Minimally Invasive Treatments for Breast Cancer
Interventional Radiology Treatments Offer New Options and Hope to Patients Who Are Not Good Surgical Candidates
In the United States, a woman is diagnosed with breast cancer every three minutes and one woman will die from the disease every 13 minutes. For these women, as well as the thousands of men diagnosed each year, breast cancer treatments can be highly effective, but often require invasive treatment options such as surgery and chemotherapy.
Surgery offers the best chance for a cure. Until long-term data are available, interventional treatments are reserved for women who cannot have surgery.
Recent advancements in technology and imaging now offer patients more tools to fight breast cancer--minimally invasive treatments known as thermal ablation and laser therapy. Thermal ablation treatment builds on the two-decade trend toward less radical approaches and utilizes local treatments for breast cancer. Although the devices used in radiofrequency ablation, cryoablation and laser therapy are FDA approved, more research and long-term data are needed to determine the role these procedures will have in the fight against breast cancer.
About Breast Cancer
When breast tissue divides and grows at an abnormal rate, a mass of extra tissue can develop into a tumor. To continue growing, a tumor generates its own blood supply to provide oxygen and nutrients. Although the cancerous cells can grow in size in the breast, they can also travel throughout a person's blood stream and become embedded in other organs, a process known as metastasis. Typically, 20 percent of breast cancer develops in the lobules where milk is produced, while 80 percent originates in the mammary ducts that carry milk from the lobules to the nipple.
As vascular experts, interventional radiologists are uniquely skilled in using the vascular system to deliver targeted treatments via catheter throughout the body. In treating cancer patients, interventional radiologists can attack the cancer tumor from inside the body without medicating or affecting other parts of the body. For breast cancer, interventional radiologists use thermal ablation, as well as some laser therapy, to kill the cancer cells. Although the devices used are FDA approved, research to evaluate the long-term effects of these treatments is ongoing.
- In the United States, a woman has about a 13% lifetime risk of developing breast cancer.
- Women 50 years of age and older account for approximately 80 percent of all breast cancers.
- Between age 40 and 50 the incidence of breast cancer doubles, and by age 70 it doubles again.
- In the United States, African Americans have the highest death rate from breast cancer compared to any other racial group.
- Breast cancer is the most common cancer among women.
- In American women, the breast is the leading cancer site and is second only to lung cancer in deaths.
Patients with invasive breast cancer are at risk for liver cancer. The liver serves as a way-station for cancer cells that circulate through the bloodstream. These cells may grow and form tumors in the liver. It is estimated that as many as 70 percent of all people with uncontrolled cancer will eventually develop secondary liver tumors, or metastases (tumors formed by primary cancer cells that have spread from other cancer sites). Interventional radiologists offer nonsurgical treatments for liver cancer, including embolization to cut off the blood supply to the tumor, radioembolization that delivers radiation directly inside the tumor, and chemoembolization, which delivers the cancer drug directly into the tumor and then cuts off the blood supply.
Breast Cancer Diagnosis
There are a number of tests that can help in the diagnosis of cancer, including blood tests, physical examination and a variety of imaging techniques including X-rays (e.g., chest X-rays and mammograms); computed tomography (CT); magnetic resonance (MR) and ultrasound. Usually, however, the final diagnosis cannot be made until a biopsy is performed. In a biopsy, a sample of tissue from the tumor or other abnormality is obtained and examined by a pathologist. By examining the biopsy sample, pathologists and other experts also can determine what kind of cancer is present and whether it is likely to be fast or slow growing. This information is important in deciding the best type of treatment. Open surgery is sometimes performed to obtain a tissue sample for biopsy. But in most cases, tissue samples can be obtained without open surgery with interventional radiology techniques.
Needle biopsy, also called image-guided biopsy, is usually performed using a moving X-ray technique (fluoroscopy) computed tomography (CT), ultrasound or magnetic resonance (MR) to guide the procedure. In many cases, needle biopsies are performed with the aid of equipment that creates a computer-generated image and allows radiologists to see an area inside the body from various angles. This "stereotactic" equipment helps them pinpoint the exact location of the abnormal tissue.
Needle biopsy is typically an outpatient procedure with very infrequent complications; less than 1 percent of patients develop bleeding or infection. In about 90 percent of patients, needle biopsy provides enough tissue for the pathologist to determine the cause of the abnormality.
Advantages of needle biopsy include:
- With image guidance, the abnormality can be biopsied while important nearby structures such as blood vessels and vital organs can be seen and avoided.
- The patient is spared the pain, scarring and complications associated with open surgery.
- Recovery times are usually shorter and patients can more quickly resume normal activities.
An X-ray of a needle inserted into the lung to obtain a sample for biopsy.
