t cnicas de ablación tumoral -...

Técnicas de Ablación Tumoral

Julia Camps Herrero. Hospital de la Ribera. Alzira

Desde la MRM de Halsted hasta la CC de Fisher

CM precoz

• El tratamiento conservador (Resección local del tumor + BSGC +RT) es el tratamiento estándar

• Se están planteando aproximaciones igual de seguras pero menos invasivas

Técnicas Mínimamente Invasivas: Ablación Tumoral

Radiofrecuencia

HIFU (High Intensity Focused Ultrasound)

Láser

Microondas

La CC no está exenta de morbilidad, mayor coste

Tumores de pequeño tamaño en campañas de cribado: técnicas menos agresivas

¿Qué se le pide a las nuevas técnicas ablativas?

A corto plazo: necrosis completa de la lesión con bordes negativos

A largo plazo: resultados iguales o superiores a los de la cirugía conservadora

A tener en cuenta: la evaluación radiológica sustituirá a la histopatológica

El éxito técnico depende en gran parte de

La valoración exacta de la extensión y del tamaño tumoral (RM)

La monitorización de los efectos en tiempo real (RM en HIFU, US en el resto)

El seguimiento de las pacientes con técnicas altamente sensibles a la persistencia o recidiva tumoral (RM)

CRIOTERMIA

HIPERTERMIA

HIFU

Radiofrecuencia

Láser

Microondas

BLES (Breast Lesion Excision System)

Criotermia

Formación rápida de cristales de hielo intra y extracelulares (fuerzas de cizallamiento sobre membranas y organelas celulares)

Deshidratación celular (el agua pasa desde intra a extracelular mediante osmosis)

Isquemia por estasis vascular y lesión endotelial

Gases: argón (+ rápido) o nitrógeno

Temperatura objetivo: -160ºC a -190ºC

Anestesia local sin sedación profunda

Tasa de necrosis muy variable (0–80%)

Poco efectiva en CDIS

Ninguna paciente estadificada con RM

7.2 Breast 227

tion was monitored by recording radial temper-atures every 15 s at 5, 10, 15, and 20 mm from the cryoprobe, and the ice-ball diameter was measured every 2.5 min. After 10 min, the probe was warmed and the time taken until it could be extracted from the liver was recorded. Warm water bath – the probe was immersed in warm water (42 C) for 15 min and the ice-ball diameter was measured at 5-min intervals.

Radial temperatures in liver declined more rap-idly (p < 0.001) and the time to probe extraction was less (p < 0.01) when the argon gas system was used. The new N-probe performed better than its older counterpart, but was still slower than the argon gas system. In liver (20 C), ice-ball diameters were similar after 10 min, but in warm water, they were larger when the new N-probe was used (p < 0.02). It would appear that the argon gas system is initially faster, but it does not achieve as large an ice-ball in a warm environment as the liquid nitrogen system (Hewitt et al. 1997). The safety of cryotherapy has already been published: a world review about 5432 patients who underwent cryotherapy for prostate cancer mentioned 3 deaths (0.06%) after the inter-vention. Mortality after cryotherapy of liver tumors is reported to be 1.5%–1.6% due to cryoshock, which is uncommon in prostate therapy (Seifert and Morris 1999). The two minor complications in the study from our group in Jena (Pfl eiderer et al. 2002) are most likely due to vessel damage during the insertion of the cryoprobe, which resulted in bleeding that was stopped after compression and the

!

transformation of a hematoma to a seroma. While complications such as those that occur in cryoshock, for example fi stulas that occurred in cryoablation of the liver or urethral strictures and incontinence with cryosurgery of the prostate, are unlikely to occur in breast therapy, skin or fatty tissue necro-sis, hematoma, intercostals nerve damage and focal neuritis may occur. Our group (Pfl eiderer et al. 2002, 2005) treated a total of 41 patients with biopsy-confi rmed breast cancers using percutaneous cryo-therapy. In all, 30 women had tumor diameters of 15 mm or smaller (Pfl eiderer et al. 2005) (range 5–15 mm, median 12 mm) whereas 11 patients pre-sented with cancers of 16 mm or more (Pfl eiderer et al. 2002). After local anesthesia a 3-mm cryoprobe was placed into the tumor under ultrasound guid-ance (Fig. 7.2.3). All tumors were subjected to two freeze cycles with an interposing thawing cycle. The size of the ice-balls and the temperature at the tip of the probe (Fig. 7.2.4) were closely monitored during the procedure. The patients underwent surgery within 6 weeks and the specimens were evaluated histologically.

The median minimum temperature reached –146 C (range: –117 C to –167 C). In 5 of 29 patients who had tumors with a size of 15 mm or smaller, remnant ductal carcinoma in situ (DCIS) was his-tologically detectable after cryotherapy beyond the margin of the cryosite in the specimens after open surgery. In 24 women no viable tumor cells were found (Pfl eiderer et al. 2005). No severe side-effects occurred. In one patient the cryo procedure was not performed completely due to technical problems.

Fig. 7.2.3a,b. Ultrasound image (B-mode) of the fi nal position of the cryoprobe in a 70-year-old patient. a, b The cryoprobe (black arrows) passed the center of a histologically proven invasive ductal carcinoma (diameter 14 mm) (white arrows) in two planes. The patient was operated after cryotherapy. The histological evaluation of the specimens after open surgery did not reveal any residual viable tumor

a b 7.2 Breast 229

residual invasive cancers occurred in tumors 17 mm or smaller or in cancers without spiculated margins at US. One tool to avoid remnant tumor as occurred in the study of Pfl eiderer et al. (2002, 2005) or Roubidoux and coworkers (2004) may be prepro-cedural MR mammography. DCIS has a character-istic appearance in MR mammography, which has a rather good sensitivity of 92% in detecting high-grade DCIS (Neubauer et al. 2003). Thus, MR mam-mography may be helpful for excluding women with an extensive intraductal component from minimally invasive therapy.

Kaufman et al. (2004) performed percutaneous cryotherapy in women with fi broadenomas. US-guided cryoablation of core biopsy-proven benign fi broadenomas, other benign breast nodules, or nodular fi brocystic change was performed on 78 lesions in 63 patients. Then, 64 of 78 lesions (mean size 2.0 cm, range 0.8–4.2 cm) were followed-up for at least 12 months after cryoablation per protocol, which included 53 fi broadenomas. At 1 year, US tumor volume resorption was 88.3% overall (87.3% for fi broadenomas), and 73% of the entire group became nonpalpable to both clinician and patient (75% for fi broadenomas). Two of the fi broadenoma patients had their palpable residual nodule excised, both revealing necrotic debris and no viable tumor in the treated volume.

