotactic or Ultrasound Biopsy
• visible several weeks
• Allows OR ultrasound localization if needed

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MRI Guided Biopsy
Breast Surgery Current State of the Art
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Coordination of Breast Cancer Care

• Either make the diagnosis or at least discuss the
  entire care plan with patient
• Surgery
• /- NeoAdjuvant Chemo or Hormonal therapy
• /- Adjuvant Chemo or Hormonal therapy
• /- Radiation Therapy
• Emotional support of patient and their
  family/friends

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Breast Surgery Current Standard of Care
State of the Art

• Office Care
• Diagnostic Imaging
• Biopsy
• Coordination of BC Treatment
• Operative Care
• Lesion Targeting for lumpectomy
• Whole Breast Surgery
• Axillary Surgery
• Post-operative
• Radiation Therapy
• Chemotherapy and Hormonal Therapy

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• Breast Surgery - Lumpectomy
• Needle Localization
• Non-Palpable to Palpable Localization
• Anchor Guide
• Cryoassisted Lumpectomy
• Palpable Mass Lumpectomy

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Breast Surgery Current Standard of Care
Breast Surgery Lumpectomy
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Breast Surgery Current Standard of Care
Lesion Targeting

• Preoperative Needle Localization (PNL)
• Tried and true, reliable
• Time-consuming
• Cumbersome Scheduling
• first case 10 AM
• limited time slots
• Little help with margin control
• Does not make lesion palpable or retractable

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Breast Surgery Current Standard of Care
Breast Surgery Needle Localization
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Lesion Targeting US guidance for US visible
lesions
Breast Surgery Current State of the Art

• Before prep
• Note depth
• Proximity to skin
• Proximity to fascia
• Mark location
• /- place wire

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US guidance for US visible lesions

• place wire (routine or selective)
• Small lesion or large breast

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US guidance for US visible lesions

• Intraoperative US
• Examine specimen

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US guidance for US visible lesions

• Intraoperative US
• Margin control
• Tissue Conservation

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Make a nonpalpable lesion palpable(and attach a
handle)

• RF assisted wire anchor
• Cryo Assisted Lumpectomy (CAL)

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Make a nonpalpable lesion palpable(and attach a
handle)

• RF assisted wire anchor
• RF wire loop at tip

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Make a nonpalpable lesion palpable(and attach a
handle)

• RF assisted wire anchor (cont.)

• Radially-oriented prongs
• deploy at opposite angles
• outward from lesion center

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Make a nonpalpable lesion palpable(and attach a
handle)

• RF assisted wire anchor (cont.)
• Deployed device tip and prongs palpable

Preliminary data Improved margin control with
tissue conservation
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Making a nonpalpable lesion palpable(and attach
a handle)

• Positive Margins
• PNL (37) 30
• AG (30) 10

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Making a nonpalpable lesion palpable(and attach
a handle)

• cryoprobe assisted lumpectomy

• Cryotherapy technology
• Cryoprobe placed through lesion with US

Image courtesy of Sanarus
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Make a nonpalpable lesion palpable(and attach a
handle)

• cryoprobe assisted lumpectomy (cont.)

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Make a nonpalpable lesion palpable(and attach a
handle)

• cryoprobe assisted lumpectomy (cont.)

• Real-time US monitors iceball formation

Images Courtesy of Lorraine Tafra, MD

• Edges of iceball advance past periphery of
  lesion

• Iceball maintained as surgeon dissects around
  now- palpable mass

• Probe acts as a handle

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Cryo Assisted Lumpectomy Study

• Prospective, randomized 330 patients
• Cancers seen on sono and lt1.7 cm
• Randomized 2/3 CAL 1/3 NWL
• Endpoints
• Operative time
• Volume of tissue removed
• Pathologic margins
• Cosmesis

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Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
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Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
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Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
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Breast Surgery Current Standard of Care
State of the Art

• Office Care
• Diagnostic Imaging
• Biopsy
• Coordination of BC Treatment
• Operative Care
• Lesion Targeting/Lumpectomy
• Whole Breast Surgery
• Axillary Surgery
• Post-operative
• Radiation Therapy
• Chemotherapy and Hormonal Therapy

