US20070197934A1 - Devices and methods for performing procedures on a breast - Google Patents

Abstract

A method of removing breast tissue may include steps of providing a tissue cutting device having a shaft, a tissue collection element and a cutting element, the cutting element being movable from a collapsed position to an expanded position. The tissue cutting device may be introduced into the patient's breast through a first incision with the cutting element in the collapsed position and the cutting element may be expanded. The cutting element may then be moved through breast tissue to cut around the tissue to be removed. The tissue cut by the cutting element may be positioned into the tissue collection element, and the tissue collection element may be removed through a second incision that is different from the first incision.

Description

CROSS REFERENCE TO RELATED APPLICATIONS
• This application is a divisional of application Ser. No. 10/923,511, filed Aug. 20, 2004, which is a continuation-in-part of application Ser. No. 10/732,670, filed Dec. 9, 2003, and a continuation-in-part of application Ser. No. 10/272,448, filed Oct. 16, 2002, now U.S. Pat. No. 6,936,014, issued Aug. 30, 2005, and a continuation-in-part of application Ser. No. 10/796,328, filed Mar. 8, 2004, which is a continuation of application Ser. No. 09/417,520, filed Oct. 13, 1999, now U.S. Pat. No. 6,423,081, issued Jul. 23, 2002, which is a divisional of application Ser. No. 09/146,743, filed Sep. 3, 1998, now U.S. Pat. No. 6,022,362, issued Feb. 8, 2000, all applications and patents of which are hereby incorporated herein by reference in their entireties and from which priority is hereby claimed under 35 U.S.C. §119(e) and §120.
BACKGROUND OF THE INVENTION
• Breast cancer is a major threat and concern to women. Early detection and treatment of suspicious or cancerous lesions in the breast has been shown to improve long term survival of the patient. The trend is, therefore, to encourage women not only to perform monthly self-breast examination and obtain a yearly breast examination by a qualified physician, but also to undergo annual screening mammography commencing atage 40. Mammography is used to detect small, nonpalpable lesions which may appear opaque densities relative to normal breast parenchyma and fat or as clusters of microcalcifications. The conventional method for diagnosing, localizing and excising nonpalpable lesions detected by mammography generally involves a time-consuming, multi-step process. First, the patient goes to the radiology department where the radiologist finds and localizes the lesion either using mammography or ultrasound guidance. Once localized, a radio-opaque wire is inserted into the breast. The distal end of the wire may include a small hook or loop. Ideally, this is placed adjacent to the suspicious area to be biopsied. The patient is then transported to the operating room.
• Under general or local anesthesia, the surgeon may then perform a needle-localized breast biopsy. In this procedure, the surgeon, guided by the wire previously placed in the patient's breast, excises a mass of tissue around the distal end of the wire. The specimen is sent to the radiology department where a specimen radiograph is taken to confirm that the suspicious lesion is contained within the excised specimen. Meanwhile, the surgeon, patient, anesthesiologist and operating room staff, wait in the operating room for confirmation of that fact from the radiologist before the operation is completed. The suspicious lesion should then be excised in toto with a small margin or rim of normal breast tissue on all sides. Obtaining good margins of normal tissue using conventional techniques is extremely dependent upon the skill and experience of the surgeon, and often an excessively large amount of normal breast tissue is removed to ensure that the lesion is located within the specimen. This increases the risk of post-operative complications, including bleeding and permanent breast deformity. As 80% of breast biopsies today are benign, many women unnecessarily suffer from permanent scarring and deformity from such benign breast biopsies.
• More recently, less invasive techniques have been developed to sample or biopsy the suspicious lesions to obtain a histological diagnosis. The simplest of the newer techniques is to attempt visualization of the lesion by external ultrasound. If seen by external ultrasound, the lesion can be biopsied while being continuously visualized. This technique allows the physician to see the biopsy needle as it actually enters the lesion, thus ensuring that the correct area is sampled. Current sampling systems for use with external ultrasound guidance include a fine needle aspirate, core needle biopsy or vacuum-assisted biopsy devices.
• Another conventional technique localizes the suspicious lesion using stereotactic digital mammography. The patient is placed prone on a special table that includes a hole to allow the breast to dangle therethrough. The breast is compressed between two mammography plates, which stabilizes the breast to be biopsied and allows the digital mammograms to be taken. At least two images are taken 30 degrees apart to obtain stereotactic views. The x, y and z coordinates targeting the lesion are calculated by a computer. The physician then aligns a special mechanical stage mounted under the table that places the biopsy device into the breast to obtain the sample or samples using fine needle aspiration, core needle biopsy, vacuum-assisted core needle biopsy or other suitable method. Fine needle aspiration uses a small gauge needle, usually 20 to 25 gauge, to aspirate a small sample of cells from the lesion or suspicious area. Core needle biopsy uses a larger size needle, usually 14 gauge to sample the lesion. Tissue architecture and histology are preserved with this method. Multiple penetrations of the core needle through the breast and into the lesion are required to obtain an adequate sampling of the lesion. Over 10 samples have been recommended by some. The vacuum-assisted breast biopsy system is a larger semi-automated side-cutting device. It is usually 11 gauge in diameter and is more sophisticated than the core needle biopsy device. Multiple large samples can be obtained from the lesion without having to reinsert the needle each time. A vacuum is added to suck the tissue into the trough. The rapid firing action of the spring-loaded core needle device is replaced with an oscillating outer cannula that cuts the breast tissue off in the trough. The physician controls the speed at which the outer cannula advances over the trough and can rotate the alignment of the trough in a clockwise fashion to obtain multiple samples.