7.2.7 Summary

Numerous methods of image-guided percutaneous minimally invasive therapy for breast cancer are under investigation, while BCT is developing less invasive methods. All procedures destroy cancer tissue by depositing thermal energy within the tumorous lesion. All reports show partial destruc-tion of the cancers to various extents. Limitations in local tumor control are still a limitation of almost all published studies. On the other hand, even after breast-conserving surgery, positive margins, which were not apparent from acute perioperative histol-ogy, occurred and may result in local cancer recur-rence. Nevertheless the presence of tumor cells at the edge of the ablation zone after percutaneous treatment of breast cancer should be avoided. Up until now, breast-conserving surgery followed by irradiation and probably chemotherapy, depending on the lymph node status and the tumor extent, is still the gold standard in the treatment of breast cancer. However, to achieve wide acceptance, mini-mally invasive ablation therapies must lead to equiv-alent or even greater effi cacy as surgical outcomes and, in the short-term, demonstrate total ablation with negative margins, while sparing normal tissue beyond the target volume. Furthermore long-term results after percutaneous ablation are not yet avail-able. Thus, further studies with larger patient series have to be carried out, especially those without sub-sequent surgery but with adjuvant therapy regimens including state-of-the-art radiotherapy and chemo-therapy.

References

Akimov AB, Seregin VE, Rusanov KV et al (1998) Nd:YAG interstitial laser thermotherapy in the treatment of breast cancer. Lasers Surg Med 22:257–267

Boehm T, Malich A, Reichenbach JR, Fleck M, Kaiser WA (2001) Percutaneous radiofrequency (RF) thermal abla-tion of rabbit tumors embedded in fat: a model for RF ablation of breast tumors. Invest Radiol 36:480–486

Bohris C, Schreiber WG, Jenne J et al (1999) Quantitative MR temperature monitoring of high-intensity focused ultra-sound therapy. Magn Reson Imaging 17:603–610

Burak WE Jr, Agnese DM, Povoski SP et al (2003) Radiofre-quency ablation of invasive breast carcinoma followed by delayed surgical excision. Cancer 98:1369–1376

Fig. 7.2.5. The surface of the ice-ball could be well delineated in all cases on the ultrasound images showing the sickle-shaped hyperechoic surface of the ice-ball. The entire area behind the ice-ball is not visible because ice refl ects ultra-sound waves resulting in dorsal acoustic shadowing

Autor y Año Pacientes Tamaño Lesional e Histopatología

Guía Resultados Observaciones

Morin (2004) 25 diámetro 12-60 mm cáncer de mama

infiltrante

RM 13/25 NC (52%) Intervención quirúrgica a las 4

semanas

Sabel (2004) 29 < 20 mm US NC sólo en los tumores < 10 mm

Intervención quirúrgica a las 1-4

semanas

Roubidoux (2004)

9 diámetro medio12 mm (8-18 mm)

cáncer de mama infiltrante

US 7/9 NC (78%) Intervención quirúrgica a las 2-3

semanas

Kaufman (2004)

63 78 lesiones diámetro medio 20 mm (8-42

mm) fibroadenomas,

cambios fibroquísticos

US 88,3% reabsorción en ecografía de las lesiones tratadas

Seguimiento al menos 12 meses

Pfleiderer (2005)

41 30 < 15 mm 11 > 15 mm

cáncer de mama infiltrante

US < 15 mm 24/30 (80%)

> 15 mm 0/11 NC (0%)

Intervención quirúrgica a las 6

semanas

Littrup (2005) 29 42 fibroadenomas volumen medio 42 cc

US 73% reducción 22/29 pacientes con anestesia local

Tabla 1. Resultados tratamiento de lesiones mamarias con crioterapia. US = Ultrasonidos. RM = Resonancia Magnética. NC = Necrosis Completa.

High Intensity Focused Ultrasound (HIFU)

o US Focalizado

Energía Mecánica0.5-4 MHz

Energía Térmica80ºC

Necrosis Coagulativa

Alto gradiente térmico: zonas de lesión bien delimitadas

0.5–4 MHz (20 cm de penetración a 1.5 MHz)

45 min a 2,5 horas de tratamiento (guiado por RM/

Ecografía)

RM para planificar, guiar y controlar la eficacia del

tratamiento: secuencias de monitorización de la

temperatura (la frecuencia de resonancia del agua

depende de la temperatura)

No está limitado por la perfusión sanguínea (lavado de

calor)

Lesiones a más de 5–10 mm de la piel y a 20 mm del CAP

tratamientos ablativos guiados por imagenHIFU

Schmitz A, Gianfelice D, Daniel B, et al. Image-guided focused ultrasound ablation of breast cancer: current status, challenges, and future directions. European Radiology (2008)

226 S. O. R. Pfl eiderer and W. A. Kaiser

a b

Fig. 7.2.2a,b. MRI-guided HIFU of breast cancer. a T1-weighted subtracted MR image after gadolinium-DTPA application which shows a breast cancer (arrow) before HIFU. b After HIFU the lesion enhances no further, indicating effective ab-lation (with courtesy of Breasto-pia Namba Hospital, Miyazaki, Japan)

7.2.5 Microwave Ablation Therapy

Microwaves applied to living tissue produce dielec-tric heat by stimulation of the water molecules within the tissue and the cells. The rapid agita-tion of the water molecules results in frictional heating and thermo-induced coagulation necrosis. Using microwave ablation therapy in breast cancer two microwave phased array waveguide applica-tors compress the breast. The energy preferentially heats tissues with a high water content, such as breast cancer tissue, whereas the surrounding tissues, for instance adipose or connective tissue and breast parenchyma, with a lower water content absorb less thermal energy. Cooling of the over-lying skin is necessary frequently. Gardner and colleagues (2002) performed microwave ablation in ten women with breast cancer. All tumors were surgically resected within 18 days after microwave ablation. A reduction of tumor size was found in 60% of the patients, using ultrasound. Histologi-cal evaluation of the operation specimens revealed tumor necrosis in 80% of cases. In another series 25 patients were treated using microwave ablation (Vargas et al. 2004). Histology revealed necrosis of the tumors, which had a mean diameter of 18 mm, in 68% of patients. Complete destruction of the invasive component of the tumor was achieved only in 2 of 25 women.

