Interstitial Laser Therapy of Breast Fibroadenomas With 6 and 8 Year Follow-Up

Feasibility and efficacy of ultrasound-guided high-intensity focused ultrasound of breast fibroadenoma

OBJECTIVE

This nonrandomized prospective clinical trial aimed to assess the efficacy, safety and follow-up outcomes of ultrasound-guided high-intensity focused ultrasound (USgHIFU) surgery in patients with breast fibroadenoma.

METHODS

With the approval of the institutional ethics committee and written informed consent, a total of 113 patients diagnosed with breast fibroadenoma by core-needle biopsy in our hospital were recruited. USgHIFU surgery was performed under local anesthesia. Contrast-enhanced ultrasound (CEUS) or contrast-enhanced MRI (CEMRI) was performed to evaluate the nonperfused volume (NPV). The patients were followed up with physical examination and ultrasound imaging.

RESULTS

The clinical outcome of 85 patients with 147 fibroadenomas with a follow-up time of more than 3 months was analyzed in this study. Fifty-two patients had one lesion, twenty-one patients had two lesions and twelve patients had more than two lesions. During USgHIFU, the median localization time for all fibroadenomas was 3 (interquartile range: 1, 5) min, and the median treatment time was 9 (interquartile range: 5, 15) min. Under local anesthesia, all the patients tolerated the treatment well. No serious epidermal burns were observed in any of the patients. Based on CEUS or CEMRI imaging evaluation, the median NPV ratio was 100% (interquartile range: 79.2%, 116.8%). The VRR were 26.77 ± 50.05%, 50.22 ± 42.01% and 72.74 ± 35.39% at 3-6 months, 6-12 months and >12 months, respectively, which showed significant statistical difference (p < .001).

CONCLUSION

Ultrasound-guided HIFU surgery is an effective and safe noninvasive alternative technique for the treatment of breast fibroadenoma.

Ultrasound radiomics features predicting the dosimetry for focused ultrasound surgery of benign breast tumor: A retrospective study

Purpose: To investigate the correlation between pre-ablation ultrasound radiomics features and the sonication energy for focused ultrasound surgery (FUS) of benign breast tumors.

Method: 53 benign breast tumors of 28 patients treated by ultrasound-guided focused ultrasound surgery (USgFUS) were included in this study. The sonication energy per unit volume of each tumor was calculated. Three-quarter point was chosen as the cut-off to divide the 53 included tumors into high sonication energy (HSE, n = 14) and low sonication energy (LSE, n = 39) groups. For each tumor, the region of interest (ROI) of both the tumor itself (tROI) and the near field tissue (nfROI) were delineated and analyzed separately using ImageJ software. Pearson correlation coefficient and multiple linear regression analysis were used for radiomics feature selection. To explore the diagnostic performance of different ultrasound radiomics features, a receiver operating characteristic (ROC) curve analysis was performed.

Results: In total of 68 radiomics features were extracted from pre-ablation ultrasound images of each tumor. Of all radiomics features, BX in tROI (p < 0.001), BX (p = 0.001) and Circ (p = 0.019) in nfROI were independently predictive features of sonication energy per unit volume. The ROC curves showed that the area under the curve (AUC) values of BX in tROI, BX, and Circ in nfROI were 0.797, 0.787 and 0.822, respectively.

Conclusion: This study provided three radiomics features of pre-ablation ultrasound image as predictors of sonication dose for FUS in benign breast tumors. Further clinical trials are needed to confirm the predictive effect of these radiomics features.

