History of cryosurgery

Cryoablation and immune synergistic effect for lung cancer: A review

The preferred treatment for lung cancer is surgical resection, but a large number of patients are not suitable for surgical resection in clinic. CT-guided cryoablation and immunotherapy can play an important role in patients with advanced lung cancer who are ineligible for surgery. CT-guided cryoablation has been widely used in the clinical treatment of lung tumors due to its advantages of less trauma, fewer complications, significant efficacy and rapid recovery. Cryoablation can not only cause tumor necrosis and apoptosis, but also promote the release of tumor-derived autoantigens into the blood circulation, and stimulate the host immune system to produce a good anti-tumor immune effect against primary and metastatic tumors. Since the study of immune checkpoint inhibitors has proved that lung cancer can be an immunotherapeutic response disease, the relationship between cryoablation and immunotherapy of lung cancer has been paid more attention. Therefore, we reviewed the literature on cryoablation for lung cancer, as well as the research progress of cryoablation combined with immunotherapy.

Cryoablation Without Excision for Low-Risk Early-Stage Breast Cancer: 3-Year Interim Analysis of Ipsilateral Breast Tumor Recurrence in the ICE3 Trial

BACKGROUND

The ICE3 trial is designed to evaluate the safety and efficacy of breast cryoablation, enabling women older than 60 years with low-risk early-stage breast cancers to benefit from a nonsurgical treatment and to avoid the associated surgical risks.

METHODS

The ICE3 trial is a prospective, multi-center, single-arm, non-randomized trial including women age 60 years or older with unifocal, ultrasound-visible invasive ductal carcinoma size 1.5 cm or smaller and classified as low to intermediate grade, hormone receptor (HR)-positive, and human epidermal growth factor receptor 2 (HER2)-negative. Ipsilateral breast tumor recurrence (IBTR) at 5 years was the primary outcome. A 3-year interim analysis of IBTR was performed, and the IBTR probability was estimated using the Kaplan-Meier method.

RESULTS

Full eligibility for the study was met by 194 patients, who received successful cryoablation per protocol. The mean age was 75 years (range, 55-94 years). The mean tumor length was 8.1 mm (range, 8-14.9 mm), and the mean tumor width was 7.4 mm (range, 2.8-14 mm). During a mean follow-up period of 34.83 months, the IBTR rate was 2.06% (4/194 patients). Device-related adverse events were reported as mild in 18.4% and moderate in 2.4% of the patients. No severe device-related adverse events were reported. More than 95% of the patients and 98% of the physicians reported satisfaction with the cosmetic results at the clinical follow-up evaluation.

CONCLUSIONS

Breast cryoablation presents a promising alternative to surgery while offering the benefits of a minimally invasive procedure with minimal risks. Further study within a clinical trial or registry is needed to confirm cryoablation as a viable alternative to surgical excision for appropriately selected low-risk patients.

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

Future in regional anesthesia: new techniques and technological advancements

Regional anesthesia has a very interesting long history, initially preferred over general anesthesia because of safety concerns, then for a period general anesthesia became safer and was preferred. The use of innovative technologies such as ultrasound technology has made the blocks safer and successful by directly visualizing targeted nerves and the location of local anesthetics. With the wide use of ultrasound in the regional anesthesia field success rate of peripheral nerve blocks increased and novel blocks techniques developed. Moreover, new extended-release local anesthetic agents have begun to be promising time-efficient and longer duration of analgesia with a single injection. In this article, we attempt to summarize some of the novel block techniques, pharmacological agents, and new technologies in the field of regional anesthesia.

Does cryoneurolysis result in persistent motor deficits? A controlled study using a rat peroneal nerve injury model

BACKGROUND

Cryoneurolysis of peripheral nerves uses localised intense cold to induce a prolonged block over multiple weeks that has the promise of providing potent analgesia outlasting the duration of postoperative pain following surgery, as well as treat other acute and chronic pain states. However, it remains unclear whether persistent functional motor deficits remain following cryoneurolysis of mixed sensorimotor peripheral nerves, greatly limiting clinical application of this modality. To help inform future research, we used a rat peroneal nerve injury model to evaluate if cryoneurolysis results in persistent deficits in motor function.

