The historical and scientific basis of cryosurgery

Cryosurgery has been in existence for more than a century since the early work of Sir James Arnott with salt/ice mixtures. In some surgical circles, acceptance of cryosurgery has been slow because of failure to appreciate the destructive nature of freezing techniques using liquid nitrogen spray or nitrous oxide probes. A review of the historical and scientific basis of cryosurgery enables one to predict the adequacy of routine cryosurgical methods and the morbidity to be expected from treatment. It is important to note that the typical freeze times needed to obtain good cure rates for most skin and mucous membrane lesions amenable to cryosurgery, do not lead to connective tissue scarring.     

Cryosurgery of basal cell carcinoma: a study of 358 patients

INTRODUCTION: Cryosurgery is a well-established therapeutic modality for basal cell carcinoma. We report herein an important series of basal cell carcinoma treated by cryosurgery, with a five year cure rate evaluation. PATIENTS AND METHOD: Retrospective study with 395 basal cell carcinomas (over 358 patients - sex ratio H/F: 0.85) treated by cryosurgery between 1981 and 1992. For each patient the data were: age, sex, size of the lesion, location, clinical sub-type, tissue-temperature monitoring, recurrence date and esthetic outcome. RESULT: The lesions were located on the face (93 p. 100) and back (7 p. 100). Mean size was 17 mm. Clinical sub-types were known for 178 lesions; 11 p. 100 of BCC were morpheaform. Tissue-temperature monitoring was performed for 55 p. 100 of cases. 111 tumors were observed for more than 5 years. The 5-year actuarial failure rate was 9 p. 100. The 5-year cure rate was not significantly altered by sex, size of lesions, location and clinical sub-type. No frequent recurrences were observed when tissue-temperature monitoring had not been performed. Complications were rare and esthetic outcome was good. DISCUSSION: The 5-year actuarial recurrence rate with cryosurgery is similar to conventional surgery. It is not essential to control tissue-temperature for preventing recurrences. Cryosurgery is a reliable treatment and outcome depends on surgeon experience. Quickness and low cost of this procedure argue for choosing cryosurgery when treating elderly patients.     

Cryosurgery of benign skin lesions

Cryosurgery is a widely used treatment modality in dermatology. Its place in cutaneous malignant and premalignant disease is well established; however, it also has great utility with benign lesions. Vascular, infectious, fibrotic diseases, solar damage, acne, as well as some cosmetic defects are amenable to freezing. The mechanism of treatment involves inducing tissue damage, vascular stasis and occlusion, as well as inflammation, to destroy unwanted tissue. After destruction of epidermal lesions, healing involves rapid re-epithelialization over a relatively cold-insensitive dermal network. Side effects are common but shortlived and are rarely severe. The equipment required is relatively economical and readily available. The technique is straightforward and reproducible, making cryosurgery an attractive option for many commonly encountered benign skin conditions. This review outlines treatment with the timed spot freeze technique of some commonly encountered benign lesions.     

Granuloma faciale: efficacy of cryosurgery in 2 cases

BACKGROUND: Granuloma faciale is a rare condition of unknown pathogenesis. Treatment often gives less than satisfactory results. We report two cases successfully treated with cryosurgery. CASE REPORT: A 42-year-old woman had a round 65 x 40 mm erythematous violet-colored papulous plaque on the right cheek. Histology reported a dense inflammatory infiltration of the superficial and mid derma around dilated vessels under a normal epidermis. The infiltration was composed of histiocytes, lymphocytes, plasma cells, neutrophils and eosinophils and was compatible with granuloma facial. Surgical treatment was performed but was followed by recurrence within a few months. Class I local steroids, cotton swab cryotherapy and oral dapsone remained ineffective. Cryosurgery however led to cure without recurrence at 1 year follow-up. The second patient was a 52-year old man with an oval reddish-brown papulous plaque on the right preauricular area. The plaque measured 40 mm in diameter and histology favored granuloma facial. Three cotton swab cryotherapy sessions and one surgical excision procedure were followed by recurrence. Cryosurgery provided successful cure without recurrence at 3.5 years follow-up. DISCUSSION: Most destructive treatments for granuloma facial, including pulverization cryotherapy, surgery, and CO(2) or argon laser are unsuccessful in preventing recurrence. Cryosurgery was proposed in 1977 but few cases have been reported since. Medical treatments have been variously successful with most authors reporting unsatisfactory results. In our two cases, surgical excision was rapidly followed by recurrence and in one case dapsone was ineffective. Cryosurgery provided rapid regression of the lesion and recurrence-free cure at 1 and 3.5 years follow-up respectively. Cryosurgery is an effective treatment for readily recurrent eosinophilic granuloma facial and should be proposed as first intention therapy.     

