Transcript Slides
Cryotherapy for a spectrum of breast
cancer: US and CT-guidance.
Peter J. Littrup, M.D.1*
Bassel Jallad, M.D.1
Priti Chandiwala-Mody, D.O.2
Monica D’Agostini1
Barb Adam, N.P.1
David Bouwman, M.D.3
1 Karmanos
Cancer Institute
2Department of Radiology, Wayne State University
3Department of Surgery, Wayne State University
* Co- Inventor/Founder: Single Phase Liquid Cooling (SPLC) by CryoMedix, LLC
Goals & Hypothesis
To assess the technical feasibility, patient
acceptance, imaging and clinical outcomes of
percutaneous cryotherapy for breast cancers.
Multiprobe cryoablation for diverse presentations
of breast cancer can be monitored to create 1cm
visible ice coverage beyond all tumor margins,
resulting in thorough cytotoxic coverage.
Introduction:
Current treatments for LOCAL Breast Cancer
include surgery, radiation and/or chemotherapy
Breast Conservation is the primary research focus
for new treatment options.
Cryotherapy works by delivering lethal cold to ANY
cell ~ -30 0C x 2 cycles
Benefits of Cryo?
– Much lower pain than heat-based ablations
– Easily visualized on CT/US/MR
– Excellent Healing ~ Eliminates disfiguring surgery
Introduction:
Breast Cryotherapy Research: Single probe
Cryotherapy-assisted lumpectomy
–Tafra, et al. Ann Surg Oncol. 2003; 10:1018 –1024
Excisional data
–Pfleiderer , et al. Invest Radiol. 2005; 40:472-477
–Roubidoux , et al. Imaging: Radiology. 2004; 233:857-867
Conclusions:
– 100% kill for all tumors <1 cm & 1-1.5 cm with no DCIS
– Unreliable kill for tumors > 1.5 cm
– Incomplete along POSTERIOR margins
Materials and Methods:
Littrup et al., Lethal Isotherms of Cryoablation in a Phantom Study: Effects of Heat
Load, Probe Size, and Number JVIR 2009; 20:1343-1351
Cryotherapy for breast cancer: A feasibility study without excision.
J Vasc Interv Radiol 2009; 20:1329–1341.
Minimum of 2 probes needed to cover 1cm tumor with lethal ice (< -30°C isotherm)
Multiple probes increase lethal ice: Surface area = 55% - 4 probes, 18% - 1 probe
• Multiple probes and/or
• Longer freeze times
correct for:
- higher heat loads
- lower probe power
Materials & Methods:
Patients - Procedures
Informed consent included thorough counseling that cryo was
NOT standard of care, esp for newly dx potentially curative
14 patients with 27 cancer foci of newly dx or recurrent breast
cancer were treated using US and/or CT-guidance
Saline injections interposed between the developing ice ball
and the skin or chest wall for further thermal protection.
Biopsy performed at ice margins immediately after procedure.
CT and MRIs were performed in CA patients at available
follow-up times, up to 6 years post-procedure.
Materials & Methods:
Equipment
Results:
Locally Advanced Breast Cancer
Littrup PJ, et al. JVIR 2009
Results:
Locally Advanced Breast Cancer
Littrup PJ, et al. JVIR 2009
Results: Newly Dx Breast Cancer
Littrup PJ, et al. JVIR 2009
Five-year
Results:
Locally Advanced BCa & Implants
Littrup PJ, et al. JVIR 2009
Cryotherapy for BrCA: Local Recurrence
Littrup PJ, et al. JVIR 2009
Pre
1 mo.
18 mo.
Immediate
Results:
Patient
Clinical difference – no resection!
14 patients:
– 7 Locally advanced – on chemo/hormonal tx
One had implants – froze into without damage
– 7 Intent to cure – multifocal + XRT/hormonal
Total tumors – 27
Average tumor size – 1.7+ 1.2 cm (range: 0.5-5.8)
Minimal distortion – 80-90% resorption 6-12 mo.
No localized recurrences
– One regional recurrence in breast/axilla
Results:
Procedure
Average cryoprobes - 3.2
Average ablation size – 51 mm
MR planning and follow-up crucial
Guidance – 8/14 pts CT and US; 6/14 US only
US/CT-guidance superb - operator dependent
No complications
Minimal discomfort - entirely outpatient
Able to address axillary nodes – nerves
Future of Breast Cryotherapy: MR-compatibility
Single Phase Liquid Cooling (SPLC)*
*CryoMedix, LLC
Vascular/Endoscopic
10 Sec
20 Sec
1 Min
2 Min
20 Thaw
MR - Compatibility
MR-monitored breast CA: Cadaver
Sagittal (left) and axial views of MR-compatible 1.5 mm cryoprobes at ~1.2mm apart,
generating immediate "cold" ice with minimal signal which then thaws over time (right),
(sharp initial margins, as well as greater T2 signal with thawing at 15 minutes).
Conclusions
Ensure cytotoxic coverage - multiple probes
Minimal pain
Cosmetic satisfaction – implants OK, breast
conservation method
Locally curative, control disease process
Future: FDA trial with more patients and use
of new MRI compatible cryotechnology
(operator independence) is being planned
Thank You!