Keywords

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FormalPara Key Points

  • Cryosurgery stands as a treatment option for vascular lesions.

  • Correct selection of vascular lesions is essential to guarantee the best therapeutic and cosmetic results.

  • Contact technique is the best alternative, although spraying and tweezers can be used for selected lesions.

  • Imaging techniques such as dermoscopy, high-frequency ultrasound, and nuclear magnetic resonance with or without contrast provide essential information to help make the correct therapeutic decision.

1 Introduction

Vascular tissue is susceptible to temperatures. High temperatures cause vasodilation, and low temperatures cause vasoconstriction. Cryosurgical destruction of a vascular nest is possible as long as the tumor is correctly selected regarding location, growth, depth, and tumor histology.

Despite the advent of several ablative procedures such as radiofrequency or laser therapy, cryosurgery continues to occupy a very important position in the therapeutic armamentarium of a dermatologist. Cryotherapy is a simple, safe, and inexpensive office procedure for the treatment of various benign, premalignant, and well-circumscribed malignant tumors. It provides satisfactory cosmetic results with minimal complications as long as patients are correctly selected and treatment is undertaken by a trained and experienced dermatologist [1, 2].

2 The Why, Where, When, and How of Vascular Tumor Cryosurgery

2.1 Why

Vascular lesions are particularly susceptible to cryosurgical destruction. The first effect of cold on vessels is vasoconstriction and, with sufficient low temperature, stasis. At −15 and −40 °C, there will be endothelial damage. With thawing, microthrombi will form inside the vessels, and the subsequent edema and hyperemia will bring about tissue necrosis [3].

The size of the vessel and the speed of blood flow are crucial. Smaller blood vessels, with slow blood flow, are ideal for cryosurgical treatment and are relatively easy to be destroyed by sub-zero temperatures of −15 and −20 °C.

Once a vascular tumor is frozen, there will be a direct damage with cell necrosis that will occur mostly at the center of the lesion where the lower temperatures are achieved. Indirect cell damage occurs after cryoablation due to damage on blood vessels. A later cryosurgical event is thrombosis which is observed in all capillaries, arterioles and venules. Platelets become activated causing thrombus formation and subsequent ischemia. The vascular stasis results in further tissue damage post-cryoablation [4].

2.2 Where

2.2.1 Tumor Selection

Treatment of benign vascular neoplasms like hemangiomas has been a matter of controversies. The most common vascular lesions amenable to cryosurgical treatment are summarized in Table 12.1.

Table 12.1 Most common vascular lesions amenable to cryosurgical treatment
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In general, cryosurgery is best suited for patients with light skin and for treatment of lesions in non-hair-bearing areas of the body. Among the advantages, one can identify the following: (a) no need of injecting local anesthesia, (b) fast and safe, (c) low cost, and (d) no incision/no suture.

It is a treatment that can be repeated when necessary, and the postoperative care is relatively simple.

2.3 When

When dealing with vascular tumors, there are multiple noninvasive techniques that will help diagnose and decide which one is the most suitable technique [5]. The first important consideration is to have a diagnostic certainty. For instance, a nasal glioma mimicking a hemangioma [6] or a malignant melanoma can be mistaken for a pyogenic granuloma (Fig. 12.1a, b).

Fig. 12.1
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(a) A pyogenic granuloma. (b) A malignant melanoma

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2.3.1 Dermoscopy

Dermoscopy can be used for diagnostic purposes [7] as well as a follow-up to cryosurgical treatment. A dermoscopic picture of the lesion can be compared to the postsurgical image in order to determine the improvement by verifying the reduction in lesion or in vessels (Fig. 12.2).

Fig. 12.2
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A dermoscopic image of a capillary hemangioma taken before treatment (left column) and at control evaluation 1 month later. It puts into evidence the areas with fibrous tissue, the diminished number of capillaries, and the color difference

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2.3.2 Temperature Control

The surface temperature of a vascular lesion is usually higher by several degrees than body temperature. By measuring the tumor’s surface temperature before and after treatment, one can register improvement. After treatment, there should be fewer vessels present and therefore a lower temperature. An infrared technology or a temple touch thermometer will be sufficient to monitor the tissue temperature (Fig. 12.3).

Fig. 12.3
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A temple touch thermometer used to measure superficial temperature in capillary hemangiomas (Courtesy of and Copyright © 2014 Medline Industries, Inc.)

