Imagine a world where a cancerous tumour in the breast is frozen and blasted into oblivion (microscopically) within 30 minutes. It sounds like sci-fiction but this technology, called cryoablation, is now available in Singapore. In addition, this minimally invasive procedure can help breast cancer patients have quicker treatment and recovery. Dr Jendana Chanyaputhipong, a Breast Surgeon from The PanAsia Surgery Group, tells us more.
What was breast cancer surgery like in the past?
In the past, breast cancer was regarded as a local disease, confined to the breast. Because of this, radical surgery called radical mastectomy and axillary clearance was the gold standard of treatment for a long time. The aim of doing such radical surgery was for both control and cure of the cancer.
In this type of surgery — which is still being done in some advanced cases today — the breast, skin, nipple-areolar area, underlying pectoralis muscle, and the group of lymph nodes in the armpit are removed.
The patient is left flat chested, with a scar across the chest. Often you will also be able to see her ribs through her skin. Apart from this, her arm on the affected side may suffer lymphedema — or arm swelling — that is prone to repeated infection.
Most importantly, this aggressive local surgery did not result in cure of the cancer.
How about the present?
Presently, breast cancer is regarded as a systemic disease. This means that breast cancer is not just a disease confined anatomically to the breast but one that can spread and involve other organs.
Hence, modern treatment of breast cancer is multimodal — it includes a combination of measures for local control (surgery and radiation therapy), as well as measures to control of disease outside the breast (chemotherapy, hormonal therapy and other targeted/drug therapy).
The mainstay of breast cancer surgery now involves mastectomy (with or without reconstruction) and lumpectomy (aka breast-conserving surgery).
For surgery to the axilla (armpit), a procedure called Sentinel Lymph Node Sampling is done to check for evidence of disease before proceeding to remove the entire group of lymph nodes in the armpit. These surgeries are less extensive, reducing unnecessary complications.
And now there’s a new treatment for breast cancer?
Yes. We may soon see another revolutionary breakthrough in breast cancer treatment, involving the use of cryoablation and immunotherapy.
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What is cryoablation?
Cryoablation is a minimally-invasive technique that destroys tumours by using extreme cold temperature. Said another way, cryoablation deep-freezes the tumour to its death within the treated breast—there is no surgery to remove it.
It comes from the Greek word Kruos (which means “icy cold” or frost) and the Latin word ablatum (which means “to remove”).
Cryoablation has been around for over 20 years but its use in the treatment of breast cancer is still limited. Though it is currently considered non-standard therapy, studies from Japan and USA have demonstrated promising short-term results (up to 10 years follow up).
Can cryoablation be used for every type of breast cancer?
Because experience with cryoablation in the treatment of breast cancer is still limited, we do not know at this point if it would be suitable for all types of breast cancer. Presently, we know that cryoablation is effective for treatment of Luminal A (ER+, HER2-) early stage breast cancer that is less than 1.5 cm.
What percentage of breast cancer in Singapore falls under this category?
According to the latest statistics, we know that approximately 30% of all breast cancer falls under stage 1 category. Based on local research led by oncologists, luminal A type of breast cancer accounts for 45% of breast cancer in Singapore.
Have you performed cryoablation for the treatment of breast cancer?
Yes. And our experience also confirmed that it has short-term effectiveness with high patient satisfaction, and almost immediate return to normal function.
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Can you take us through the procedure please?
Certainly. This procedure is done using ultrasound-guidance in day surgery facility or other facilities that can house the necessary equipment and monitoring. Patients can choose to be awake throughout the procedure, or be sedated with the use of drugs given intravenously.
When the patient is lying supine, the treatment area is cleaned and protected by a sterile drape. Local anaesthetic is injected to numb the skin and the treatment area. If the patient is fully awake during the procedure, she will feel a pinprick and a stinging sensation (or slight pain) when the local anaesthetic is being injected.
A single 3-5 mm skin incision is made. Then, under ultrasound visualisation, a special needle-like applicator called a cryoprobe is guided to the site of treatment.
Once the cryoprobe is in the diseased breast tissue, liquid nitrogen flows into the cryoprobe. This creates extremely cold temperatures (-170°C) that causes rapid freezing (and destruction) of the diseased tissue that is in contact with the probe.
This results in the formation of an ice ball around the tumor, which is monitored until it reaches the desired size. If the patient is awake during the procedure, she will feel its coolness.