Methods of monitoring thermal ablation of soft tissue tumors - A comprehensive review

Thermal ablation is a form of hyperthermia in which oncologic control can be achieved by briefly inducing elevated temperatures, typically in the range 50-80°C, within a target tissue. Ablation modalities include high intensity focused ultrasound, radiofrequency ablation, microwave ablation, and laser interstitial thermal therapy which are all capable of generating confined zones of tissue destruction, resulting in fewer complications than conventional cancer therapies. Oncologic control is contingent upon achieving predefined coagulation zones; therefore, intraoperative assessment of treatment progress is highly desirable. Consequently, there is a growing interest in the development of ablation monitoring modalities. The first section of this review presents the mechanism of action and common applications of the primary ablation modalities. The following section outlines the state-of-the-art in thermal dosimetry which includes interstitial thermal probes and radiologic imaging. Both the physical mechanism of measurement and clinical or pre-clinical performance are discussed for each ablation modality. Thermal dosimetry must be coupled with a thermal damage model as outlined in Section 4. These models estimate cell death based on temperature-time history and are inherently tissue specific. In the absence of a reliable thermal model, the utility of thermal monitoring is greatly reduced. The final section of this review paper covers technologies that have been developed to directly assess tissue conditions. These approaches include visualization of non-perfused tissue with contrast-enhanced imaging, assessment of tissue mechanical properties using ultrasound and magnetic resonance elastography, and finally interrogation of tissue optical properties with interstitial probes. In summary, monitoring thermal ablation is critical for consistent clinical success and many promising technologies are under development but an optimal solution has yet to achieve widespread adoption.

Metformin as a new option in the medical management of breast fibroadenoma; a randomized clinical trial

BACKGROUND

Fibroadenoma (FA) is the most common benign solid breast mass in women, with no definite method of management. Because fibroadenoma is dependent on female sex hormones and comprises hypertrophic changes at cellular levels, we investigated the effects of metformin (MF), a safe hypoglycemic agent with anti-estrogenic and anti-proliferative properties, in the management of fibroadenoma.

METHODS

In this randomized clinical trial study, eligible women with fibroadenomas were assigned randomly to the metformin (1000 mg daily for six months) or the placebo group. Breast physical and ultrasound exam was performed before and after the intervention, and the changes in the size of fibroadenomas were compared in the two groups.

RESULTS

Overall, 83 patients in the treatment, and 92 in the placebo group completed the study. A statistically significant difference in changing size between the two groups was observed only in the smallest mass. In the largest FAs, the rate of size reduction was higher in the treatment group (60.2 % vs. 43.5 %); while a higher rate of enlargement was observed in the placebo group (38 % vs. 20.5 %). In the smallest FAs, the rate of the masses that got smaller or remained stable was about 90 % in the treatment group and 50 % in the placebo group. We categorized size changes of FAs into < 20 % enlargement and ≥ 20 % enlargement. The odds ratio (OR) for an elargemnt less than 20% was 1.48 (95 % CI = 1.10-1.99) in the treatment group in comparison with the placebo group; the odds for an enlargement less than 20% was higher in women with multiples fibroadenomas (OR = 4.67, 95 % CI: 1.34-16.28). In our study, no serious adverse effect was recorded, and the medicine was well-tolerated by all users.

CONCLUSIONS

This is the first study that evaluates the effect of MF on the management of fibroadenoma, and the results suggest a favorable effect. Larger studies using higher doses of MF and including a separate design for patients with single or multiple FAs are suggested in order to confirm this effect.

TRIAL REGISTRATION

This trial (IRCT20100706004329N7) was retrospectively registered on 2018-10-07.

Volume reduction for ≥2 cm benign breast lesions after ultrasound-guided microwave ablation with a minimum 12-month follow-up

OBJECTIVE

To prospectively evaluate the efficacy of microwave ablation (MWA) for benign breast lesions (BBLs) ≥2 cm and explore the possible factors associated with the volume reduction rate (VRR) of ablated lesions.

MATERIALS AND METHODS

From November 2013 to December 2017, a total of 80 patients with 104 biopsy-proved BBLs larger than 2 cm in size underwent MWA. After the procedure, patients were followed up via physical and imaging examination consisting of contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging (MRI). Possible factors associated with 12-month VRR were assessed, including basic patient characteristics, index lesions and parameters of ablation technique.