METHODS

Male Lewis rats (n=30) had their common peroneal nerves exposed bilaterally at the proximal lateral margin of the knee and subsequently underwent cryoneurolysis on one limb and sham treatment on the contralateral limb. Outcomes were evaluated on days 3, 14, 30, 90 and 180. The primary end point was motor function, based on ankle dorsiflexion torque. In addition, sensory function was tested based on von Frey's filament sensitivity to the peroneal sensory distribution. A subset of animals was sacrificed following functional testing at each time point, and general tissue morphology, connective tissue deposition, and axon counts were evaluated.

RESULTS

Motor deficits in treated limbs were observed at 3 and 14 days but had resolved at time points beyond 1 month. Bilateral sensory deficits were also observed at 3 and 14 days, and also resolved within 1 month. Consistent with motor functional deficits, axon counts trended lower in treated nerves compared with contralateral controls at 3 days; however, axon counts were not significantly different at later time points.

CONCLUSIONS

When applied to a mixed sensorimotor nerve, cryoneurolysis did not result in persistent motor deficits.

Local Treatment of Breast Cancer Liver Metastasis

Breast cancer represents a leading cause of death worldwide. Despite the advances in systemic therapies, the prognosis for patients with breast cancer liver metastasis (BCLM) remains poor. Especially in case of failure or cessation of systemic treatments, surgical resection for BCLMs has been considered as the treatment standard despite a lack of robust evidence of benefit. However, due to the extent and location of disease and physical condition, the number of patients with BCLM who are eligible for surgery is limited. Palliative locoregional treatments of liver metastases (LM) include transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Percutaneous thermal ablation methods, such as radiofrequency ablation (RFA) and microwave ablation (MWA), are considered potentially curative local treatment options. They are less invasive, less expensive and have fewer contraindications and complication rates than surgery. Because conventional ultrasound- and computed tomography-guided single-probe thermal ablation is limited by tumor size, multi-probe stereotactic radiofrequency ablation (SRFA) with intraoperative image fusion for immediate, reliable judgment has been developed in order to treat large and multiple tumors within one session. This review focuses on the different minimally invasive local and locoregional treatment options for BCLM and attempts to describe their current and future role in the multidisciplinary treatment setting.

Novel Methodologies in Regional Anesthesia for Knee Arthroplasty

Maximizing analgesia is critical following joint arthroplasty because postoperative pain is a major barrier to adequate physical therapy. Continuous peripheral nerve blocks have been the mainstay for acute pain management in this population; however, this and similar techniques are limited by their duration of action. Cryoneurolysis and peripheral nerve stimulation are two methodologies used for decades to treat chronic pain. With the advent of portable ultrasound devices and percutaneous administration equipment, both procedures may now be suitable for treatment of acute pain. This article reviews these two modalities and their application to joint arthroplasty.

Primary cryotherapy for localised or locally advanced prostate cancer

BACKGROUND

Traditionally, radical prostatectomy and radiotherapy with or without androgen deprivation therapy have been the main treatment options to attempt to cure men with localised or locally advanced prostate cancer. Cryotherapy is an alternative option for treatment of prostate cancer that involves freezing of the whole prostate (whole gland therapy) or only the cancer (focal therapy), but it is unclear how effective this is in comparison to other treatments.

OBJECTIVES

To assess the effects of cryotherapy (whole gland or focal) compared with other interventions for primary treatment of clinically localised (cT1-T2) or locally-advanced (cT3) non-metastatic prostate cancer.

SEARCH METHODS

We updated a previously published Cochrane Review by performing a comprehensive search of multiple databases (CENTRAL, MEDLINE, EMBASE), clinical trial registries (ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform) and a grey literature repository (Grey Literature Report) up to 6 March 2018. We also searched the reference lists of other relevant publications and conference proceedings. We applied no language restrictions.

SELECTION CRITERIA

We included randomised or quasi-randomised trials comparing cryotherapy to other interventions for the primary treatment of prostate cancer.

DATA COLLECTION AND ANALYSIS

Two independent reviewers screened the literature, extracted data, and assessed risk of bias. We performed statistical analyses using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence (QoE) according to the GRADE approach.