Another thin needle is inserted. This infuses saline into the treated area to protect the skin from the extreme cold. Hence the breast will be swollen at the end of the procedure.
Typically, the total treatment time lasts about 30 minutes.
At the end of the procedure, the cryoprobe is removed, and any bleeding stopped. The wound is stitched and covered with dressing. The patient goes home, or can be admitted for overnight observation.
How much downtime is required? How much leave will I have to take?
Patients who have done this tell us that they felt close to normal even on the same day, and were able to do simple household tasks. The treated breast will feel heavier and swollen for a few weeks, however this did not hinder their movement or activity, or give them much discomfort.
“I was fortunate to not need painkillers at all, except on day of procedure, as a precaution.”
However, I would advise taking at least three to seven days to recuperate. This will help the patient to get comfortable with the body changes and regain her confidence.
Will there be swelling or scarring?
At the end of the procedure, a hard lump (dead tissue in the treated area) and mild breast swelling can be expected. The swelling can last for several weeks. However there is no pain or discomfort as the body re-absorbs it over time. The sensation of a hard lump may take several months (up to one year) to disappear completely. The scar from the incision is negligible as it is only about 5 mm long.
“I was working at my office throughout, with no particular awareness or sensation of this. The feeling of a ‘harder disc’ within the breast remained for several months, though it felt smaller as the days went by.”
Do I have to get larger-sized bras to wear while healing?
No, you do not require larger-sized bras to wear during healing. The author of the largest series of women with breast cancer treated by cryoablation has also shown that scarring within the breast is minimal, and there is hardly any loss of volume when measured objectively.
“The appearance of my breast is virtually the same as before, save for the temporary swelling.”
Can I still breastfeed after cryoablation?
Non-surgical cryoablation is viewed as an alternative to surgical lumpectomy, where treatment is only to the area of the breast that houses the cancer. Patients undergoing cryoablation, similar to those undergoing lumpectomy, will need radiation therapy to treat the rest of the remaining breast tissue. The effects of radiation to the remaining breast tissues vary from one to another. Some can still breastfeed; others can’t.
How is sensation in the breast affected by cryoablation?
Patients report that cryoablation did not cause any loss of sensation or feeling in the treated breast.
Cryoablation really sounds too good to be true. Is it?
Yes. In fact, researchers also believe that there may be additional benefits to the treatment of cryoablation. Because the (dead) tumour tissue is left within the body to be cleared after the procedure, the immune system can learn to recognise the antigen that is present on the cancer cells. Hence if there were to be a recurrence, the immune system would be able to behave like ‘auto-vaccine’, mounting an attack against tumour recurrence.
Nonetheless, let’s await long-term data, as well as the results from other trials that are ongoing to address the full use of cryoablation and its short-and long-term effectiveness in the treatment of breast cancer.
In the meantime, though we offer the treatment, we are careful to select good candidates for this because we hold dear to the principle of ‘do no harm.’
What if another tumour appears?
There are many factors to consider, including the type and biology of the tumour, its location, and stage of the new tumour. We have to do a full re-evaluation again.
Can cryoablation be done if there is more than one tumour in the breast?
Yes, if it is located in different quadrants.
Are there any age or health restrictions?
There are no age or health restrictions. In fact, cryoablation is more likely to be offered as an alternative treatment option for patients who are unfit to undergo standard surgery. That said, patients with the following should not undergo cryoablation:
- Patients who cannot undergo radiation therapy, such as those with severe active skin disease like scleroderma or those who refuse radiation therapy.
- Patients whose tumour size exceeds 1.5 cm or have tumours with extensive DCIS are not recommended for cryoablation.
You mentioned immunotherapy as a form of treatment for breast cancer. Is this the next stage?
I believe so. There are already success stories on this, where a stage 4 patient who did not respond to any chemo drugs became cancer-free after being treated with immunotherapy. This may represent the true revolutionary breakthrough in cancer care, which will not be limited to the treatment of breast cancer alone.
Dr Jendana Chanyaputhipong is a consultant general surgeon with special interest in diseases of the breast. After completing her advanced surgical training in Singapore, she further sub-specialised in oncoplastic and post-mastectomy reconstructive surgery, spending two years at Siriraj Hospital, Bangkok. Before coming out to private practice in 2018, Dr Jendana served at SGH and KTPH. Providing cutting edge therapeutic options for breast cancer patients, Dr Jendana is the first, and currently the only, breast surgeon with experience in performing cryoablation for the treatment of early breast cancer in Singapore.
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