CRYOSURGERY IN GYNEACOLOGY

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Department of Obstetrics Gyneacology
and Gynecological Oncology
St Alexander City Hospital
Kielce, Poland
CRYOSURGERY
IN
GYNECOLOGY
Kuwait City 10/24/2010
Wojciech Rokita MD, PhD
1
HISTORY OF CRYOSURGERY
ANCIENT EGYPT AND CLASSIC ANTIQUITY
• 3000 BC - the use of cold compresses to treat compound
skull fractures and infected wounds was mentioned in an
Egyptian papyrus [1]
• 5th century BC - Hippocrates advocating the use of cold to
control hemorrhages [2]
1.
BREASTED JH: The Edwin Smith surgical papyrus. Vol III. Chicago: University of Chicago,
Oriental Institute Publications, 1930,72-73
2.
DAWBER RPR: Cold kills! Cin Exp Dermatol 1988, 13, 137-150
2
THE 19th CENTURY
• 1845 - James Arnott - the first successful treatments of
advanced breast and uterine cancer with cold
(iced saline solutions)
BIRD HM: James Arnott, MD (Aberdeen) 1797-1883. A pionieer in refrigeration
analgesia. Anaesthesia 1949, 4, 10-17
3
THE ERA OF MODERN CRYOSURGERY
• 1961 - introduction of the first cryosurgical system capable
of delivering liquid nitrogen (-1960C) [1]
• 1967 - introducion cryosurgery as a method of treatment for
cervical intraepithelial neoplasia (CIN) [2]
1.
COOPER JS, LEE A: Cryostatic congelation: system for producting a limited controlled region of
cooling of freezing of biologic tissues. J Nerv Ment Dis 1961, 133, 259-263
2.
CRISP WE: Cryosurgery for gynecological malignancy. Obstet Gynecol 1967, 30, 551
4
THE ERA OF MODERN CRYOSURGERY
• 1967 -
cryoablation was used to treat the endometrium [1]
• April 2001 - Her Option Cryoablation Therapy System
was approved by FDA for endometrial ablation[2]
1.CAHAN WG, BROCKUNIER A: Cryosurgery of the uterine cavity. Am J Obstet Gynecol, 1967,
99(1), 138-153.
2.ROY KH, MATTOX JH: Advances in endometrial ablation. Obstet Gynecol Surv 2002, 87, 789-802.
5
PRINCIPLES OF CRYOSURGERY
JOULE-THOMSON EFFECT
•
adiobatic principle of gas expantion resulting in reduction
of
gas temperature
GARAMY G: Engineenring aspects of cryosurgery. In: Rand RW, Rinfret AP,
von Leden H eds. Cryosurgery. Springfield, IL: Charles C. Thomas, 1968, 92-132
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Cellular injury and cell death
temperatures of less than -200C are required for tissue necrosis [1]
•
• freezing of tissue results after formation of an iceball
• the cellular membranes are pierced by the ice crystals that form,
releasing the intracellular contents and causing vascular thrombosis
and microcirculatory failure anoxia and ischiemia [2]
1.
GAGE AA: What temperature is lethal for cells? J Dermatol Surg Oncol 1979, 5, 459-64
2.
DANIELS F: Some of the cryobiology behind cryosurgeryCutis 1975, 16, 421-4
7
Relevant cryotherapy temperatures
• Liquid nitrous oxide – boiling point (-195,8 0C)
• Nitrous oxide - boiling point (-89,50C )
• Carbon dioxide – boiling point (-78,5 0C)
• Nitrous oxide system – cryoprobe tip temperature (- 650C)
FERRIS DG, Ho JJ: Cryosurgical equipment: A critical review. J Fam Pract 1992, 35, 185-193
8
• Lethal zone (-20 0C isotherm)
• Recovery zone (0 0C isotherm)
9
10
Determinig freeze termination
• CIN 3 extends 5 mm deep into gland clefts
• Lethal zone extending 5 mm into epithelium is required
•
iceball should have a diameter 7 mm
ABDUL-KARIM FH, FU YS, REAGAN JW., WENTZ WB: Morphometric study of
intraepithelial neoplasia of the uterine cervix. Obstet Gynecol 1982, 60, 210-4.