• If a fine needle aspirate, needle core biopsy or vacuum-assisted biopsy shows malignancy or a specific benign diagnosis of atypical hyperplasia, then the patient needs to undergo another procedure, the traditional needle-localized breast biopsy, to fully excise the area with an adequate margin of normal breast tissue. Sometimes the vacuum-assisted device removes the whole targeted lesion. If this occurs, a small titanium clip should be placed in the biopsy field. This clip marks the area if a needle-localized breast biopsy is subsequently required for the previously mentioned reasons.
• Another method of biopsying the suspicious lesion utilizes a large end-cutting core device measuring 0.5 cm to 2.0 cm in diameter. This also uses the stereotactic table for stabilization and localization. After the lesion coordinates are calculated and local anesthesia instilled, an incision large enough is permit entry of the bore is made at the entry site with a scalpel. The breast tissue is cored down to and past the lesion. Once the specimen is retrieved, the patient is turned onto her back and the surgeon cauterizes bleeding vessels under direct vision. The incision, measuring 0.5 to larger than 2.0 cm is sutured closed. The newer conventional minimally invasive breast biopsy devices have improved in some ways the ability to diagnose mammographically detected nonpalpable lesions. These devices give the patient a choice as to how she wants the diagnosis to be made.
SUMMARY OF THE INVENTION
• In one aspect of the present invention, a method of removing breast tissue, may include steps of providing a tissue cutting device having a shaft, a tissue collection element and a cutting element, the cutting element being movable from a collapsed position to an expanded position; introducing the tissue cutting device into the patient's breast through a first incision with the cutting element in the collapsed position; expanding the cutting element; moving the cutting element through breast tissue to cut around the tissue to be removed; positioning the tissue cut by the cutting element into the tissue collection element; and removing the tissue collection element through a second incision different from the first incision.
• The removing step may be carried out with a removal device extending through the second incision, the removal step including the step of coupling the removal device to the tissue collection element. The removing step may be carried out with the removal device having a distal end movable between a collapsed position and an expanded position, the expanded position being flared outwardly. The removing step may be carried out with the removal device having a suction opening coupled to a vacuum source, the removal device adhering to the tissue collection element with the suction opening.
• These and other aspects of the present invention will become apparent from the following drawings and description.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 shows a needle made in accordance with the present invention.
• FIG. 2 shows a tissue removing device.
• FIG. 3 shows the needle introduced into a breast.
• FIG. 4 shows a first anchor deployed within the breast.
• FIG. 5 shows a second anchor deployed within the breast.
• FIG. 6 shows a stiffener removed to provide a flexible proximal end.
• FIG. 7 shows the flexible, proximal portion taped to the breast.
• FIG. 8 shows a tissue removing device advanced over the needle and a cutting element deployed.
• FIG. 9 is a perspective view of a combination introducer and suction sleeve, according to another embodiment of the present invention.
• FIG. 10 is a side cross-sectional view of the combination introducer and suction sleeve ofFIG. 9.
• FIG. 11 is a perspective view of the combination introducer and suction sleeve ofFIG. 9, with a trocar inserted therein.
• FIG. 12 is a side cross-sectional view of the combination introducer and suction sleeve ofFIG. 9, illustrating exemplary structure with which the suction sleeve may attach to the interventional device.
• FIG. 13 is a perspective cross-sectional view of the combination introducer and suction sleeve, attached to an exemplary interventional device
• FIG. 14 is a perspective view of another embodiment of a suction sleeve according to the present invention, coupled to an exemplary interventional device.
• FIG. 15 shows another guide element used to introduced a cutting device into the tissue.
• FIG. 16 shows a piercing element removed from a lumen in the guide member.
• FIG. 17 shows a cutting device introduced into the guide element.
• FIG. 18 shows guide member retracted and anchored to the tissue with needles and an adhesive tape.
• FIG. 19 shows a perspective view of another guide member having a window through which the cutting element extends when cutting the tissue.
• FIG. 20 shows a tube which is cut to form a lip.
• FIG. 21 is a cross-sectional view ofFIG. 21 along line I-I.
• FIG. 22 shows the tube ofFIG. 21 covered with a shrink tube.
• FIG. 23 is a cross-sectional view ofFIG. 23 along line II-II with the addition of a cutting element shown in an expanded or bowed configuration.
• FIG. 24 is a cross-sectional view ofFIG. 23 along line III-III.
• FIG. 25 shows another device for cutting or incising tissue.
• FIG. 26 shows a removable core.
• FIG. 27 is a cross-sectional view of the device ofFIG. 26 along line A-A.
• FIG. 28 shows the removable core positioned within a sheath.