RESULTS

The mean tumor size was 2.6 ± 0.6 cm (ranging 2.0-6.3 cm). Of the 104 lesions, 70 were fibroadenomas, 27 adenosis and 7 fibrocystic changes. Post-procedure CEUS or contrast-enhanced MRI showed that all lesions were completely ablated. No immediate or delayed complications were observed. All patients were followed up for more than 12 months (median follow-up 12.5 months). After MWA, the ablated lesion volume decreased significantly by 12 months (p < 0.001), with a mean volume reduction of 80.2 ± 13.1%. Multiple linear regression analysis showed that location adjacent to areola (β = 7.5, 95%CI: 1.0-13.9, p = 0.025) and location adjacent to skin (β = -7.4, 95%CI: -12.7 to -13.9, p = 0.007) were independent factors respectively associated with the increased and decreased 12-month VRR.

CONCLUSION

For BBLs larger than 2 cm, US-guided MWA is a favorable treatment modality, with BBLs adjacent to the areola being associated with more significant 12-month VRR after MWA.

Ultrasound-Guided Laser Ablation After Excisional Vacuum-Assisted Breast Biopsy for Small Malignant Breast Lesions: Preliminary Results

Background:

The purpose of this preliminary study is to evaluate the feasibility of the excisional ultrasound (US) guided vacuum-assisted breast biopsy (VAE), followed by US-guided Laser Interstitial Thermal Therapy (LITT) in the treatment of unifocal ductal breast carcinomas ≤ 1 cm and estimate the ablation rate analyzing the final histopathological results after subsequent surgical excision.

Methods:

In a single session 11 female patients with unifocal less than a centimeter breast cancer underwent 2 different minimally invasive percutaneous US-guided techniques: a VAE breast biopsy with an 8 G needle to remove the lesion and, immediately after, a LITT ablation in the biopsy site. Four weeks later, all patients underwent radiological follow-up. Afterward, a systematic surgery was performed, the ablation rate was calculated, and iconographic and histological features were correlated.

Results:

Average maximum diameter of the lesions was 7.6 mm (5-10 mm). No patient reported pain or discomfort during procedure. 1/11 patient (9.1%) reported an early minor complication (a small superficial skin burn). After surgical excision, the histopathological evaluation reported in 10/11 cases (90.9%) complete ablation of the target lesion. In only one case (9.1%) residual cancer was detected. The necrotic-hemorrhagic cavities showed a mean maximum diameter of 27.3 mm (20-35 mm).

Conclusions:

Laser ablation performed after excisional biopsy could be considered a valid alternative to surgical excision for the treatment of lesions ≤ 1 cm, if carried out by expert radiologists. The association of these minimally invasive percutaneous methods has proven to be reliable, fast, and safe with an ablation rate of 90.9% and excellent aesthetic results. RM and CESM are potentially able to quantifying treatment results and to follow-up the ablation effects.

Breast fibroadenomas: a review in the light of current literature

&lt;br&gt;&lt;b&gt;Introduction:&lt;/b&gt; Fibroadenomas are one of the most common benign tumors of the breast in the adolescent females accounting for about 2/3&lt;sup&gt;rd&lt;/sup&gt; of all the breast lumps and more than half of all the biopsied breast lesions. They come into being due to overgrowth of glandular tissue under the influence of hormonal changes that the girls undergo at the time of puberty. Due to the wide prevalence of fibroadenomas and the psychosocial morbidity associated with the finding of a breast mass, it is imperative for physicians treating adolescent patients to be thoroughly familiar and updated with this disease. &lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The article aims at providing a brief review of the classification, presentation, diagnosis, and update on the management of breast fibroadenomas on the basis of recent literature.

Ablative techniques for the treatment of benign and malignant breast tumours

Minimally invasive techniques like high intensity focused ultrasound, radiofrequency ablation, cryo-ablation, laser ablation and microwave ablation have been used to treat both breast fibroadenomata and breast cancer as an alternative to surgical excision, potentially reducing the complications, improving cosmesis and reducing hospital stay. This review describes the most common minimally invasive techniques available, their history and some of the studies performed with these techniques in both benign and malignant lesions. In addition we described some of the difficulties of using these minimally invasive techniques such as optimization of anaesthesia, imaging and immobilisation in order to increase the complete histopathological ablation rates.