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Mastectomy
Breast Surgery Current Standard of Care

• Elliptical Incisions
• Avoid the Dog Ears - oncoplastic
• Reconstruction Options
• TRAM Flap
• Latissimus Flap
• Implant/Expander

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Whole Breast Surgery
Breast Surgery Current State of the Art

• Skin Sparing Mastectomy with reconstruction
• ?Nipple Sparing Mastectomy controversial
• Oncoplastic Techniques
• Lumpectomy with reduction
• Local tissue advancement flaps
• Contralateral reduction/mastopexy to match
  ipsilateral reconstruction

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Breast Surgery Current Standard of Care
State of the Art

• Office Care
• Diagnostic Imaging
• Biopsy
• Coordination of BC Treatment
• Operative Care
• Lesion Targeting/Lumpectomy
• Whole Breast Surgery
• Axillary Surgery
• Post-operative
• Radiation Therapy
• Chemotherapy and Hormonal Therapy

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Axillary Surgery

• Past (? Present) Complete Axillary Lymph Node
  Dissection
• Morbid lymphedema, ROM, neuro deficits
• Less accurate
• Techniques varied

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Axillary Surgery

• Present Standard of Care Sentinel Lymph Node
  Biopsy

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Axillary Surgery

• Present Standard of Care Sentinel Lymph Node
  Biopsy

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Axillary SLN Surgery

• NSABP B-32 Randomized study of SLN vs. SLN
  CALND in SLN negative patients (5600 pts)
• Identification rate 97
• False negative 9.7
• 60 only one positive lymph node
• SLN significantly less morbid than CALND

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Axillary SLN Surgery

• ACOSOG Z10 Immunohistochemical analysis of
  negative SLNs and bone marrow (5400 pts)
• Low morbidity with SLN
• 12 IHC () unknown clinical significance

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Axillary SLN Surgery

ACOSOG Z11 Randomized Trial of Observation vs.
CALND for SLN Positive Pts
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Axillary Surgery

• Present State of the Art Sentinel Lymph Node
  Biopsy
• or PET

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Axillary Surgery

• Present State of the Art Sentinel Lymph Node
  Biopsy
• or PET Ultrasound Monitoring

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Breast Surgery Current Standard of Care
State of the Art

• Office Care
• Diagnostic Imaging
• Biopsy
• Coordination of BC Treatment
• Operative Care
• Lesion Targeting
• Breast Surgery
• Axillary Surgery
• Post-operative
• Radiation Therapy
• Chemotherapy and Hormonal Therapy

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Radiation Oncology

• Present Standard of Care
• Whole Breast Radiation with tumor bed boost
• possible treatment of regional basins

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Radiation Oncology

• Partial Breast Radiation

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Multi-catheter Brachytherapy
Kuske template
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Mammosite Balloon Catheter

• MammoSite device (Proxima Therapeutics)
• Inflatable Balloon Placed In Lumpectomy Cavity
• Remote Afterloading
• 3400 cGy (340 cGy X 10) in 5 days
• FDA approval May 2002

Proxima Therapeutics
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3D Conformal External Beam RadiotherapyPhase
I/II PBI Trial- William Beaumont Hospital -
Lt ASIO
Rt PSIO
Rt AISO
Lt AISO
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Systemic Therapy

• Past Hormonal Tamoxifen
• Chemotherapy CMF, AC, T, others
• Present Hormonal AIs
• Chemotherapy Her/EGFR blockers chemo

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The Future
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Future Shock

• Breast Specialization by 2009 - 75 of breast
  cancer care will be delivered by 250 centers
• Breast Imager
• Breast Surgeon
• Breast Medical Oncologist
• Breast Radiation Oncologist

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Future Interactions ?
Imager/Surgeon
Medical Oncology
Radiation
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High Risk Assessment

• Gail Risk Assessment
• Claus Model Assessment
• Genetic Profiling
• Brca testing
• Oncovue

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Future Breast Cancer Treatment