7.2.6 Cryotherapy

During cryotherapy three basic phenomena occur resulting in cell death:

Rapid formation of intracellular and extracellu-lar ice crystals, which leads to mechanical shear forces on cell membranes and organelles causing mechanical cell damageCellular dehydration, which occurs due to shift-ing of water from intracellular to extracellular spaces by osmosis causing destruction of critical cellular componentsIschemia as a result of vascular stasis and damage to the blood vessels, which prevents nutrients from reaching remnant viable cells

The faster low temperatures are reached, the more severe is the damage to the treated tissue. Compared to nitrogen-based systems, operating temperature is reached faster with argon-based systems, and cells are damaged more effectively. So Hewitt and coworkers (1997) compared nitrogen-based cryo-therapy with cryoablation using argon gas. Three different 3-mm cryoprobes were used: an old liquid nitrogen probe (N-probe), a new N-probe featuring gas bypass, and an argon gas probe. Each probe was tested in two models:

Fresh sheep liver at 20°C – the probe was inserted to a depth of 1.5 cm; the rate of ice-ball forma-

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Breastopia Namba Hospital. Miyazaki. Japón

HIFU: estudios publicados guiados por RM

RM LESIONES tamaño% necrosis completa

tratamiento

ZIPPEL 2005

GIANFELICE 2003

KHIAT 2006

GIANFELICE 2003

FURUSAWA 2006

GIANFELICE 2003

FURUSAWA 2007

HYNYNEN 2001

10 < 30 mm 20% cirugía





24 < 25 mm 79%no cirugía

Tumor R 21%


3-26 meses1 recidiva

11 FAD NC 73% parcial no cirugía

HIFU: estudios publicados guiados por US

US LESIONES tamaño % necrosis completa tratamiento

WU 2003

WU 2005

WU 2007

23 < 60 mm 100% cirugía


3-60 mesesrecidiva 9%

23 < 60 mm 100% cirugía

Margen de seguridad tumoral superior (15-20 mm)

HIFU: resumen estudios publicados

Los tratamientos guiados por RM tienen peores resultados que

los guiados por US

La RM se perfila sin embargo como la técnica más prometedora

por su capacidad de estadificar, guiar, monitorizar y controlar los

resultados del tratamiento

En los tumores no intervenidos quirúrgicamente se emplea una

combinación de BAG+RM seriadas*

La BSGC no se ve afectada (Vargas 2003) pero lo más lógico es

realizarla antes del tratamiento con HIFU

* Kim SH, Jung SE, Kim HL, Hahn ST, Park GS, Park WC. The potential role of dynamic MRI in assessing the effectiveness of high-intensity focused ultrasound ablation of breast cancer. International Journal of Hyperthermia. 2010;26(6):594–603.

Futuro potencial:

respuesta autoinmune inducida por FUS

control de la expresión transgénica en células tumorales

terapias diana inducidas por calor

High intensity focused ultrasound in clinical tumor ablation

Yu-Feng Zhou

Yu-Feng Zhou, Division of Engineering Mechanics, School of Mechanical and Aerospace Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore 639798, SingaporeAuthor contributions: Zhou YF solely contributed to this paper.Correspondence to: Yu-Feng Zhou, PhD, Division of Engi-neering Mechanics, School of Mechanical and Aerospace Engi-neering, Nanyang Technological University, 50 Nanyang Avenue, Singapore 639798, Singapore. [email protected]: +65-67904482 Fax: +65-67924062Received: June 24, 2010 Revised: July 26, 2010Accepted: August 2, 2010Published online: January 10, 2011

AbstractRecent advances in high intensity focused ultrasound (HIFU), which was developed in the 1940s as a viable thermal tissue ablation approach, have increased its popularity. In clinics, HIFU has been applied to treat a variety of solid malignant tumors in a well-defined volume, including the pancreas, liver, prostate, breast, uterine fibroids, and soft-tissue sarcomas. In compari-son to conventional tumor/cancer treatment modalities, such as open surgery, radio- and chemo-therapy, HIFU has the advantages of non-invasion, non-ionization, and fewer complications after treatment. Over 100 000 cases have been treated throughout the world with great suc-cess. The fundamental principles of HIFU ablation are coagulative thermal necrosis due to the absorption of ultrasound energy during transmission in tissue and the induced cavitation damage. This paper reviews the clinical outcomes of HIFU ablation for applicable can-cers, and then summarizes the recommendations for a satisfactory HIFU treatment according to clinical experi-ence. In addition, the current challenges in HIFU for engineers and physicians are also included. More recent horizons have broadened the application of HIFU in tu-mor treatment, such as HIFU-mediated drug delivery, vessel occlusion, and soft tissue erosion (“histotripsy”). In summary, HIFU is likely to play a significant role in

the future oncology practice.

© 2011 Baishideng. All rights reserved.

Key words: High intensity focused ultrasound; Thermal ablation; Image-guided therapy; Cancer; Bubble cavi-tation; Bioeffects

Peer reviewer: Nathalie Lassau, MD, PhD, Imaging Depart-ment, Institut Gustave Roussy, 39 Rue Camille Desmoulins, 94800 Villejuif, France; Ali Syed Arbab, MD, PhD, Associate Scientist and Director, Cellular and Molecular Imaging Laborato-ry, Department of Radiology, Henry Ford Hospital, 1 Ford Place, 2F, Box 82, Detroit, MI 48202, United States; Ravi Murthy, MD, Interventional Radiology, UT MD Anderson Cancer Center, 1400 Pressler Street, Unit 1471, Houston, TX 77042, United States; Ronald Xiaorong Xu, PhD, Assistant Professor, Biomedical Engi-neering Department, The Ohio State University, 270 Bevis Hall, 1080 Carmack Rd., Columbus, OH 43210, United States

Zhou YF. High intensity focused ultrasound in clinical tumor ablation. World J Clin Oncol 2011; 2(1): 8-27 Available from: URL: http://www.wjgnet.com/2218-4333/full/v2/i1/8.htm DOI: http://dx.doi.org/10.5306/wjco.v2.i1.8

INTRODUCTIONCancer is a major public health problem for human beings in both developed and developing countries. Currently, one in four deaths in the United States is due to cancer[1]. Cancer therapy demand in the United States will grow annually by 10% through 2009. Increases will be driven by more incidence and detection of cancer coupled with a range of highly effective, but expensive, new treatment modalities. $16.8 billion are spent each year for cancer therapies in the United States[2]. This represents historical demand data from 1994, 1999 and 2004 and forecasts to 2009 and 2014 by cancer type (e.g. breast, digestive system, genital system, leukemia, lymphoma), by product/proce-dure (e.g. chemotherapy drugs, surgery, radiation therapy, biotechnology-based drugs, hormonal therapy, vaccines, nanotechnology, stem cells), and by institution/provider

TOPIC HIGHLIGHT

World J Clin Oncol 2011 January 10; 2(1): 8-27 ISSN 2218-4333 (online)

© 2011 Baishideng. All rights reserved.