Cryosurgery for the dermatology nurse

While cryosurgery is not a panacea for all malignant skin tumors, it is a very useful tool in the armamentarium of the cancer therapist confronted with a malignancy of the skin. Cryosurgery and the nurse's role in educating patients receiving the treatment are discussed.     

Cryosurgery in difficult to treat basal cell carcinoma

BACKGROUND: Basal cell carcinoma (BCC) is the most common human malignancy. Although BCC has a low mortality, it has a large morbidity. Patients frequently present with difficult to treat BCC because of the lesion itself, the condition of the patient, or both. Satisfactory results have been reported in the cryosurgery of low-risk BCC. There is no agreement, however, about indication, cure rate, technical modalities, and results of cryosurgery in tumors larger than 1 cm, in critical locations, and of aggressive histologic type. OBJECTIVE: The purpose of the study was to establish the cure rate, functional preservation, cosmetic results, acceptance, and complications of cryosurgery in difficult to treat BCC. METHODS: One hundred and thirty six consecutive patients with 171 difficult to treat BCC (because of size, location, nature, or patient condition) were treated by the mixed technique of curettage followed by liquid nitrogen application. RESULTS: After an average follow-up of 5.2 years (6 months to 9.1 years), a cure rate of 91.8% was achieved. The treatment was well tolerated, widely accepted by the patients, of low cost, and with good functional and cosmetic results. Complications were few and minor. CONCLUSION: Cryosurgery is a well-tolerated therapeutic modality that offers an acceptable cure rate and good functional and cosmetic results in difficult to treat BCC.     

History of Mohs surgery

Mohs micrographic surgery (MMS) has become the gold standard for treating many forms of primary and recurrent contiguous skin cancers and offers the highest cure rates and maximum tissue conservation compared with other modalities. Developed by Dr Frederic E. Mohs in the 1930s, it was initially called chemosurgery and used zinc chloride paste in a process called fixed tissue technique. Although this technique had high cure rates, it could take days to complete, and it gradually gave way to fresh tissue technique, renamed MMS. Now, MMS is practiced widely as part of a multidisciplinary approach for treating skin cancer.     

Histologic cure of basal cell carcinoma treated with cryosurgery

BACKGROUND: Cryosurgery is a method of treatment for basal cell carcinoma (BCC). Despite numerous studies reporting excellent cure rates with cryosurgery, there are no studies in the literature that have shown a histologic cure of BCC. OBJECTIVE: We sought to show histologically that cryosurgery is an effective cure for well-defined, noduloulcerative BCC of the trunk and upper extremities. METHODS: Twelve noduloulcerative BCCs of the trunk and proximal upper extremities less than 1 cm were treated with single freeze-thaw cryosurgery using a cryoprobe apparatus with liquid nitrogen. A thermocouple needle measured temperature, with the goal to reach between -50 degrees C and -60 degrees C. One to 2 months later, the site was excised and examined with horizontal step sections throughout the entire tissue. RESULTS: No tissue specimens had histologic evidence of tumor. CONCLUSION: Single freeze-thaw cryosurgery provides a histologic cure of well-defined, noduloulcerative BCCs of the trunk and extremities less than or equal to 1 cm.     

