Freezing Breast Tumors
What are benign breast tumors?
Dr. Bedi: When a patient has a lump in the breast, it could be benign, malignant and several other things in between. Probably about 80 percent to 90 percent of benign lumps in the breast are fibroadenomas. They’re more common in younger women, but they can occur at any age. Benign breast tumors can grow, can remain unchanged in size, or they can become smaller and go away completely. The problem with benign tumors is trying to diagnose that they are indeed benign and not malignant. In the past, before we had minimally invasive procedures, the only way to diagnose whether a tumor was benign or malignant was to take it out. People had to have excisional surgical biopsies, but now a large majority of women can have what’s called a minimally invasive biopsy, which is either guided by a mammogram or ultrasound. The doctor takes pieces of tissue, it’s called a core biopsy, and those pieces of tissue can be analyzed by the pathologist, which gives you a pretty definitive diagnosis as to whether a lump is benign or malignant. If the tumors are diagnosed as benign based on this core biopsy, we really don’t need to do anything further with them other than follow them. You have to continue to follow it because a biopsy only takes pieces of tissue from part of the tumor, and there can be a part of the lump that is malignant that you have not biopsied. If it doesn’t grow in size, you don’t need to do anything because all malignant tumors will keep growing.
Are women usually content to leave the benign tumor alone, or do they want it removed?
Dr. Bedi: If patients have a benign biopsy, we tell them that they have a choice not to do anything, and a large number of women choose not to do anything. But it’s quite amusing how many of them, even though they know that the lump is benign, want it out. They want to get rid of it because they don’t want to deal with the worry of wondering whether this is growing or not. It gives them much greater piece of mind if the lump is gone.
If it is not necessary to remove a benign tumor, why do so many opt to have them removed?
Dr. Bedi: Because if you biopsy a lump and it is benign, we tell the patient, “We can be 99-percent sure that it is completely benign, but there is still that 1-percent to 2-percent possibility that it is not.” About a third of the benign tumors grow as you watch them, which means they will have to be removed. And people don’t want that uncertainty, especially if they’ve had a history in the family or someone they know has had a lump. It just worries and bothers them. The only absolute certainty is when the lump is gone.
How do these women have their tumors removed?
Dr. Bedi: In the past, we always surgically excised these tumors if the patients wanted them to be removed. But now there are very minimally invasive procedures. The tumor’s lesions can be destroyed in place by using various modalities, such as freezing, radio frequencies, or ultrasonic waves — these ultrasonic waves are not the usual ultrasound waves that you do but high-frequency, targeted ultrasounds. Of these, the one that seems to appear the most is cryoablation, where you freeze the tumor in place. You first have to biopsy the lesion to make sure that what you’re destroying is a benign lump. Then, by the same procedure under the guidance of an ultrasound, you put this probe through the lesion. Then, using argon gas that’s passed through the probe, an ice ball is formed around the tumor, which essentially engulfs the lesion. This extreme cold destroys the cells and the lesion itself. These cells that have now been destroyed get auto-absorbed by the body over a couple of months. The lump is not immediately removed because you’ve just destroyed the cells in place. Essentially, it’s dead tissue, and that has to be reabsorbed by the body.
Why is cryoablation the most popular of the minimally invasive procedures to remove the tumor?
Dr. Bedi: The patient has a tiny incision, just a few millimeters in size. It’s an office-based procedure; they don’t have a surgical scar. They don’t have to go to the operating room, and it’s tolerated very well. We like the cryoablation as opposed to other ways of destroying the tumor because this ice ball that forms can be seen very well under ultrasound guidance. As the ice ball is forming, you can see the area that is being engulfed to make sure that you’ve destroyed the entire lesion. If you use radio frequency waves and other modalities, you can’t be sure because you can’t see exactly what you are destroying. So, that’s the big benefit of doing this cryoablation.
Do women complain of pain during or after the procedure?
Dr. Bedi: For the procedure itself, we give them local anesthetic, and the procedure itself is targeted very well. They complain that we have them keep their arm above their head to sleep, but the procedure itself is not painful. Some patients, and it’s amazing, have done a few. Some patients complain of pain the week after the procedure and others don’t. Many say that they’ve had no pain at all, not even requiring Tylenol. I think for the most part, it is just minimal discomfort. It’s just a small incision, so the incision itself doesn’t cause discomfort. Destruction of the tissue in place in some women can cause mild discomfort but nothing significant.
