AJR 2005; 184:S126-S128
© American Roentgen Ray Society
Palliative Radiofrequency Ablation of a Fungating, Symptomatic Breast Lesion
Eric vanSonnenberg1,
Sridhar Shankar2,3,
Leroy Parker4,
Lawrence Cheung2,
Paul R. Morrison2,
Stuart G. Silverman2 and
Dirk Igelhart5
1 Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115.
2 Department of Radiology, Dana-Farber Cancer Institute, Brigham and Women's
Hospital, Harvard Medical School, Boston, MA.
3 University of Massachusetts Memorial Health Center, Worcester, MA 01655.
4 Department of Medical Oncology, Division of Breast Oncology, Dana-Farber
Cancer Insititute, Brigham and Women's Hospital, Harvard Medical School,
Boston, MA.
5 Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's
Hospital, Harvard Medical School, Boston, MA.
Received April 21, 2004;
accepted after revision June 14, 2004.
Address correspondence to E. vanSonnenberg
(ericvansonnenberg{at}yahoo.com).
Introduction
Radiofrequency ablation has been used for a myriad of malignancies
in numerous organs, both for cure and palliation. The use of this therapeutic
technique for breast carcinoma is limited. Reports in the literature have
focused on preoperative radiofrequency ablation followed by resection, as
feasibility studies
[1-7].
Cryotherapy also has been piloted experimentally and clinically for ablation
of breast tumors [8]. We
describe radiofrequency ablation that provided some benefit to a patient with
a large exophytic, symptomatic breast cancer.
Case Report
A 43-year-old nurse with a history of invasive ductal carcinoma was
referred by her breast oncologist for consultation regarding radiofrequency
ablation of a symptomatic lesion in her reconstructed left breast. Core needle
biopsy showed recurrent invasive carcinoma. The fungating and protuberant
lesion measured 7.7 x 2.6 cm and extended from the inferior region of
the breast into the inframammary fold; the tumor invaded the soft tissue and
muscles of the left anterior chest wall.
The patient was first diagnosed with invasive ductal carcinoma in June
1997, and a partial left mastectomy was performed, followed by combined
radiation and chemotherapy. She remained well until January 2000, when biopsy
of a suspicious, ipsilateral breast lesion confirmed recurrent disease. Total
left mastectomy was then performed with a transverse rectus abdominis muscle
flap reconstruction without adjuvant therapy. A biopsy performed in July 2002
showed further progression in the reconstructed left breast and chest wall.
Subsequent PET and CT scans showed metastatic lesions in the liver and in the
right axillary and left supraclavicular lymph nodes. The patient was treated
unsuccessfully with vinorelbine tartrate for 4 months, and then with docetaxel
for 2 months. The disease continued to progress rapidly in her reconstructed
breast and in the liver while she was on these agents. The patient was started
on doxorubicin hydrochloride liposome injection in February 2003, which was
moderately successful at controlling her systemic disease. The dominant liver
metastasis decreased from 7 to 4 cm in diameter; however, the drug proved
ineffective at the site of the local recurrence.
Because local control could not be achieved with chemotherapy and because
of local discomfort, frequent bleeding, and oozing from the large, fungating
tumor (Fig. 1A), the patient
was referred for palliative radiofrequency ablation of the breast lesion in
June 2003. Before the procedure, the patient also met in consultation with a
breast surgeon who agreed with ablation as the course of action, as no further
surgical option was available. An MRI examination before the procedure showed
a large soft-tissue density extending from the inferior aspect of the
reconstructed left breast to the anterior aspect of the left rib cage that
enhanced after IV gadopentetate dimeglumine was administered. Multiple liver
lesions again were seen.
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Fig. 1A. —43-year-old woman with fungating breast lesion. Lesion is at
inframammary fold of reconstructed breast, the latter being cephalad to
lesion. Lesion is ulcerated and has areas of dried blood.
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The procedure was performed under the institutional review board
"Innovative Therapy" mechanism. General anesthesia was
administered with endotracheal intubation. CT was used for guidance and
monitoring. A 15-cm-long "cool-tip" radiofrequency probe
(Radionics) with a 2-cm active tip was used. Two radiofrequency applications
of 5- and 4-min duration, respectively, were performed on the medial and
lateral aspects of the exophytic portion of the tumor (Figs.
1B and
1C) to induce an approximately
6-cm3 zone of necrosis. The skin overlying the tumor was denuded
and the probe was placed within 1 cm of the surface. Tissue temperature was
raised to 76-80°C, an effective range for coagulation. After each
application, the probe was removed while we cauterized the entry tract.
Minimal, self-limited bleeding at the sites of probe entry occurred but abated
by the end of the procedure. Immediately postablation, a contrast-enhanced CT
scan showed decreased enhancement. A 1.5-cm region of skin discoloration was
present with moderate erythema immediately inferior in relation to the medial
portion of the tumor. The patient recovered from general anesthesia without
complications.
