Nonsurgical Ablation of Breast Cancer: Future Options for Small Breast Tumors

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Key points

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    Nonsurgical ablation has several potential advantages over lumpectomy for the treatment of early stage breast cancer.

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    A variety of technologies are available for nonsurgical ablation, each with its own advantages and disadvantages.

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    Ablate and resect trials have shown the ability of nonsurgical techniques such as cryoablation, radiofrequency ablation, and high-intensity focused ultrasonography to completely ablate breast tumors.

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    There are limited data from ablation alone trials, and many questions

Mechanism

Interstitial laser therapy (ILT) involves the placement of a laser fiber with a diffusing tip through a trocar into a breast cancer. Laser light is then delivered directly to the target lesion, and the resultant thermal effect results from the interaction between the laser photons and the molecules of the tissue. Absorption of the laser light results in transformation of laser energy to heat, which increases the tissue temperature and creates a zone of thermal ablation. One advantage to ILT is

Mechanism

Radiofrequency ablation (RFA) involves the placement of an electrode into a tumor. A high-frequency alternating current flowing through the electrode causes ionic agitation, which in turn leads to friction heat and thermal damage, depending on the resultant temperature. Heating to 50°C to 55°C causes irreversible cellular damage in a few minutes, whereas heating between 60°C and 100°C causes instantaneous tissue coagulation. Different types of electrodes are used, including expandable

Mechanism

Cryoablation is performed by placing a cryoprobe at the center of a tumor. A cryoprobe is a high-pressure, closed-loop gas expansion system, in which the metal probe is insulated, except for the tip. The cryoprobe is rapidly cooled by means of the Joule-Thomson effect (rapid expansion of a gas results in a change in the temperature of the gas), removing heat from the tissue contacting the probe. For ablation of smaller tumors, a single probe is typically placed under ultrasound guidance through

Mechanism

Ultrasound ablation is a truly noninvasive ablation technique, because it does not require the minimally invasive placement of a catheter or probe at the tumor site. Ultrasound beams are generated by an ultrasound transducer and propagate through tissue as a high-frequency pressure wave. When an ultrasound beam is focused at a specific point at a certain distance from the source, the acoustic energy is converted to heat, leading to tissue coagulation.51 Using frequencies in the range of 0.5 to

Mechanism

Another truly noninvasive approach to breast cancer ablation is microwave ablation therapy. As with HIFU, no probe needs to be placed percutaneously. Instead, the breast is compressed between 2 microwave phased array waveguide applicators. Microwaves produce dielectric heat through the rapid agitation of water molecules within the tissue and the cells, leading to thermoinduced coagulation necrosis. It takes advantage of the fact that tissues with high water content, such as breast cancer cells,

Novel technologies

Although several modalities are being examined for breast cancer ablation, newer technologies continue to be developed. Irreversible electroporation (IRE) involves inserting needle electrodes in or around a tumor and then delivering short-length, high-voltage electric pulses.66 Depending on the change in potential, the electroporation pulse can either reversibly open the cell membranes, allowing the cell to survive, or irreversibly open the cell membrane, resulting in cell death.67 The former

Concerns for the future

A wide variety of technologies may be used in the ablation of a tumor in vivo. Some are minimally invasive (requiring the percutaneous placement of a probe or catheter[s]), whereas others are truly noninvasive. Some use hyperthermic ablation, some are hypothermic, and others use physical destruction without a change in tissue temperature. Although each technology may have its own unique advantages and disadvantages, there are some common obstacles facing clinical implementation.

For many, it

Summary

Although technologies for the nonsurgical ablation of breast cancer, such as cryoablation or HIFU, show clinical promise in early trials, more data are needed before these can be considered as viable alternatives to lumpectomy. Most current and pending data are from ablate and resect trials, with limited information from ablation alone trials. More information is needed on how nonsurgical ablation might affect subsequent radiation, adjuvant therapy, and breast imaging. Lumpectomy, with minimal

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    Disclosure: The author is on an advisory board for IceCure.

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