Palliative Treatment with Cryosurgery

Fig. 21.1

(a) A 92-year-old patient with a morpheiform basal cell carcinoma on the nose. The patient did not want Mohs surgery. A double freeze-thaw cycle with open technique (spraying). (b) Almost two years later, no recurrence

Since most large inoperable tumor masses are in older patients, it is not infrequent to have other underlying medical conditions which make alternative forms of therapy difficult or prevent them altogether. Some patients have lost the capacity to make decisions on their own; therefore, treatments have to be discussed with family or other caretakers.

Some tumors are life threatening per se or may be the cause of bothersome symptoms which include oozing, bleeding (Fig. 21.2a, b), pain, foul smell, and functional problems (like tumors located in anatomical areas that prevent the wearing of glasses, the use of hearing aid, the wearing of shoes, etc.). Sometimes tumors may give off unpleasant odors due to superinfection, causing social isolation from family, caretakers, and even pets [2].

Fig. 21.2

(a) Patient with dementia who lived in a nursing home. She presented a poorly differentiated squamous cell carcinoma that bled easily. Double freeze-thaw cycle with semi-open technique (cone) in one session. (b) After 2 months, there was tumor left but no bleeding. Cryosurgery was repeated

More than any other type of surgery, palliative treatment needs to focus on the patient’s or the caretaker’s expectations. Since suffering is the origin of consultation, reducing it becomes the final goal. False expectations can be a terrible blow even after a successful surgical treatment. Treatment needs to be tailored to the needs and expectations of the patient. Inoperable tumors require multidisciplinary approaches, and the team must include nurses and psychologists/psychiatrists, without losing sight at any moment the cultural aspects of the individual.

Most patients have gone through numerous surgeries, radiotherapy, and chemotherapy. Some are tired of treatments that have left them weaker, and others are just not willing to go through them for any number of reasons.

Cryosurgery stands as an excellent alternative [3, 4] that can be used alone or in combination with other treatment modalities [5]. It is safe and easily performed on bedridden patients or patients constrained to a wheelchair. One session is usually sufficient. This aspect is one of the strong points in favor of cryosurgery: the reduction of the need to move the patient from one place to another for numerous sessions (as required in radiotherapy).

21.2 When

Palliative treatment with cryosurgery is proposed when [6] (Table 21.1):

Table 21.1

Summary of the most frequent conditions under which palliation can be considered in order to alleviate symptoms

Related to the tumor

An actively growing tumor that could reach vital structures around the tumor

Pressure of the tumor on nearby structures producing discomfort and the need to assume antalgic positions

Pain caused by local destruction and disfigurement

Episodes of bleeding/oozing/secretions which tend to weaken the patient, stain clothing, require constant change of gauze, and risk bacterial infection

Infection of an exposed tumoral mass. Foul smell caused by local infection which can be severe and affect patient and caretakers. The impact on caretakers can in turn impact the patient’s well-being

Related to the patient

The patient’s underlying medical conditions are too risky for alternative therapies

Patients with underlying mental conditions make other therapeutic treatments difficult

The proposed alternative treatments are disfiguring and not accepted by the patient

Lack of response to other treatment modalities

The secondary effects of other treatments are not accepted by the patient

Patients refuse other treatment alternatives out of fear or due to advanced age

Related to the social environment

Not feasible to transfer the patient one or more times to obtain treatment in other centers

The patient’s underlying medical conditions are too risky for alternative therapies: this includes serious illnesses such as heart disease, chronic obstructive pulmonary disease, emphysema, kidney disease, or diabetes. Surgery of a large tumor in a patient with an underlying heart condition or coagulopathy can be a threat to his/her life.
Patients with underlying mental conditions that make surgical management or radiotherapy difficult (Fig. 21.3a, b).

Fig. 21.3

Patient in a nursing home with Alzheimer and confined to a wheelchair. (a) Large bleeding squamous cell carcinoma on the head which was treated in one session with a double freeze-thaw cycle semi-open technique (rubber cone) while sitting in a wheelchair. (b) One month after treatment. No recurrence 6 months later
The proposed alternative treatments are disfiguring and not accepted by the patient and/or family/caretakers (Fig. 21.4a, b).

Fig. 21.4

(a) Patient with a destructive basal cell carcinoma on the nose. He refused any other treatment modality. One session treatment with a double freeze-thaw cycle with open technique (spraying). (b) Five weeks later
The tumor(s) has/have not responded to other treatments, such as chemotherapy, radiotherapy, surgical treatment.
The secondary effects of other treatments are not accepted by the patient and/or caretakers.
Patients refuse other treatment alternatives out of fear, due to advanced age, or because of the impossibility or difficulty of transferring the patient from one center to another.

21.3 How

21.3.1 Spray or Open Technique

Spraying or open technique is probably the most utilized mode used to treat a large tumoral mass. Most palliative treatments are performed on protruding masses of irregular surface. Curetting down (debulking) is recommended [7] but is not always possible because it increases the risk of bleeding since most of these tumors are per se vascularized.

Spraying with large opening tips (0.8–1.0 mm) should be done from the center of the mass, allowing the freezing front to advance gradually toward the base of the tumor and expanding 0.5 cm or more toward the periphery. Depending on the size of the tumor, thawing can take a long time (over 30 min). Freezing should be repeated at least two times.

Allow for the complete postoperative process to occur and then repeat treatment over areas with residual tumor [8].

21.3.2 Semi-open or Cone Technique

Rubber cones are very useful to circumscribe freezing. They are commercially available in different sizes, up to 38 mm. The idea is to include the tumor and up to a 1 cm margin and spray the tumor until the whole area is frozen. The cone has to adhere to the skin surface in order to avoid liquid nitrogen (LN) leakage from the sides. Temperature at the margin should be on the order of −50 °C. A double freeze-thaw cycle is required.

Only gold members can continue reading. Log In or Register to continue