Cryosurgery: An oldie but goodie

Key Points

Newark, N.J. - In the age of complex procedures, cryotherapy is a reliable treatment modality that continues to be effective in treating numerous skin lesions.

"Cryotherapy is a very versatile therapy that can be used very effectively in the treatment of benign, pre-malignant, as well as malignant lesions," according to Emanuel G. Kuflik, M.D., clinical professor, department of dermatology, New Jersey Medical Center in Newark, N.J.

Effective tx modality

Treatment usually can be completed in one session, depending on the size of the lesion. He says no special facilities are needed, and treatments can be performed in a hospital, a nursing home or an office.

According to Dr. Kuflik, the treatment modality is perfect for geriatric patients, even if they have medical problems. He says it is particularly useful for patients who have blood dyscrasias or allergy to a local anesthetic, or for those who simply do not want surgery.

If the tumor is very large, Dr. Kuflik says he breaks the tumor up into segments and treats a small section, lets it heal for a few weeks, and then treats the next section.

"Cryotherapy is particularly effective in tumors on the ears, eyelids (especially around the area of the lacrimal duct), dorsum of the hands, as well as the scalp, where tissues may be sometimes difficult to move," he tells Dermatology Times.

"Just before the procedure, I debulk the tumor a bit with a curette, if necessary, and use the tissue as a biopsy specimen. A typical BCC will take 40 seconds to 45 seconds of spray, then I let it thaw out for about two minutes, and then repeat the treatment," Dr.Kuflik says.

Dr. Kuflik explains that during the freeze, intra- and extra-cellular ice formation occur. During the thaw period, there is a certain amount of microvascular destruction or vascular stasis.

"For BCC and SCC, you will need to do two to three freeze-thaw cycles. You freeze it, and let it thaw out spontaneously; then, a few minutes later, freeze it again. This is to increase the lethality, and I only do this with malignant lesions, not with benign lesions," he says.

Distinct margins

Dr. Kuflik explains that to perform cryotherapy responsibly and effectively, especially with malignancies, doctors need to have recognizable and distinct margins.

Morphea BCC is tricky because cryotherapy can destroy the tumor, but sometimes the edges cannot be realized, and they often have indistinct margins. Here, cryotherapy is not the treatment of choice, and such lesions should be dealt with surgically.

Dr. Kuflik also treats SCCs of the scalp, but does not treat de novo SCCs, and as these tumors can be more biologically active, cryotherapy may not be the best solution.

"Besides the duration of freezing known as the freeze time, another point that is important with malignancies and cryotherapy is the lateral spread of freeze. Just as an excision should be done approximately 5 mm in healthy tissue, so should the freeze," Dr. Kuflik says.

According to Dr. Kuflik, good indications for cryotherapy in pre-malignant lesions can include actinic keratoses, Bowen's disease, actinic cheilitis and lentigo maligna.

"I freeze actinic keratoses with a spray from four to seven seconds at the most. They will clear after only one treatment, and I can treat multiple lesions in one sitting. A crust will form and then fall off about 10 days after treatment. There is no reason to treat it strongly like a malignancy.

"I treat Bowen's disease the same way, just a little longer - about 20 to 25 seconds, for a lesion that is 1 to 2 cm," Dr. Kuflik says.

Lentigo maligna

He says lentigo maligna is another very good indication for cryotherapy.