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2.3.3 High-Frequency Ultrasound/Doppler

Ultrasound (US), especially with a high-resolution transducer, has been advocated as useful in examining small and superficial soft tissue masses that are suggestive of hemangiomas or vascular malformations. Vascular tumor ultrasound stands as one of the easier and more universally practiced noninvasive techniques [8] that give information about size, shape, depth, and, more importantly, vascularity [9]. In addition, US will help differentiate between a cystic and a solid lesion. Doppler US will give information about the presence or absence of flow and the degree of vascularization (Fig. 12.4). The Doppler characteristics of vascular malformations are helpful in differentiating low- from high-flow vascular malformations [10]. The sonographic depiction of abundant low-flow vascular channels can be a predictor of the potential success of percutaneous sclerosis. In addition, US can be used to guide needle placement during percutaneous sclerosis in a combination treatment approach (cryosurgery plus infiltration).

Fig. 12.4
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Color Doppler analysis of the vascular mapping of a vascular malformation in the abdomen of a child

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2.3.4 CT Scan Angiography and Nuclear Magnetic Resonance Imaging

CT scan angiography is an imaging technique that combines a CT scan with an injection of contrast material to produce a picture of the vasculature of a tumor. It can help differentiate between a hemangioma and a vascular malformation [11]. A 3D reconstruction displays the total volume of the lesion as well as the thickness and number of vessels (Fig. 12.5). MR imaging with gadolinium contrast is the diagnostic modality of choice for large and deep lesions or for those where US has not been diagnostic [8]. Intravenous gadolinium helps differentiate between cystic or solid tumors and between venous and lymphatic malformations [12], allowing the determining of lesion size and number and size of vessels involved [13]. This information is necessary to determine the feasibility of cryosurgical treatment or the need to combine treatment modalities.

Fig. 12.5
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3D reconstruction of a CT scan done on a mixed capillary hemangioma in the frontal area of the same patient in Fig. 12.6

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2.3.5 Other Noninvasive Imaging Techniques: Reflectance Confocal Microscopy (RCM)

Confocal microscopy might be helpful in characterizing vascular lesions in vivo before cryosurgical treatment. There is good correlation between RCM morphology and established histopathology criteria for common vascular lesions such as pyogenic granuloma, capillary vascular malformations, and venous lakes [14].

2.4 How

2.4.1 The Rule of the 4 Ps

As a general rule for most vascular lesions, cryosurgical treatment is performed with probe or close technique, although there are conditions where spraying or tweezers can work as well. When using probes, there is a simple rule to follow called the 4P rule (probe, pressure, previously frozen probe, patience):

  • Probe: Blood is a warm liquid (around 38 ºC) that has a slightly higher temperature than the body. If a superficial freezing is performed, there will only be destruction of the most superficial skin structures, leaving the rest of the vessels untreated. Blood present in deeply seated vessels will keep the area warm. Therefore, the ideal treatment of vascular lesions is with probes (contact or close cryosurgery). Probes will freeze deeper at a constant low temperature. Metal probes limit the “heat sink” effect.

  • Pressure: Vascular tumors tend to be non-painful renitent tumors. They can be pressed, squeezing out some of the blood inside them. By doing so, the lesion’s temperature goes down (less blood, less temperature). Pressure minimizes blood flow. As the blood flow is reduced, local temperature will be lower and cryosurgical treatment more effective.

  • Previously frozen probe: A previously frozen probe sticks less to the surface. When treating vascular tumors, it is best to have the possibility of removing it fast from the skin surface. The reasons are (a) a sudden movement while doing the procedure from the patient or surgeon’s part could cause an accidental breaking of the vascular tissue and a profuse undesired bleeding (this is especially true when dealing with small children). (b) Once freezing has been completed, the probe has to be removed as soon as possible to avoid further freezing that could leave an undesired scar. In vascular tumors, there is no need to freeze margins above 1 mm.

  • Patience: Despite all precautions such as drying the surface and previously freezing the probe, probes can occasionally get stuck to the surface. Be patient: the need to remove the probe from the site should not tempt the surgeon to force it out because this will simply break the tissue. In the case of a vascular lesion, bleeding can become a real issue. If, in spite of these precautions, the probe cannot be removed, allowing some warm water to run over the probe will rapidly release it from the surface. Keep a cup with warm water at hand as a precaution at all times.

