9. Cryotherapy and electrodessication and curettage
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[edit source]
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, 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.
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Definition and mechanism of effect (cryotherapy)[edit source]
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). In addition, cryotherapy has been employed for more than 50 years for the treatment of selected skin cancers.
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.
The aim of therapy is to produce a selective volume of tissue necrosis equivalent to that removed by simple excision.
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 disease (cutaneous squamous cell carcinoma in situ, also known as intra-epidermal squamous cell carcinoma), primary superficial or small papular basal cell carcinomas (BCCs), keratoacanthomas, and small primary well-differentiated cutaneous squamous cell carcinomas (cSCCs).
Cryotherapy may be combined with initial curettage to debulk the tumour and to provide a specimen for histological analysis.
Cryotherapy for low-risk primary KCs (AK, Bowen’s disease, BCC) may offer special advantages for elderly high-risk surgical patients, especially those with a pacemaker or coagulopathy, for those who refuse surgery, and for sites where scar contracture is best avoided, such as digits.
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.
Alternative forms of treatment, mainly surgical excision, are indicated for large nodular, sclerosing (morphoeic), or ill-defined BCCs, moderately to poorly differentiated cSCCs, recurrent/residual tumours, and certain high-risk facial sites. Nevertheless, many studies attest to the efficacy and acceptable cosmetic results achieved by cryosurgery in specialist clinics, even for difficult cancers.
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.
Rarely, cryosurgery may be used for palliation of incurable cancers to lessen tumour bulk or pain and reduce malodorous discharge.
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Relative contraindications[edit source]
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 disease (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 sclerosing)
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[edit source]
Definition and mechanism of effect[edit source]
Electrodessication and curettage is a specialised technique used in the management of BCC, cSCC, KA and Bowen’s disease.
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. 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.
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 sclerosing 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[edit source]
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.
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Topics covered in this section include:
- ↑ 1.0 1.1 Ahmed I, Berth-Jones J, Charles-Holmes S, O'Callaghan CJ, Ilchyshyn A. Comparison of cryotherapy with curettage in the treatment of Bowen's disease: a prospective study. Br J Dermatol 2000 Oct;143(4):759-66 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11069453.
- ↑ 2.0 2.1 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1820764.
- ↑ 3.0 3.1 De Lanza MP, Ralfs I, Dawber RP. Cryosurgery for Bowen's Disease of the skin. Br J Cancer 1980;18:14. 103(18) p14.
- ↑ Lubritz RR, Smolewski SA. Cryosurgery cure rate of actinic keratoses. J Am Acad Dermatol 1982 Nov;7(5):631-2 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7142470.
- ↑ 5.0 5.1 5.2 Fraunfelder FT, Farris HE Jr, Wallace TR. Cryosurgery for ocular and periocular lesions. J Dermatol Surg Oncol 1977 Jul;3(4):422-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/893764.
- ↑ Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 1989 Mar;15(3):315-28 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2646336.
- ↑ Hall VL, Leppard BJ, McGill J, Kesseler ME, White JE, Goodwin P. Treatment of basal-cell carcinoma: comparison of radiotherapy and cryotherapy. Clin Radiol 1986 Jan;37(1):33-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3514075.
- ↑ 8.0 8.1 8.2 8.3 Zacarian SA. Cryosurgery of cutaneous carcinomas. An 18-year study of 3,022 patients with 4,228 carcinomas. J Am Acad Dermatol 1983 Dec;9(6):947-56 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6643791.
- ↑ 9.0 9.1 Fraunfelder FT, Zacarian SA, Limmer BL, Wingfield D. Cryosurgery for malignancies of the eyelid. Ophthalmology 1980 Jun;87(6):461-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7413134.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 Holt PJ. Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery. Br J Dermatol 1988 Aug;119(2):231-40 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3166941.
- ↑ 11.0 11.1 Graham GF. Statistical data on malignant tumors in cryosurgery: 1982. J Dermatol Surg Oncol 1983 Mar;9(3):238-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6826880.
