9. Cryotherapy and electrodessication and curettage

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Clinical practice guidelines for keratinocyte cancer > 9. Cryotherapy and electrodessication and curettage


Introduction

The 'destructive therapies', cryotherapy (cryosurgery, cryoablation) and electrodessication and curettage (EDC), are commonly used in the day-to-day treatment of skin cancers and premalignant skin lesions.

Although these modalities have been widely used for decades to treat keratinocyte cancers (KCs) and related premalignant conditions, few randomised clinical trials have evaluated their efficacy. The evidence for efficacy is primarily based on non-controlled prospective or retrospective series.

Advantages and disadvantages of cryotherapy and electrodessication curettage

Cryotherapy and EDC are simple, inexpensive and quick procedures, compared with surgical excision, topical agents, photodynamic therapy or radiotherapy, and are easily carried out in a doctor’s office.

Cryotherapy and EDC are useful treatment modalities when treating patients with large numbers of lesions and where other therapies may be impractical. They also provide an alternative when surgery may not be suitable (e.g. in patients with other medical conditions such as coagulopathies or those with pacemakers, or those with KCs at body sites where scar contractures may be a problem).

In addition to the limited availability of evidence to guide their use, the main disadvantage of destructive therapies is that their cosmetic results are unpredictable. Effects may include hyper- and hypo-pigmentation, and hypertrophic or atrophic scarring. Wounds at some sites, particularly lower limbs, may be slow to heal,[1] and patients may experience pain, during and after treatment.

The outcomes of cryotherapy and EDC are operator-dependent. Better outcomes have been reported for those who perform these procedures more often.[2][3]
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Cryotherapy

Definition and mechanism of effect (cryotherapy)

Cryotherapy is the destruction of tissue by the direct application of a cryogenic agent such as liquid nitrogen (or, less commonly, carbon dioxide snow or nitrous oxide). It is a widely used, rapid, cost efficient and effective therapy for actinic (solar) keratoses (AKs).[4][5] In addition, cryotherapy has been employed for more than 50 years for the treatment of selected skin cancers.[1][6][7][8][9][10][11][3][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]

The most common method of applying cryogenic agents is with the use of cryospray devices. These are considered to be more reliable than cotton-tipped applicators and the results more reproducible.

Cryotherapy causes tissue destruction through multiple mechanisms. Proposed mechanisms include physical damage of cellular components by ice crystals, osmotic damage during thawing, ischaemic damage due to cold injury to small vessels, and immunological stimulation with the release of antigenic components.

The extent of injury is proportional to the rate of freezing and thawing. Repeated freeze–thaw cycles produce much greater tissue damage than a single freeze due to increased conductivity and impaired circulation of previously frozen tissue, allowing for a faster and greater degree of cold penetration.[32]

The aim of therapy is to produce a selective volume of tissue necrosis equivalent to that removed by simple excision.

Indications

In addition to its widespread use in the treatment of actinic keratoses, in general cryotherapy is most suited for low-risk primary tumours with well-defined margins on the trunk or limbs (Table 8), namely Bowen’s diseasecSCC in situ (also known as intra-epidermal SCC) (cutaneous squamous cell carcinoma in situ, also known as intra-epidermal squamous cell carcinoma),[10][12][13][14] primary superficial or small papular basal cell carcinomas (BCCs),[11][18][22][26] keratoacanthomas,[10][17] and small primary well-differentiated cutaneous squamous cell carcinomas (cSCCs).[8][10][17][18][22]

Cryotherapy may be combined with initial curettage to debulk the tumour and to provide a specimen for histological analysis.[19][24][27][33][34][35][36][37]

Cryotherapy for low-risk primary KCs (AK, Bowen’s diseasecSCC in situ (also known as intra-epidermal SCC), BCC) may offer special advantages for elderly high-risk surgical patients, especially those with a pacemaker or coagulopathy,[34][38][39] for those who refuse surgery, and for sites where scar contracture is best avoided, such as digits.[40]

Occasionally, in geographical regions where access to surgical options is limited by cost and a lack of services, cryotherapy may be the preferred treatment option.[24]

Alternative forms of treatment, mainly surgical excision, are indicated for large nodular, sclerosingscar-like (morphoeic) (morphoeic), or ill-defined BCCs,[10][24][26][29] moderately to poorly differentiated cSCCs,[8][18][19] recurrent/residual tumours, and certain high-risk facial sites.[5][8][10][19][28][29][30] Nevertheless, many studies attest to the efficacy and acceptable cosmetic results achieved by cryosurgery in specialist clinics, even for difficult cancers.[5][9][19][22][23][24][25][27][29][30][31][41]