Large core needle biopsy. In this technique, a special needle is used that enables the radiologist to obtain a larger biopsy sample. This technique is often used to obtain tissue samples from lumps or other abnormalities in the breast that are detected by physical examination or on mammograms or other imaging scans. Because approximately 80 percent of all breast abnormalities turn out not to be cancer, this technique is often preferred by women and their physicians because it:
- is less painful and requires less recovery time than open surgical biopsy, and
- avoids the scarring and disfigurement that may result from open surgery.
A similar technique called fine needle aspiration can be used to withdraw cells from a suspected cancer. It also can diagnose fluids that have collected in the body. Sometimes, these fluid collections also may be drained through a catheter, such as when pockets of infection are diagnosed.
Many interventional radiology procedures for the diagnosis and treatment of cancer can be performed on an outpatient basis or during a short hospital stay. In many cases, the procedures:
- offer new cancer treatment options
- are less painful and debilitating for patients
- result in quicker recoveries
- have fewer side effects and complications.
Thermal Ablation Treatments
For cancerous tumors, radiofrequency ablation (RFA) offers a nonsurgical, localized treatment that kills the tumor cells with heat, while sparing the healthy breast tissue. Because of the localized nature of this treatment, RFA does not have any systemic side effects. Radiofrequency ablation can be performed without affecting the patient's overall health and most people can resume their usual activities in a few days.
In this procedure, interventional radiologists use imaging to guide a small needle through the skin into the tumor. From the tip of the needle, radiofrequency energy is transmitted into the target tissue, where it produces heat and kills the tumor. Most patients experienced mild to moderate discomfort during the 15 minute RFA time. Following the RFA, the dead tumor tissue shrinks and slowly forms an internal scar. Because there is no surgical incision, RFA barely affects the appearance of the breast.
|Click on images to enlarge|
Depending on the size of the tumor, RFA can shrink or kill the tumor, extending the patient's survival time and greatly improving their quality of life while living with cancer. RFA can extend patients' lives or in a small number of cases cure patients.
Because it is a local treatment that does not harm healthy tissue, the treatment can be repeated as often as needed to keep patients comfortable. RFA is a very safe procedure, with few complications. It is effective for small to medium-sized tumors, and emerging new technologies should allow the treatment of larger cancers in the future. One study showed 100 percent tumor cell death using RFA, with no complications after the procedure. 10 RFA is often reimbursed by insurance carriers.
Currently, the protocol is to "ablate and resect," in other words, to kill the tumor with heat and then remove the dead cells to ensure all the cancer cells were destroyed. As research progresses, the treatment pattern will become "ablate and follow"-simply treat the patient with RFA and track their progress over the following years.
For some women, surgery is not an option, due to other health concerns. For these patients, RFA is an excellent treatment option. In one study of postmenopausal women 60 years of age and older, 95 percent of women would be willing to have RFA again and 95 percent would be willing to have RFA without definitive surgery if it was known that RFA could kill their entire tumor.
Although the use of RFA in other organs, especially in the liver, has shown promising results for killing cancer cells, the technique is not a mainstream treatment option for breast cancer patients. Current research is underway to further explore this treatment and the long-term effects on the disease and patients.
A LIVER TUMOR TREATED WITH RFA
Dead tissue appears larger and darker than the living tumor. Over time, the tumor shrinks as the body absorbs and excretes dead cells
- Has low complication rates
- May be performed under conscious sedation or general anesthesia
- Is well tolerated. Most patients can resume their normal routines the next day and may feel tired only for a few days.
- Can be repeated if necessary
- May be combined with other treatment options
- Can relieve pain and suffering for many cancer patients
- Causes minimal postprocedure pain
Interventional radiologists use special X-ray equipment to guide therapy directly to the site of tumors
Cryoablation is similar to RFA in that the energy is delivered directly into the tumor by a probe that is inserted through the skin. But rather than killing the tumor with heat, cryoablation uses an extremely cold gas to freeze it. This technique has been used for many years by surgeons in the operating room, but in the last few years, the needles have become small enough to be used by interventional radiologists through a small nick in the skin, without the need for an operation. The "ice ball" that is created around the needle grows in size and destroys the frozen tumor cells.
Laser therapy causes cell death through the delivery of laser energy by a fiberoptic probe that is inserted into the tumor using imaging for guidance. During the procedure, local anesthesia is applied around the tumor, followed by the insertion of four metal markers. Next, using imaging for guidance, an interventional radiologists inserts a laser needle into the center of the tumor through a small nick in the skin, followed by the insertion of a multisensor thermal needle through another site. The laser needle is then replaced with an optic fiber through which the energy is transmitted into the tumor. It is an outpatient procedure.
The current research is promising, with one study finding that complete tumor necrosis (death) was achieved in 66 percent of the tumors treated10 and another study showing 93 and 100 percent tumor death in two groups, with no adverse effects.