- ↑ 12.0 12.1 Mortimer PS, Sonnex TS, Dawber RP. Cryotherapy for multicentric pigmented Bowen's disease. Clin Exp Dermatol 1983 May;8(3):319-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6883799.
- ↑ 13.0 13.1 Thestrup-Pedersen K, Ravnborg L, Reymann F. Morbus Bowen. A description of the disease in 617 patients. Acta Derm Venereol 1988;68(3):236-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/2455417.
- ↑ 14.0 14.1 Cox NH, Dyson P. Wound healing on the lower leg after radiotherapy or cryotherapy of Bowen's disease and other malignant skin lesions. Br J Dermatol 1995 Jul;133(1):60-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7669642.
- ↑ Morton CA, Whitehurst C, Moseley H, McColl JH, Moore JV, Mackie RM. Comparison of photodynamic therapy with cryotherapy in the treatment of Bowen's disease. Br J Dermatol 1996 Nov;135(5):766-71 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8977678.
- ↑ Lubritz RR. Cryosurgical management of multiple skin carcinomas. J Dermatol Surg Oncol 1977 Jul;3(4):414-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/893762.
- ↑ 17.0 17.1 17.2 Martins O, Oliveira Ada S, Picoto Ada S, Verde SF. Cryosurgery of large tumors on the dorsa of hands. J Dermatol Surg Oncol 1980 Jul;6(7):568-70 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7391333.
- ↑ 18.0 18.1 18.2 18.3 Kuflik EG, Gage AA. The five-year cure rate achieved by cryosurgery for skin cancer. J Am Acad Dermatol 1991 Jun;24(6 Pt 1):1002-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1820761.
- ↑ 19.0 19.1 19.2 19.3 19.4 Nordin P. Curettage-cryosurgery for non-melanoma skin cancer of the external ear: excellent 5-year results. Br J Dermatol 1999 Feb;140(2):291-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10233225.
- ↑ Graham GF. Cryosurgery. Clin Plast Surg 1993 Jan;20(1):131-47 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8420702.
- ↑ Kingston T, Jackson A, August P. Cryosurgery in the treatment of skin cancer. Br J Cancer 1988;119 (suppl):33-39.
- ↑ 22.0 22.1 22.2 22.3 Kuflik EG. Cryosurgical treatment for large malignancies on the upper extremities. J Dermatol Surg Oncol 1986 Jun;12(6):575-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3711418.
- ↑ 23.0 23.1 Kuflik EG. Treatment of basal- and squamous-cell carcinomas on the tip of the nose by cryosurgery. J Dermatol Surg Oncol 1980 Oct;6(10):811-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7229166.
- ↑ 24.0 24.1 24.2 24.3 24.4 Nordin P, Larkö O, Stenquist B. Five-year results of curettage-cryosurgery of selected large primary basal cell carcinomas on the nose: an alternative treatment in a geographical area underserved by Mohs' surgery. Br J Dermatol 1997 Feb;136(2):180-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9068728.
- ↑ 25.0 25.1 Gonçalves JC. Fractional cryosurgery for skin cancer. Dermatol Surg 2009 Nov;35(11):1788-96 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19732116.
- ↑ 26.0 26.1 26.2 McLean DI, Haynes HA, McCarthy PL, Baden HP. Cryotherapy of basal-cell carcinoma by a simple method of standardized freeze-thaw cycles. J Dermatol Surg Oncol 1978 Feb;4(2):175-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/624804.
- ↑ 27.0 27.1 27.2 Spiller WF, Spiller RF. Treatment of basal-cell carcinomas by a combination of curettage and cryosurgery. J Dermatol Surg Oncol 1977 Jul;3(4):443-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/893768.