3 Capillary Hemangiomas

Capillary hemangiomas, also called strawberry or infantile hemangiomas, are sometimes classified as benign neoplasms or vascular hyperplasias. They are the most frequent benign tumors of infancy and are composed of proliferating endothelial-like cells. Clinically, they can present themselves as superficial, deep, or mixed hemangioma (Fig. 12.6a, b), with regard to the depth of the vascular nest within the skin. Superficial hemangioma are bright red and sometimes called strawberry tumors. Deep lesions are violaceous tumors covered with normal skin, and mixed lesions have the bright and granulous surface but tend to be elevated. Histopathologically, hemangiomas can present as well-circumscribed, densely packed endothelial cells and small vascular spaces. These tumors usually appear after 1–2 weeks of birth and begin a rapid process of growth that can last up to 6 months. They sometimes ulcerate in the process of growing. After the growth period, they begin a very slow involution period that can last up to 6–7 years. During this period, certain hemangiomas ulcerate. Therefore, ulceration can be a sign of both rapid growth or involution [15].

Fig. 12.6
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(a) A large frontal mixed capillary hemangioma ulcerated in the center. A combined treatment with steroid infiltration for the deep part of the lesion and close (probe) technique on the ulcerated superficial and medial part of the tumor. (b) A control image 3 years after treatment

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According to the American Academy of Dermatology, the goals in the management of hemangiomas are to prevent or reverse the complication of alarming hemangiomas, prevent permanent disfigurement, minimize psychosocial stress for patients and relatives, avoid aggressive and potentially unsightly procedures, and prevent or adequately treat ulceration, thereby minimizing scarring, infections, and pain [16].

Possible interventions are left for those rapidly growing hemangiomas, especially those in areas that put the child in danger, such as:

  • Tumors close to airways that can limit breathing capacity.

  • Bleeding tumors.

  • Tumors around eyelids that can cause occlusion amblyopia. This in turn can degenerate to irreversible loss of vision due to damage to ocular dominance columns during the critical period (first 2 years of life).

  • Large tumors which are causing irreversible damage.

  • Tumors in visible areas capable of affecting the social and emotional well-being of the child.

  • Tumors in genital areas that get easily irritated/ulcerated and cause discomfort.

Correct selection for lesions is indispensable [17]. Lesions that have begun spontaneous involution and are not putting the child in any risk are best left to regress spontaneously.

Hemangiomas involve a therapeutic challenge for dermatologists. About 10–20 % of these require active treatment due to functional interference and/or significant disfigurement [18]; cryosurgery today is still an alternative [19, 20] and often the method of choice [21–24]. Smaller lesions yield better results than larger ones [25]; genital and mucosal lesions yield excellent results from cryosurgical treatment [26].

Although there are many options available nowadays to treat hemangiomas, cryosurgery stands as an alternative [27] for its excellent results, simplicity of the procedure, quick application, and low cost [28, 29]. Each case should be studied carefully, and the best therapeutic alternative available should be offered.

Once decided that a hemangioma will be treated with cryosurgery, one suggestion is to have the caretaker bring the child in very hungry, with no recent meal in the stomach in order to avoid the possibility of having the child regurgitate during the procedure. Most important is the fact that babies feel comforted if fed immediately after the procedure and seem to forget about the stressful or uncomfortable surgical situation they have just been put through.

Local anesthesia (EMLA) can help, but make sure to remove and dry the surface very well before attempting to apply the probe; otherwise, there is a risk that it will get stuck to the skin. One cycle, with a previously frozen probe, applied with pressure for a few seconds (until the tumors turn completely white) is sufficient to destroy most superficial hemangioma vessels (Fig. 12.7a, b). Treat superficial capillary hemangiomas with one freeze-thaw cycle with a 1-mm margin with a precooled (previously frozen) probe (Fig. 12.8a–c). A mixed hemangioma will require combination treatments with cryosurgery and local infiltrations of depot steroid, and the freezing period will be longer. Extensively deep hemangioma should not be treated with cryosurgery.

Fig. 12.7
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(a) A superficial hemangioma on the left arm. (b) One single freeze-thaw cycle with close (probe) technique, with a precooled probe applied with pressure for few seconds

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Fig. 12.8
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(a) Large capillary hemangioma on the head of a child. (b) The lesion was treated with a precooled 2 cm flat probe, applied with pressure for a few seconds with one freeze-thaw cycle. (c) One month after treatment

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4 Cherry or Senile Angiomas

Cherry nevi need to be treated as infantile hemangiomas. Apply a precooled (previously frozen) probe with pressure. The probe has to match in size or be slightly smaller than the lesion. A few seconds are sufficient, and the freezing front should not expand more than 1 mm over the external lesion margin (Fig. 12.9a, b). Large lesions might require a second freeze cycle. For protruding lesions, cryotweezers can be an optional treatment (Fig. 12.10).