MAIN RESULTS

We included only one comparison of whole gland cryotherapy versus external beam radiotherapy, which was informed by two trials with a total of 307 randomised participants. The median age of the included studies was around 70 years. The median follow-up of included studies ranged from 100 to 105 months.Primary outcomes: we are uncertain about the effect of whole gland cryotherapy compared to radiation therapy on time to death from prostate cancer; hazard ratio (HR) of 1.00 (95% confidence interval (CI) 0.11 to 9.45; 2 trials, 293 participants; very low QoE); this would correspond to zero fewer death from prostate cancer per 1000 men (95% CI 85 fewer to 520 more). We are equally uncertain about the effect of quality of life-related urinary function and bowel function (QoL) at 36 months using the UCLA-Prostate Cancer Index score for which higher values (range: 0 to 100) reflect better quality of life using minimal clinically important differences (MCID) of 8 and 7 points, respectively; mean difference (MD) of 4.4 (95% CI -6.5 to 15.3) and 4.0 (95% CI -73.96 to 81.96), respectively (1 trial, 195 participants; very low QoE). We are also uncertain about sexual function-related QoL using a MCID of 8 points; MD of -20.7 (95% CI -36.29 to -5.11; 1 trial, 195 participants; very low QoE). Lastly, we are uncertain of the risk for major adverse events; risk ratio (RR): 0.91 (95% CI 0.47 to 1.78; 2 trials, 293 participants; very low QoE); this corresponds to 10 fewer major adverse events per 1000 men (95% CI 58 fewer to 86 more).

SECONDARY OUTCOMES

we are very uncertain about the effects of cryotherapy on time to death from any cause (HR 0.99, 95% CI 0.05 to 18.79; 2 trials, 293 participants; very low QoE), and time to biochemical failure (HR 2.15, 95% CI 0.07 to 62.12; 2 trials, 293 participants; very low QoE). Rates of secondary interventions for treatment failure and minor adverse events were either not reported in the trials, or the data could not be used for analyses.We found no trials that compared whole gland cryotherapy or focal cryotherapy to other treatment forms such as radical surgery, active surveillance, watchful waiting or other forms of radiotherapy.

AUTHORS' CONCLUSIONS

Based on very low quality evidence, primary whole gland cryotherapy has uncertain effects on oncologic outcomes, QoL, and major adverse events compared to external beam radiotherapy. Reasons for downgrading the QoE included serious study limitations, indirectness due to the use of lower doses of radiation in the comparison group than currently recommended, and serious or very serious imprecision.

Ablative techniques for the treatment of benign and malignant breast tumours

Minimally invasive techniques like high intensity focused ultrasound, radiofrequency ablation, cryo-ablation, laser ablation and microwave ablation have been used to treat both breast fibroadenomata and breast cancer as an alternative to surgical excision, potentially reducing the complications, improving cosmesis and reducing hospital stay. This review describes the most common minimally invasive techniques available, their history and some of the studies performed with these techniques in both benign and malignant lesions. In addition we described some of the difficulties of using these minimally invasive techniques such as optimization of anaesthesia, imaging and immobilisation in order to increase the complete histopathological ablation rates.

Ultrasound-guided percutaneous cryoneurolysis providing postoperative analgesia lasting many weeks following a single administration: a replacement for continuous peripheral nerve blocks?: a case report

Cryoneurolysis entails using low temperatures to reversibly ablate nerves, with a subsequent analgesia duration measured in weeks or months. Previously, clinical applications for acute pain were limited because treatment originally required exposing the target nerve surgically. However, three developments have now made it possible to provide prolonged postoperative analgesia by cryoneurolysis: 1) new portable, hand-held cryoneurolysis devices, 2) ultrasound machine proliferation, and, 3) anesthesiologists trained in ultrasound-guided peripheral nerve block administration. This report is the first to describe the use of a single preoperative administration of ultrasound-guided percutaneous cryoneurolysis to provide multiple weeks of analgesia following shoulder rotator cuff repair and total knee arthroplasty. Considering the significant benefits of cryoanalgesia relative to continuous peripheral nerve blocks (e.g., lack of catheter/pump care, extremely long duration), this analgesic modality may be a practical alternative for the treatment of prolonged post-surgical pain in a select group of surgical patients.