Online Submissions: http://www.wjgnet.com/2218-[email protected]:10.5306/wjco.v2.i1.8

World Journal ofClinical OncologyW J C O

E YK Ng, PhD, PGDTHE, Associate Professor, Series Editor

8 January 10, 2011|Volume 2|Issue 1|WJCO|www.wjgnet.com

Radiofrecuencia

tratamientos ablativos guiados por imagenRADIOFRECUENCIA

riñón

hígado

riñónriñónriñón

pulmón

AGITACIÓN IÓNICA CALOR POR FRICCIÓNEXPANSIÓN POR CONDUCCIÓN

composición y vascularización tisular

conductividad eléctrica y térmica (impedancia tisular)

temperatura y tiempo de RF

GRADO DE NECROSIS

Ecuación del BIOCALOR(Pennes 1948)

(distribución de la temperatura)

necrosis coagulativa =

energía depositada x interacciones tisulares locales - pérdida de calor





46ºC - 60 minutos52ºC - 4-6 minutos






60-100ºC






60-100ºC

> 105-155ºC






60-100ºC

citotoxicidad

> 105-155ºC






60-100ºC

citotoxicidad

coagulación proteínica(enzimas mitocondriales y citosólicos)

> 105-155ºC






60-100ºC

citotoxicidad

coagulación proteínica(enzimas mitocondriales y citosólicos)

> 105-155ºC vaporización tisularcarbonización

tratamientos ablativos guiados por imagenRADIOFRECUENCIA en CÁNCER DE MAMA

Ensayos clínicos FASE II

INDICACIONES

Canceres de pequeño tamaño

Pacientes inoperables

CONTRAINDICACIONES

CDIS

Ca Lobulillar

Componente intraductal extenso

Multifocalidad/ Multicentricidad


GUIA IMAGEN: ecografía o mamografía + frío local

TIEMPO DE TRATAMIENTO: 8–12 min

CONTROL EFICACIA TRATAMIENTO

NADH Diaforasa

RM en pacientes no intervenidas

Vanderploeg et al. Radiofrequency ablation for breast cancer: A review of the literature. European Journal of Surgical Oncology (EJSO) (2007) vol. 33 (6) pp. 673-677

RADIOFRECUENCIA: ANÁLISIS HISTOPATOLÓGICO

HEMATOXILINA EOSINA (H&E) valora estructura

NADH-diaforasa valora viabilidad celular

RADIOFRECUENCIA: ANÁLISIS HISTOPATOLÓGICO

HEMATOXILINA EOSINA (H&E) valora estructura

NADH-diaforasa valora viabilidad celular

Las biopsias no tienen valor si son procesadas H&E

Dr Luís Apesteguía. Hospital Virgen del Camino. Pamplona

Figura 4

Figura 6

Figura 3

Autor y Año Pacientes Tamaño Lesional

Necrosis Completa

Observaciones

Jeffrey (1999) 5 40-70 mm 40% Escisión quirúrgica inmediata

Izzo (2001) 26 < 30 mm 96% 1 quemadura cutánea Escisión quirúrgica inmediata

Hayashi (2003) 22 < 30 mm 86% 1 quemadura cutánea 4 infecciones herida quirúrgica

Intervención quirúrgica a las 1-2 semanas

Burak (2003) 10 5-20 mm 90% Intervención quirúrgica a las 1-3 semanas

Fornage (2004) 20 < 20 mm 95% Escisión quirúrgica inmediata

Noguchi (2006) 10 5-20 mm 100% Escisión quirúrgica inmediata

Earashi (2007) 24 < 20-30 mm 100% 17 Pacientes escisión inmediata / 7 pacientes escisión a los 1-7

meses

Susini (2007) 3 < 20 mm 100% Tratamiento Paliativo

Oura (2007) 52 5-20 mm Ninguna recidiva Estadificación con RM Seguimiento medio 15 meses

Control efectividad RF con RM y citología

Khatri (2007) 15 < 15 mm 93% 2 casos retracción cutánea 1 infección herida quirúrgica Escisión quirúrgica inmediata

Medina-Franco (2008)

25 9-38 mm (media 20

mm)

76% 3 quemaduras cutáneas 1 infección herida quirúrgica Escisión quirúrgica inmediata

Imoto (2009) 30 < 20 mm 87% Estadificación con RM 2 quemaduras cutáneas 7 quemaduras músculo

Escisión quirúrgica inmediata

Manenti (2009) 34 < 20 mm 97% Estadificación con RM Control efectividad RF con RM


Nagashima (2009)

17 < 20 mm Ninguna recidiva Estadificación con RM Control efectividad RF con RM

Ninguna complicación Seguimiento medio 19 meses

Apesteguía (2009)

35 < 20 mm 77% Ninguna complicación Intervención quirúrgica a las 2-4

semanas

Tabla 2. Resultados tratamiento de cánceres de mama con radiofrecuencia. La guía de imagen fue en todos los casos la ecografía. NC = Necrosis Completa.

Autor y Año Pacientes Tamaño Lesional

Necrosis Completa

Observaciones

Jeffrey (1999) 5 40-70 mm 40% Escisión quirúrgica inmediata

Izzo (2001) 26 < 30 mm 96% 1 quemadura cutánea Escisión quirúrgica inmediata

Hayashi (2003) 22 < 30 mm 86% 1 quemadura cutánea 4 infecciones herida quirúrgica


Burak (2003) 10 5-20 mm 90% Intervención quirúrgica a las 1-3 semanas

Fornage (2004) 20 < 20 mm 95% Escisión quirúrgica inmediata

Noguchi (2006) 10 5-20 mm 100% Escisión quirúrgica inmediata

Earashi (2007) 24 < 20-30 mm 100% 17 Pacientes escisión inmediata / 7 pacientes escisión a los 1-7

meses

Susini (2007) 3 < 20 mm 100% Tratamiento Paliativo

Oura (2007) 52 5-20 mm Ninguna recidiva Estadificación con RM Seguimiento medio 15 meses

Control efectividad RF con RM y citología

Khatri (2007) 15 < 15 mm 93% 2 casos retracción cutánea 1 infección herida quirúrgica Escisión quirúrgica inmediata

Medina-Franco (2008)

25 9-38 mm (media 20

mm)

76% 3 quemaduras cutáneas 1 infección herida quirúrgica Escisión quirúrgica inmediata

Imoto (2009) 30 < 20 mm 87% Estadificación con RM 2 quemaduras cutáneas 7 quemaduras músculo

Escisión quirúrgica inmediata

Manenti (2009) 34 < 20 mm 97% Estadificación con RM Control efectividad RF con RM


Nagashima (2009)

17 < 20 mm Ninguna recidiva Estadificación con RM Control efectividad RF con RM

Ninguna complicación Seguimiento medio 19 meses

Apesteguía (2009)

35 < 20 mm 77% Ninguna complicación Intervención quirúrgica a las 2-4

semanas

Tabla 2. Resultados tratamiento de cánceres de mama con radiofrecuencia. La guía de imagen fue en todos los casos la ecografía. NC = Necrosis Completa.