• FIG. 29 shows the cutting or incising device positioned within the sheath.
• FIG. 30 shows the cutting device positioned so that the cutting element will sweep around the tissue area being removed.
• FIG. 31 shows a tissue removal device introduced through another incision.
• FIG. 32 shows the tissue removal device attached to the tissue.
• FIG. 33-35 show use of the tissue cutting device to create a path for removing the tissue.
• FIG. 36 shows the cutting device used to penetrate the tissue to create a tissue removal incision.
• FIG. 37 shows the tissue contained within a tissue collection element having a tether which is coupled to the tissue cutter.
• FIG. 38 shows the tissue cutter removed with the tether extending from the excised tissue.
• FIG. 39 shows a side view of a tissue cutting device adjacent a tissue area to be removed.
• FIG. 40 shows the cutting element beginning to sweep around the tissue area.
• FIG. 41 shows the cutting element partially retracted to trap tissue between the cutting element and the shaft of the device.
• FIG. 42 shows the tissue cutting device marking the tissue.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
• Referring toFIGS. 1-8, aneedle2 may be used to guide another medical device, such as atissue cutting device6, when performing a procedure on the breast. Any suitable tissue cutting device may be used such as the devices disclosed in U.S. Pat. Nos. 6,440,147 and 6,022,362 which are also hereby incorporated herein by reference. Thetissue cutting device6 has acutting element8 capable of assuming positions between collapsed and bowed positions. Thetissue cutting device6 is pivoted or rotated so that the cuttingelement8 sweeps through and cuts the tissue along an arc. Atissue collection element10 may also be provided which collects the tissue being cut. Theneedle2 may also include astiffener4 which is used in the manner described in application Ser. No. 10/272,448, filed Oct. 16, 2002.
• Theneedle2 may also have one ormore indicators14 to mark an angular position relative to the longitudinal axis16 of theneedle2. Theindicator14 extends radially outward from the needle at a angle selected by the user. Theindicator14 may also simply be alongitudinal stripe18 or other marking on the shaft which indicates a particular angular orientation on theneedle2. Theindicator14 may provide information to the user regarding various parameters depending upon the procedure being performed. For example, when using thedevice6 described above, the angular position, or positions, provides the user with the angular extent of the tissue to be removed.
• Theindicators14 may be coupled to one more anchors20 which are deployed to anchor theneedle2. Theanchor20 is preferably curved, such as J- or C-shaped, and extends radially to lie within the same angular orientation as theindicator14. An advantage of coupling theindicator14 to theanchor20 is thatanchor20 itself provides information regarding the relative orientation or theneedle2,anchor20 and tissue area of interest. Thus, theanchor20 itself may be one of theindicators14. Although theanchor20 andindicator14 are preferably aligned at the same angular orientation, they may also be offset to account for the geometry of other devices used with theneedle2. As can be appreciated, of course, theindicators14 may also be independent of any anchoring elements. For example, theneedle2 may be placed in the breast and theindicators14 could then be moved to selected angular position(s). Theneedle2 may also havedepth markers22 along the body. Theanchor20 is preferably a stainless steel wire having a sharpened tip to pierce through the tissue. The orientation of theanchor20 is partially guided by the geometry of the arc-shaped lumens (not shown) receiving theanchors20.
• Use of the device is now described in connection with a tissue removal procedure with reference toFIGS. 1-8. Of course, other procedures may be performed without departing from the scope of the invention. Theneedle2 is introduced into the area of interest under suitable guidance such as ultrasound visualization. Once theneedle2 has been introduced in a desired or known orientation relative to the tissue area of interest, theentire needle2 is rotated so that thefirst indicator14 andmarker18 are aligned with a first angular position relative to the tissue area of interest. Thefirst anchor20 is then deployed into the tissue with theanchor20 deployed at the selected angular orientation. Thesecond indicator14 is then rotated to a second selected angular orientation with respect to the area of interest. The second orientation is determined by visualizing the area of interest relative to theneedle2 and/orfirst anchor20 to determine the appropriate location for thesecond anchor20. Thesecond anchor20 is then deployed by advancing the anchor into the tissue. As can be appreciated, theneedle2 and anchors20 themselves provide visual landmarks for locating the area of interest. The markings on theneedle2 and theindicators14 also help to guide use of thetissue cutting device6 as described herein.
• Thestiffener4 is then removed to provide the flexible proximal portion. The flexible proximal portion may be taped to the patient to prevent inadvertent contact as shown inFIG. 7. When performing the procedure, the flexible condition may be maintained to provide the benefit described above such as the ability to pull from varying angles as compared to a conventional rigid needle. Thetissue removal device6 may then be coupled to theneedle2 as shown inFIG. 8 and then advanced while being guided by theneedle2. Theneedle2 may be introduced to a predetermined depth where thelongitudinal stop38 guides the depth of introduction of the tissue removal device. Of course, theneedle2 may be introduced deeper into the tissue with the user using thedepth markings40 on theneedle2 and/ortissue removal device6 to determine the appropriate introduction depth for thetissue removal device6. The cuttingelement8 is then deployed to the bowed position and the cuttingelement8 is swept through tissue to cut around the tissue area of interest. The tissue is then collected by thecollection element10 for removal. Thedevice6 is then withdrawn and anchors30, which are described in more detail in application Ser. No. 10/272,448, filed Oct. 16, 2002, are retracted to permit withdrawal of theneedle2 as well.