Fig. 12.9
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(a) A small cherry angioma treated with a 2 mm precooled flat probe with one freeze-thaw cycle. (b) One month post treatment

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Fig. 12.10
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A cherry angioma grasped with a cryotweezer. The freezing front will be allowed to reach just to the skin surface

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5 Vascular Malformations

The most common congenital vascular lesions are vascular malformations (VMs). These lesions are the outcome of errors in vascular formation during embryonic life. VMs do not proliferate. Nevertheless, the dilated blood vessels that build up these lesions gradually enlarge. VMs can be classified, based on the type of blood flow, into slow-flow (capillary, venous, lymphatic) lesions, high-flow (arterial) lesions, and combined slow-/fast-flow lesions (Fig. 12.11a, b). Based on the size of the lymph lumens, these lesions can be divided into microcystic lesions (previously termed lymphangiomas), macrocystic lesions (previously termed cystic hygromas), and a combined form [30].

Fig. 12.11
figure 11

(a) A mixed vascular malformation (capillary, venous, and arterial) in a type 3 skin patient. Treatment was done by a multidisciplinary team (vascular surgeons ligated the large feeding blood vessels, cryosurgeons froze the tumoral mass in the inner mucosa). (b) Cosmetic result after 6 months of treatments

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Hypertrophic capillary malformations can present large vascular “nodular” areas that can be treated as venous lakes (1–2 freeze-thaw cycle, previously frozen probe). For protruding lesions, cryotweezers can be an option (Fig. 12.12a, b).

Fig. 12.12
figure 12

(a) Hypertrophic capillary malformation in the face. (b) Cryotweezer treatment of nodular A component

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Large areas of hypertrophic tissue are of cosmetic concern to some patients. The result of dye laser treatment is usually unsatisfactory due to the thickness of the involved tissue. Large flat probes or door knob probes can be used to diminish such thickness in chosen areas of major concern.

Lymphangiomas and hemolymphangiomas as well as hypertrophic capillary malformations are suitable for cryosurgical treatment. Mucous lymphangiomas respond well to probe cryosurgery. In the skin, the presence of a moderate fibrous element makes them less responsive to treatment. Two or more treatments might be required (Fig. 12.13a, b). A combined excisional and cryosurgical approach is sometimes useful.

Fig. 12.13
figure 13

(a) Hemolymphangioma of the tongue. Multiple one freeze-thaw cycle separated into 4 week intervals. (b) Result after 4 sessions

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6 Pyogenic Granulomas

Pyogenic granulomas are very common lesions present at the site of superficial traumatisms in pregnant women and in small children, and it is considered by some as an excess growth of granulation tissue [31]. Some have a thrombosis of small superficial vessels that make it mandatory to rule out a nodular malignant melanoma.

Cryosurgery has been proven effective for treating pyogenic granulomas [32, 33]. Freezing has to include the whole lesion and extend up to 1 mm at the base. Treatment can be performed using a concave probe, ideal for large raised lesions of a size that fits the probe. One cycle is sufficient.

For small lesions, one cycle with a previously frozen probe or even a cryotweezer will do. For very large lesions, an excellent option is spray freezing from the center, allowing the freezing front to advance slowly down to the base. Once completely frozen, shaving can be done and the specimen can be sent for histologic examination. Before complete thawing, freeze the base where the feeding vessel emerges or apply a hemostatic solution. Make sure that, once complete thawing has occurred, there is no bleeding before covering the lesion (Fig. 12.14a–c).

Fig. 12.14
figure 14

(a) Large pyogenic granuloma on the finger tip. The lesion bled easily, and the patient was afraid to cut her fingernail. (b) One freeze-thaw cycle with open (spraying) technique from the center, allowing the freezing front to advance slowly until it reached the skin surface. (c) Shaving of the tumor while it was still frozen with no bleeding. A hemostatic solution was applied as thawing set in

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7 Venous Lakes

These lesions are superficial varicose veins that are present in actinically damaged skin. They are very frequent in older people and mostly present in the lips, oral mucosa, earlobes, and face. They are easily depressed, a sign that helps to confirm the diagnosis.