CT guided cryoablation for locally recurrent or metastatic bone and soft tissue tumor: initial experience

Background

Historically, local control of recurrent sarcomas has been limited to radiotherapy when surgical re-resection is not feasible. For metastatic carcinomas to the bone or soft tissue, radiotherapy and some interventional radiology treatment along with other systemic therapies have been widely advocated due to the possibility of disseminated disease. These techniques are effective in alleviating pain and achieving local control for some tumor types, but it has not been effective for prolonged local control of most tumors. Recently, cryoablation has been reported to have satisfactory results in lung and liver carcinoma treatment. In this study, we analyzed the clinical outcome of CT-guided cryoablation for malignant bone and soft tissue tumors to elucidate potential problems associated with this procedure.

Methods

Since 2011, 11 CT-guided cryoablations in 9 patients were performed for locally recurrent or metastatic bone and soft tissue tumors (7 males and 2 females) at our institute. The patients’ average age was 74.8 years (range 61–86) and the median follow up period was 24.1 months (range 5–48). Histological diagnosis included renal cell carcinoma (n = 4), dedifferentiated liposarcoma (n = 2), myxofibrosarcoma (n = 2), chordoma (n = 1), hepatocellular carcinoma (n = 1), and thyroid carcinoma (n = 1). Cryoablation methods, clinical outcomes, complications, and oncological outcomes were analyzed.

Results

There were 5 recurrent tumors and 6 metastatic tumors, and all cases had contraindication to either surgery, chemotherapy or radiotherapy. Two and 3 cycles of cryoablation were performed for bone and soft tissue tumors, respectively. The average length of the procedure was 101.1 min (range 63–187), and the average number of probes was 2.4 (range 2–3). Complications included 1 case of urinary retention in a patient with sacral chordoma who underwent prior carbon ion radiotherapy, 1 transient femoral nerve palsy, and 1 minor wound complication. At the final follow up, 4 patients showed no evidence of disease, 2 were alive with disease, and 3 died of disease.

Conclusions

Reports regarding CT-guided cryoablation for musculoskeletal tumors are rare and the clinical outcomes have not been extensively studied. In our case series, CT-guided cryoablation had analgesic efficacy and there were no cases of local recurrence post procedure during the follow-up period. Although collection of further data regarding use of this technique is necessary, our data suggest that cryoablation is a promising option in medically inoperable musculoskeletal tumors.

Cryosurgery for Tumors — A Clinical Overview

Cryosurgery, a method of treating disease by the production of freezing temperatures in the tissue, is a useful technique for the treatment of tumors. When the modern era of cryosurgery began in the mid 1960's, the technique was used only for tumors easily accessible by direct observation or via endoscopy, such as those of the skin, oral cavity, and prostate gland. In general, the technique had limited usefulness in the next two decades. However, with the advent of intraoperative ultrasound as a method of monitoring the process of freezing and with the development of more effective cryosurgical apparatus, the cryosurgical treatment of tumors of the viscera and other deep tissues became practical in the 1990's. This review assesses the present day status of cryosurgery in the management of diverse tumors.

Intrarectal ice application prior to transrectal prostate biopsy: a prospective randomised trial accessing pain and collateral effects

Objectives

To analyze the efficacy of intrarectal ice application as an anesthetic method prior to transrectal ultrasound (TRUS) guided prostate biopsy.

Materials and Methods

A total of 120 consecutive men were included into the study prospectively. Patients were equally randomized as group 1 and 2 with 60 patients each. Ice was applied as an anesthetic method 5 minutes before procedure to the patients in group 1. Patients in group 2 were applied 10 ml of 2% lidocaine gel 10 minutes before procedure. Twelve core biopsy procedure was performed for all patients. The pain level was evaluated using a visual analogue scale (VAS).

Results

Median pain score was 3.5 (1-8) in group 1 and 5 (1-8) in group 2. There is significantly difference between groups regarding the mean sense of pain level during the procedure. (p=0.007) There was also no difference in complications between two groups about presence and duration of macroscopic hematuria and rectal bleeding.

Conclusions

Intrarectal ice application prior to TRUS prostate biopsy has an effect on reducing pain. Development of new techniques about cold effect or ice can make this method more useful and decrease complication rates.

Dystrophic calcification of the prostate after cryotherapy

We present a previously undocumented complication of dystrophic calcification of the prostate after cryotherapy. An 87-year-old male presented with recurrent lower urinary tract infections and was found to have an obstructing large calcified mass in the right lobe of the prostate. Subsequently, he underwent transurethral resection of the prostate (TURP) and bladder neck with laser lithotripsy to remove the calculus. We propose that chronic inflammation and necrosis of the prostate from cryotherapy resulted in dystrophic calcification of the prostate. As the use of cryotherapy for the treatment of localized prostate cancer continues to increase, it is important that clinicians be aware of this scenario and the technical challenges it poses.