11
Cryoprobe tips
• The shape of the cryoprobe determines the shape of the
cryoiceball with in tissue
• Poor contact between the cryoprobe surface and the cervical
epithelium may lead to treatmant failure
• A flat cryoprobe tip is less efficacious than a nipple or coneshaped probe tip
BOONSTRA H, KOUDSTAAL J, OOSTERHIUS JW. et al.: Analysis of cryolesionis in the uterine cervix:
application techniques, extension and failures. Obstet Gynecol 1990, 75, 232-9
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flat cryoprobe
Poland, Kielce 10/24/2010
nipple cryoprobe
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• flat cryoprobe
• conical cryoprobe
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Immunologic response
• Neoplasia with in the lethal zone is readily
destroyed by cryonecrosis
FERRIS DG, COX TJ, O’CONNOR DM et al. : Management of Lower Genital Tract Neoplasia in: Modern Colposcopy
Textbook and Atlas 2 nd ed. Ed. Ferris DG, Cox TJ, O’Connor DM, Wright CV, Foester J. Kendall/Hunt Publishning
Company, Dubuque, Iowa 2004, 579-662
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Immunologic response
• Tissue temporarily frozen in the recovery zone may
regress following cryotherapy through the actions of
the immune system
• After cryotherapy debulks a large central viral (HPV)
load the immune system may be better able to
eradicate a limited amound of surrounding low-grade
residual disease
FERRIS DG, COX TJ, O’CONNOR DM et al. : Management of Lower Genital Tract Neoplasia in: Modern
Colposcopy Textbook and Atlas 2 nd ed. Ed. Ferris DG, Cox TJ, O’Connor DM, Wright CV, Foester J.
Kendall/Hunt Publishning Company, Dubuque, Iowa 2004, 579-662
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CRYOSURGERY IN GYNECOLOGY
Introduction
CRYOSURGERY = CRYOTHERAPY = CRYOCAUTERY
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CRYOSURGERY IN GYNECOLOGY
Purpose
• To destroy pathologic tissues of the cervix, vagina, vulva
and endometrium by cryonecrosis
• Cryosurgery involves the freezing of lower genital tract
tissues using extremely cold gases (nitrous oxide, liquid
nitrogen, carbon dioxide)
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CRYOTHERAPY OF THE CERVIX
Objectives
• expose all CIN to lethal tissue temperatures
• destroy the entire transformation zone
• protect surrounding normal lower genital tract
tissue from thermal injury
19
Objectives
• minimize treatment side effects of patient
discomfort and complications of cervical stenosis
and infertility
• prevent the development of cervical cancer
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Cervical Ablation Triage Guidelines
• satisfactory colposcopic examination
• pathologic/colposcopic diagnosis agreement
• absence of endocervical canal neoplasia
• cervical cancer presence excluded
WRIGHT TC, COX TJ, MASSAD LS et al. : for the 2001 Consensus Guidelines for the Management of
Women with Cervical Intraepithelial Neoplasia. Am J Obstet Gynecol 2003, 189, 295-304
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satisfactory colposcopic examination
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absence of endocervical canal neoplasia
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cervical cancer presence excluded
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„Soft” indications
• recrruent cervicitis
• cervical erosion (ectropion)
25
„Soft” indications - prerequisites
• cytologic assessment (normal PAP smear)
• normal colposcopy
normal PAP smear is not sufficiently sensitive to
guarantee normalitiy
FERRIS DG, COX TJ, O’CONNOR DM et al. : Management of Lower Genital Tract Neoplasia in: Modern Colposcopy
Textbook and Atlas 2 nd ed. Ed. Ferris DG, Cox TJ, O’Connor DM, Wright CV, Foester J. Kendall/Hunt Publishning
Company, Dubuque, Iowa 2004, 579-662
26
recrruent cervicitis
27
cervical erosion (ectropion)
28
„Hard” indications
• cervical intraepithelial neoplasia (CIN 1-CIN 3))
• best for small lesions and LSIL (HPV/CIN1)
29
• advanced stages of cervical cancer for control of
bleeding while awaiting conventional therapy [1,2]
1.
