Cryotherapy

Cryotherapy

Reviewed By:
Mark Oren, M.D., FACP
Martin E. Liebling, M.D., FACP

Summary

Cryotherapy is the use of cold to treat medical conditions. A form of this treatment known as cryosurgery increasingly is being used to treat various forms of cancer. In this treatment, extremely cold liquid nitrogen (or argon gas) is applied to the tumor to destroy the abnormal tissue.

In the past, cryosurgery has been used for treatment of precancerous skin lesions, moles and skin cancers. With advanced technology, this freezing technique has expanded to be effective treatment of cervical, prostate and liver cancer. Currently research is being conducted to determine its effectiveness in treating other cancers, including breast, lung and brain cancers.

Cryotherapy has several advantages over other forms of cancer treatment. These include limited destruction of healthy tissues and flexibility to repeat the procedure if necessary. However, the long-term effectiveness of cryotherapy remains largely unknown. As a result, many physicians consider it to be an experimental treatment for certain cancers.

About cryotherapy

Cryotherapy is any treatment that uses cold temperatures to cure or control illnesses ranging from a swelled ankle to cancer. When cold is applied to these tissues, it causes a response that ranges from an inflammatory reaction (e.g., frostbite) to a more severe reaction, such as the death of the tissue. The use of cold temperatures to freeze abnormal tissues dates back to the 1800s, when iced saline (salt) solutions were used to treat advanced cancers of the cervix and breast.

For certain conditions, cryotherapy has proven to be an effective form of treatment. These conditions include:

  • Early-stage skin cancers. This treatment is  used for small, early-stage non melanoma skin cancers, including both basal cell carcinoma and squamous cell carcinomas. After treating the lesions with liquid nitrogen, the area thaws and the dead skin falls off.
  • Actinic keratosis. This is a precancerous skin growth.

  • Retinoblastoma. This rare childhood eye cancer may be effectively treated with cryosurgery when the tumor is small and located in the anterior (front) part of the retina.

  • Cervical intraepithelial neoplasia. This precancerous condition of the cervix involves abnormal cell changes that can develop into cervical cancer. Cryosurgery is widely available in gynecologists’ offices in the United States.

Cryosurgery is still considered to be somewhat of an experimental procedure for other medical conditions. For this reason,  insurance companies may not always cover the procedure. Cryosurgery is currently being evaluated in treating some cancers, including:

  • Prostate cancer. Used on cancer that is in its early stages and confined to the prostate gland. It may be used to treat men who cannot have radiation therapy or conventional surgery due to their age or other factors. Cryosurgery has also been used to treat recurrent prostate cancer that has remained confined to the gland; the term for this procedure is salvage cryotherapy. The therapy may be used as a secondary treatment when primary treatment has not been successful and it can be repeated. Though cryotherapy appears to be effective in treating prostate cancer, its long-term outcome is not yet known.
  • Liver cancer. Cryosurgery is often used on primary liver cancer that has not spread, and cancer that has metastasized to the liver from other sites. This therapy often is used when other factors prevent the use of traditional therapies. In some cases, chemotherapy or radiation therapy may be used before cryosurgery.

  • Low-grade cancerous and noncancerous bone tumors. Cryosurgery may help reduce the risk of joint damage when compared to more extensive surgery, and may help lessen the need for amputation.

  • Tumors of the brain and spinal cord

  • Tumors of the trachea (windpipe) that may develop with non-small cell lung cancer

  • AIDS-related Kaposi’s sarcoma. Small and localized skin lesions can be effectively treated with cryosurgery.

The American Cancer Society recently has reported encouraging statistics showing the following results eight years after cryotherapy treatment for prostate cancer:

  • Patients with low-grade tumors have a 92 percent chance of showing no evidence of disease.

  • Patients with slightly more aggressive tumors have 80 percent chance of showing no evidence of disease.

  • Patients with the most aggressive tumors have 65 percent chance of showing no evidence of disease.

In addition, between 85 percent and 95 percent of biopsies taken after cryotherapy are negative for malignancy, regardless of the cancer’s original nature.