• FIG. 9 is a perspective view of a combination introducer andsuction sleeve902. The sleeve92 may be used in the same manner as the guide members described herein and such uses is expressly incorporated here.FIG. 10 is a side cross-sectional view thereof. Considering nowFIGS. 9 and 10 collectively, the firstexternal surface904 of the combination introducer andsuction sleeve902 may have a generally tapered or funnel shape, in that it defines a relatively narrow diameter distal end and a relatively wider proximal end. Such a generally funnel or tapered shape eases the introduction of the device802 within tissue. The combination introducer andsuction sleeve902 has asuction port908 that opens to aninternal lumen916 defined by theinternal surface918. The combination introducer andsuction sleeve902 also includes a secondexternal surface912 that defines a tapered appearance. Defined within the first and/or secondexternal surfaces904,912 are a plurality ofopenings906 that open to theinternal lumen916. InFIGS. 9-11, only the firstexternal surface904 definessuch openings906, although the openings are not limited to this surface. Thesuction port908 is configured to couple with a vacuum line, as shown at116. The combination introducer andsuction sleeve902 may further include structures to couple to one or more devices. Such coupling structure(s) may include, for example, a snap or interference fitting914 and/or one or more O-rings, such as shown at910.
• FIG. 11 is a perspective view of the combination introducer and suction sleeve ofFIG. 9, with atrocar1102 inserted therein. According to an embodiment of the present invention, thetrocar1102 may be inserted into the combination introducer andsuction sleeve902 and the assembly may be packaged as a (preferably single use) unit. According to another embodiment of the present invention, a physician may utilize the assembly as follows:
• An incision into tissue is made with a blade;
• The physician then inserts the assembly including thetrocar1102 into the tissue and pushes the combination introducer andsuction sleeve902 into the tissue through the incision into position under or near the lesion or targeted site within the tissue. The pointed and/or sharpdistal tip1104 of thetrocar1102 and the tapered profile of the combination introducer andsuction sleeve902 aid the assembly's advancement within the tissue;
• Thetrocar1102 may then be removed from the combination introducer andsuction sleeve902 and a desired (excisional RF, for example) device may then be inserted therethrough, with the shaft thereof disposed within and protruding from theinternal lumen916;
• The combination introducer andsuction sleeve902 may then be pulled back until it contacts, snaps and/or otherwise locks onto the device, as shown atFIGS. 12 and 13. InFIGS. 12 and 13, only thehandle102 of the device is shown, and theshaft104 thereof is omitted for clarity of illustration. Examples of a tissue cutting device coupled to the combination introducer andsuction sleeve902 coupled thereto is shown inFIG. 14;
• A vacuum line, such as shown at116, may then be attached to thesuction port908;
• If needed, the device with the combination introducer andsuction sleeve902 attached thereto may then be repositioned at, near, under or within the target lesion, as desired. This repositioning may be carried out under ultrasound guidance, for example. Theopenings906 may aid with the ultrasound visualization. The combination may include other features and/or markings to increase the visibility thereof under various imaging modalities, and
• The physician may then continue with the intended procedure as per the instructions for use of the device utilized.
• Alternatively, thetrocar1102 may be removed from the combination introducer andsuction sleeve902 and the desired RF device introduced and locked therein. The distal tip of the desired RF device protruding from the distal end of the combination introducer andsuction sleeve902 may then be used to reach the intended biopsy site.
• Alternately still, a stopcock may be attached to thesuction port908 instead of thesuction line116 and one or more beneficial agents (e.g., antibiotics, fibrin, lidocaine) may be delivered to a target site through theopenings906.
• The present combination vacuum sleeve andsuction sleeve902 may aid in positioning a biopsy or other interventional device where it is needed. For example, interventional devices that include a rather bulky or high-drag distal end may be readily positioned at the intended site by means of the introducer functionality of thecombination902. While thecombination902 is advantageous before the biopsy or other interventional procedure is started by easing the positioning of the biopsy instrument at or near the target site, it is also useful during the procedure itself, as it is effective in evacuating hot gasses and fluids from the biopsy cavity, thereby decreasing collateral tissue thermal damage. The same combination may then also be used to treat the cavity post-procedure by, for example, providing a ready-made pathway for the introduction of beneficial agents, compositions and/or cavity treatment devices to the cavity or lesion site.
• Referring now toFIGS. 15-18, anothersystem200 and method are shown wherein the same or similar reference numbers refer to the same or similar structure. As mentioned above, aguide member202 may be used to guide acutting device204. Theguide member202 may be any of the suitable guide members described herein including theneedle2 ofFIGS. 1-8 or theintroducer902 ofFIGS. 9-14. Thecutting device204 may be any of the cutting devices described herein or another suitable device such as those described in U.S. Pat. No. 7,044,956, issued May 16, 2006, which is hereby incorporated herein by reference in its entirety. Thecutting device204 has acutting element205 which bows outwardly when expanded.