Photodynamic therapy vs. cryosurgery of basal cell carcinomas: results of a phase III clinical trial

BACKGROUND: A previously reported randomized clinical trial showed treatment of Bowen's disease using photodynamic therapy (PDT) with topically applied delta-aminolaevulinic acid (ALA) to be at least as effective as cryosurgery and to be associated with fewer adverse effects. OBJECTIVES: To compare ALA-PDT and cryotherapy in the treatment of histopathologically verified basal cell carcinomas (BCCs) in a non-blinded, prospective phase III clinical trial. METHODS: One lesion from each of 88 patients was included. The BCCs were divided into superficial and nodular lesions. The follow-up period was restricted to 1 year with close follow-up for the first 3 months. Efficacy was assessed as the recurrence rate 12 months after the first treatment session, verified by histopathology. Tolerability was evaluated as the time of healing, pain and discomfort during and after the treatment, and final cosmetic outcome. RESULTS: Histopathologically verified recurrence rates in the two groups were statistically comparable and were 25% (11 of 44) for ALA-PDT and 15% (six of 39) for cryosurgery. However, clinical recurrence rates were only 5% (two of 44) for PDT and 13% (five of 39) for cryosurgery. Additional treatments, usually one, had to be performed in 30% of the lesions in the PDT group. The healing time was considerably shorter and the cosmetic outcome significantly better with PDT. Pain and discomfort during the treatment session and in the following week were low, and were equivalent with the two treatment modalities. CONCLUSIONS: In terms of efficacy, ALA-PDT is comparable with cryosurgery as a treatment modality for BCCs. Retreatments are more often required with PDT than with cryosurgery. This can easily be performed due to the shorter healing time, less scarring and better cosmetic outcome that follows ALA-PDT.     

Porokeratosis of Mibelli: successful treatment with cryosurgery

Porokeratosis of Mibelli, a disorder of keratinization, should be treated because of the possibility of development of malignant epithelial tumors on the porokeratotic lesions. Liquid nitrogen cryosurgery is considered to be particularly useful in the treatment of precancerous and benign skin lesions. We aimed to evaluate the efficiency of this method in the treatment of porokeratosis of Mibelli. Eight patients with 20 porokeratotic lesions were treated with spray cryosurgery. Each lesion was frozen for 30 seconds with a spray tip after the keratotic borders were removed conically by sharp dissection. Eighteen of the 20 lesions were healed successfully with slight atrophy in one session. One more session was necessary for the other two lesions. Liquid nitrogen cryosurgery may be considered superior to other destructive methods in the treatment of porokeratosis of Mibelli, with advantages such as simplicity, high cure rates, low cost, short treatment period, and few complications.     

Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery

Three hundred and ninety five selected non-melanoma skin cancers were treated and followed up during the period 1981-1986, using a standardized cryosurgical technique. There was an overall cure rate of 97%. Recurrences were seen in 6 out of 225 (2.7%) treated basal cell carcinomas at a median time of 18 months, 1 of 34 (2.9%) squamous cell carcinomas, with a recurrence at 6 months post-operatively and 1 out of 128 (0.8%) of Bowen's tumours which recurred 6 months after treatment. The patients were treated as out-patients using local anaesthesia and all tolerated the treatment well. This study has shown that cryosurgery is a safe, low cost and effective method of treating selected non-melanoma skin cancer and produced excellent cosmetic results with a high cure rate. It is suggested that patients treated with cryosurgery are followed up carefully for 2 years post-operatively.     