When lesions are 2–5 mm, they are easily treated by cryosurgery. For small lesions (2.3 mm), no local anesthesia is required. In larger ones, local anesthesia is an option. One cycle using a previously frozen probe of the correct size applied with pressure will be sufficient (approximately 10 s freezing) (Fig. 12.15).

Fig. 12.15
figure 15

Probe technique for venous lakes. The probe was precooled and applied with pressure. The finger was placed under the lesion and helped to keep the probe in place, assisted in pressuring the tumor toward the probe, and allowed for sensing that the freezing front was reaching the mucosa (“tattoo” formation)

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8 Spider Angiomas

These common vascular lesions are basically formed by a central arteriole that arises vertically from the dermis with many horizontal small branches.

Cryosurgery can be applied with a pointed probe. Some prefer to apply it without previously freezing the probe in order to be more precise in locating the fine point right in the central vessels. One cycle is sufficient (Fig. 12.16a, b). In recurrence, the procedure can be repeated.

Fig. 12.16
figure 16

(a) Spider telangiectasia in the lower eyelid. Treatment was performed with a sharp pointed probe, not precooled (in order to position it more precisely over the “head” of the telangiectasia), and applied with pressure for a few seconds. (b) One month posttreatment

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9 Angiokeratomas (AK)

For the four clinical types of acquired angiokeratomas (solitary or sporadic, of Fordyce, of Mibelli, corporis diffusum) [28] described, cryosurgery can be an option for the first three types. Angiokeratomas have in common dilated vessels located in the upper dermis and hyperkeratotic epidermis. In individual lesions, local thrombosis can give a black appearance that can mimic a malignant melanoma or vice versa. A confirmation of the diagnosis is mandatory.

A double freeze-thaw cycle with a previously frozen probe, fitting the lesion and applied with pressure, should be sufficient. For residual lesions, the procedure can be repeated (Fig. 12.17a, b). No local anesthesia is required.

Fig. 12.17
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(a) Multiple small angiokeratomas on the labia majora. (b) Two months after a one session treatment with a precooled probe (2 mm) applied with pressure. No topical or local anesthesia required

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10 Other Vascular Lesions

10.1 HIV-Related Kaposi Sarcoma

These lesions can be treated by performing two 30 s freeze-thaw cycles with 3-mm margins every 4 weeks. It is a treatment that should be reserved for unaesthetic lesions that persist after antiretroviral treatment, preferably in the upper part of the trunk, the arms, or the face. It can be done by spraying or probe; in the latter, protect the probe with a protective cover for ultrasound transducers or a “finger” cut out from a latex glove.

11 Postoperative Considerations

Once a vascular lesion has been treated with cryosurgery, the follow-up is relatively simple. Daily cleaning with water and soap is sufficient. For large tumors, it is recommended that you cover it right after cleaning because oozing can be copious. The only important consideration is concerning crust formation. The crust should never be removed after vascular tumor cryosurgery in order to avoid exposing vessels that could result in bleeding. Once the crust starts forming, the patient has to apply antibiotic ointment daily. For small children, it is convenient to keep the lesion covered in order to avoid accidental removal or infection.

Essential Tidbits

  • For vascular lesion treatment, abide by the 4P rule: probe, pressure, previously frozen probe, patience.

  • For probes stuck on the skin or mucosa, never use force. Let the thaw begin and remove gently. If necessary to unstick to avoid excessive freezing, let some warm water run over the probe until it thaws and detaches.

  • During postoperative care, never remove the crust. Let it fall off when dry.

12 Conclusions

Cryosurgery is an excellent alternative treatment in the management of the most common vascular tumors. Although many alternatives exist – lasers, surgery, topical and oral medication, and infiltration – some cases respond with just one single modality treatment, others require multiple sessions, and still others long periods of oral medication. In addition, combined vascular malformations tend to be difficult to treat and require a multidisciplinary approach.

In small superficial hemangiomas, cryosurgery stands as a fast, convenient, and inexpensive treatment that provides excellent results, with good medical and cosmetic outcomes, even with mild, superficial cryosurgery [22]. For pyogenic granulomas and spider angiomas, one single session is usually sufficient, while venous lakes can recur if a large feeding vessel is present.

Besides the expected edema, healing is fast and cosmetic results excellent. The speed of the procedure and the low cost are additional advantages.