Breast Cancer Cryoablation in Chandler, Arizona

Introduction

I'm Dr. Meghna Krishnan, an American Board of Radiology certified breast and body imaging radiologist. My practice, URPrecious Imaging, offers automated 3D breast ultrasound with AI, 2D breast and body ultrasound with color Doppler and elastography, mammogram, ultrasound and mammogram-guided aspirations and biopsies, second opinion reading, breast cancer cryoablation, and REMS EchoLight ultrasound for bone density. Today I'm going over a cryoablation case, before and after treatment.

The patient and the ultrasound findings

A 72-year-old woman came to us with a palpable lump in the upper outer right breast. She had a left breast cancer treated with lumpectomy about 15 years ago, declined radiation at the time, and has been on holistic naturopathic oncological care. She declined mammography and came for an ultrasound.

The ultrasound showed a suspicious, irregular, hypoechoic mass with angular, indistinct margins. It was non-parallel (taller than wide) with an echogenic rim, measuring about 2.5 × 1.4 × 1.9 cm, with blood flow on color Doppler. Elastography, which checks how stiff a lesion is, showed a lot of red signal. The stiffer the lesion, the more suspicious it typically is.

While scanning the lower axilla, we found a second mass, about 1.4 × 1 × 1.4 cm, with blood flow. It could have been a completely replaced lymph node with metastatic disease or a second primary.

Biopsy results and MRI

We biopsied both masses the same day. Both were invasive ductal carcinoma of no special type, the most common type of breast cancer. The axillary mass contained traces of lymph node tissue, so it was a metastatic lymph node. The cancer was estrogen receptor positive, progesterone receptor positive, and HER2-neu negative.

A breast MRI confirmed the extent of disease. The 10 o'clock right breast mass measured about 2.4 × 1.6 × 2.3 cm and the right lower axillary mass about 1.4 × 1.2 × 1.9 cm, closely matching the ultrasound measurements.

Why she chose cryoablation

She could have been a good candidate for surgery, but she preferred cryoablation for several reasons:

• It is done in the office, not in an operating room, so patients are more comfortable.
• There is no general anesthesia. We use lidocaine.
• Recovery is usually easier without anesthesia.
• The only mark is a small needle entry site, like a biopsy, with no stitches.
• Many patients tell me they love being able to keep their native breast. Not having parts of their body cut away can matter emotionally in a patient's recovery and outlook.

How breast cryoablation is performed

We use the IceCure Medical ProSense liquid nitrogen cryoablation system. Liquid nitrogen flows through a hose to the cryoprobe, and the ice ball forms at the probe tip once it is in the tissue.

With the probe placed through the tumor under ultrasound guidance, we start the liquid nitrogen. Within about a minute the probe cools to -170°C, and we hold the freeze cycle. We then thaw by stopping the liquid nitrogen and letting the tissue warm on its own, then freeze a second time through the same probe.

Freezing cuts off the tumor's blood supply and freezes the water inside and outside the cells, stopping their machinery. During the thaw, extracellular water floods into the cells and opens up the membranes, so the cells can no longer function. This causes necrosis in the treated area.

Planning the treatment: tumor size and ablation zones

Studies based on ice ball size show that tumors smaller than 2 cm can be treated effectively with one cryoprobe using a freeze-thaw-freeze cycle. This patient's main mass was 2.5 cm, so we used two overlapping ablation zones to cover the whole mass plus 1 cm of surrounding normal tissue. We used one zone for the axillary mass, which was just under 2 cm.

After the second freeze, the ice ball at the 10 o'clock mass measured about 5.4 cm (right to left) by 4.7 cm (head to toe). The axillary ice ball measured about 5.1 × 3.5 cm.

Protecting the skin

We monitor the skin throughout. If needed, we inject warm saline below the skin with a spinal needle, or gently pour warm saline over the skin while massaging, to prevent frostbite. This patient's lesion was not close to the skin.

After the procedure

At the end, the patient gets Steri-Strips and a Tegaderm dressing, with no sutures. The body then enters a post-cryoablation inflammation phase, clearing fluid and dead tumor cells.