Cryosurgery as a Minimally Invasive Alternative Treatment for a Patient with Erosive Adenomatosis of the Nipple

Erosive adenomatosis of the nipple (EAN), also known as nipple adenoma, florid papillomatosis, or papillary adenoma of the nipple, is a benign neoplasm originating from a lactiferous duct of the breast. Although the potential for malignant change is invariably negligible, the nature of the disease is quite intractable despite several treatment methods. Surgical excision is known as the treatment of choice, but this invasive approach is generally not acceptable to the vast majority of patients due to the cosmetic outcomes. Cryosurgery could be an alternative choice to preserve the structure of the nipple-areola complex, though its application has not been studied due to the paucity of cases. A 22-year-old female presented with a unilateral, crater-like erosion of the left nipple with serosanguineous discharge. The skin biopsy revealed proliferation of tubular structures, which corresponded to EAN. She was treated with 4 sessions of cryosurgery (open cryospray with liquid nitrogen) over 6 months, and the skin lesion resolved completely without any recurrence for 12 months. Although further study is required to determine the optimal treatment regimen for EAN, cryosurgery should be considered as an effective option to surgical excision.     

Curettage, electrosurgery and skin cancer

The scientific literature is replete with reports extolling the virtues of curettage and electrosurgery in the treatment of skin disease. Published cure rates for selected skin cancers consistently equal those for other treatment modalities, including scalpel excision. Despite this, curettage is often overlooked as a first line treatment for skin cancer. We review the evidence-based literature for patient selection criteria and curettage and electrosurgery techniques.     

Cryosurgery in oral lesions

Background Cryosurgery is a therapeutical method successfully used for many cutaneous conditions. Its use is increasing for several conditions in the oral cavity.
Methods Liquid nitrogen spray or cryoprobe have been used alone or associated with other surgical methods in various types of oral lesions, such as pyogenic granuloma, angioma, actinic cheilitis, keratoacantoma, fibroma, HPV lesions in HIV and non-HIV patients, hypertrophic lichen planus, leukoplakia and erythroplakia, verrucous carcinoma, mucous cysts, and papillary hyperplasia of the palate, among others.
Results Our experience and the literature have shown that cryosurgery is a very useful technique for treatment of oral lesions. The oral mucosa, because of its characteristics of humidity and smoothness, is an ideal site for this technique. It shows a very good esthetic result and it may be either the first choice or an alternative option to conventional surgery.
Conclusions Cryosurgery is a very safe, easy to perform, and relatively inexpensive technique for treating various oral lesions in an out-patient clinic.     

Cutaneous cryosurgery

Cryosurgery is a therapeutic modality useful for treating cutaneous benign, premalignant, and malignant lesions. It consists of lowering lesional temperature below a critical level to cause its destruction. Lowering skin temperatures without the intent to directly cause lesional destruction (to trigger an immune mechanism, for example) is termed cryotherapy.     

Regressionsphase als therapeutisches Ziel der kryochirurgischen Behandlung wachsender kapillärer Säuglingshämangiome

BACKGROUND AND OBJECTIVE: Cryosurgery is a widely accepted modality for the treatment of capillary hemangiomas of the newborn. However, no studies clearly supporting its effectivity are available. PATIENTS AND METHODS: Out of 116 consecutive outpatients with 147 hemangiomas, 105 growing tumors in 91 patients were treated by cryosurgery. 13 further growing tumors were not treated because of lack of parental consent. Hemangiomas without growth within the last 2 weeks and with clinical signs of regression were not treated. After a follow-up of 1 year, the outcome of the treatment was classified as either regression (> 10% size reduction), no change (size alteration < 10%) or progression (> 10% size growth). The effectiveness of the treatment was assessed as clinical improvement of the hemangioma on an arbitrary scale per treatment session. RESULTS: Cryosurgery of growing hemangiomas efficiently initiated the regression phase (p < 0.05), in the most cases (68%) after a single treatment. Cryotherapy was most effective when employed in older children (p < 0.05) and for small hemangiomas (p < 0.05). Probably, this reflects associated spontaneous regression. CONCLUSIONS: Thus cryosurgery is a verifiably effective treatment modality for infantile capillary hemangiomas, shortening significantly their growth phase.     