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Fig. 1B. —43-year-old woman with fungating breast lesion. CT-guided
radiofrequency ablation of fungating breast tumor with patient under general
anesthesia. Noncontrast supine CT scan shows radiofrequency needle probe
entering from patient's right in medial portion of tumor.
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The patient was discharged from the hospital the next day after an
uneventful overnight stay. Follow-up MRI examination the day after the
procedure revealed that the treated portion of the breast mass did not enhance
after gadopentetate dimeglumine was administered, suggesting that the
procedure was effective in inducing coagulative necrosis of the tumor (Figs.
1D and
1E).
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Fig. 1D. —43-year-old woman with fungating breast lesion. MRI pre- and
postradiofrequency ablation procedure, showing efficacy of ablation.
Preprocedure, T1-weighted spoiled gradient-echo MRI (D) (TR/TE, 7/2.2;
TI, 40; flip angle, 10°) after 20 mL of IV gadopentetate dimeglumine are
administered and using body coil. Lesion has enhanced notably with contrast
medium (arrows). After ablation, T1-weighted spoiled gradient-echo
MRI (E) (TR/TE, 7.7/2.028; TI, 40; flip angle, 10°) shows lack of
enhancement in lesion. Note deeper breath on MRI compared with CT, as the
patient was awake for MRI examination.
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Fig. 1E. —43-year-old woman with fungating breast lesion. MRI pre- and
postradiofrequency ablation procedure, showing efficacy of ablation.
Preprocedure, T1-weighted spoiled gradient-echo MRI (D) (TR/TE, 7/2.2;
TI, 40; flip angle, 10°) after 20 mL of IV gadopentetate dimeglumine are
administered and using body coil. Lesion has enhanced notably with contrast
medium (arrows). After ablation, T1-weighted spoiled gradient-echo
MRI (E) (TR/TE, 7.7/2.028; TI, 40; flip angle, 10°) shows lack of
enhancement in lesion. Note deeper breath on MRI compared with CT, as the
patient was awake for MRI examination.
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At 2 weeks, the patient had recovered well and her symptoms had improved. A
healing ulcer covered by a thick eschar developed at the ablation site
(Fig. 1F). The patient was
pleased with the results of the procedure; her discomfort abated, the erythema
surrounding the ulcer resolved, and she no longer experienced spontaneous
bleeding or oozing from the tumor. The exophytic portion of the lesion notably
decreased in size.
Four months after the radiofrequency procedure, the patient's condition
declined significantly, caused by complications from her liver metastases. She
died shortly thereafter from complications of liver failure.
Discussion
The intended goals for the use of radiofrequency ablation in our patient
were achieved with reasonable success. The discomfort that the patient felt
from the large exophytic mass had improved, possibly related to the reduction
in lesion size due to the coagulation necrosis, with subsequent eschar
formation and sloughing of much of the exophytic portion of the tumor. The
oozing and mild bleeding that she experienced also were ameliorated. The
patient and her husband expressed satisfaction with the effects of the
ablation procedure; a previous study also reported good patient acceptance of
radiofrequency ablation for breast tumors
[2].
The choice of probe type in this patient was based on the geography and
geometry of the particular lesion. We elected to treat only the large
exophytic mass, as this was the symptomatic area. The proximity of the tumor
in the chest wall to the heart mitigated against deep therapy. As the cool-tip
single probe creates a cylindric coagulative burn, this was thought to be
appropriate, given the oblong nature of the tumor. We elected to perform two
burns and to cauterize the tract on probe removal; the latter maneuver was
additive to the overall ablation.
The use of radiofrequency ablation in this patient was predicated on
virtually no options left to treat the symptoms and signs in this relatively
young woman. She had become refractory to all forms of chemotherapy, and no
surgical option was available. Although there were risks of deep tissue
injury, further bleeding, and increased pain, the potential benefits were
thought to outweigh these risks. The patient's breast oncologist, oncologic
breast surgeon, and interventional radiology ablation group agreed on this
treatment.
Our choice to use CT guidance and general anesthesia proved satisfactory,
although sonographic guidance
[2] and conscious sedation were
alternatives. CT offered excellent visualization of the probe positioning and
repositioning within the lesion and the chest wall and intrathoracic
structures including the heart, which was only a few centimeters away from the
site of ablation. General anesthesia allowed a pain-free procedure for the
patient, who, based on this experience, eagerly inquired about the possibility
of radiofrequency ablation for lesions in other sites of her body.
Although this is a single case, and only palliation was achieved rather
than cure, the patient's and family's satisfaction, the amelioration of
symptoms and signs, and the lack of complications in this patient encourage
further exploration of uses of radiofrequency for problematic breast
cancers.
Acknowledgments
We thank Sue Ellen Lynch for preparation of the manuscript.
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Introduction
Case Report
