Minimally Invasive Techniques Breast Cancer

1
Emerging Minimally Invasive Techniques for Breast
CancerThe Foremost cancer

• By Ashraf Noureldin Msc, PhD, FEBBS

2
(No Transcript)
3

• For 100s of years, radical operations were the
  treatment of breast cancer.
• Mastectomy, first documented during the
  Renaissance and later standardized by Halsted in
  the 19th century remained the standard of care
  until in the late 20th century.

4
Introduction

• Breast cancer is no longer a local disease that
  can be surgically removed or can be treated by
  only one physician. It is a serious, multifaceted
  and complex disease with various forms and
  shapes.

5

• Management of breast disease is entering a phase
  of dramatic changes based on screening, more
  sophisticated therapy, and the development of
  high technology solutions.

6

• Gone are the days in which a single physician
  knows everything about patient management.
• Multidisciplinary and even Interdisciplinary
  breast care teams should occur.

7
Sentinel lymph node Biopsy (SLNB)

• SLNB is a minimally invasive technique for
  determining the status of the axilla, which
  remains the single most important independent
  prognostic factor in breast cancer.

8

• Although the origin of breast lymphatic mapping
  dates back to the 17th century, until recently
  the lymphatic drainage of the breast has been
  poorly understood.

9
SLNB

• Recent studies were done during surgical
  procedures when the lymphatics of the breast are
  in active physiologic process allowing the lymph
  to flow.

10
SLNB

• The indications for SLNB is related to the SLN
  concept which is dependant on the orderly
  progression of tumor metastasis as they travel
  through lymphatic channels.

11
SLNB

• Accepted indications
• -Clinical T1a-c N0M0 -Clinical T2N0M0
• -DCIS (palpable) -DCIS with microinvasion
• -Male breast cancer.
• Controversial indications
• -Clinical T3N0M0 -Multifocal cancer
• -DCIS (detected by mammography only, low grade)
  -After pre-op chemotherapy
• -After large excision upper outer breast.

12
SLNB

• Contraindications
• -Clinically ve nodes or biopsy proven metastasis
• -Locally advanced Br cancer -Previous axillary
  dissection

13
(No Transcript)
14
SLNB
15
(No Transcript)
16
SLNB

• SLNB team must have documented experience with
  SLNB in breast cancer. Team includes surgeon,
  radiologists, nuclear medicine physician,
  pathologist, and prior discussion with medical
  and radiation oncologists on use of SLN for
  treatment decisions.

17
SLNB

• Multilevel node sectioning with hematoxylin and
  eosin staining should be done and Cytokeratin
  Immunohistochemistry (ICH) may be used for
  equivocal cases on HE.

18
Ductoscopy

• Because most breast cancers form initially in the
  ducts or lobules, 2 technical approaches have
  been developed.
• Ductoscopy uses a fiber-optic 0.55 mm
  mini-endoscope to examine the mammary ducts
  visually.

19
Ductoscopy

• Ductoscopy can identify a radiographically missed
  EIDC visually and include it in lumpectomy.
• Ductoscopy offers the surgeon the ability and
  conclusively to identify the source of bloody
  nipple discharge.

20
Ductoscopy

• Ductoscopy identifies ductal carcinoma-in-situ
  and premalignant cellular changes.

21
Ductal lavage

• Ductal lavage is a relatively noninvasive
  procedure to identify atypical cells in patients
  at high risk of developing breast cancer.
• Early attempts to examine nipple aspirate in high
  risk women has met with only limited success
  (samples contained insufficient cells for
  analysis).

22
Ductal lavage

• Ductal lavage produces an valuable fluid which
  increases the number of cells by more than
  100-fold.

23
Breast duct with mucus
Reddish duct wall spots in a patient with DCIS
24
Intraductal brush cytology
25
Ductal discharge Duct papilloma

26
Normal abnormal ducts
27
Ductoscopy and Lavage

• Mammary ductoscopy combined with ductal lavage
  may have a role in the management of patients
  with nipple discharge, the guiding of
  breast-conserving surgery for cancer, and in
  screening for high-risk women.
• The addition of molecular and genetic analysis of
  cells obtained by mammary ductoscopy will enhance
  the use of this technique.

28
Cryosurgery

• Cryoablation technology mainly used to treat
  liver metastasis, is now sufficiently advanced to
  eradicate benign breast tumors under US guidance.
• Studies are underway to evaluate the
  effectiveness of this improved cryoablation for
  in-situ destruction of selected breast cancers.