Bowen's disease, solar keratoses and superficial basal cell carcinomas treated by photodynamic therapy using a large-field incoherent light source

BACKGROUND: Photodynamic therapy (PDT) has not yet been demonstrated to be superior to conventional treatment in the treatment of superficial skin cancers and premalignant skin conditions. A limitation for PDT is the absence to date of a light source suitable for the treatment of larger lesions or 'field changes' where several lesions are present on one anatomical site. OBJECTIVES: To investigate the safety and efficacy of a large field light source, the Waldmann PDT 1200, in the treatment of Bowen's disease (BD), superficial basal cell carcinomas (BCCs) and solar keratoses (SKs). METHODS: After application of 5-aminolaevulinic acid for 4-6 h, each lesion was irradiated with 105 J cm-2 of incoherent red light centred on 640 nm. Eighty-eight patients with 239 lesions were recruited. RESULTS: Within two treatments, 88% of BD lesions, 95% of BCCs and 99% of SKs showed complete clinical clearance. At 12 months the complete response rates were 69% for BD, 82% for BCC and 72% for SK. CONCLUSIONS: This study confirms that PDT is a useful treatment and that selected superficial BCCs and SKs respond well to PDT. The PDT 1200 light source proved capable of treating multiple lesions amounting to a 'field change' and also lesions up to 10 cm in diameter within an acceptable treatment time. Thus far, PDT has failed to become established as a routine treatment for small premalignant and malignant skin lesions as it has not proved superior to simple cheaper conventional therapies such as cryotherapy, curettage and cautery, topical chemotherapy with 5-fluorouracil, or surgery. However, PDT has become established as a treatment for selected cases in some centres. This study suggests a role for PDT in the treatment of large premalignancies, superficial BCCs and field change where existing treatments may be problematic.     

A prospective study of the use of cryosurgery for the treatment of actinic keratoses

BACKGROUND: Actinic keratoses are the most common actinic lesions on Caucasian skin. Cryosurgery with liquid nitrogen is commonly used to treat actinic keratoses, but there have been few studies examining the true rate of cure in everyday dermatologic practice. AIM: To determine prospectively the true efficacy of cryosurgery as a treatment for actinic keratoses in everyday dermatologic practice. METHODS: A prospective, multicentered study (a subsidiary study of a photodynamic therapy trial) was performed. Patients with untreated actinic keratoses greater than 5 mm in diameter on the face and scalp were recruited. Eligible lesions received a single freeze-thaw cycle with liquid nitrogen given via a spray device and were reviewed 3 months thereafter. Each center used their preferred freeze time. The only treatment criterion was complete freezing of actinic keratoses and a 1-mm rim of normal skin. Treated lesions were assessed as complete response or noncomplete response. The influence of the duration of freeze, cosmetic outcomes, and adverse events were examined. RESULTS: Ninety adult patients from the community with 421 eligible actinic keratoses were recruited. The overall individual complete response rate was 67.2%[SEM = +/-3.5%; 95% confidence interval (CI) = 60.4-74.1%]. Complete response was 39% for freeze times of less than 5 s, 69% for freeze times greater than 5 s, and 83% for freeze times greater than 20 s. Cosmetic outcomes were good to excellent in 94% of complete response lesions. The main adverse events were pain, stinging, and burning during treatment, and hypopigmentation after healing. CONCLUSIONS: Cryosurgery is an effective treatment for actinic keratoses. The true complete response rate is significantly lower than that previously reported. The freeze duration influences successful treatment. Adverse events are mild and well tolerated.     

Cryosurgery of porokeratosis plantaris discreta.

Porokeratosis plantaris discreta is a distinct clinical and pathological entity often resistant to conservative management. Twenty-one lesions of porokeratosis plantaris discreta were treated cyrosurgically in 11 patients. Removal of the blister roof two weeks after cryosurgery with retreatment of any residual lesion proved an effective method for removal of such lesions without scarring. A cure rate of 90.5% was achieved using this technique.