• Diagnostic Biopsy tumor/genetic markers
• Treatment
• MRI to map complete extent of tumor
• Neo-ablation therapy to maximally shrink tumor
• Percutaneous ablation ultrasound, stereo, or
  MRI guided
• MRI to assess complete destruction
• Sentinel node irrelevant
• Radiation therapy focused or whole breast based
  on initial MRI pattern of tumor

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Future Breast Cancer Treatment

• Diagnostic Biopsy tumor/genetic markers
• Oncotech
• Precision Therapeutics
• Gene Arrays
• Oncotype DX
• Tumor typing

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Oncotype DX Technology Final Gene Set
PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2
ESTROGEN ER PGR Bcl2 SCUBE2
HER2 GRB7 HER2
GSTM1
REFERENCE Beta-actin GAPDH RPLPO GUS TFRC
CD68
INVASION Stromolysin 3 Cathepsin L2
BAG1
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Oncotype DX Need for Better Markers of
Recurrence
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Future Breast Cancer Treatment

• Diagnostic Biopsy tumor/genetic markers
• Treatment
• MRI to map complete extent of tumor
• Neo-ablation therapy (chemo/biologic/hormonal)
  to maximally shrink tumor
• Percutaneous ablation ultrasound, stereo, or
  MRI guided
• MRI to assess complete destruction
• Sentinel node irrelevant
• Radiation therapy focused or whole breast based
  on initial MRI pattern of tumor

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Ablative Techniques

• Technology developed for hepatic tumors now
  applied to treatment of other tumors including
  breast
• Core biopsy pre-ablation for definitive
  histologic diagnosis and thorough analysis of the
  cancer
• ER/PR, Her-2/neu, EGFR, Oncotype DX, etc.
• Current protocols for breast malignancy are
  ablation followed by resection (future MRI
  examination for completeness of ablation plus
  peri-tumoral core biopsies)

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Ablative Techniques

• Current ablative techniques under investigation
  include radiofrequency, cryoablation, focused
  ultrasound, microwave and laser
• Image-guided (ultrasound, stereotactic or MR)
  which allows localization of tumor in
  three-dimensions for percutaneous ablation

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Ablative Techniques

• Ablation of breast lesions can be performed in
  the radiology suite, office setting or in
  ambulatory operating room
• Will offer patients an alternative to surgical
  excision for treatment of benign and malignant
  disease

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Radiofrequency (RF) Ablation

• Destruction of solid tumors through heat
• Generated by high frequency alternating current
• Probe itself is not the source of heat, but a
  frictional heat from ions within tissue changing
  direction with alternating current

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RF Breast Cancer Ablation

• Insulated 15 g probe placed by ultrasound or
  stereotactic guidance
• Electrode prongs emerge in star-like array
• Allows larger diameter of tissue destruction
• Size adjustable
• Temperature sensing feedback to assess target
  temperature

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RF Breast Cancer Ablation

• 5-7 minute to reach target temperature 950C
• 15 minutes at target
• 1 minute cool down

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Edge of ablation zone
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RF Breast Cancer Ablation

• Pathological Analysis
• Standard HE
• NADH tumor viability stain
• Viable cells stain - blue (cytoplasmic granules
  with NADH oxidation reaction)
• Non-viable cells stain- grey-washed out

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RF Breast Cancer Ablation Studies
Jeffrey et al, Arch Surg, 1999Izzo et
al, Cancer, 2001Elliot et al, Amer Surg, 2002
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RF Ablation and Pre/Post Imaging

• Burak et al, 10 pts with RF ablation and
  subsequent resection
• Pre and post ablation MRI
• 9/10 no enhancement on post ablation MRI
• Corresponded with residual diseases upon
  resection
• Burak et al, Cancer, 98, 2003

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Cryoablative Technique

• Longstanding successful treatment of metastatic
  hepatic tumors
• Similar technology now being applied as primary
  treatment for variety of tumors including
  fibroadenomas
• Investigational studies are underway for breast
  cancer
• Core biopsy or FNA pre-ablation for definitive
  diagnosis

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Cryoablative Technique

• Image-guided via ultrasound which allows 3D
  localization of tumor for percutaneous ablation
• Local anesthetic to skin freezing acts as
  anesthetic to deep tissue
• Cryoablation of fibroadema can be performed in
  the office setting or in ambulatory operating
  room