Before, during and after the procedure

The preparation for the procedure varies greatly depending on the location and type of cancer. Patients should follow all preparatory steps suggested by their physician. People undergoing open surgery, such as for liver cancer, might want to give blood in advance in case a transfusion is needed. Patients may be placed under a local anesthetic or general anesthesia, depending on the type of cancer that is being treated. In some cases, the procedure will be performed on an outpatient basis. In other cases, a hospital stay may be required.

In treating internal tumors, the physician will use a hollow device known as a cryoprobe.  This is a vacuum-insulated tube made of stainless steel that is used to freeze the suspect tissue. This probe will be placed on or in the tumor either through a surgical incision or through the skin (percutaneously). Heating devices may be placed on nearby tissues to prevent damage.

When the probe is placed on or in the tumor, liquid nitrogen (or argon gas) flows over the tissue, freezing it to a temperature of approximately -320 degrees Fahrenheit (-196 degrees Celsius). Depending on the location of the tumor, the physician may use an ultrasound device or magnetic resonance imaging (MRI) to guide the cryoprobe to the cancer site. MRI can help the physician monitor the treatment and ensure that the tissue is destroyed.

External tumors are treated with liquid nitrogen applied with a cotton swab or spraying device.

One procedure may involve several freeze-and-thaw cycles and the damaged tumor tissue is left in place. A tumor that has been treated inside the body will eventually be reabsorbed into the body tissues. In contrast, a tumor on the exterior of the body will dissolve and form a scab.  

The nature of the cancer being treated will dictate exactly how the surgery itself unfolds. Differences can be seen in the following examples:

  • Skin cancers. Little preparation is necessary as the area is frozen with liquid nitrogen using a probe. The lesions thaw, form a scab and eventually fall from the body part.

  • Cervical intraepithelial neoplasia. The patient remains awake for the procedure. The vaginal canal is held open typically with a speculum to allow the physician to view the cervix. The cryoprobe is inserted into the vagina and placed against the cervix, and the tissue is frozen. The treatment is most effective when the cervix is then allowed to thaw, and the procedure is repeated. A sanitary pad is usually worn afterwards to absorb water and fluid discharge. 

  • Prostate cancer. The patient receives general, spinal or epidural anesthesia. An incision is made in the abdomen and a catheter (plastic tube) is inserted through the urethra into the bladder to pass urine in case the prostate swells and blocks the flow of urine (a common side effect). Warm saltwater is circulated through the catheter to keep the urethra from freezing. An incision is made through the skin between the anus and scrotum.  A cryoprobe or multiprobe device is inserted through the incision, with transrectal ultrasound (TRUS) used to guide the probe to the tumor site. The cancerous tissue is frozen, allowed to thaw and then refrozen. The procedure lasts an hour or two. Patients often are able to go home the same day. The catheter is usually removed within a couple of weeks, allowing normal urination.

  • Liver cancer. After the patient undergoes anesthesia, an incision is made to open the abdominal cavity. The liver is left in place but freed from some attachments to other structures. The physician feels the liver with both hands and uses ultrasound to search for tumors. The cryoprobe is passed into each tumor and each tumor is frozen. Up to five probes may be used to completely destroy large tumors.

     
  • Retinoblastoma. The patient (usually a young child) is put under general anesthetic and the cryoprobe is placed on the outer surface of the eyeball next to the tumor. The tissue is then frozen. Typically, the procedure must be repeated several times before it is successful. Cryosurgery used on retinoblastoma is also called cryocoagulation. It may be used in place of photocoagulation (laser therapy) or in addition to radiation therapy.

Depending on the exact nature of cryotherapy treatment, patients may be able to go home after the procedure. In some cases, patients may need to spend one to two nights in the hospital for recovery.

Potential benefits and risks of cryotherapy

There are several major advantages associated with cryosurgery. The procedure is less invasive than standard surgery, requiring just a small incision and insertion of the cryoprobe. This helps minimize pain and bleeding and reduces the amount of time needed for recovery. In many instances, a hospital stay is not required because the procedure can be performed with local anesthesia. However, in some cases – such as cryotherapy to treat liver cancer or prostate cancer – general, spinal or epidural anesthesia and a hospital stay may be required. 