Camps Herrero J. Intervencionismo Mamario: Ablación de Tumores. Avances en Mama. Colegio Interamericano de Radiología. Journal Ed. Buenos Aires 2010

www.elsevier.es/rx

ORIGINAL

Ablacion por radiofrecuencia de carcinomas de mama: resultadospreliminares de un ensayo clınico

L. Apesteguıaa,!, A. Ovelara, F. Domınguez-Cunchillosb, C. Alfaroa, R. Trujillob, M.A. Sanzb,C. de Miguelc, B. Reparazc e Y. Ruiz de Azuac

aServicios de Radiologıa, Unidad de Patologıa Mamaria, Hospital Virgen del Camino, Servicio Navarro de Salud,Pamplona, EspanabCirugıa General, Unidad de Patologıa Mamaria, Hospital Virgen del Camino, Servicio Navarro de Salud, Pamplona, EspanacAnatomıa Patologica, Unidad de Patologıa Mamaria, Hospital Virgen del Camino, Servicio Navarro de Salud,Pamplona, Espana

Recibido el 17 de abril de 2009; aceptado el 10 de julio de 2009Disponible en Internet el 12 de noviembre de 2009

PALABRAS CLAVECancer de mama;Tratamiento;Ablacion, cateter deradiofrecuencia;Ecografıaintervencionista

ResumenObjetivo: Entre las alternativas a la cirugıa conservadora del cancer de mama, la ablacionpor radiofrecuencia (ARF) es la que ha alcanzado mayor difusion. Nuestro objetivo esdeterminar la factibilidad, seguridad y eficacia de esta tecnica en nuestro medio.Material y metodos: Se realiza ARF de carcinomas de mama con anestesia local y en lasala de ecografıa, tratamiento quirurgico y comprobacion histologica posterior, evaluandolos efectos de la ARF sobre el tumor y los tejidos circundantes.Se incluyeron 35 pacientes con edad media de 61,278,25 anos, todas con carcinomainfiltrante confirmado percutaneamente,o2 cm, alejado de la piel y la pared toracica.Tamano tumoral medio 8,972,9mm. Se realizo linfadenectomıa selectiva antes de la ARF.A las 2–4 semanas de esta se llevo a cabo el tratamiento quirurgico.El grado de necrosis de coagulacion y la afectacion de margenes se evaluaron con tincionde hematoxilina-eosina, y la viabilidad celular o efectividad de la ARF mediante NADH-diaforasa.Resultados: El 85,7% de pacientes no sintio molestias. El 11,4% refirio dolor ligero quepudo ser controlado. El dolor intenso obligo a detener el procedimiento en 1 paciente. Nose produjeron otras complicaciones.Se encontraron cambios de necrosis coagulativa en todos los casos, catalogada comocompleta en 32/35 (91,4%). La NADH-diaforasa resulto negativa en 27/32 casos en que serealizo. Una fue ligeramente positiva y 4 no valorables.Conclusion: La ARF es una tecnica factible, bien tolerada, segura y eficaz en casi el 90% delos tumores infiltrantes de mama. La confirmacion de su eficacia debera hacerse mediante

ARTICLE IN PRESS

0033-8338/$ - see front matter & 2009 SERAM. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.doi:10.1016/j.rx.2009.07.003

!Autor para correspondencia.Correo electronico: [email protected] (L. Apesteguıa).

Radiologıa. 2009;51(6):591–600

Documento descargado de http://www.elsevier.es el 25/08/2011. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

35 pacientes CDI < 20 mm Intervención quirúrgica a las 2-4 semanas Viabilidad celular con NADH diaforasa Necrosis coagulativa completa en 32/35 (91,4%)

RESUMEN ESTUDIOS PUBLICADOS

TAMAÑO: < 30 mm

NECROSIS COMPLETA: 86–100% (100% en < 20 mm)

ESTADIFICACIÓN: mamografía + ecografía

BSGC: antes de la RF

GUÍA IMAGEN: ecográfica

ANESTESIA: sedación profunda o anestesia general

CONTROL RESULTADO: NADH diaforasa

COMPLICACIONES: 3 pacientes con quemadura piel y

en mamas pequeñas (Oura), masa palpable

Tamaño no superior a 15 mm, tumor único no CDIS, CLI

BAG pre RF con multiples cilindros (Her2, RH)

Anestesia local +/- sedación profunda

< 1 cm piel, pared: Bolsa aislante de glucosa 5% 20–60 ml

Guía ecográfica / estereotaxia

Monitorización con RM (antes, durante y después)

Monitorización con contraste ecográfico

tratamientos ablativos guiados por imagenRADIOFRECUENCIA propuestas

Algoritmo Proyecto d-GEICAM

LáserILT Interstitial Laser Therapy

Energía Térmica100ºC

Láser

7.2 Breast 223

Fig. 7.2.1a–e. Interstitial laser therapy. a The tip of the laser fi ber is visualized as a tiny ear-shaped loss of sig-nal (black arrows). b On the subtracted phase images a small hypointense zone of increased temperature can be delineated after 120 s of laser treatment (3 W, 600 s). c It is expanding after 360 s and d furthermore after 600 s (white arrows). e The follow-up examination 1 week later shows an anlog hypointense zone indicating co-agulation necrosis

a b c

d e

patible needle was inserted into the cancer and ILT was controlled by MRI. The appearance of a hypointense zone indicated the heating area. Com-plete destruction was achieved in only three women who had tumors with diameters under 3 cm. In the other patients large tumors were destroyed incom-pletely (Harms 2001). Akimov et al. (1998) reported on 35 patients with primary breast cancer who were treated with ILT. In 28 patients, ILT was performed before radical resection, and in 7 patients it was the only invasive treatment. Of 7 patients treated without surgery, local tumor control was achieved in 5, and in 3 stage-I to stage-III patients disease-free survival was followed for 19–60 months. After ILT plus surgery, 3-year disease-free survival was 27% in premenopausal and 92% in menopausal patients.

7.2.3 Radiofrequency Ablation (RFA)

During radiofrequency ablation (RFA), alternat-ing current is sent into the tissue through needle electrodes. The alternating current generates ionic movement and agitation as ions oscillate at the applied frequency. Localized friction results in tissue heating, which leads to cell death. Histologi-cally tissue shows coagulation necrosis and protein denaturation after RFA. Macroscopically the abla-tion zone is characterized by a yellow-white center, which is surrounded by a hyperemic red rim refl ect-ing hemorrhage (Mirza et al. 2001). Boehm and coworkers (2001) developed an experimental tumor model for RFA of breast tumors surrounded by fat to investigate the minimally invasive treatment of

Fibras láser compatibles con RM

(secuencias T1 y difusión)

modalities.10–15 In all of these modalities, a change in

temperature is used to lethally damage the intracellularDNA binding structures, thereby causing cell death.16,17

LITT requires a laser fiber to guide the light energy directly

into the tissue to be treated. Upon absorption in the tissue,heat is produced, inducing lethal thermal injury. At present,

LITT and radiofrequency ablation are mostly used to treat

unresectable colorectal liver metastases as an alternative tosurgery.18,19 The results are promising, and possibly in the

future, these modalities could also be used for the local

ablation of breast carcinoma in a curative setting.To implement this minimally invasive approach, several

steps need to be taken. First, the exact tumor size should be

reliably assessed. Second, the treatment should be safe andable to completely destroy all tumor tissue (including in-

situ cancer) locally. Finally, a reliable real-time way to

monitor the treatment results should be available.In this feasibility study, we evaluated the second

prerequisite by ultrasound-guided LITT for local treat-

ment of patients with clinically small palpable breastcarcinomas.