LASH AF. The immediate control of hemorrhage from gynecologic malignancies by cryosurgery. Int J Gynecol Obstet
1972, 10, 72
2.
WRIGHT TC Jr, MASSAD LS, DUNTON CJ et al. 2006 consensus guidelines for the management of women with
cervical intraepithelial neoplasia or adenocarcinoma in situ. Am J Obstet Gynecol 2007, 197 (4), 340-5
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cervical intraepithelial neoplasia (CIN 1)
31
32
33
small lesions (CIN 2)
34
LSIL (HPV/CIN1)
35
cervical cancer for control of bleeding
36
„Hard” indications - prerequisites
• biopsy confirmed CIN lesion
• CIN on the ectocervix, no extention to the vagina and/or endocervix
• fully visible lesion margins
• minimal endocervical exstension (2-3 mm) of the transformation zone
SELLORS JW, SANKARANANAYANAN R. Treatment of cervical intraepithelial neoplasia by cryotherapy.
In: Colposcopy and treatment of cervical neoplasia: a beginner manual Lyon: International Agency for
Research on Cancer 2003, 95-102
37
„Hard” indications - prerequisites
• no evidence of invasive cancer or glandular involvement
• normal endocervix
• excellent probe – epithelium contact
• satisfactory iceball formation (3-4 mm beyond lesion margins)
• lesion adequately covered by cryoprobe tip of 25 mm diameter
SELLORS JW, SANKARANANAYANAN R. Treatment of cervical intraepithelial neoplasia by
cryotherapy. In: Colposcopy and treatment of cervical neoplasia: a beginner manual Lyon:
International Agency for Research on Cancer 2003, 95-102
38
Contraindications
• cervical cancer
• prior in-utero DES exposure
• pregnancy
• acute cervicitis
• menstruation
• persistent low-grade CIN after previous cryotherapy
KALSTONE C: Cervical stenosis in pregnancy: a complication of cryotherapy in diethylstilbestrolexposed women. Am J Obstet Gynecol 1992, 166, 502-3
39
Contraindications
cervical cancer
40
Contraindications
acute cervicitis
41
Contraindications
menstruation
42
Contraindications
persistent low-grade CIN after previous cryotherapy
43
Contraindications
• cryoglobulinemia
• positive endocervical curettage
• unsatisfactory colposcopic examination
• large cervical lesion
• lesions extending into endocervical canal
• lesions with irregular surface contur
SELLORS JW, SANKARANANAYANAN R. Treatment of cervical intraepithelial neoplasia by cryotherapy. In:
Colposcopy and treatment of cervical neoplasia: a beginner manual Lyon: International Agency for Research on
Cancer 2003, 95-102
44
Contraindications
lesions extending into endocervical canal
45
45
Contraindications
lesions with irregular surface contur
46
Equipment and supplies
• cryogun (cryoprobe handling)
• large nitrous oxide tank with a pressure gauge
• various sizes and shapes of cryotips
• water-soluble lubricating gel
• vaginal speculum
SPITZER M, BROTZMAN GL, APGAR BS: Practical therapeutic options for treatment of cervical intraepithelial
neoplasia In: Colposcopy principles and practice An integral Textbook and Atlas ed. Spitzer M, Brotzman GL,
Apgar BS. WB Sanders Company Philadelphia, 2002, 447-462
47
Cryosurgical unit
48
Cryosurgical unit
49
Various cryoprobes
50
• colposcope
• 3% to 5% acetic acid
• vaginal wall retractors
• disinfectant for cryoprobes
• mobile cart
SPITZER M, BROTZMAN GL, APGAR BS: Practical therapeutic options for treatment of cervical intraepithelial
neoplasia In: Colposcopy principles and practice An integral Textbook and Atlas ed. Spitzer M, Brotzman GL,
Apgar BS. WB Sanders Company Philadelphia, 2002, 447-462
51
Technique
• select the best time to perform cryosurgery
• prepare check list prior to cryosurgery
• perform cryotherapy procedure
52
Check list prior to cryosurgery
• indications for the procedure
• contraindications
• Papanicolaou (Pap) smear report
• colposcopy report