How long does the procedure take?
Dr. Bedi: About half an hour to 45 minutes.
Of the one-third of tumors that continue to grow, could those still be benign? Or does growth mean it is definitely malignant?
Dr. Bedi: Ninety-nine percent of them are still benign, and only about 1 percent have undergone some change. But you don’t know who is of that 1 percent, so you’ve got to remove them.
If the tumors are benign and stay benign is there any danger of having them in your breast?
Dr. Bedi: No. None whatsoever. A large number of women choose not to do anything.
How common are these benign breast tumors and lumps?
Dr. Bedi: I would say that for every cancer that is diagnosed, there are about three to six benign lumps you deal with.
Who is cryoablation a good option for?
Dr. Bedi: Well, even now some women choose to have their lump removed rather than have it destroyed in place. But cryoablation is another option available for women and especially for the younger women, where the benign lumps are much more common. Younger women don’t want a scar on their breast, and cryoablation has a scar that is barely visible. Many women want the lump out but they don’t want a surgical procedure or they don’t want the scar, and this is another option that is available. Most fibroadenomas are of a size that can be treated this way. There are some women who have multiple fibroadenomas that are growing, and in that case, you don’t want to be operating on them and doing multiple surgeries. Cryoablation is a great option for them rather than having three or four surgical scars.
How long have you been a breast surgeon?
Dr. Bedi: Five years.
With your experience, what have you seen as the freezing of tumors has come into play? Are more and more women opting for this?
Dr. Bedi: This is a very new procedure. I think it received FDA approval only about a year and a half ago. I think it also takes the surgeons time to get comfortable with it. Initially, I’d only use it in a patient who I was very comfortable with her size and position of fibroadenomas. All patients don’t want to have procedures done in the office. Some people want whatever procedure is done with them asleep in the operating room. There are others who don’t want their lump destroyed in place. So, I still take out many more benign lumps in the operating room than I do freeze them. However, it is a very viable option. For example, I had a patient who tends to keloid. Her scars become very hypertrophic. It’s a young lady who had a fibroadenoma, and she wanted it out but didn’t want surgery. Cryoablation was the perfect thing for her.
If the patient is younger than 18, she does not have this procedure because most young girls cannot cooperate with you. They’re too afraid to have a procedure done with them awake, cooperate for that 30 minutes to 45 minutes, and to be willing to have two procedures in the office — one to biopsy it to prove that it is benign and the second one then to do the cryoblation.
How many patients do you get under 18?
Dr. Bedi: A lot. Fibroadenomas are very common in young black women. If there is a large fibroadenoma, you want to take the whole thing out because then there is the possibility of a malignant lesion. So, for young girls under the age of 18, I’d much rather take them to the operating room, have them asleep, and take them out if they need to come out.
Can only a breast surgeon perform cryoablation?
Dr. Bedi: First, it has to be somebody who is able to use the ultrasound, and he or she has to be comfortable doing the minimally invasive procedures. Not all of the breast surgeons do that. Most general surgeons who do breast surgery are not trained to do ultrasound and to do the minimally invasive procedures. So right now, it’s people who are specialized in breast surgery and have become comfortable with doing breast ultrasound.
Is the procedure covered by insurance?
Dr. Bedi: We have to get pre-authorization because it is a newer procedure. We send a letter to the insurance company, which has to be authorized first, and then we go ahead and do the procedure. Most of them approve it.
Are there any complications that can occur with the freezing?
Dr. Bedi: A potential problem with this includes, like you said, minimal discomfort, but is tolerated well. The cosmetic outcome is great. It doesn’t cause any problems. The only complication that has been reported is with the skin. You never want any procedure to come close to the skin. You don’t want to freeze the skin, so that’s why cryoablation is much better than the other modalities because you can see where the ice ball is going. With the ultrasound, you can see the ice ball growing, and if there is a lump that is close to the skin, we inject some saline between the skin and the growing ice ball. I’ve never used the other modalities; this is the only one that I’ve used because this made more sense.