• Theguide member202 has atubular body206 and a removablepenetrating element208 having asharp tip210 for piercing tissue during introduction. Theguide member202 also has aport212 coupled to avacuum source214 for removing hot gasses generated during cutting. The penetratingelement208 has ashaft216 extending through alumen217 in theguide member202. Theguide member202 may include one ormore anchors218 which holds theguide member202 at the desired position. Theanchor218 may simply be anadhesive strip220 which the user peels away from the body and adheres to the skin. Theanchor218 may also be another suitable anchor such as one ormore needles221 which are advanced into the tissue. Theanchors218 help to resist movement of theguide member202 so that theguide member220 may be used to guide longitudinal and even rotational positioning of thecutting device204 as explained herein. Referring toFIG. 19, theanchor218 may also be aballoon221 which is inflated to anchor the guide member.
• After theguide member202 has been introduced to the desired depth, the penetratingelement208 is then removed and thetissue cutting device204 is introduced and advanced into the guide member220 (FIG. 17). Theguide member202 may include astop222 which prevents further advancement of thetissue cutting device202 so that thedevice204 remains in the same longitudinal position. Theguide member202 may also include one or moreangular indicators224 which may be theanchors218. Referring toFIG. 19, anotherguide member202A is shown which has awindow226 oriented in the desired direction of cutting. Thewindow226 guides the user by limiting and/or defining the cutting motion to help guide the cutting procedure. The use and structural features of theguide member220,indicators224, anchors118 and stop222 may be the same or similar to those described in connection withFIGS. 1-8.
• Referring again toFIG. 14, the cuttingelement108 preferably has anultrasound marker232 at an anticipated apex of the cuttingelement108 when the cuttingelement108 is expanded to help position the device. The apex232 does not necessarily correspond with the geometric middle of the cuttingelement108 when the cuttingelement108 is collapsed since only one end of the cuttingelement108 may be moved to bow thecutting element108 outward. For example, the proximal end of the cuttingelement108 may be advanced distally to bow thecutting element108 outward in which case thefirst marker232 would appear to be closer to the proximal end when the cuttingelement108 is collapsed. Thecutting device204 may also include asecond marker234 and athird marker236 which correspond to the ends of the cuttingelement108 when the cuttingelement108 is collapsed. Referring again toFIG. 17, theguide member20 may have afirst marker229, corresponding to ananticipated apex229 of the cuttingelement108, and asecond marker228 and a third marker230 corresponding to theends228,230 of the cuttingelement108 when collapsed. In this manner, theguide member202 may help properly position the cutting device. Of course, any of the guide members or tissue cutting devices described herein, such as theneedle2, may also have the ultrasound markers positioned in this manner. The cutting element and the guide may be marked in any suitable manner. For example, the cutting element or guide may include a hollow area which would enhance the ultrasound signature. When placing a marker on the cutting element, the marker may be designed to be easily visible when the cuttingelement205 is powered at a level lower than the power level used during cutting. For example, the cuttingelement205 may be designed to become more visible when an RF generator is switched to coagulation mode which has lower power than the cutting mode used when cutting tissue.
• Referring now toFIGS. 20-24, thetissue cutting device204 may have ashaft240 with an asymmetrical cross-sectional shape adjacent to thecutting element205 to aid parting off the tissue when completing the cutting operation. Theshaft240 is thicker in the direction in which thecutting element205 expands as compared to the direction opposite cutter expansion. Stated another way, theshaft240 may be thicker on aleading side242, which leads the cutting element when rotated in the direction ofarrow245, than on an opposing or trailingside244. Theshaft240 may also be thicker on the leading side in a direction substantially perpendicular to expansion of the cuttingelement205A (shown mounted toshaft240 in the dotted-line position). Cuttingelement205A is mounted to theshaft240 in an orientation about90 degrees from the orientation of the cuttingelement205. Of course, the cuttingelement205A may be mounted to theshaft240 in other orientations relative to the thicker part of the shaft such as any position betweenelement205 andelement205A. Stated still another way, the cuttingelement205 may be oriented and mounted on theshaft240 in any manner which provides a thicker side within the first 90 degrees of the leading side compared to the shaft thickness in the 90 degrees trailing the cuttingelement205. In the various suggested configurations described, the thicker part of theshaft240 is preferably at least 1.25 times, 1.50 times, or even 1.75 times thicker than the thinner part of theshaft240.
• Theshaft240 may be formed in any suitable manner. Referring toFIGS. 20-24, for example, ametallic tube248 is cut to form alip250 which is bent outwardly to provide the thicker shaft section. Thetube248 is then covered with ashrink tube252 and heated to bond theshrink tube252 to thetube248. Theshrink tube252 covers the opening in the tube created by formation of thelip252. Theshrink tube252 also forms abeveled surface254 which covers anopening253 in thetube248 created by thelip250.