This process may also trigger the abscopal effect, where the immune system recognizes the tumor's dead cells and may be able to respond to tumor cells outside the treated zone. This has been shown in laboratory mice, and there are anecdotal reports in people, but it is not guaranteed. We also recommend that patients see an oncology specialist about additional treatment such as radiation, anti-hormonal therapy, or anti-HER2 therapy, anything that supports a comprehensive approach.

Three-week follow-up results

At three weeks, her breast was no longer swollen and she was comfortable. She had breast swelling and discomfort for the first day or two and couldn't lie on that side, but then returned to her routine. Recovery is usually shorter and quicker than after surgery, which is one reason patients prefer it.

The ultrasound showed:

• Original tumor: The dark, distinct, highly suspicious mass had become a bright area consistent with fat necrosis.
• Blood flow: Some flow around the edges of the treated zone, which is expected from inflammation, but none within the tumor's location.
• Elastography: The treated area, previously red and very firm, now showed blue, light blue, and some yellow, meaning soft. Clinically the lump was soft and pliable.
• Axillary mass: A lot of fat necrosis and no blood flow or Doppler activity. We call this a "tumor ghost": the shape remains, but there is no activity.
• Ablation zones: The ice balls had merged during the procedure, and the fat necrosis areas between the axilla and the 10 o'clock site had merged as well.

Contact us

To learn more or to ask about cryoablation, call 602-878-7501 or visit urprecious.com.

Introduction

I'm Dr. Meghna Krishnan, a breast and body radiologist, and I'd like to share a case where cryoablation was used to treat a multicentric, 9 cm ulcerated invasive lobular carcinoma. Our practice provides automated 3D breast ultrasound with AI, 2D breast and body ultrasound with color Doppler and elastography, ultrasound-guided aspirations and biopsies, second opinion reading, breast cancer cryoablation, and REMS EchoLight ultrasound, which measures bone density and bone quality to assess osteoporosis, osteopenia, fragility score, and 5-year fracture risk.

The patient's history

The patient is a 67-year-old woman. In 2022 she had a locally advanced, large, ulcerated left central breast mass with axillary metastasis. It was estrogen receptor positive, progesterone receptor negative, and HER2-neu negative. I'm sorry for the graphic photos, but this is how it looked in 2022, and you can see how locally advanced it was, with involvement of the skin.

She underwent holistic oncological management, including insulin potentiation therapy, low-dose chemotherapy, and other options her naturopathic oncologist preferred. She declined surgery and radiation at that time. Within about a year she had improved significantly, even with that holistic treatment.

The 2023 recurrence

In 2023 a new area appeared on the left side. Ultrasound showed a mass at 11:00, 3 cm from the nipple, with blood flow, a second smaller mass at 12:00, and a third mass at 4:00.

Why she chose cryoablation

The surgical option for her would basically have been a mastectomy, but she was interested in cryoablation. She had also heard about the abscopal effect, an immunological benefit that may come from cryoablation, where the dead tumor's DNA is available for the immune system to recognize and mount a response. This has been shown in mice and in anecdotal cases around the world, and we know it is possible from radiation experience too.

Cryoablation does not require general anesthesia, which is an advantage. And, most important emotionally for many women, she gets to keep her own native breast. There are excellent reconstruction options these days, but many women prefer to keep their own breast if they can.

Imaging and treatment planning

When she came for cryoablation, we found the disease was extensive: not just three isolated masses but a large area of the breast. Ultrasound showed a hypoechoic mass at 11:00 touching the skin, with no gap between the skin and the mass. Normally we place a spinal needle and inject saline to separate the skin from the mass and prevent frostbite, but that was not possible here.

She also had breast implants. Implants are okay in cryoablation, and in our experience the ice ball does not damage the implant. It is nice to separate the mass from the implant or skin when you can, but in this case we could not.

The lesion measured nearly 6 cm in length (5.64 cm) and 3.4 cm in the craniocaudal (head to toe) dimension, much more than a 3 cm mass. These measurements matter because we have to plan where to place the probe so that we cover not only the mass but also 1 cm of normal tissue around it, since the margins should be clean too.

The masses at 11:00, 4:00, and 12:00 were no longer separate. In person it was a 9 cm by 9 cm area, with redness over the whole region. We knew that to be successful we should treat the whole area as one entity.