- ↑ 28.0 28.1 McIntosh GS, Osborne DR, Li AK, Hobbs KE. Basal cell carcinoma--a review of treatment results with special reference to cryotherapy. Postgrad Med J 1983 Nov;59(697):698-701 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6647186.
- ↑ 29.0 29.1 29.2 29.3 Biro L, Price E, Brand A. Cryosurgery for basal cell carcinoma of the eyelids and nose: five-year experience. J Am Acad Dermatol 1982 Jun;6(6):1042-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7096667.
- ↑ 30.0 30.1 30.2 Biro L, Price E. Basal-cell carcinomas of eyelids: experience with cryosurgery. J Dermatol Surg Oncol 1979 May;5(5):397-401 Available from: http://www.ncbi.nlm.nih.gov/pubmed/458007.
- ↑ 31.0 31.1 Kuflik EG. Cryosurgery for basal-cell carcinomas on and around eyelids. J Dermatol Surg Oncol 1978 Dec;4(12):911-3 Available from: http://www.ncbi.nlm.nih.gov/pubmed/730935.
- ↑ Thai KE, Sinclair RD. Cryosurgery of benign skin lesions. Australas J Dermatol 1999 Nov;40(4):175-84; quiz 185-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10570551.
- ↑ Graham G, Garnett A, Kuflik E, Lubritz R. Guidelines of care for cryosurgery. American Academy of Dermatology Committee on Guidelines of Care. J Am Acad Dermatol 1994 Oct [cited 2018 Oct];31(4):648-53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8089292.
- ↑ 34.0 34.1 Kuflik EG. Cryosurgery for cutaneous malignancy. An update. Dermatol Surg 1997 Nov;23(11):1081-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9391569.
- ↑ 35.0 35.1 Kuijpers DI, Thissen MR, Berretty PJ, Ideler FH, Nelemans PJ, Neumann MH. Surgical excision versus curettage plus cryosurgery in the treatment of basal cell carcinoma. Dermatol Surg 2007 May;33(5):579-87 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17451581.
- ↑ 36.0 36.1 Peikert JM. Prospective trial of curettage and cryosurgery in the management of non-facial, superficial, and minimally invasive basal and squamous cell carcinoma. Int J Dermatol 2011 Sep;50(9):1135-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22126880.
- ↑ 37.0 37.1 Lindemalm-Lundstam B, Dalenbäck J. Prospective follow-up after curettage-cryosurgery for scalp and face skin cancers. Br J Dermatol 2009 Sep;161(3):568-76 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19624544.
- ↑ 38.0 38.1 Kuflik EG. Cryosurgery updated. J Am Acad Dermatol 1994 Dec;31(6):925-44; quiz 944-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/7962774.
- ↑ Albright SD 3rd. Treatment of skin cancer using multiple modalities. J Am Acad Dermatol 1982 Aug;7(2):143-71 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6752218.
- ↑ Motley R, Kersey P, Lawrence C, British Association of Dermatologists., British Association of Plastic Surgeons.. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Plast Surg 2003 Mar;56(2):85-91 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12791348.
- ↑ 41.0 41.1 Fraunfelder FT, Zacarian SA, Wingfield DL, Limmer BL. Results of cryotherapy for eyelid malignancies. Am J Ophthalmol 1984 Feb;97(2):184-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6696028.
- ↑ Gage AA. Cryosurgery of advanced tumors. Clin Dermatol 1990 Jan;8(1):86-95 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1697497.
- ↑ 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/6512037.
- ↑ Tillman DK Jr, Carroll MT. A 36-month clinical experience of the effectiveness of curettage and imiquimod 5% cream in the treatment of basal cell carcinoma. J Drugs Dermatol 2008 Jan;7(1 Suppl 1):s7-14 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18277457.
- ↑ Rigel DS, Torres AM, Ely H. Imiquimod 5% cream following curettage without electrodesiccation for basal cell carcinoma: preliminary report. J Drugs Dermatol 2008 Jan;7(1 Suppl 1):s15-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18277458.