• Use of thesystem200 is now described with reference again toFIGS. 15-19. Theguide member202 is introduced into the tissue to an appropriate depth relative to the tissue to be removed. As explained above, theguide member202 may be used to help define and/or guide aspects of the cutting motion such as the depth of insertion and/or one or more angular positions indicating the angular extent of the targeted tissue. For example, theultrasound marker229 may be used to position theguide member202 so that the anticipated apex of the cuttingelement205 is positioned appropriately. When theguide member202A ofFIG. 19 is used, the cuttingwindow226 is positioned in the desired angular orientation which positions the tissue to be removed within thewindow226. Thewindow226 may have an opening a bit larger than the anticipated requirement so that thewindow226 guides, but not necessarily overly limits, the angular and longitudinal position of thecutting device204.
• Once theguide member202,202A has been positioned properly relative to the desired cutting operation thetissue penetrating element208 may be removed and thecutting device204 is introduced into theguide member202. Theguide member202 is then retracted a predetermined amount so that theguide member202 is properly positioned to remove hot gases generated during RF cutting as described above. When using theguide member202A having the cuttingwindow226, the guide member does not, of course, need to be retracted.
• Thecutting device204 is then used to cut around the tissue to be removed. The tissue may be removed in a tissue collection element10 (seeFIG. 2). Alternatively, vacuum means may also be used to remove the tissue as now described and further described in application Ser. No. 10/796,328, filed Mar. 8, 2004. Thecutting device204 may be any suitable cutting device such as those described in U.S. Pat. No. 7,044,956, issued May 16, 2006.
• Referring now toFIGS. 25-29, another system is shown which uses asheath495 to receive one or more devices such as acore400, which may be used for imaging, and anexcisional device100 which is used to cut the tissue. Thecore400 has anactive element440 configured to perform intra-tissue imaging and of relaying information back to a display device (shown inFIG. 30) via a communication channel, such as shown atreference numeral460. Thecommunication channel460 may be wireless or may include, for example, optical fibers and/or electrical conductors. Theactive element440 may draw power from an internal battery (not shown) or from a power source, such as shown atreference numeral480. Theactive element440 may include an ultrasound transducer. Other types of transducers may be used instead of or in addition to an ultrasound transducer. Theremovable transducer core400 preferably includes a generallytubular shaft430. Aproximal section450 is included near the proximal portion of thetransducer core400.
• To accommodate theremovable transducer core400, theexcisional device100 ofFIG. 25 includes aninternal lumen420 through which theremovable transducer core400 may be inserted. Preferably, theexcisional device100 is used once and disposed of, for safety and functional reasons. Theremovable transducer core400, however, may either be disposable or re-usable for a limited number of uses. To allow theactive element440 of thetransducer core400 to image the lesion to be excised and the surrounding tissue, a generallytubular member110 of theexcisional device100 includes atransducer window410. When theremovable transducer core400 is inserted within theinternal lumen420, theproximal section450 of the core400 preferably snaps into a locked configuration with the proximal end of theexcisional device100. When in its locked configuration, theactive element440 of thetransducer core400 is aligned with and faces thetransducer window410, to allow theactive element440 to image the lesion and the surrounding tissue therethrough.
• FIG. 26 shows an embodiment of theremovable core400 according to the present invention. As theremovable core400 may advantageously be used independently of theexcisional device100, theremovable core400 includes a distal taperedtip470, to allow it to easily penetrate soft tissue. Moreover, its thin profile allows the surgeon to insert theremovable core400 within soft tissue without, however, unduly damaging the tissue or making a large incision. Theremovable core400 allows the surgeon to precisely localize the lesion to be excised from within the tissue itself. For example, theactive element440 of theremovable core400 may include an ultrasound transducer and may be used alone or in addition to surface ultrasound to localize the lesion with a great degree of precision.
• FIG. 27 shows a cross section of the embodiment of theexcisional device100 ofFIG. 25, taken along line AA′. As shown inFIG. 27, thecutting tool125 is exposed through thetransducer window120. Thewindow120 may, as shown inFIG. 27, include support guides122 to support and guide thecutting tool125 as it is outwardly extended and bowed. Thetissue collection device260, for clarity, is not shown in either FIGS.25 or27. However, to accommodate the bulk of the excised tissue sample collected in thetissue collection device260 after the cutting and collecting operation described herein, thetubular member110 may include a recessedsection131. The recessed section provides space for the collected (e.g., bagged) tissue sample in thetissue collection device260 when the excisional device is removed from the soft tissue mass. In this manner, the collected tissue sample within thetissue collection device260 does not protrude from the generally smooth outer surface of theexcisional device100 upon retraction of the latter from the soft tissue mass from which the tissue sample is excised. Theinternal lumen420 allows theremovable core400 to slide therein and to properly position theactive element440 facing thetransducer window410.
• FIG. 28 shows theremovable core400 inserted within theexpandable sheath495. Theexpandable sheath495 includes aproximal base section510. Attached to theproximal base section510 is a generally cylindricalexpandable meshwork500 of, for example, plastic or nylon fibers. Themeshwork500 may be somewhat tapered at itsdistal end520, to provide a smooth transition between theexpandable meshwork500 and theremovable core device400. Theproximal section450 of thecore400 may snap-fit to theproximal base section510 of theexpandable sheath495, so as to be securely and removably attached thereto. As shown inFIG. 28, theexpandable meshwork500 expands just enough to accommodate theremovable core400 inserted therein. In practice, theexpandable sheath495 andremovable core400 assembly may be inserted within the soft tissue together, to allow the surgeon to image the lesion prior to inserting the somewhat greater diameterexcisional device100 therein. Thereafter, the surgeon may retract theremovable core400 from theexpandable sheath495, leaving theexpandable sheath495 in place within the soft tissue, such as the breast.