New Cancer Treatments on the Horizon
Interventional radiology is playing a role in developing new techniques that may improve cancer treatment in the future, including the use of magnetic particles to draw cancer-killing agents into tumors; and the delivery of genetic material, called gene therapy, to fight or prevent cancers. These techniques are still investigational, but they offer new hope in the war against cancer.
Interventional radiologists are currently investigating a new technique in which magnets are used to pull chemotherapy drugs into tumors. Microscopic magnetic particles are attached to the cancer-killing drugs and infused through a catheter into the blood vessel that feeds the tumor. A rare earth magnet is positioned over the patients body directly above the site of the tumor. The magnet pulls the drug-carrying particles out of the blood vessel so that they lodge in the tumor. Although the technique is still experimental, early research is promising. Physicians are hopeful that it will bolster the effects of chemotherapy while avoiding some of the drugs side effects, such as hair loss and nausea.
In recent years, scientists have gained a new understanding about genesthe basic biological units of heredityand the role they play in disease. This knowledge has set the stage for medical science to alter patients genetic material to fight or prevent cancer. Although the science of gene therapy is still in the early, experimental stages, researchers are hoping that in the future the therapy can be used to:
Researchers in gene therapy search for new ways to treat cancer and other genetic diseases
- alter the cells of a patients natural immune system with cancer-fighting genes and returning them to the body, where they could more forcefully attack the cancer;
- remove cancer cells from the body and alter them genetically so that the patients own immune system will mount a strong defense against them. In this technique, the altered cancer cells would act as a cancer vaccine;
- replace a faulty gene responsible for the growth of cancer with a "good" gene;
- inject a tumor with genes that will make it more susceptible to chemotherapy or other cancer-fighting agents; and
- make bone marrow and other organs resistant to chemotherapy, so that the drugs will destroy tumors without damaging healthy tissue.
One of the challenges of gene therapy is finding safe and effective ways to deliver genes or genetically altered cells to the site of the tumor. Interventional radiologists, with their special expertise in using X-rays and other imaging techniques to guide catheters and other tools through the body are expected to play an important role in this new technology.
Treatments for Cancer Complications
There are also a number of interventional radiology techniques that are used to treat the complications of cancer, including pain, bleeding, obstruction of vital organs, blood clots and infection. Although these treatments do not cure cancer, they can make patients more comfortable, extend life by treating serious complications and improve the quality of life for cancer patients.
Control of pain is one of the most important aspects of cancer care. Pain not only affects patients quality of life and ability to function, it may also lower their tolerance for needed cancer treatments.
In many cancer patients, pain results from the spread of the tumor into surrounding nerves and other tissues. For example, patients with cancer of the pancreas or stomach, sometimes experience pain from the spread of the tumor into a network of nerves and blood vessels in the abdomen called the celiac plexus. To treat the pain, interventional radiologists insert catheters or needles into the affected area and administer alcohol or other agents that destroy the nerves causing the pain.
A particularly painful complication of cancer is when the disease spreads (metastasizes) to bones. In a technique called transcatheter embolization, interventional radiologists inject tiny particles, the size of grains of sand, through a catheter and into the artery that supplies blood to the tumor. The particles cause clotting that decreases the tumors blood supply, reducing pain and decreasing the likelihood of bone fracture.
If a cancer spreads to the blood vessels it may cause hemorrhage or bleeding. An interventional radiology technique called transcatheter embolization can be used to clot the affected blood vessels and stop the bleeding.
Treating Organ Obstruction and Infection
Cancers can obstruct the normal flow of urine or bile, causing these fluids to build up in the body. If left untreated, these conditions are not only painful but may also result in organ failure or infection. Under X-ray guidance, catheters can be inserted to drain the collection of fluids. Often, a small device called a stent is inserted into the organ to bypass the obstruction and allow fluids to drain internally.
Treating Blood Clots
One common side effect of cancer or cancer treatments is the development of blood clots, or emboli, that can be life-threatening if they travel to the brain, lungs or heart. There are two interventional radiology procedures that can reduce the risks posed by blood clots:
Small mesh cylinders called stents are used to open obstructed organs and allow fluids such as urine and bile to drain.
- Intra-arterial thrombolysis. In this technique, the interventional radiologist guides a catheter through the blood vessels and to the site of a blood clot. Clot-busting drugs are infused through the catheter to break up the clot.
- Filter placement. This technique is most often used when a blood clot is detected in the blood vessels of the leg (a condition called deep vein thrombosis). The interventional radiologist guides a small filter into the blood vessel that receives blood from the lower body (the vena cava) and carries it to the heart. If the blood clot dislodges from the vein in the leg, the filter will trap it before it can reach the heart.
Interventional Radiologists are Minimally Invasive Experts
Interventional radiologists work with other specialists on a multidisciplinary cancer team to determine the best treatment for each individual patient. Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments. Interventional oncology is a growing area within interventional radiology.