Cryoablation of Breast Fibroadenomas
Cary S. Kaufman
CRYOABLATION TREATMENT FOR BREAST FIBROADENOMAS—OVERVIEW
Cryoablation is a minimally invasive, innovative treatment for breast fibroadenomas. The treatment is performed in an office setting rather than an operating room, resulting in a cost-effective and patient-friendly procedure with little to no scarring. Published reports demonstrate that cryoablation as primary treatment for breast fibroadenomas is safe and effective and at long-term follow-up, demonstrates progressive resolution of the treated area, with excellent patient and physician satisfaction (Table 1).
About 80% of the approximately 1.3 million biopsies performed annually in the United States reveal benign conditions, primarily benign tumors or fibrocystic change. The most common benign breast tumor is a fibroadenoma.1, 2, 3
Although not life threatening, benign breast tumors can cause fear, anxiety, and discomfort in the patient, and definitive treatment is often desired.3, 4, 5
Fibroadenomas consist of a proliferation of epithelial and connective tissue elements within the lobular region of the breast. They are usually sharply demarcated from the adjacent breast tissue and give the clinical and imaged appearance of being encapsulated.5
DIFFERENTIAL DIAGNOSIS
These benign breast tumors have a classic physical examination: rubbery texture, smooth and well defined, circular to oval, and freely moveable within the breast.
Other breast lesions that may have similar clinical presentations include phyllodes tumors, juvenile fibroadenomas, breast cancer (particularly medullary carcinomas), or breast cysts. Diagnosis is resolved by imaging and core needle biopsy.
Table 1: Potential Advantages for Cryoablation in the Treatment of Fibroadenoma | ||||||||||||||
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PATIENT HISTORY AND PHYSICAL FINDINGS
Patients with small- to medium-sized single tumors that are not too close to the skin or nipple are appropriate candidates for cryoablation. Indications and contraindications are listed in Table 3.
The target lesion must be clearly visible with ultrasound and not be within 1 cm of the skin or immediately deep to the nipple.
A histologic diagnosis using a core biopsy should demonstrate a classic fibroadenoma without atypia. Other histologic lesions are not appropriate for cryoablation.
Tumors should be measured in three dimensions and the longest dimension used to calculate freezing time (FIG 1).
It is important to discuss with the patient the process of cryoablation and the progressive resorption of the residual necrotic debris over time (FIG 2).
The candidate should not currently have breast cancer in the ipsilateral breast and be otherwise healthy. She should not be pregnant, breastfeeding, or have breast implants.
IMAGING AND OTHER DIAGNOSTIC STUDIES
If the patient is in the mammography screening age-group, a pretreatment screening mammogram should be obtained and be normal except for the fibroadenoma (FIG 3).
There are classic imaging findings of fibroadenoma on both ultrasound and mammography, but histology is needed for an accurate diagnosis1,3,9,17 (FIGS 3 and 4A,B, ultrasound and mammogram of a fibroadenoma).
The differential diagnosis includes the larger and faster growing juvenile fibroadenomas and phyllodes tumors.1,7,9
MANAGEMENT OPTIONS
There are three treatment options for a confirmed fibroadenoma: (1) serial observation (“watchful waiting”), (2) surgical removal, and (3) cryoablation. Surgery for fibroadenoma provides definitive treatment while confirming the diagnosis and eliminating patient anxiety and future monitoring. Drawbacks to surgical excision include patient discomfort, anesthetic and surgical recovery, skin incision and potential scarring as well as operating room costs.18
On the other hand, many women choose serial observation with the advantages of no surgical pain, avoidance of the operating room and anesthesia, less cost, and only a minimal scar from the large-core needle biopsy. Drawbacks to conservative management include ongoing patient anxiety regarding the presence and potential growth of a lump, the inconvenience of serial office visits, and the confusion of physical examination and mammography evaluations caused by the mass effect.7,19
Table 2: Published Reports of Cryoablation for Fibroadenomas
Author
Fibroadenomas (n)
Mean Size (cm)
Freeze Time (min)
Skin Injury
Any Growth @ 1 y
Still Palpable @ 1 y
Volume Decr (%) @ 1 y
Cosmesis by Patient @ 1 y
Satisfied Patient @ 1 y
Edwardsa
310
1.8
N/A
0%
None
33%
97%
92%
100%
Nurkob
444
1.8
22
0%
None
35%
71%
82%
88%
Hahnc
23
<3.0
10
4%
None
22%
76%
96%
96%
Kaufmand
70
2.1
15
6%
None
25%
89%
100%
97%
Total/average
847
1.9
16
3%
None
29%
83%
93%
95%
a From Edwards MJ, Broadwater R, Tafra L, et al. Progressive adoption of cryoablative therapy for breast fibroadenoma in community practice. Am J Surg. 2004; 188:221-224.
b bFrom Nurko J, Mabry CD, Whitworth P, et al. Interim results from the FibroAdenoma Cryoablation Treatment Registry. Am J Surg. 2005;190(4):647-651.
c cFrom Hahn M, Pavlista D, Danes J, et al. Ultrasound guided cryoablation of fibroadenomas. Ultraschall Med. 2013;34(1):64-68.
d dFrom Kaufman CS, Littrup PJ, Freman-Gibb LA, et al. Office-based cryoablation of breast fibroadenomas: 12-month followup. J Am Coll Surg. 2004;198:914-923.
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