• FIG. 29 shows another embodiment of a soft tissueexcisional device assembly600 according to the present invention. In the configuration shown inFIG. 29, theremovable core400 is inserted and secured within theexcisional device100 so that theactive element440 faces out of thetransducer window410. Preferably, theexcisional device100 is removable from the expandedsheath495 shown inFIG. 14, while leaving the expandedsheath495 in place within the soft tissue. In this manner, after retraction of theexcisional device100 from thesheath495, thesheath495 remains in place within the soft tissue to allow other instruments to be inserted therethrough. For example, theremovable core400 may, after the excisional procedure proper, be re-inserted through the expandedsheath495 to the excision site. Thetissue collection device260 is not shown, for clarity but may be used in any manner described herein or in the applications or patents incorporated herein without departing from the scope of the invention.
• InFIG. 29, theexcisional device100 is shown inserted within theexpandable sheath495. Indeed, theexcisional device100, inFIG. 29, is shown inserted within and past thedistal end520 of themeshwork500, so the distal portion of theexcisional device100 including the cutting element ortool125 and thetransducer window410 extends therethrough. Themeshwork500, inFIG. 30, has expanded to accommodate the diameter of theexcisional device100. The proximal portion of theexcisional device100 may extend from the proximal base section of theexpandable sheath495. This allows the push or turn knob526 (aturn knob526 shown inFIG. 29) to be manually accessible to the surgeon.
• A number of peripheral devices may be connected to theassembly600. Examples of such include acore power source480, which may be, for example, an electrical source for an ultrasound transducer, one or more data processing anddisplay devices550 on which the internal structure of the tissue imaged by theactive element440 of thecore400 may be displayed, suction means490, a cutting tool power source (a variable RF energy source, for example or any suitable RF power source found in most operating rooms), and/or other devices590. Thesuction device490 may provide a suction force to thewindow120 through an internal lumen to facilitate cutting of the tissue by thecutting tool125. Any other suitable cutting or excisional device may be used in connection with the present invention such as those described in U.S. Pat. No. 7,044,956, issued May 16, 2006.
• The vacuum means may be associated with the cutting tool125 (FIG. 25) or the cutting device204 (FIG. 17) or may be aseparate removal device300 as shown inFIG. 30. As will be further described, the tissue may also be removed through the same incision or a separate incision from the incision through which thecutting device204 extends. Referring still toFIG. 31, thetissue removal device300 may have one ormore suction ports302 at a distal end308. Thesuction port302 is coupled to alumen304 which in turn is coupled to avacuum source306. Thesuction port302 can be flared outwardly to enhance suction adherence and to help retract tissue away from the tissue being removed as shown inFIG. 32. The end308 may have longitudinal slots (not shown) covered by anelastic cover309 which permits the end308 to flare outwardly in a manner similar to expandable trocars and cannulae as is known in the art. The end308 may be actuated with athumb switch310 or other suitable actuator. Of course, thetissue removal device300 may also directly grasp or pierce the tissue with piercingelements311, such asneedles313, rather than relying on suction adherence. For example, thetissue removal device300 may advance needles312 into the tissue to anchor and grasp the tissue.
• Thetissue removal device300 may be introduced through the same incision as thetissue cutting device204 or may be introduced through a different incision. For example, the user may choose to introduce thecutting device204 based primarily on the desired orientation of thecutting device200 relative to the tissue area being removed. The user may then choose the removal incision based on other factors such as proximity to the skin or for cosmetic considerations. Referring toFIGS. 33-35, the removal incision may be partially or completely created with thetissue cutting device204. For example, the cuttingelement205 may be expanded and energized when the shaft is being withdrawn and/or advanced so that the cuttingelement205 creates a tissue channel. This procedure may be repeated to create the desired channel such as an X- or Y-shaped channel. The cuttingelement205 may have a movable insulatingsheath260 which covers a portion of the cuttingelement205, such as the distal portion of theelement205, to prevent inadvertent cutting of the tissue being removed when creating the tissue channel. Use of a movableinsulating sleeve260 is described in U.S. Pat. No. 7,198,626, issued Apr. 3, 2007, which is hereby incorporated herein by reference in its entirety.