MATERIALS AND METHODS

The study was approved by the medical ethical com-

mittee of our hospital. All patients had a palpable invasive

breast carcinoma diagnosed by an ultrasound-guided large-core needle biopsy (LCNB). The tumor characteristics (i.e.,

grade, estrogen receptor status, progesterone receptor sta-tus, HER-2/neu status, and mitotic activity index) were

preoperatively determined on the LCNB.

Inclusion criteria were age [18 years, palpable cT1 (asmeasured by preoperative ultrasound and mammography),

unifocal invasive breast carcinoma, tumor visible on

ultrasound, preoperative tumor characteristics available,and distance of C1 cm from the thoracic wall and the

overlying skin.

A sentinel lymph node biopsy (SLNB) was performedbefore the LITT procedure. For the SLNB, four depots of a

total of 120 MBq 99mTc nanocolloid were injected peritu-

morally, and static images were acquired up to 4 h afterinjection. Peroperatively, 1 mL of patent blue (Bleu

patente V ‘‘Guerbet’’) was injected peritumorally. The

exact tumor size was measured in two dimensions after theSLNB by ultrasound (Philips, iU22 scanner, equipped with

an 8 MHz linear array transducer).

Next, a 17-gauge guidance needle (Bard Truguide,Covington, United Kingdom) was placed into the center of

the tumor. The position of the needle was checked ultr-

asonographically in three dimensions. Both the tumor sizeassessment and the placement of the guidance needle were

performed by a dedicated breast radiologist.

Next, an uncooled Microdom LITT laser fiber with an

active length of 2.5 cm was inserted into the tumor andattached to an Nd:YAG continuous laser of 1045 nm (KLS

Martin, Umkirch, Germany). After confirming the exact

position, the guidance needle was retracted to avoid heathconduction to the skin and the procedure commenced. The

amount of energy needed to fully ablate the tumor was

determined in an experimental ex vivo setting in bovineudder tissue. The maximum tumor size determined the

amount of energy that was used.After the ablation, a wide local excision or mastectomy

was performed according to local practice.

At pathology, the margins of the specimen were inkedand the specimen was sliced in 5-mm slices. The macro-

scopic lesion size was recorded, and samples were taken

from the center of the coagulated area and the transitionzone between tumor and tumor-free margin (Fig. 1). The

samples were snap frozen and embedded in paraffin. Both

hematoxylin and eosin staining of paraffin-embedded sec-tions and nicotinamide dinucleotide adenosine diaphorase

(NADH) staining of the frozen sections were used to

determine tumor vitality after ablation. Participatingpatients underwent routine outpatient follow-up and stan-

dard breast radiotherapy as a part of BCS. On the basis of the

status of the sentinel node and primary tumor characteris-tics, patients underwent an additional axillary dissection

and/or adjuvant chemotherapy.

RESULTS

Fourteen patients completed the LITT procedure.

Baseline characteristics are summarized in Table 1.Most of the tumors (50%) were located in the upper lat-

eral quadrant of the breast, and 12–14 tumors were invasive

ductal carcinomas. All patients underwent a SLNB beforeablation; in 13 (93%) of 14, the sentinel node was found. Six

patients had axillary metastases, with isolated tumor cells in

FIG. 1 Macroscopic view of ablated tumor tissue. Outer circleindicates the ablation zone; inner circle shows fiber track

2260 S. van Esser et al.

Zona de AblaciónTrayecto fibra láser

van Esser S, Stapper G, van Diest PJ, van den Bosch MAAJ, Klaessens JHGM, Mali WPTM, et al. Ultrasound-guided laser-induced thermal therapy for small palpable invasive breast carcinomas: a feasibility study. Ann Surg Oncol. 2009 Aug. 1;16(8):2259–2263.

Autor y Año Pacientes Tamaño Lesional e

Histopatología


Akimov (1998) 35 pacientes

cáncer de mama

US control local en 5/7 pacientes sin

tratamiento quirúrgico

28 pacientes intervenidas posteriormente

7 pacientes seguimiento

Harms (2001) 22 lesiones en 12

pacientes

cáncer de mama

RM NC en 3/12 pacientes (25%)

Las tres pacientes con NC presentaban tumores

< 30 mm

Dowlatshahi (2002)

56 < 23 mm cáncer de

mama

STX 70% NC 54 pacientes intervenidas posteriormente, 30%

tumor residual 2 pacientes, seguimiento

2 años sin recidiva

van Esser (2009)

14 17 mm (rango 8-37 mm)

US 50% NC (88% NC en tumores <

20 mm)

Excisión quirúrgica posterior

1 quemadura cutánea y 1 neumotórax

Tabla 4. Resultados tratamiento de lesiones mamarias con Láser Intersticial. US = Ultrasonidos. RM = Resonancia Magnética. STX = Estereotaxia (mamografía). NC = Necrosis Completa.


Histopatología


Gardner (2002) 10 9-80 mm cáncer de mama

US NC en 4/10 (40%)

Pacientes candidatas a mastectomía.

Necrosis de la piel postmastectomía en 3/10

pacientes

Vargas (2004) 25 diámetro medio 18 mm

US NC en 2/25 (8%) Intervención quirúrgica posterior

No evalúan bordes peritumor

Tabla 5. Resultados tratamiento de lesiones mamarias con Microondas. US = Ultrasonidos. NC = Necrosis Completa.

Pocas series publicadas

Mayor eficacia en tumores de tamaño < 20 mm

Excluir CDIS y Carcinoma Lobulillar

Gran ventaja: monitorizable en tiempo real con RM

Grado de necrosis variable

Tratamiento menos económico que RF

Resumen resultados tratamientos conLáser en cáncer de mama

Microondas

Thermotherapy Scale for Cancer Treatment

Fenn AJ, Breast Cancer Treatment by Focused Microwave Thermotherapy, Jones and Bartlett 2007

Focused microwave ablation with external applicators uses ablation temperatures in the range of 50°C ± 2°C

AblationHyperthermia

Alan J. Fenn, PhD, 2008

Focused Microwave Phased Array

Combination E-Field Focusing and

Temperature Probe

Artist’s concept

Microwave Waveguide Applicator

(Air cooled)

Microwave Waveguide Applicator

(Air cooled)

Focused microwave energy surrounds microscopic

carcinomas in the margins

Focused microwave energy surrounds an irregularly

shaped tumor


Breast Compression

Plates


Treatment Procedure for Focused Microwave Ablation


Catheter/Probes Treatment



Histopatología


Akimov (1998) 35 pacientes

cáncer de mama

US control local en 5/7 pacientes sin

tratamiento quirúrgico

28 pacientes intervenidas posteriormente

7 pacientes seguimiento

Harms (2001) 22 lesiones en 12

pacientes

cáncer de mama

RM NC en 3/12 pacientes (25%)

Las tres pacientes con NC presentaban tumores

< 30 mm

Dowlatshahi (2002)

56 < 23 mm cáncer de

mama

STX 70% NC 54 pacientes intervenidas posteriormente, 30%

tumor residual 2 pacientes, seguimiento

2 años sin recidiva

van Esser (2009)

14 17 mm (rango 8-37 mm)

US 50% NC (88% NC en tumores <

20 mm)

Excisión quirúrgica posterior

1 quemadura cutánea y 1 neumotórax

Tabla 4. Resultados tratamiento de lesiones mamarias con Láser Intersticial. US = Ultrasonidos. RM = Resonancia Magnética. STX = Estereotaxia (mamografía). NC = Necrosis Completa.