A biopsy giving histological confirmation of the tumour is mandatory before treatment if used for invasive tumours, or if there is evidence of residual tumour following treatment.[10][38][41]

Rarely, cryosurgery may be used for palliation of incurable cancers to lessen tumour bulk or pain and reduce malodorous discharge.[42]
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Relative contraindications

Cryotherapy at tumoricidal depth generally leaves hypopigmented atrophic scars, and is therefore not the treatment of choice when the cosmetic outcome is important. For the same reason, cryotherapy is relatively contraindicated in most dark-skinned individuals, in whom hypopigmentation can be obvious and disfiguring.

Table 8. Relative indications and contraindications for cryotherapy and electrodessication and curettage in keratinocyte cancers

Relative indications Relative contraindications
Tumour type Actinic keratoses (any site if discrete and non-suspicious)

Bowen’s diseasecSCC in situ (also known as intra-epidermal SCC) (especially on trunk or limbs)

Keratoacanthomas (if small and at low-risk sites)

BCCs of low-risk type (especially on the trunk and limbs)

cSCCs of low-risk type (especially on the trunk and limbs)

High-risk BCC (e.g. ill-defined or sclerosingscar-like (morphoeic))

High-risk cSCC (e.g. poorly differentiated, thick tumours)

Tumour site Sites with increased risk of keloid scars with other modalities (e.g. upper arms and upper trunk) Site where cosmetic outcome is a priority (e.g. face and neck)

Sites where difficult to ascertain depth of tumour penetration (e.g. face or neck)

Sites where deep recurrence poses greater potential risks (e.g. face or neck)

Tumour stage Palliation for inoperable tumours Recurrent tumours where surgical excision with histological confirmation of clear margins is essential
Patient-related factors Unfit for surgery due to comorbidity or age Younger patients in whom cosmetic outcome is a priority
Health system-related factors Geographic region with poor access to surgical facilities
BCC: basal cell carcinoma; cSCC: cutaneous squamous cell carcinoma


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Electrodessication and curettage

Definition and mechanism of effect

Electrodessication and curettage is a specialised technique used in the management of BCC, cSCC, KA and Bowen’s diseasecSCC in situ (also known as intra-epidermal SCC).

Electrodessication and curettage technique varies slightly between operators, but essentially involves one to three cycles of curettage, each followed by the application of electrodessication or diathermy (or CO2 laser ablation) to the base.

To achieve the cure rates described in published literature, both careful lesion selection and critical attention to technique are required.[2][43] Specialised training is considered to be a necessary prerequisite for the use of EDC.

Skin cancers appropriate for EDC have a stroma that is relatively gelatinous, compared with the surrounding normal dermis. In these lesions, the curette easily enucleates the gelatinous tissue, but makes no further progress when it reaches the surrounding healthy dermis. Thus, the operator can differentiate between normal and cancerous tissue.

Contraindications

Electrodessication and curettage is not appropriate for lesions that penetrate through the dermis, cicatricial lesions, or thin skin. If the lesion penetrates through into subcutaneous fat, the technique loses its selectivity because fat does not resist the curette in the same way as healthy dermis.

This technique is not effective in the treatment of cicatricial lesions such as sclerosingscar-like (morphoeic) BCC, which do not have a gelatinous stroma.

On very thin skin, such as eyelids, lip or genitalia, tearing of tissue would allow the curette to break through to the subcutaneous layer.

Alternative curettage techniques

Some operators now use carbon dioxide laser in place of electrodessication.

For BCCs, other alternatives to electrodessication or diathermy are cryotherapy in combination with curettage and imiquimod 5% cream followed by curettage. Several single-centre, single arm, non-randomised, non-controlled studies have reported favourable results with these approaches in the treatment of BCC.[35][36][37][44][45]
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References

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  2. 2.02.1 Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 2: Curettage-electrodesiccation. J Dermatol Surg Oncol 1991 Sep;17(9):720-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1820764.
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  42. Gage AA. Cryosurgery of advanced tumors. Clin Dermatol 1990 Jan;8(1):86-95 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1697497.
  43. Spiller WF, Spiller RF. Treatment of basal cell epithelioma by curettage and electrodesiccation. J Am Acad Dermatol 1984 Nov;11(5 Pt 1):808-14 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/6512037.
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