Angiogenic effects of cryosurgery with liquid nitrogen on the normal skin of rats, through morphometric study

BACKGROUND

Cryosurgery is an efficient therapeutic technique used to treat benign and malignant cutaneous diseases. The primary active mechanism of cryosurgery is related to vascular effects on treated tissue. After a cryosurgical procedure, exuberant granulation tissue is formed at the injection site, probably as a result of angiogenic stimulation of the cryogen and inflammatory response, particularly in endothelial cells.

OBJECTIVE

To evaluate the angiogenic effects of freezing, as part of the phenomenon of healing rat skin subjected to previous injury.

METHODS

Two incisions were made in each of the twenty rats, which were divided randomly into two groups of ten. After 3 days, cryosurgery with liquid nitrogen was performed in one of incisions. The rats' samples were then collected, cut and stained to conduct histopathological examination, to assess the local angiogenesis in differing moments and situations.

RESULTS

It was possible to demonstrate that cryosurgery, in spite of promoting cell death and accentuated local inflammation soon after its application, induces quicker cell proliferation in the affected tissue and maintenance of this rate in a second phase, than in tissue healing without this procedure.

CONCLUSIONS

These findings, together with the knowledge that there is a direct relationship between mononuclear cells and neovascularization (the development of a rich system of new vessels in injury caused by cold), suggest that cryosurgery possesses angiogenic stimulus, even though complete healing takes longer to occur. The significance level for statistical tests was 5% (p<0,05).

Cryoablation of early-stage primary lung cancer

Worldwide, lung cancer is the most commonly diagnosed cancer, and lobectomy is the gold-standard treatment for early-stage non-small cell lung cancer (NSCLC). However, many patients are poor surgical candidates for various reasons. Recently, image-guided ablation is being used for lung tumors. Cryoablation has been applied for the treatment of cancer in various nonaerated organs; recently it has been adapted to the treatment of lung tumors. Since an ice ball can be detected by computed tomography (CT), cryoablation of lung tumors is performed under CT guidance. Its first clinical application was reported in 2005, and it has been reported to be feasible in a few studies. Minor complications occurred at a high frequency (up to 70.5%), but major complications were rare (up to 1%). The most common complication is pneumothorax, and most cases need no further intervention. Local efficacy depends on tumor size and presence of a thick vessel close to the tumor. Midterm survival after cryoablation is 77%–88% at 3 years in patients with early-stage NSCLC. Although surgery is the gold-standard treatment for such patients, the initial results of cryoablation are promising. In this paper, the current status of cryoablation for primary lung tumors is reviewed.

Ablation therapy for hepatocellular carcinoma: past, present and future perspectives

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide, and is most commonly found in the setting of liver cirrhosis. Treatment of HCC must consider both the tumors present, as well as the remaining dysfunctional liver that both hinders treatment and can produce additional HCC over time. Ablation is an evolving part of the multimodality treatment approach to HCC that can effectively destroy tumors while preserving surrounding liver parenchyma. New technologies have made ablation an indispensable tool in the treatment of all stages of HCC. This review presents the history, present technologies and future potential of ablation in the treatment of HCC.

Laser ablation and cryotherapy of melanoma metastases

Both laser therapy and cryotherapy have been used with good results in the ablation of cutaneous melanoma metastases. There is less literature evidence in support of cryotherapy. Carbon dioxide laser therapy is a simple, low cost, patient-friendly technique, effective for palliation of individual lesions. There is evidence of a more profound regional effect, with unexplained absences of recurrence at treated sites and reported complete remissions, which demands further investigation.

Review of the efficacy and safety of cryoablation for the treatment of small renal masses

PURPOSE

Small renal masses are increasingly being discovered incidentally on imaging for another reason. The standard of care of these masses involves excision by open or laparoscopic techniques. Recently, ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, have taken a more prominent role in the treatment algorithm of these masses. We evaluate the effectiveness and safety of cryoablation to treat renal tumours.

METHODS

A review of the literature was conducted. There was no language restriction. Studies were obtained from the following sources: the Cochrane Library, PUBMED, EMBASE and LILACS.

