CRYOSURGERY IN ORAL LESIONS - International Journal of Dermatology 1998;1998;37(4):283-285

Cleide Eiko Ishida, MD 1
Marcia Ramos-e-Silva, MD, PhD 2

From the Post Graduation Course in Dermatology and the Sector of Dermatology, HUCFF-UFRJ - School of Medicine, Federal University of Rio de Janeiro, Brazil.
1. Assistant Professor, Cryosurgery Supervisor.
2. Associate Professor, Oral Dermatology Supervisor.

Abstract: The authors discuss the use of cryosurgery in various types of oral lesions, such as fibroma, cheilitis, lichen planus, leukoplakia, keratoacanthoma, mucous cyst, angioma and pyogenic granuloma, among others. Their own experience is presented and they conclude that it is a very safe, efficient and easy technique to perform in this localization.
Key words: cryosurgery; mouth; therapeutics; ambulatory surgery.

Abstract:
Background: Cryosurgery is a therapeutical method sucessfully used for many cutaneous conditions. Its use is increasing for several conditions in the oral cavity.
Methods: Liquid nitrogen in spray technique or cryoprobe has been performed alone or associated to other surgical methods in various types of oral lesions, such as pyogenic granuloma, angioma, actinic cheilitis, keratoacantoma, fibroma, HPV lesions in HIV and non-HIV patients, hypertrophic lichen planus, leukoplakia and erythroplakia, verrucous carcinoma, mucous cyst, and papillary hyperplasia of the palate, among others.
Results: Our experience and the literature consulted has shown that cryosurgery is very useful for oral lesions. The oral mucosa, because of its characteristics of humidity and smoothness, is an ideal site for this technique. It shows a very good esthetic result and it may be either the first choice or an alternative option to conventional surgery.
Conclusions: Cryosurgery is a very safe, easy to perform, and relatively unexpensive technique for treating various oral lesions in an Out-Patient Clinic.
Key words: cryosurgery; mouth; therapeutics; ambulatory surgery.

The Egyptians were the first to use cold for trauma and inflammation. Hippocrates used it to stop hemorrhage and pain.1 In the last century, Baron Lorrey observed its utility in anesthesia and sedation for amputation in soldiers.1,2 Arnott used it for neuralgia and as a palliative for terminal cancer patients.1,2 Cailletet and Pictet obtained liquefaction of oxygen and carbon monoxide; and Dewar manufactured vacuum containers for cryogens. White is considered the first cryosurgeon, using freezing for warts, nevus, precancerous lesions and carcinoma.1 In the beginning of our century, Whitehouse developed the spray technique and Zacharian and Torres, in the sixties, developed liquid nitrogen spray equipments for various lesions, including neoplasms.1-3

Cryosurgery is a therapeutical method that uses freezing to obtain a tissular inflammatory and/or a destructive response, but in Dermatology it can be used for many conditions without necessarily provoking destruction of the tissues. There are various techniques, including direct contact, open atomization or spray, cone atomization and solid contact, with probe. Liquid nitrogen is the refrigerant of choice for dermatologic surgery because it is the coldest and most versatile, as well as it can give adequate lowering of temperature if malignant lesions are to be treated.

The general indications are benign, precancerous and malignant lesions, patients that use pacemaker, with high surgical risks, and anesthesia allergy. It also can be used as a palliative procedure for inoperable patients, for metastasis and for obstructive lesions.4 There are some contraindications, as cold intolerance, cold urticaria, cryoglobulinemia, agammaglobulinemia, dysfibrinogenemia, Raynaud's and collagen diseases, pyoderma gangrenosum, patients undergoing hemodialysis or immunosuppressive therapy, patients with platelet alterations or with multiple myeloma.5,6

Cold sensitivity varies. Melanocytes are the more susceptible cells, followed by basal cells, keratinocytes, bacteria, connective tissue, axon myelin sheath and virus.7 There are various mechanisms of action. The first is the direct or cellular effect, by intra and extracellular crystallization, consequently leading to rupture of cell membrane; intracellular dehydration by increase of hydroelectrolytic concentration; membrane, nuclear and mitochondrial lipoprotein denaturation; and cytoplasmic enzyme inhibition, producing metabolic alterations.7,8

Secondary or vascular effects are due to increase of vascular permeability; capillary liquid extravasation to the outside of the cell, resulting in capillary hemoconcentration; and microcirculation thrombosis, provoking isquemia and necrosis. It is also believed that there are immunological effects since this procedure could stimulate the host's immune system and there are reports of disappearance of distant metastasis after cryosurgery of the primary tumor.7,8