Ultrasound guided percutaneous microwave ablation of benign breast lesions

The benign breast lesions (BBLs) share a high incidence for women and therapy methods with minimal invasion and better cosmetic outcome are thirsted for. In this study, 122 patients with 198 biopsy-proved BBLs were enrolled. Ultrasound (US)-guided microwave ablation (MWA) was performed with local anesthesia from November, 2013 to April, 2016. The mean longest tumor size assessed was 1.6±0.7 cm (ranging 0.7-4.9 cm). MWA was successfully performed in all cases including 85 lesions adjacent to the skin, pectoralis and areola. The mean ablation time was 3.2mins (ranging 0.5-18.3 mins). 99.5% of BBLs showed complete ablation when assessed by magnetic resonance imaging and 100% of them by US. At the median 14-month follow-up, the BBLs were not palpable in 45.9 % of the cases (palpable in 90.2 % of the cases before MWA) and the mean volume reduction ratio was 78.4±33.5% for total lesions and 89.3±20.8%, 84.7±27.6% and 55.9±32.9% for ≤1.0 cm, 1.1-2.0cm and >2.0 cm lesions in 12-month follow-up, respectively. Cosmesis were reported as good or excellent in 100 % by physician and patients. No side effect was found. The MWA of the BBLs proved feasible and effective, while showing meaningful reduction in volume, palpability and cosmetic satisfying outcomes.

Laser interstitial thermotherapy application for breast surgery: Current situation and new trends

While breast specialists debate on therapeutic de-escalation in breast cancer, the treatment of benign lesions is also discussed in relation to new percutaneous ablation techniques. The purpose of these innovations is to minimize potential morbidity. Laser Interstitial ThermoTherapy (LITT) is an option for the ablation of targeted nodules. This review evaluated the scientific publications investigating the LITT approach in malignant and benign breast disease. Three preclinical studies and eight clinical studies (2 studies including fibroadenomas and 6 studies including breast cancers) were reviewed. Although the feasibility and safety of LITT have been confirmed in a phase I trial, heterogeneous inclusion criteria and methods seem to be the main reason for LITT not being yet an extensively used treatment option. In conclusion, further development is necessary before this technique can be used in daily practice.

[Common benign breast tumors including fibroadenoma, phyllodes tumors, and papillary lesions: Guidelines]

OBJECTIVES

To provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning common benign breast tumors: fibroadenoma (FA), phyllodes breast tumors (PBT), and papillary lesions (BPL).

METHODS

Bibliographical search in French and English languages by consultation of PubMed, Cochrane and international databases.

RESULTS

In case of percutaneous biopsy diagnosis of FA, clinico-radiologic and pathologic discordance or complex FA or proliferative lesions or atypia with FA, a family history of cancer, it seems legitimate to discuss management in a multidisciplinary meeting. When surgery is proposed for FA, periareolar compared to direct incision is associated with more insensitive nipple but better aesthetic results (LE4). When surgery is proposed for FA, indirect incision is preferable for better cosmetic results (Grade C). Techniques of percutaneous destruction or resection can be used (Grade C). The WHO classification distinguishes three categories of phyllodes tumors (PBT): benign (grade 1), borderline (grade 2) and malignant (grade 3). For grade 1 PBT, the risk of local recurrence after surgical excision increases when PBT lesion is in contact with surgical limits (not in sano). After in sano resection, there is no correlation between margin size and the risk of recurrence (LE4). For grade 2 PBT, local recurrence after surgical excision increases for margins under 10mm margins (LE4). For grade 1-2 PBT, in sano excision is recommended. For grade 2 PBT, 10-mm margins are recommended (Grade C). No lymph node evaluation or neither systematic mastectomy is recommended (Grade C). Breast papillary lesion (BPL) without atypia, complete resection of radiologic signal is recommended (Grade C). For BPL with atypia, complete excisional surgery is recommended (Grade C).

