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Case Study: Cryoablation of a Fibroadenoma: A minimally invasive treatment option.
Cryoablation Introduction/background:
Cryoablation of benign and malignant tumors of the prostate, lung and kidney has been reported in the literature
for decades. Cryoablation specific to fibroadenomas (FAs) has been available since 1999 and the most recent
generation of the technology now makes it a viable in-office treatment option for patients wanting a minimally
invasive solution to their painful, palpable or growing fibroadenomas.
Clinical case summary for our patient:
30 yr old Hispanic female presented with a painful, palpable Fibroadenoma (FA) in her left breast (5 O’clock, 5 cm
FN) measuring 2.8 cm x 2.3 cm x 1.8 cm. Core biopsy confirmed FA diagnosis. The patient requested information
about her treatment options. Observation of the benign tumor was rejected because she no longer wanted to
endure the monthly pain and tenderness at the fibroadenoma site. She also did not want surgical excision,
because of the cost and time associated with surgery as well as not wanting the potential scarring and changes in
the shape of her breast associated with excision of the large ( approximately 3 cm) lesion. She chose cryoablation
as her treatment because it is minimally invasive, maintains her breast cosmesis and shape, is a relatively short inoffice procedure that does not require systemic anesthetics for procedural pain control and is less expensive than
surgery.
Procedure summary: The patient was prepped with aseptic technique, and anesthetized with local anesthesia
around the FA and along the cryoprobe insertion trajectory. The cryoprobe was inserted down the longest
dimension and centered in the lesion. An 8 minute treatment algorithm was initiated based on the anticipated
time it would take to engulf the FA (see Table 1). The pictures below demonstrate the lesion’s maximum length,
width and height (a, b); the iceball as it is engulfing the FA in the longitudinal and transverse views (c, d). And the
iceball size (ablation zone) in 2 views at the end of the procedure (e,f).
Image gallery:
a.
b.
FA
FA
Iceball
Iceball
c.
4S Ranch
16918 Dove Canyon Rd
Suite 206
San Diego, CA 92127
Tel: (858) 956-1000
d.
Carlsbad
6185 Paseo Del Norte
Suite 110
Carlsbad, CA 92011
Tel: (760) 494-0556
Gateway Radiology
15725 Pomerado Rd
Suite 100 & 101
Poway, CA 92064
Tel: (858) 485-6500
Parkway on Elm
255 N. Elm St
Suite 102
Escondido, CA 92025
Tel: (760) 739-5400
Rancho San Diego
10225 Austin Dr
Suite 105
Spring Valley, CA 91978
Tel: (619) 797-8248
www.ValleyRad.com
Iceball
Iceball
e.
f.
Outcomes/Follow-up:
Short duration spot pressure was applied to the insertion site after probe removal. A wound closure adhesive was
applied and the patient was instructed to wear a comfortable bra for one week post procedure. The patient
tolerated the procedure well and no immediate complications were encountered. Patient reported mild soreness
of the breast, similar to the recent core biopsy procedure she had prior to the cryoablation procedure. This is an
expected finding. During a phone interview the following morning, the patient indicated no complaints and the
mild soreness she had reported immediately post procedure has already begun to subside. She was happy as to
how quick and relatively painless the procedure was. She had already returned to work. The patient was
recommended to return for a surveillance ultrasound in a year’s time and to expect the cyclic breast pain
associated with her FA to be minimal to nonexistent. The involution of the ablation zone will continue for at least
a year; the size and palpability of the affected area should improve over time as well.
Discussion:
Technology/Procedure and Outcomes reported in the literature:
The most recent generation of the technology utilizes liquid nitrogen circulating thru a small cryoprobe. This
process allows for a nominal 3 mm skin incision and a very short treatment time depending on the FA’s size. (See
table 1)
Table 1
FA size
1-1.4 cm
1.5-2 cm
2-2.5 cm
2.5-3 cm
3-4 cm
Typical treatment time
3 minutes
4.5 minutes
6 minutes
8 minutes
12 minutes
This new technology also allows for targeted cryoablation, engulfing the entire FA in ice, minimizing the ablation of
the surrounding healthy breast tissue. The result is an ablation zone that is consistent with the size of the original
FA which immediately begins the involution process that replaces the necrotic tissue in the ablation zone with
breast tissue over time. The involution time frame varies based on lesion size, patient age, health, and healing
history. The literature reports that FAs less than 2 cm are non-palpable 86% of the time by 12 months. (Kaufman
2005). Littrup (2004) reported that 89% of all FAs in his study, independent of original size, were non-palpable at
12 months. The CRYSTAL study (Hahn, 2013) which reports data specific to the IceSense technology, stated the
average volume of the ablation zone was reduced by 75% at 12 months, indicating the FA was destroyed and being
reabsorbed. Liu, et al. (2011) described the average scar length for fibroadenoma surgical excision as 4.6 cm.