Histopatología


Gardner (2002) 10 9-80 mm cáncer de mama

US NC en 4/10 (40%)

Pacientes candidatas a mastectomía.

Necrosis de la piel postmastectomía en 3/10

pacientes

Vargas (2004) 25 diámetro medio 18 mm

US NC en 2/25 (8%) Intervención quirúrgica posterior

No evalúan bordes peritumor

Tabla 5. Resultados tratamiento de lesiones mamarias con Microondas. US = Ultrasonidos. NC = Necrosis Completa.

Dooley WC, Vargas HI, Fenn AJ, Tomaselli MB, Harness JK. Focused

microwave thermotherapy for preoperative

treatment of invasive breast cancer: a review of clinical studies. Ann Surg Oncol. 2010 Apr.;17(4):

1076–1093.

Randomized Study Results*: Focused Microwave Ablation for Invasive Breast Cancer

*10 participating institutions, IRB, FDA-IDE approved study. Study was stopped early due to inconsistent delivery of targeted equivalent minutes thermal dose (resulting in inconsistent tumor ablation) attributed to learning curve


Pocas series publicadas

Porcentaje de necrosis variable (8–40%)

Requiere dos aplicadores de microondas refrigerados

que compriman la mama a ambos lados

Los CM (alto contenido en agua) se calientan más

rápidamente que el tejido sano

Es importante monitorizar la temperatura en la piel

Resumen resultados tratamientos conMicroondas en cáncer de mama

otras opciones..BLES

(Breast Lesion Excision System)

BREAST

The breast lesion excision system (BLES): a novel techniquein the diagnostic and therapeutic management of smallindeterminate breast lesions?

Steven D. Allen & Ashish Nerurkar &

Guidabaldo U. Querci Della Rovere

Received: 19 May 2010 /Revised: 29 September 2010 /Accepted: 8 October 2010# European Society of Radiology 2011

AbstractObjective To investigate whether the breast lesion excisionsystem (BLES) could render formal surgery unnecessary inpatients with small indeterminate breast lesions.Methods Following review board ethical permission andthe consent of each patient, we aimed to perform acomplete excision biopsy, with a margin, of small indeter-minate breast lesions that measure less than 1 cm. 76patients with small BIRADS type 3 breast lesions under-went a BLES biopsy. Mean radiological lesion size was7.1 mm (range 2–10 mm).Results 61 lesions had a final benign diagnosis, 6 of whichunderwent subsequent surgery although only 1 showingresidual lesion. 15 lesions were malignant but with residualtumour at re-excision present in only 5 cases.Conclusion The BLES biopsy is an efficacious technique atexcising small indeterminate breast lesions with a completemargin without the need for follow-up diagnostic surgery inthe majority.

Keywords Breast . Biopsy . Vacuum . Breast cancer .

Ultrasound

Introduction

Small solid breast lesions that are radiologically indetermi-nate sometimes yield an indeterminate histopathologicalassessment following a radiologically guided biopsy.Although some centres may wish to just follow theselesions up, increasingly these are being treated usingradiological wire localisation followed by open surgery inthe form of a wide local excision. However many of theseare subsequently benign on final surgical pathology. Morerecently there have been alternative radiological manage-ment to excise biopsy proven benign lesions, usuallyfibroadenomas, in women wishing to have them removed[1]. This has been with vacuum assisted biopsy devices,such as the mammotome™ (Johnson and Johnson EthiconEndo-Surgery Inc, Cincinnati, Ohio, USA) Encor™ (C.R.Bard, New York, USA) and Suros ATEC™ (Suros SurgicalSystems Inc, Indianapolis, USA). The advantages of thesemore minimally invasive approaches to many women willundoubtedly make this technique increasingly popular[2–5]. They can be performed usually in less than 30 min, withonly local anaesthetic and a minimal scar. Complicationrates are very low, and the procedures are extremely welltolerated. These procedures are particularly suitable foryoung women where risk of the lesion being non benign isvery low, and cosmesis is premium[2–5]. The obviouslimitation of this technique however, is that as it is onlyable to remove lesions in a “piecemeal” fashion. Suchexcisions are unable to provide an assessment of margins ofthe excision, thus there is no way of determiningcompleteness of excision and whether any residual lesionis left behind. While this may not be particularly relevant ifthe lesions excised are fibroadenomas, or other such similarbenign lesions, it will however obviate the vacuum assistedexcision from being utilised for many other more “border-

S. D. Allen (*)Department of Radiology, The Royal Marsden Hospital,Downs Road,Sutton, Surrey SM2 5PT, UKe-mail: [email protected]

A. NerurkarDepartment of Histopathology, Royal Marsden Hospital,Downs Road,Sutton, Surrey SM2 5PT, UK

G. U. Q. Della RovereDepartment of Surgery, Royal Marsden Hospital,Downs Road,Sutton, Surrey SM2 5PT, UK

Eur RadiolDOI 10.1007/s00330-010-2000-7

Allen SD, Nerurkar A, Rovere della GUQ. The breast lesion excision system (BLES): a novel technique in the diagnostic and therapeutic management of small indeterminate breast lesions? Eur Radiol. 2011 Jan. 15;

Excisión completa “en bloc”, asa de cauterio por RF

Calibre 6G, tipo “basket” de 15–20 mm, 1 cm excisión

Muestras 21x10x9 mm de media

76 pacientes con lesiones BI-RADS 3 (7,1 mm) (55 B3)

18 pacientes reintervención

61 lesiones benignas (60/61)

15 lesiones malignas -> Bordes afectos 8/15 (CDIS)

Exclusión: marcapasos, embarazo, lesiones superficiales,

axilares o muy profundas

No aprobado por FDA en lesiones malignas

BLES como método de ablación tumoral

B3 biopsy result. 21 patients had no prior core biopsyperformed but opted for a BLES procedure when given allthe biopsy options following recall with an abnormalmammogram. All cases included in this technical studywere performed by just one of the authors, S.A. Theradiological and pathological size was recorded for theselesions as well as pathological diagnosis, follow-up surgicalexcision and imaging. All pathology was performed by oneof two dedicated breast pathologists, both with more than10 years of breast pathology experience.