RESULTS

There was no clinical trial identified in the literature. Thus, we described the results from 23 case series and retrospective studies with a reasonable sample size (number of reported patients in each study ≥30), with a total of 2104 analyzed tumours from 2038 patients. There was wide variability in the outcomes reported, but success rates were generally good. Follow-up was generally short, but some series reported outcomes at 5 years. The most common complications reported were hemorrhage (some of the patients requiring transfusion), perinephric hematoma and urine leaks.

CONCLUSION

Cryoablation presents a feasible treatment for patients with small renal masses. Only short-term data are available and, as such, meaningful conclusions regarding long-term cancer control cannot be made. More rigorous studies are needed.

Cryotherapy and its applications in the management of urologic malignancies: a review of its use in prostate and renal cancers

Cryotherapy has been established as an ablative modality for the treatment of a wide range of malignancies. Being minimally invasive, it is associated with less morbidity than conventional extirpative surgical procedures. In recent years, it has been used with success for treating two of the common urologic malignancies, that is, prostate and renal cancer. In this review, we highlight the role of cryotherapy as a treatment modality, the proposed destructive mechanisms of action and the risks of its use in the management of prostate and renal malignancy.

EASL and mRECIST responses are independent predictors of survival in hepatocellular carcinoma patients treated with cryoablation

OBJECTIVE

The aim of this study was to determine which response evaluation criteria will best help predict the treatment efficacy of cryoablation for hepatocellular carcinoma.

MATERIALS AND METHODS

We retrospectively analyzed clinical data of 64 patients with hepatocellular carcinoma treated with cryoablation. Triphasic helical computed tomography scans were analyzed on the basis of WHO, Response Evaluation Criteria In Solid Tumors 1.1 (RECIST 1.1), modified RECIST (mRECIST), and European Association for the Study of the Liver (EASL) guidelines. We assessed the concordance among response guidelines and selected the most reliable model depending upon the correlation with overall survival.

RESULTS

Both objective response rates and disease control rates were higher for mRECIST and EASL than for WHO and RECIST 1.1 for both overall responses and target responses. The κ-value of comparisons between WHO and RECIST 1.1 and mRECIST and EASL was not more than 0.20 for both overall responses and target responses. There was consistency between WHO and RECIST 1.1 [κ=0.82, 95% confidence interval (CI): 0.72-0.91 for overall responses and κ=0.87; 95% CI, 0.76-0.94 for target responses], the same as that between mRECIST and EASL (κ=0.91, 95% CI, 0.73-0.98 for overall responses and κ=0.88, 95% CI, 0.72-0.95 for target responses). There was no significant association with survival for WHO and RECIST 1.1 responses or all target responses. The Cox-regression model showed that both mRECIST and EASL were independent predictors of overall survival, with a 51% risk reduction for mRECIST and a 61% risk reduction for EASL.

CONCLUSION

The enhancement models including mRECIST and EASL guidelines should be used in preference to WHO, RECIST 1.1, or target responses to assess the efficacy of cryotherapy.

Image-guided thermal ablation of lung malignancies

Primary and secondary lung malignancies are often treated with surgery. Many patients are poor surgical candidates owing to advanced age or medical comorbidities. Alternatives to surgery for localized disease include radiation therapy and the newer treatments known as image-guided thermal ablation. Image-guided thermal ablation involves the use of needlelike applicators that are placed directly into tumors by using imaging guidance. Tumors are destroyed by the application of either intense heat or cold. The specific ablative modalities of radiofrequency ablation, microwave ablation, laser ablation, and cryoablation are reviewed with respect to the various clinical indications for treatment of both primary and secondary lung malignancies.

Cryoimmunology for malignant bone and soft-tissue tumors

Several new methods have recently been developed for the treatment of malignant bone and soft-tissue tumors, and many of these targeted therapies have yielded promising initial results in clinical settings. As more sarcomas become amenable to effective molecular-targeting therapy, the need to evaluate the synergistic effects of combination therapies with anticancer drugs will grow. Other immunologic therapies have also been reported, such as exogenous cytokines, dendritic cell (DC) therapy and peptide vaccines. Cryoimmunology has shown promising results in some malignant tumors after cryosurgery and is expected to influence the next generation of tumor immunotherapy. In this report, we describe the induction of a systemic antitumor immune response following liquid nitrogen cryotreatment of a destructive murine osteosarcoma. Combining tumor cryotreatment with DCs to promote tumor-specific immune responses enhanced systemic immune responses and inhibited metastatic tumor growth. We also describe the induction of a systemic antitumor immune response following reconstruction for malignant bone tumors using frozen autografts treated with liquid nitrogen.