The complications can be immediate: pain during freezing, edema and exudation, vesicles and bullae, and frontal or temporal headache. The prolonged complications can be hyperpigmentation, milia, hypertrophic scars and neuropathy.9,10,11

The late are appearance of pseudoepitheliomatous hyperplasia, post surgical infection, fever, and pyogenic granuloma. There are also some permanent complications as hypopigmentation, atrophy, alopecia and ectropion, when performed near the eyes. 9,10,11

For mucosa, cryosurgery has been used by the stomatologist, gynecologist, ophthalmologist, proctologist and otorhinolaringologist.2,12 It is very useful for oral lesions, because of the characteristics of the oral mucosa. It is humid and smooth, so it is an ideal site for freezing.2

For this procedure we need good illumination with fluorescent lamp, vapor aspiration, and often association with other techniques, as shaving or radiosurgery. This way we can reduce the size of the lesion before cryosurgery, may have greater efficacy and also can obtain a specimen for histopathologic exam. Cryosurgery can be performed on the lips and on the anterior region of the mouth with or without anesthesia. There is a risk of ventilatory impairment when performed on the base of the tongue, posterior wall of the larynx and tonsils. And it is necessary to protect the openings of the salivary glands, the Wharton and the Stensen ducts, since there can be a sialoadenitis, usually transitory.13

Oral or intramuscular corticosteroid may be given prior to cryosurgery for reduction of edema, especially when performed on the tongue, floor and posterior region of the mouth.3,13 Main indications for benign lesions are angioma, lymphangioma, pyogenic granuloma, mucous cyst and HPV lesions.5,13

For precancerous lesions, it can be used in cheilitis, leukoplakia, lichen planus, nicotinic stomatitis and prosthetic hyperplasia of the palate. And for malignant lesions, the technique may be performed in carcinoma in situ, erythroplakia, oral florid papillomatosis and squamous cell carcinoma. The number of cycles and the time varies according to the severity of the lesion.13 Contact cryosurgery is preferred for deeper lesion and those with liquid content.

At the Out-Patient Clinics of Cryosurgery and of Oral Dermatology the method has been used very often for many different types of oral lesions. We have used it for pyogenic granuloma, angioma, actinic cheilitis, keratoacantoma, fibroma, HPV lesions in HIV and non-HIV patients hypertrophic lichen planus, leukoplakia and erythroplakia, verrucous carcinoma, mucous cyst, and papillary hyperplasia of the palate, with very good results.

Conclusion
Our experience has shown that cryosurgery is a safe and reatively unexpensive method for treating various oral lesions. A biopsy specimen can be obtained before the procedure and two or three freeze-thaw cycles may be necessary. The oral mucosa, because of its humidity and smoothness, is an ideal site for this technique.

REFERENCES
1. Dawber R, Colver G, Jackson A. Cutaneous cryosurgery. Principles and clinical practice. London:Martin Dunitz, 1992:1-5.
2. Shepherd J, Dawber RPR. The historical and scientific basis of cryosurgery. Clin Exp Dermatol 1982;7:321-8.
3. Kuflik EG. Cryosurgery updated. J Am Acad Dermatol 1994;31:925-44.
4. Kuflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York:Igaku-Shoin, 1990:237-42.
5. Graham GF. Cryosurgery for benign, premalignant and malignant lesions. In: Wheeland RG ed. Cutaneous Surgery. Philadelphia:WB Saunders, 1994:835-69.
6. Kuflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York:Igaku-Shoin, 1990:15-33.
7. Dawber R, Colver G, Jackson A. Cutaneous cryosurgery. Principles and clinical practice. London:Martin Dunitz, 1992:7-15.
8. Kuflik EG, Gage AA. Cryosurgical treatment of skin cancer. New York:Igaku-Shoin, 1990:35-51.
9. Torre D, Lubritz RR, Kuflik EG. Practical cutaneous cryosurgery. Connecticut:Appleton & Lange, 1988:51-60.
10. Dawber R, Colver G, Jackson A. Cutaneous cryosurgery. Principles and clinical practice. London:Martin Dunitz, 1992:139-53.
11. Faber WR. Side effects and complications in cryosurgery. Dermatol Monatsschr 1993;179:247-51.
12. Turjansky E, Stolar E. Lesiones de piel y mucosas. Técnicas terapéuticas. Buenos Aires:Edama, 1995:19-44.
13. Turjansky E, Stolar E. Lesiones de piel y mucosas. Técnicas terapéuticas. Buenos Aires:Edama, 1995:121-34.

Figure 1: Fibroma of the buccal mucosa
Figure 2: three weeks later
Figure 3: Actinic cheilitis
Figure 4: three months later
Figure 5: Keratoacanthoma of the lip
Figure 6: three months later