Results

All procedures were well tolerated at the time of theprocedure, with moderate to minor discomfort experiencedin most patients for the 8 s of sample acquisition, butpassing very shortly afterwards in all cases. This wasformally evaluated with a simple pain scoring questionnaire

performed on follow up. Only one patient suffered morethan moderate discomfort during the procedure, and nopatients had more than mild discomfort in the time periodimmediately following the 8 s of the acquisition. Medianpain score during the procedure was 3 (out of 10). Mediansatisfaction score 1 week following the procedure was 9.5(out of 10). Median satisfaction score for the scar was 9(out of 10) [9]. One patient had a delayed haematoma butthis was managed conservatively. No post procedure woundinfections have yet occurred.

45 procedures were conducted with 20 mm wands, 31procedures were conducted with 15 mm wands. 20procedures were performed under ultrasound guidance, 56using stereotaxis on a prone table. Mean largest radiologicallesion size was 7.1 mm (range 2–10 mm). Pathologicalspecimens all yielded pathology appropriate to the targetlesions, with minimal diathermy effects (<1 mm). Ourpathologists found the specimens far faster and easier toanalyse than equivalent sized vacuum assisted biopsy

Fig. 1 The breast lesion exci-sion system (BLES) biopsy sys-tem and wand. (a) Theequipment consists of an elec-tronically operated base systemwith attached lightweight hand-held piece where removablewands are inserted (arrow). (b)Handheld component and re-movable wand. (c) We havemeasured the wands to be 6-gauge in diameter and arepassed through typically a10 mm skin incision to the edgeof the anaesthetized target underultrasound or stereotactic guid-ance. 4 or 5 metallic prongs(wand size depending) with theirtips connected by an extensiblecutting radiofrequency ring wirethen pass from the wand andenvelop an area of tissue in only8 s. The prongs pass radiofre-quency waves into surroundingtissue in order to excise andallow haemostasis, but not to theextent of damaging the sample.(d) Wand sizes vary, with basketdiameters ranging from 10 mmto 20 mm. Sample sizes accord-ingly fluctuate with the basketsizes. The sample is removedfrom the basket by cutting theprongs with sharp scissors

Eur Radiol

specimens. This is in line with the USA experience [10].Following fixation in formalin the samples measuredapproximately one gram and had a mammographic meansize of 21 mm (range 15–30 mm) ! 10 mm (range 6–18 mm) ! 9 mm (range 5–12 mm). They showed minimaldiathermy artefact at the edge of the sections, which wasinvariably less than 1 mm in depth and very rarelyinterfered with the histological evaluation (Fig. 3). In thesesections, apart from the diagnosis, the size of the lesion wasmeasured accurately as well as the adequacy of the excisionin all cases [11].

Final pathology is summarised in Table 1. 61/76 (80%)lesions had a final benign pathology. A total of 18 patientsunderwent subsequent surgical re excision. 6 of these werein benign/borderline lesions where margins were notcomplete or residual lesion was seen on the mammogramimmediately following the procedure (5/11). Only one ofthese had residual lesion, with the BLES biopsy siteidentified in all cases. Tumour was seen at the biopsy marginin 8/15 malignant cases. On surgical re-excision of biopsymargins, residual disease was present in 5/12 patients (twohaving more extensive intermediate grade DCIS that wasmammographically occult, another three with microscopicfoci of DCIS at a distance from the excision). At histopath-ological analysis of the surgical resections, the BLES biopsycavities were identified in all cases.

The 7 low grade DCIS cases with excision marginsof >1 mm and no residual mammographic target wereall discussed at the unit multidisciplinary meeting withregards proposed further management. Follow up sur-gery was offered in all but in these cases the volumeand grade of disease was considered so low in risk thatfollow up only was offered as an alternative option.These cases were not considered of sufficient risk to

Fig. 3 A haematoxylin and eosin stained slide showing a radial scarwithin a BLES excision biopsy specimen that was completely excisedpathologically. There were no atypical features

Fig. 2 Ultrasound guided BLES excision biopsy in a 51 year oldwoman. (a) An indeterminate lesion measuring only 6 mm isidentified in the left breast. (b) A 15 mm diameter BLES is introducedunder direct visualisation following the routine anaesthetic protocol.(c) Following excision, a specimen radiograph shows the lesioncentrally placed in the sample and radiologically excised. This wasconfirmed as a benign papilloma, and also shown to be excisedpathologically

Eur Radiol

Conclusiones Finales

RF HIFU LASER MW

asequibleeconómica

no monitorización

in vivo

efecto calórico limitado (98ºC)

monitorización in vivo

mayor efecto calórico


no lavado de calor

mayor efecto calórico (180ºC)

no lavado de calor

mayor grado de

complicaciones

RF HIFU LASER MW

asequibleeconómica

no monitorización

in vivo

efecto calórico limitado (98ºC)


mayor efecto calórico


no lavado de calor

mayor efecto calórico (180ºC)

no lavado de calor

mayor grado de

complicaciones

La RM, clave de éxito para la estadificación y el seguimiento

La CC + RT y QT sigue siendo el estándar de tratamiento

Las nuevas técnicas ablativas asociadas a la RM muestran

un potencial enorme para tratar cánceres de pequeño

tamaño unifocales y abren las puertas a otros tratamientos

(inmunoterápicos, terapias transgénicas y terapias diana

mediadas por calor)

La RM es la guía de imagen del futuro (3D, real-time)

Puede ser una alternativa en cánceres hormono-negativos

no operables

Se necesitan un mayor número ensayos clínicos fase II y

fase III donde la RM juegue un papel preponderante

tratamientos ablativos guiados por imagenCONCLUSIONES

Es un debate abierto necesariamente multidisciplinar cuyo

objetivo es ofrecer a nuestras pacientes las máximas

garantías de eficacia y seguridad

tratamientos ablativos guiados por imagenCONCLUSIONES

★EURORAD está abierto a todo el mundo★Primero hay que solicitar ser miembro de la European Society of Radiology en www.myesr.org/membership★Gratis para los radiólogos no residentes en Europa★Después, ir a la página www.eurorad.org

http://www.myesr.org/membership

http://www.myesr.org/membership

http://www.eurorad.org

http://www.eurorad.org

Annual ScientificMeeting 2012

in cooperation withSociedad Espanola de Diagnostico por Imagen de la Mama

October 12-13, 2012Barcelona/ES

www.eusobi.org

EUSOBI 2011Annual Scien+fic Mee+ng – Facts, Figures and Future Perspec+ves

Annual ScientificMeeting 2012

in cooperation withSociedad Espanola de Diagnostico por Imagen de la Mama

October 12-13, 2012Barcelona/ES

www.eusobi.org

EUSOBI 2011Annual Scien+fic Mee+ng – Facts, Figures and Future Perspec+ves

Special Fees for SIBIM members

Muchas Gracias

t cnicas de ablación tumoral -...

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