Regulatory T cells are associated with post-cryoablation prognosis in patients with hepatitis B virus-related hepatocellular carcinoma

BACKGROUND

We carried out this study to evaluate the association between regulatory T cells (Treg) and prognosis and progression after cryoablation in patients with hepatitis-B virus-related hepatocellular carcinoma.

METHODS

Peripheral Treg frequency in 111 patients with hepatocellular carcinoma (HCC) was detected by flow cytometry. Treg frequency and function were re-examined during patient follow up. A possible association between Treg and α-fetoprotein (AFP) was also analyzed, and the distribution of resident CD4(+) and CD8(+) T cells and FoxP3(+) T cells in the liver tissue of patients with HCC was examined by immunohistochemistry.

RESULTS

Treg frequency significantly increased with disease progression. Our longitudinal study showed that Treg frequency had significantly decreased in 17 patients with HCC regression following cryoablation, but the frequency had dramatically increased in 14 patients with HCC recurrence or progression. Furthermore, AFP levels varied in a way comparable with Treg frequency in patients with elevated AFP recorded before therapy. Significantly increased suppressive effects of Treg on proliferation and cytokine secretion of CD8(+) and CD4(+) T cells were observed during follow up in patients with tumor progression, but not in patients with tumor response. Moreover, the numbers of CD8(+), CD4(+), and FoxP3(+) cells infiltrating the tumors around the cryotherapeutic zones were significantly decreased after argon-helium cryoablation, and this was associated with a reduction in the FoxP3/CD8 ratio. Importantly,increased quantities of circulating CD4(+)CD25(+)FoxP3(+) Treg and tumor infiltrating FoxP3(+) cells before cryoablation were associated with high recurrence or risk of progression in HCC patients after cryoablation.

CONCLUSIONS

Treg variation is associated with tumor regression or progression in HCC following cryoablation and may be used as a marker to estimate HCC progression.

Innovative therapy of cutaneous T-cell lymphoma: beyond psoralen and ultraviolet light and nitrogen mustard

Cutaneous T-cell lymphoma is a malignancy of skin-homing T cells. This unique population of lymphocytes requires alternative therapies to those used in nodal lymphomas. Although phototherapy and nitrogen mustard have been standard treatments for decades, newer therapies have been arriving with increased frequency. Moreover, some therapies, currently used to treat other diseases, have been used with good effect. These innovative therapies are discussed, with review of current data and examples of how these therapies may be used today.

Is there an optimal management for localized prostate cancer?

Widespread screening with prostate-specific antigen (PSA) has led to a significant increase in the detection of early stage, clinically localized prostate cancer (CaP). Various treatment options for localized CaP are discussed in this review article including active surveillance, radical prostatectomy, radiation therapy, and cryotherapy. The paucity of high-level evidence adds a considerable amount of controversy when choosing the "optimal" intervention, for both the treating physician and the patient. The long time course of CaP intervention outcomes, combined with continuing modifications in treatments, further complicate the matter. Lacking randomized trials that compare treatment options, this review article attempts to summarize the different treatment options and associated side-effects, including effects on health-related quality of life, from current published literature.

Hepatic tumor ablation

Ablation of liver tumors is part of a multimodality liver-directed strategy in the treatment of various tumors. The goal of ablation is complete tumor destruction, and ultimately improvement of quality and quantity of life for the patient. Technology is evolving rapidly, with important improvements in efficacy. The current state of ablation technology and indications for ablation are described in this review.

Experimental cryosurgery investigations in vivo

Cryosurgery is the use of freezing temperatures to elicit an ablative response in a targeted tissue. This review provides a global overview of experimentation in vivo which has been the basis of advancement of this widely applied therapeutic option. The cellular and tissue-related events that underlie the mechanisms of destruction, including direct cell injury (cryolysis), vascular stasis, apoptosis and necrosis, are described and are related to the optimal methods of technique of freezing to achieve efficacious therapy. In vivo experiments with major organs, including wound healing, the putative immunological response following thawing, and the use of cryoadjunctive strategies to enhance cancer cell sensitivity to freezing, are described.