Breast fibroadenomas in adolescents: current perspectives

Fibroadenomas are one of the most common benign tumors of the breast in the adolescent population. They account for 68% of all breast masses and 44%–94% of all biopsied breast lesions. Fibroadenomas can range from asymptomatic masses to painful and rapidly growing tumors that can cause significant esthetic distortions of the breast. Given the prevalence of fibroadenomas in the adolescent population and the psychosocial morbidity of finding a mass in the adolescent breast, it is imperative for physicians treating adolescent patients to be familiar and up to date with this disease process. The goal of this article is to provide a brief review of the classification, etiology, symptoms, initial work-up, and update on the management of breast fibroadenomas in the adolescent population.

Laser interstitial thermotherapy of small breast fibroadenomas: numerical simulations

BACKGROUND

Laser interstitial thermotherapy (LITT) is potentially a novel method to treat small breast fibroadenoma, without the need for surgical removal. Dosimetry planning and conformation of the treated area of tumor remain major issues, especially for a moving organ such as the breast. Pre-treatment simulation planning of this therapy is an effective method to predict the final thermal damage. In this study, a mathematical model is elaborated to simulate the heat distribution and the thermal damage.

METHODS

The mathematical model was based on finite element method (FEM) to solve the light distribution, bioheat, and thermal damage equations. Six simulations were performed with the following powers: 5, 6, 7, 8, 9, and 10 W (λ = 980 nm), and for an irradiation time of 125 seconds, with a 50 °C iso-damage temperature. To validate these simulations, six turkey breast samples were irradiated with parameters used for simulations. Volumes of thermal damage were calculated by using formulas: spherical, Elliptical, and Carlsson volumes and compared to the simulated volumes.

RESULTS

Differences between volumes were from 0.01 to 1 cm3. Interpolations between volumes from ex vivo experiments with corresponding powers were established. The relationship between the volume of the thermal damage and the laser power was described by a polynomial equation (R2  = 0.99). The power estimated by the interpolation to obtain 1 cm3 of thermal damage was 7.4 W (922 J) and the maximum corresponding temperature was 90 °C.

CONCLUSION

In this study, a good correlation was established between simulation and ex vivo experiments of LITT for fibroadenoma breast cancer.

Clinical Implications of Micrometastasis Detection in Internal Mammary Nodes of Breast Cancer Patients

BACKGROUND: The aim of this study was to assess the efficiency of step-serial sectioning (SSS) combined with hematoxylin and eosin (H&E) and immunohistochemical (IHC) staining in detecting micrometastasis of internal mammary lymph nodes (IMLNs). PATIENTS AND METHODS: 135 IMLNs from 88 breast cancer patients were re-examined by SSS, combined with either H&E or IHC staining of the biomarkers cytokeratin-19 and epithelial membrane antigen. RESULTS: Of the 135 IMLNs, 6 nodes from 5 cases displayed 1 or more micrometastases. Histological grade and lymphovascular invasion status were significantly correlated with micrometastasis in the IMLNs (p = 0.018 and 0.001, respectively). Of the 6 nodes positive for micrometastasis, 1 node was detected by both H&E and IHC staining. The remaining 5 nodes from 4 cases showed evident tumor cells only by IHC staining. Finally 8 of the 83 patients (9.64%) without IMLN metastasis showed distant metastasis, while 2 of the 5 patients (40%) with IMLN metastasis showed distant metastasis within 28 months of operation. CONCLUSION: SSS combined with H&E and IHC staining is more efficient in detecting micrometastasis than classic routine single-slice H&E only.

Ablative therapies of the breast

Minimally invasive ablative therapy techniques are being used in research protocols to treat benign and malignant tumors of the breast in select patient populations. These techniques offer the advantages of an outpatient setting, decreased pain, and improved cosmesis. These therapies, including radiofrequency ablation, cryotherapy, interstitial laser therapy, high-intensity focused ultrasonography, and focused microwave thermotherapy, are reviewed in this article.