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Cryoablation of Fibroadenoma

• Argon gas creates sonographic freezeball
• Real-time monitoring encompass tumor
• Multiple freeze-thaw cycles with target temp
  -160 / -196oC

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Cryoablation of Fibroadenomas

• Multi-institutional series (50 patients)
• Core biopsy dx/cryoablation w/o resection
• Tumor size
• range 0.7cm-4.2cm
• median 2.0 cm
• Tumor volume decrease
• 65 at 6 months
• 95 at 12 months
• Kaufman et al, Amer J Surg, 1842002

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Cryoablation of Fibroadenomas

• FDA approved treatment of fibroadenomas
• Currently being used in several institutions off
  protocol for treatment without surgical removal

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Cryoablation for Breast Cancers
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Cryoablation Breast Cancer Studies Rand
et al, Cryobiology, 1985Staren et al, Arch Surg,
1997Stocks et al, Abstract, Amer Soc of Breast
Surgeons, 2002
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Cryoablation of Breast Cancers

• 27 breast T1 invasive breast cancers
• Mean tumor size 1.2cm (range 0.6-2.0cm)
• Ultrasound guided cryoablation
• Surgical resection by lumpectomy post ablation
• Average time to resection 14 days (range 6-30
  days)
• SLNB performed in 25/27 patients
• M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
  Stocks, R. Simmons, M. Schultz
• Ann Surg Onc, 2004

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Cryoablation of Breast Cancers

• No procedural complications
• No patient required narcotics for analgesia
• M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
  Stocks, R. Simmons, M. Schultz
• Ann Surg Onc, 2004

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Cryoablation of Breast Cancers

• 23/27 patients (85) showed no viable invasive
  tumor
• 4/27 showed DCIS surrounding the cryozone
• 2 cases adjacent to cryozone
• 2 cases multifocal disease away from cryozone
• M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
  Stocks, R. Simmons, M. Schultz
• Ann Surg Onc, 2004

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Success of Cryoablation Dependent Upon Size and
Histology

• All patients 27 21(78)
• Tumors lt1.0cm 11
  11(100)
• Tumors gt1.0cm 16
  10 (75)
• Any size lobular/colloid 5
  2 (40)
• Any size IFDC with EIC 5
  3(60)
• Any size IFDC/medullary - EIC 17
  15(88)
• Tumors lt1.5cm/IFDC/med -EIC 10
  10(100)
• Tumors gt1.5cm/IFDC/med EIC 7
  5 (71)
• M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
  Stocks, R. Simmons, M. Schultz
• Ann Surg Onc, 2004

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Laser Ablation of Breast Cancers

• Image-guided by stereotactic mammography or MR
• Laser generates heat to destroy cancer
• Can be applied to mammographic microcalcifications
  or lesions seen only on MR

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Laser Ablation of Breast Cancers

• Lesion localized by standard stereotactic needle
• Parallel to needle temperature monitor probe
• Target temperature 80-100oC 15-20 minutes
• MR temperature maps to monitor remaining breast
• Photo courtesy of Dr. Kombiz Dowlatshahi

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Laser Ablation of Breast CancersBloom et
al, Amer J Surg, 2001Photo courtesy of Dr.
Kombiz Dowlatshahi

• Gross path concentric rings
• Central cavity-laser tip
• Peripheral ring-fat necrosis
• Pseudo-viable zone between
• recognizable histological tumor
• Immunostaining shows non-viable tissue

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HE SectionPhoto courtesy of Dr. Kombiz
Dowlatshahi
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Cytokeratin SectionPhoto courtesy of Dr.
Kombiz Dowlatshahi
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Laser Ablation Breast Cancer Studies
Dowlatshahi, et al, Arch Surg,
2000Harms, et al, SPIE, 1999
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Ablative Techniques

• The challenge in the success of these techniques
  is the ability to completely map the cancer
  within the breast and then to assure complete
  treatment of the cancer (MR, PEM, thermal
  imaging, ultrasound, core biopsies).

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Conclusions

• High Risk Analysis
• Imaging
• Local Control
• Regional Control
• Systemic Control
• Long Term Follow-Up