Lethal isotherms of cryoablation in a phantom study: effects of heat load, probe size, and number

PURPOSE

To assess the effects on the proportions of lethal ice (ie, colder than -30 degrees C) in phantoms with different heat loads created by varying the size and number of cryoprobes spaced 2 cm apart.

MATERIALS AND METHODS

Thermocouples at 0.5-, 1.0-, and 1.5-cm intervals from 1.7- or 2.4-mm-diameter cryoprobes were held by jigs accommodating a maximum of four cryoprobes. Agar phantoms (N = 24) used three sets of baseline temperatures: approximately 6 degrees C, 24 degrees C, and 39 degrees C. Temperatures during 15-minute freeze cycles were correlated with actual thermocouple locations seen within the ice by computed tomography (CT). Diameters and surface areas of the -30 degrees C lethal isotherm were assessed over time as percentages of the overall ice ball.

RESULTS

The high-heat load phantom experiments (39 degrees C) showed the greatest impact on lethal zones by percentage for all probe configurations. At 15 minutes, single-, double-, triple-, and quadruple-probe arrangements of 2.4-mm cryoprobes had average lethal ice diameters of 1.2, 3.3, 4.1, and 4.9 cm, respectively, comprising 13%, 46%, 51%, and 56% surface areas of lethal ice, respectively. Surface areas and diameters of lethal ice made by 1.7-mm cryoprobes were 71% and 84% of those made by 2.4-mm cryoprobes, respectively. Lethal ice resides less than 1 cm behind the leading edge for nearly all probe configurations and heat loads.

CONCLUSIONS

Single cryoprobes create very low percentages of lethal ice. Multiple cryoprobes overcome the high heat load of body temperature phantoms and help compensate for the lower freeze capacity of thinner cryoprobes.

Update on cryotherapy for localized prostate cancer

Stage migration has led to an increased incidence of localized and low-risk prostate cancer. Intermediate-term data are emerging on the efficacy of cryotherapy, but direct comparison to other therapeutic modalities is difficult as the parameters for recurrence are not well defined. Studies using the American Society for Therapeutic Radiation and Oncology and the Phoenix (nadir plus 2) criteria for biochemical recurrence show that primary cryotherapy appears to be comparable for low-risk prostate cancer as other treatment modalities. In addition, health-related quality-of-life measures have improved with the most recent third-generation systems demonstrating low incontinence and urethrorectal fistula rates. Erectile dysfunction is high with whole gland ablation, but focal therapy may reduce these rates while still ablating unilateral cancerous tissue. Prostate cryotherapy for localized prostate cancer is an evolving but viable therapeutic option. Long-term data are still needed to establish a definitive role for cryosurgery in prostate cancer treatment.

Endoscopic cryosurgery of the thyroid and parathyroid

In this study we looked at the efficacy of cryosurgery for thyroid and parathyroid tissue ablation in the porcine model. An endoscopic neck approach was successfully used in six 25 kg pigs. T4, free T4 and calcium serum levels were measured pre- and post-operatively. Gross and histologic examination of the glands and surrounding tissue were performed on postoperative Day 40. Postoperative T4, free T4 and calcium levels were not significantly different from preoperative values. Gross examination of the thyroid showed scar tissue in the region that underwent cryosurgery. Parathyroid that was frozen was replaced by scar tissue. Histologic examination of the glands confirmed the gross findings. Trachea, vagus nerve and carotid artery were also resected, and no changes were noted on histological examination. There was no damage to the surrounding tissues after cryosurgery. Directed cryosurgery of the thyroid and parathyroid is safe and feasible in this model.

Temperature mapping of thermal ablation using MRI

MRI is a unique tool for minimally invasive thermal ablation in that it can provide both targeting, monitoring and control during the procedure. Monitoring is achieved by using MRI temperature mapping. In this review the relevant physics is explained as a background to the state-of-the-art methods for computing temperature maps as well as the more cutting edge methods. The review covers both methods to monitor heating and cooling of tissue and explains temperature mapping using Proton Resonance Frequency shift, T1 mapping, diffusion mapping, R2* mapping and thermal models.