• Referring toFIG. 36, the cuttingelement205 may also be used to create a separate incision for removal of the tissue by cutting a channel directly from the area in which the tissue has been cut and extending outwardly from the severed portion. The cuttingelement205 is positioned so that further extension and bowing of the cuttingelement205 will essentially create a path outwardly from the severed portion of the tissue. This procedure may be performed after severing the tissue in this area so that the cuttingelement205 can be initially positioned without RF power. The ultrasound markers described herein, and in particular the marker near the apex of the cuttingelement205 when expanded and bowed, are particularly useful in properly positioning thecutting element205 at this time. The cuttingelement205 may then be powered with RF to partially or completely create the tissue channel. This procedure may be desirable when the cutting procedure causes thecutting element205 to pass near the skin. Thecutting device204 may also include a movableinsulating sleeve261 which covers part of the cuttingelement205, such as portions on the ends of the cuttingelement205, during this part of the procedure to reduce the excess lateral cutting during creation of the tissue channel.
• When removing the tissue, the tissue may be contained within atissue collection element320 released by thecutting device204 when the tissue is severed or which is deployed by itself after excision of the tissue. Thetissue collection element320 may simply trail the cuttingelement205 similar to the patents and applications incorporated by reference herein in which the tissue collection element remains coupled to the device.
• FIG. 37 shows thecollection element320 containing the tissue with atether322 extending from thetissue collection element320 and being withdrawn as thecutting device204 is removed. Thetether322 may be used to guide advancement and engagement of thetissue removal device300. For example, thetissue collection element320 may have aconnector324 which engages theremoval device300 with a suitable mechanical, magnetic or suction connection. Theconnector324 may be positioned at the end of thetether322 so that engagement with theconnector324 is easily guided by thetether322.
• Referring still toFIG. 37, thetether322 may be particularly useful when removing the tissue through a separate incision since thetether322 can be easily retrieved using a conventional suture snare or the like. Thetether322 may also be used without thetissue collection element320 by simply attaching thetether320 to the tissue with a needle, screw321 (seeFIG. 37) or other suitable attachment feature. Thetether320 may be delivered by thecutting device204 or may be part of another device such as the tissue removal devices described herein.
• Referring toFIGS. 39-41, still another aspect of the present invention is shown. Thetissue cutting device204 is shown and all features and aspects of the tissue cutting devices described herein are incorporated here. Thetissue cutting device204 is shown sweeping around the tissue to be removed. The cuttingelement205 is then partially retracted so that only a small piece of tissue connects the tissue to be removed from the surrounding tissue as shown in FIG.41. Thetissue cutting device205 may then be used to manipulate the tissue to assist or prepare the tissue for removal. Thetissue cutting device204 may be designed to lock thecutting element205 in the partially opened position ofFIG. 41 to trap the tissue between the cuttingelement205 and theshaft240 so that thecutting device204 may be used to manipulate the tissue. For example, the tissue may be manipulated while the tissue is being encapsulated in a tissue collection element or when the tissue is being engaged by any of the tissue removal devices described herein such as thedevice300. When it is desired to remove the tissue, the cuttingelement205 is collapsed further to complete the cut.
• Thetissue cutting device204 may also mark the tissue sample and/or the tissue surrounding the tissue sample as shown inFIG. 42. Marking the tissue may assist in identifying the tissue for removal or to mark the tissue remaining in the body for subsequent therapy or treatment. The tissue may be marked in any suitable manner such as those described in application Ser. No. 10/871,790, filed Jun. 17, 2004, which is hereby incorporated herein by reference in its entirety. For example, thetissue cutting device204 may have one or moredye injection ports330 to mark the tissue. Of course, the cutting device may also leave behind a marker, such as a spiral spring or coil as described above, to mark the tissue rather than marking the tissue with a dye or the like. It is understood that marking the tissue being removed and/or marking the tissue remaining in the body may be used in connection with any of the other features and aspects of the present invention including use with any of the tissue cutting or removal devices described herein.
• The present invention has been described in connection with the preferred embodiments, however, it is understood that many alternatives are possible without departing from the scope of the invention.

Claims (4)

1. A method of removing breast tissue, comprising the steps of:

providing a tissue cutting device having a shaft, a tissue collection element and a cutting element, the cutting element being movable from a collapsed position to an expanded position;

introducing the tissue cutting device into the patient's breast through a first incision with the cutting element in the collapsed position;

expanding the cutting element;

moving the cutting element through breast tissue to cut around the tissue to be removed;

positioning the tissue cut by the cutting element into the tissue collection element; and

removing the tissue collection element through a second incision different from the first incision.

2. The method ofclaim 1, wherein:

the removing step is carried out with a removal device extending through the second incision, the removal step including the step of coupling the removal device to the tissue collection element.

3. The method ofclaim 2, wherein:

the removing step is carried out with the removal device has a distal end movable between a collapsed position and an expanded position, the expanded position being flared outwardly.

4. The method ofclaim 2, wherein:

the removing step is carried out with the removal device having a suction opening coupled to a vacuum source, the removal device adhering to the tissue collection element with the suction opening.

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