How many ablation zones are needed

One probe treats about 2 cm of disease successfully. Trials support this, and the 5-year follow-up of the ICE3 trial showed excellent results, with about 3.5% recurrence at 5 years, which compares well even with lumpectomy. To cover this patient's whole area, we planned multiple overlapping ablation zones. She needed seven.

How breast cryoablation is performed

We use a device from IceCure Medical, an Israeli company. The liquid nitrogen is held in a tank, and a probe is inserted into the mass to form an ice ball. The temperature graph shows how fast it drops once the liquid nitrogen starts: to -170°C within a minute. The freeze can be held for as long as needed. We usually prefer 6 minutes or more, generally 6 to 12 minutes, to be sure the tumor cells are killed. We do a freeze-thaw-freeze cycle.

Freezing the water inside and outside the cells and stopping blood flow leaves the tumor without oxygen or blood supply, so it undergoes necrosis. During the thaw phase, water from outside rushes into the cells and stretches the membranes, so the cells can no longer function. After that, healing begins.

The ice ball appears dark on ultrasound. We extend it so that it covers not only the tumor but also 1 cm around it, to cover the margin.

Recovery in the first days

For the next few days her breast was swollen, which is inevitable. She managed with a well-fitting bra, and Tylenol was all she might have needed for pain. We like the inflammation because it lets the body mount a beneficial immune response and clear the debris. We want blood to come in and the lymphatics to work.

To help the lymphatics, we recommend a lymphatic massage therapist if needed, or a vibration plate at home for whole-body lymphatic flow, as this patient used. Monitor for fever, redness, discoloration, increased pain, or increased swelling, and contact your cryoablation doctor if any of these occur.

Skin healing after cryoablation

One month after cryoablation she sent us a photo showing skin blistering. The swelling had come down, but the skin changes were noticeable. We knew that because the tumor was touching the skin, necrosis of the back wall of the skin was going to happen anyway.

Wound management by a doctor was an option, but she was comfortable caring for it at home, because she had already learned how to manage the ulcerated lesion before. She kept the skin dry, applied silver sulfadiazine ointment about twice a day, and used a home ozone kit three times a week for 10 minutes each. The machine makes ozone from oxygen, which is delivered through tubing to an apparatus placed on the breast.

Within a few weeks she sent another photo showing the blisters had opened and there was good improvement. The skin changes were still there, but it was going in the right direction. A little later we saw further healing, with complete resolution of the skin changes and some scab remaining. She could have gone to a wound center to have it debrided, but she continued to monitor and care for it at home. The area kept shrinking and the skin looked much better. The best part is that she still has her own breast, in spite of the journey she has had from the beginning.

Ultrasound follow-up

At the 3-month ultrasound, I was amazed to see that the previously distinct mass was no longer there. There were only bright echogenic changes with some edema. In the central area where the skin had opened up, there was no blood flow. Everything was fat necrosis. The color visible outside is normal movement-related signal, and there was nothing in the cryoablation area.

At 4 months, the most recent follow-up, the skin scab was still there and she may have it removed. That is minor compared to the malignancy she had, and I think cryoablation played a role in helping her through this journey.

Summary of her course

In 2022 she had holistic oncological treatment, and the original tumor was very large. She then had a local recurrence in the breast, then cryoablation. She is doing well for now and is being monitored, and I continue to help her with the journey.

Her native breast is still in place, which I think makes a huge difference. I'm not saying every woman needs this, and there is a role for surgery too. But if a woman is strongly motivated and keeping her breast is important to her, this option is available. There was no general anesthesia, only lidocaine, and she had a very quick recovery. If she still needs surgery, that remains an option because her own breast is still there.

Why cryoablation for breast cancer matters

I'm excited that we are in a day and age where this is possible. Cryoablation has been approved and used for about 20 years for kidney, prostate, and liver tumors, and more recently lung tumors. I'm surprised it took so long to reach the breast, which is so easy to access for procedures. I think this is a great option, and I hope more women can benefit and more providers come on board.

Thank you for the opportunity, and I wish you and your family very good health always.

Contact us

To learn more or to ask about cryoablation, call 602-878-7501 or visit urprecious.com.