29
Cryosurgery

• Fibroadenoma can be eliminated with this
  technology.
• Cryoablation is similar for both benign and
  malignant tumors

30
Cryosurgery

• The surgeon locateas the tumor with US, advances
  a small insulated cryoprobe thru the tumor using
  an argon gas tabletop system. The formed ice ball
  is monitored thru the real time US, the surgeon
  uses 2 freeze particles to optimize the
  destruction of the neoplastic tissues.

31
Cryosurgery

• For malignant tumors, current protocols include
  lumpectomy 1 to 3 weeks after the ablation
  procedure.
• Histopathologic end points include the
  completeness of tumor destruction and
  morphological findings of the resulting
  cryo-lesion in the surrounding tissue.

32
Cryosurgery

• In a multiinstitutional trial, 28 patients
  underwent cryoablation for malignant tumors.
• In 16 patients, no tumors remained at lumpectomy.
• The 12 remaining patients had persistent viable
  tumor due to eccentric probe (2 pts),
  components of tumor that were poorly imaged
  (7pts), and tumor size underestimation by US.

33
Cryosurgery

• The lesion is immediately rendered non-viable,
  but the lesion remains palpable for 6-12 months.
  After 12 months, 89 of lesions lt 2.5 cm have
  regressed to less than 1 cm.
• Satisfaction has been reported as good to
  excellent by 94 of the patients.
• In 2001, the FDA approved cryoablation for
  fibroadenomas.

34
Cryo-assisted biopsy and lumpectomy

• Tafra and colleagues have reported a more
  immediate application for modern cryoprobe
  technology.
• The use of this approach has resulted in clear
  margin resection in 95 of cases.

35
Radiofrequency Ablation

• A high-frequency alternating current is produced
  between an electrode placed in the tumor and a
  grounding pad outside the body.
• The current itself does not generate heat. Rather
  frictional heating is caused by the rapid
  movement of ions in the tissue attempting to
  follow the alternating current.
• Thermal injury to tumor cells begins at
  approximately 41 C and cell death occurs at a
  temp of 45 to 50 c.

36
Radiofrequency Ablation

• The physician guides the placement of this needle
  using image guidance, such as PET/CT or
  Ultrasound.

37
Radiofrequency Ablation

• Once the needle is properly placed, metal tines
  are deployed from the hollow core of the needle.
  These tines penetrate and envelope the tumor.
• In most studies, US has been used to support RFA
  ablation in breast tumors, but it proved to be
  effective in only small tumors with clear borders.

38
Radiofrequency Ablation

• Tissue changes that occur in the breast during
  RFA are difficult to distinguish clearly by US.
• MRI has proved more effective than US in showing
  the extent and for detecting multicentric and
  multifocal tumors.

39
(No Transcript)
40
Radiofrequency Ablation

• Because of the heavy reliance of RFA on accurate
  imaging, new development in imaging technology
  will be especially important.
• In vivo cellular and molecular imaging is an
  important development.
• With this approach, light wave length ranging
  from UV to near infrared would be used to
  quantify both biochemical and structural features
  of breast disease.

41
Radiofrequency Ablation

• Fluorescense spectroscopy of suspected breast
  lesions could be carried out.
• This would detect the light from endogenous
  fluorophores that differ in concentration in
  benign versus malignant tissues.

42
Laser Ablation

• Interstitial Laser Therapy (ILT) has shown to be
  effective in ablation of small breast tumors.
• In 1994, Harries reported ILT in 44 patients with
  breast cancer (1-5 cm) treated under local
  anesthesia.
• They achieved tissue necrosis detected by US.

43
Skin Sparing mastectomy

• Although many patients are candidates to BCT or
  minimally invasive treatment, some patients will
  need mastectomy, for these patients SSM is an
  effective option.

44
Areolar Preservation

• Preservation of the nipple areolar complex (NAC)
  is done in selected cases.
• Reservations for NAC removal was due to the
  abundance of lactiferous ducts and lymphatics
  associated with the nipple. (5.6 in mastectomy
  specimens).
• When the areola was evaluated separately it was
  involved in 0.9.

45
Conclusion

• The Future is not what it used to be.
• A 21st Century Breast Surgeons should
  enthusiastically move into this exiting phase for
  breast cancer management so that patients can
  receive the best option.
• Multidisciplinary and Interdisciplinary teams are
  a must in the management of breast disease
  patients.

46

• Thank You