Other advantages include:

  • Limited destruction of healthy tissues. Cryosurgery allows the physician to treat a precise area, sparing other tissues from damage.
  • Ability to repeat treatment. If necessary, patients can have additional cryosurgery sessions. Cryosurgery can also be used in tandem with surgery, chemotherapy, hormone therapy and radiation therapy.
  • Broadened patient options. Cryotherapy may be used on cancers that are considered inoperable or that do not respond to standard therapies. It can also be used on patients ineligible for other therapies because of age or medical conditions.
  • Lower cost. Cryotherapy is less expensive than many other cancer treatments.

Perhaps the biggest risk associated with cryosurgery is uncertainty about its long-term effectiveness. Not enough data has been collected over a long period of time to determine the effectiveness of cryosurgery in comparison with other methods of treatment.

In addition, although cryotherapy can effectively treat visible cancers, the procedure may miss some cancer cells that are not evident.  

Cryosurgery also has been associated with certain side effects when used to treat various cancers, including:

  • Prostate cancer. Side effects are more likely to appear in men who have had radiation therapy to the prostate, and include:
    • Impotence. Erectile dysfunction occurs in up to 80 percent of men undergoing prostate cryotherapy, but newer nerve-sparing cryotherapy keeps sexual function intact in about half the patients.
    • Obstruction of urine flow or incontinence. Permanent incontinence is uncommon.
    • Blood in the urine
    • Swelling of the penis or scrotum
    • Injury to the rectum during the procedure (rare)
    • Abnormal opening (fistula) between the rectum and bladder (rare)
  • Liver cancer. Cryotherapy may cause damage to the bile ducts and/or major blood vessels. This can lead to heavy bleeding (hemorrhage) or infection. Other possible side effects include:
    • Fluid in the lungs
    • Abnormal leakage of bile from the liver
    • Temporary decrease in kidney function
  • Cervical intraepithelial neoplasia (precancerous cells of the cervix). Cryotherapy does not affect a woman’s fertility, but can cause cramping, pain or bleeding.
  • Skin cancer (including Kaposi’s sarcoma). Cryotherapy may cause the following:
    • Scarring and swelling
    • Loss of sensation if nerves are damaged
    • Loss of pigmentation and hair loss in treatment area
  • Bone cancer. Cryotherapy may cause destruction of nearby bone tissue, resulting in fractures. Oftentimes, these symptoms may not appear until a long period of time after treatment.
  • Retinoblastoma. Swelling of the eye and eyelid is normal after cryosurgery.

In addition, cryosurgery sometimes interacts poorly with chemotherapy. A patient’s cancer care team can best determine the benefits and risks of cryotherapy for treatment.

Ongoing research regarding cryotherapy

Researchers are investigating the effectiveness of cryotherapy in treating a number of cancers, including breast, colon and kidney cancer. Early results have been promising. Studies continue to examine the long-term effectiveness of cryotherapy, particularly in the treatment of prostate cancer.

Research continues in the technology to perform the cryosurgery. More precise thermosensors and probes are being developed to target the cancer cells with less damage to healthy tissue and nerves. In addition, physicians are studying the intensity and extent of cryotherapy necessary to achieve optimal results.

Cryotherapy also is being tested in combination with other cancer treatments, including chemotherapy, radiation therapy, hormone therapy and surgery.

Questions for your doctor about cryotherapy

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about cryotherapy:

  1. Can cryotherapy be used with my form of cancer?

  2. What type of cryotherapy will be used?

  3. What is the preparation for the procedure?

  4. What type of anesthesia will I receive?

  5. Will cryotherapy be an outpatient procedure?

  6. What are the risks associated with cryotherapy for my cancer?

  7. How effective is this treatment?

  8. What can I expect in terms of recovery?

  9. Will I need follow-up treatments?

  10. How will I know if the procedure was successful in destroying the cancer?

  11. Will I need other cancer treatments in addition to cryotherapy?

  12. How will my cancer be monitored?

  13. Is cryotherapy considered experimental for my type of cancer?

  14. Can cryotherapy be used more than once?

  15. Am I eligible for any clinical trials involving cryotherapy?
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