• histopatology report (if treatment is for CIN)
• current or past medical or surgical history
SHAKUNTALA BALIGA B. Step by step cryosurgery of the cervix. In: Step by step Colposcopy,
Cryosurgery and LEEP. Jaypee Brothers Medical Pubishers (P) LTD. New Dheli 2008, 153-172
53
• history of allergies especially to analgetics and antibiotics
• proper counseling
• general and systemic examination performed
• informed written consent taken
• equipment and instruments checked (pressure in the gas
cylinder)
54
• prophylactic antibiotics started (if needed)
• patient is not constipated
• patient has evacuated her bladder
• change of clothes for patient, doctors and nurses
55
STEP BY STEP CRYOSURGERY OF THE CERVIX
• complete the check list
• position the patient in litothomy position
• insert an intravaginal speculum
• visualize the cervix (use a vaginal sidewall retractor)
• prevent inadvertent freezing of the vagina
56
• perform colposcopy
• record the findings by videocolposcope or photocolposcope
• select appropriate cryoprobe tip size and type
• check the tank presure (change the tank if pressure is less)
• check there is no leakage of gas
57
• moisten the probe tip with saline or lubricant gel
• position probe tip on cervix with tip at external os
• large transformation zone – treatment with ice ball overlapping
• confirm good contact of cryoprobe with the tissue
• activate the unit and start freeze the tissue
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overlapping technique of cryotherapy
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• continue freeze until at least a 7-10 mm ice ball is present
outside the probe (3-5 minutes)
• deactivate cryogun/cryounit
• remove the probe tip after complete thawing (4-15 minutes)
• examine the cervix for bleeding
60
• apply some xylocaine jelly to the introitus
• check the pulse and blood pressure of the patients
• apply a large sanitary napkin to the vulva
61
• record the details of the procedure
• fix the follow-up date and time
• decontaminate and clean the equipment
62
• A double freeze (freeze-thaw-freeze) treatment is more
effective than a single-freeze procedure
SCHANTZ A, THORMANN L: Cryosurgery for dysplasia of uterine ectocervix: a randomized stydy of the
efficacy of the single- and-double-freeze techniques. Acta Obstet Gynecol Scan 1984, 63, 417-20
63
Induction and defrost
• rapid freeze and a slow defrost is the most effective means
of inducing tissue damage
• slow freeze and rapid defrost technique is less effective
64
FOLLOW-UP
• several serial Pap smears (4 months intervals)
• colposcopy (after 4 and 12 months)
• DNA tests (99% negative predictive value)
65
Side effects and complications
• watery vaginal discharge (lasting 3-4 weeks)
• crampy uterine pain during cryotherapy
• injury or freezing of the proximal vagina
• heavy bleeding (rare)
• vasovagal episodes
HARPER DM, MAYEAUX EJ, DAALEMAN T et al.:The natural history of cervical cryosurgical
healing. J Fam Pract 2000, 49, 694-700
66
Side effects and complications
• postoperative infections (rare)
• cervical stenosis (moderate or clinically significant)
• cervical incompetence (extremly rare)
• paraceratosis (leucolpakia)
• inadequate treatment (persistent lesion)
HILLARD PA, BIRO FM, WILDEY L: Complications of cervical cryotherapy in adolescents. J Reprod
Med. 1991, 36, 711-6
67
OUTCOMES- AVERAGE CURE RATES
• 94% - CIN 1
• 93% - CIN 2
• 84% - CIN 3/CIS
FERRIS DG, CRAWLEY GR, BAXLEY EG ET AL.: Cryotherapy precision: Clinicians estimate of
cryosurgical ice ball lateral spread of freeze. Arch Fam Med 1993, 2, 269-75
68
OUTCOMES
69
OUTCOMES
70
OUTCOMES
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CRYOSURGERY IN GYNEACOLOGY

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