When comparing the potential scar and breast deformity that occurs post FA removal with the documented
excellent breast cosmesis associated with cryoablation (Kaufman, 2005, Littrup, 2004) the decision to offer
cryoablation as a treatment option at Valley Radiology is self-evident.
4S Ranch
16918 Dove Canyon Rd
Suite 206
San Diego, CA 92127
Tel: (858) 956-1000
Carlsbad
6185 Paseo Del Norte
Suite 110
Carlsbad, CA 92011
Tel: (760) 494-0556
Gateway Radiology
15725 Pomerado Rd
Suite 100 & 101
Poway, CA 92064
Tel: (858) 485-6500
Parkway on Elm
255 N. Elm St
Suite 102
Escondido, CA 92025
Tel: (760) 739-5400
Rancho San Diego
10225 Austin Dr
Suite 105
Spring Valley, CA 91978
Tel: (619) 797-8248
www.ValleyRad.com
Reimbursement considerations
As demonstrated in Table 2, the cost of cryoablation is much less than its surgical counterpart. This cost reduction
not only makes this procedure appealing to the patient but also to the referring institution. For those patients who
want treatment for their symptomatic fibroadenomas cryoablation is a safe, minimally invasive alternative to
surgical excision.
Table 2
Average U.S. Commercial Reimbursement for Treatment of Fibroadenoma
Across Multiple Payers & Markets
NY Metro
Midwest
West Coast
CPT 19120
Surgery
Facility Fee
Anesthesiology
Pathology
Professional
Total
$3,500
$300
$70
$655
$4,525
$4,225
$205
$300
$461
$5,191
$3,687
$455
$149
$1,849
$6,140
CPT 19105
Cryoablation
Professional
Total
$3,042
$3,042
$2,328
$2,328
$3,422
$3,422
% Difference
48%
55%
44%
Sources & Methodology: Data was submitted to an independent third party. Results are the average
rates across multiple payers from their respective markets. More information upon request.
2013 HealthAgree LLC. All rights reserved.
References:
Kaufman CS, Littrup PJ, Freeman-Gibb LA, Smith JS, Francescatti D, Simmons R, Stocks LH, Bailey L, Harness JK,
Bachman BA, & Henry CA. (2005). Office-based cryoablation of breast fibroadenomas with long-term follow-up.
The Breast Journal.11(5), 344-50.
Littrup PJ, Freeman-Gibb L, Andea A, White M, Amerikia KC, Bouwman D, Harb T, & Sakr W. (2005). Cryotherapy
for breast fibroadenomas. Radiology.234(1), 63-72.
M. Hahn et al. “Ultrasound Guided Cryoablation of Fibroadenomas (Ultraschallgesteuerte Kryoablation von
Fibroadenomen)”. Ultraschall in Med © Georg Thieme Verlag KG Stuttgart. New York. ISSN 0172-4614.
Liu XF, Zhang JX, Zhou Q, Chen F, Shao ZM, & Lu C. (2011). A clinical study on the resection of breast fibroadenoma
using two types of incision. Scandinavian Journal of Surgery. 100(3), 147-52.
HealthAgree LLC. (2013) Results from independent 2012-2013 study by HealthAgree LLC of three commercial
markets comparing average total insurance reimbursement of cryoablation and surgical excision of fibroadenomas.
4S Ranch
16918 Dove Canyon Rd
Suite 206
San Diego, CA 92127
Tel: (858) 956-1000
Carlsbad
6185 Paseo Del Norte
Suite 110
Carlsbad, CA 92011
Tel: (760) 494-0556
Gateway Radiology
15725 Pomerado Rd
Suite 100 & 101
Poway, CA 92064
Tel: (858) 485-6500
Parkway on Elm
255 N. Elm St
Suite 102
Escondido, CA 92025
Tel: (760) 739-5400
Rancho San Diego
10225 Austin Dr
Suite 105
Spring Valley, CA 91978
Tel: (619) 797-8248