General Information

Cryosurgery is used as an adjunct to surgery. It is a specialized technique that only a handful of surgeons in the country know how to perform. It utilizes liquid nitrogen to freeze a tumor cavity to sub zero temperatures in order to kill microscopic tumor cells and reduce the chances of the tumor coming back. It is used most commonly for benign aggressive tumors (giant cell tumor, aneurysmal bone cysts, chondroblastoma, chondromyxofibroma, desmoplastic fibroma, osteoblastoma) and for low grade cartilage tumors (chondrosarcomas) and chordomas of the sacrum. In general, these tumors are curetted (scooped out from the bone). If just scooped out of the bone, there is a 30%-70% chance of the tumor returning and causing more destruction of the bone potentially requiring removal of the bone and reconstruction with a prosthesis or even occasionally requiring an amputation. Once a tumor comes back once, it may come back multiple times.

Book Chapters

From Musculoskeletal Cancer Surgery by Martin M. Malawer and Paul H. Sugarbaker Kluwer Academic Publishers 2001 Ch. 6: The biology and role of cryosurgery in the treatment of bone tumors

Papers And Publications

Role of adjuvant cryosurgery in intralesional treatment of sacral tumors

Cancer. 2003 Jun 1;97(11):2830-8
Kollender Y, Meller I, Bickels J, Flusser G, Issakov J, Merimsky O, Marouani N, Nirkin A, Weinbroum AA

BACKGROUND: Cryosurgery is an adjuvant surgical technique for the treatment of benign aggressive, low-grade malignant and metastatic tumors of long bones. It has been used rarely to treat sacral tumors, mainly because of potential damage to nerves, blood vessels, and intrapelvic organs. The authors described their experience with this procedure and provided medium and long-term follow-up results. METHODS: Fifteen procedures of cryosurgery of the sacrum were performed in 14 patients to improve the therapeutic outcome of a variety of tumors. The patient group included 7 males and 7 females with a mean age of 42 +/- 24 years. Three patients were younger than 20 years of age. The procedures were performed at the Tel Aviv Sourasky Medical Center between January 1991 and January 1999. There were seven benign aggressive lesions (four giant cell tumors and three aneurysmal bone cysts), one benign schwannoma, one low-grade chondrosarcoma, five metastatic carcinomas, and one high-grade Ewing sarcoma, all localized at level S(2) or higher. Eight of the bone tumors also involved significant anterior or posterior soft tissue. All patients had severe preoperative pain radiating to the buttocks, perineum, and lower limbs and 9 (64%) patients had bladder and/or rectal dysfunction. Invasive diagnostic procedures and radiation (if warranted) preceded surgery. Sacral posterior fenestration and burr drilling were followed by two-cycle cryosurgery using the open pour technique or the argon-helium-based heat-freeze system. RESULTS: All interventions were performed under combined general and regional anesthesia and concluded uneventfully with moderate blood loss. Thirteen patients were discharged home after 8 +/- 5 days (one patient remained hospitalized for 30 days). Only two patients experienced local disease recurrence during a 3-11-year follow-up period: one was retreated successfully by cryosurgery and the other underwent sacrectomy and radiotherapy elsewhere, with a subsequent loss of visceral functions. No patient suffered chronic pain, deep wound infections, or significant neurologic deficits and all were satisfied with the esthetic outcome. CONCLUSIONS: Cryosurgery is a conservative, feasible, and safe adjuvant technique in the treatment of sacral tumors. It is associated with minimal permanent neurologic and vascular injury compared with sacrectomy. Copyright 2003 American Cancer Society. | DOWNLOAD FULL ARTICLE

Giant cell tumor of the hand: Superior results with curettage, cryosurgery, and cementation

J Hand Surg [Am] 2001 May; 26(3):546-55
Wittig JC, Simpson BM, Bickels J, Kellar-Graney KL, Malawer MM

At our institution giant cell tumors arising in all locations are treated with curettage, cryosurgery, and cementation to avoid resection or amputation, increase local tumor control over curettage alone, and avoid the morbidity associated with immobilization. We report the oncologic and functional results of 3 patients with giant cell tumors arising from the tubular bones of the hand who were treated in this manner. | DOWNLOAD FULL ARTICLE

Radiation therapy in the treatment of giant cell tumor of bone

Int J Radiat Oncol Biol Phys. 1999 Mar 15;43(5):1065-9
Nair MK, Jyothirmayi R.

PURPOSE: To assess the local control rate and potential complications of radiotherapy, and the factors influencing response to radiotherapy for primary and locally recurrent giant cell tumor of bone. METHODS AND MATERIALS: Twenty patients were irradiated for giant cell tumor of bone between 1983 and 1993. Fourteen patients received radiotherapy at the time of primary diagnosis (10 had biopsy and 4 partial surgery) and 6 patients at the time of local recurrence (following additional surgery in 2). Fourteen patients had tumors of the extremity and six of the vertebral column. The radiotherapy dose ranged from 40-60 Gy in 15-30 fractions over 3-6 weeks. The response to radiotherapy was assessed by clinical and radiological criteria and the probable factors influencing response were analyzed. RESULTS: The median follow-up period was 48 months (range, 4 months to 13 years). Local control was obtained in 18/20 patients. The two local failures were salvaged, one by reirradiation and the other by surgery. Only one patient died of giant cell tumor, following extensive bone marrow infiltration. There was no serious late toxicity or malignant transformation. The response to radiotherapy was not influenced by disease status at presentation, tumor site, radiotherapy schedule, or presence of soft tissue extension. CONCLUSIONS: Radiotherapy is effective in producing local control in primary as well as recurrent giant cell tumor of bone. There are no major complications and no significant risk of malignant transformation. Radiotherapy could be considered as the primary treatment modality in patients where surgery would produce functional deficits. | DOWNLOAD FULL ARTICLE

Cryosurgery in the treatment of giant cell tumor. A long-term followup study

Clin Orthop Relat Res. 1999 Feb;(359):176-88
Malawer MM, Bickels J, Meller I, Buch RG, Henshaw RM, Kollender Y

Between 1983 and 1993, 102 patients with giant cell tumor of bone were treated at three institutions. Sixteen patients (15.9%) presented with already having had local recurrence. All patients were treated with thorough curettage of the tumor, burr drilling of the tumor inner walls, and cryotherapy by direct pour technique using liquid nitrogen. The average followup was 6.5 years (range, 4-15 years). The rate of local recurrence in the 86 patients treated primarily with cryosurgery was 2.3% (two patients), and the overall recurrence rate was 7.9% (eight patients). Six of these patients were cured by cryosurgery and two underwent resection. Overall, 100 of 102 patients were cured with cryosurgery. Complications associated with cryosurgery included six (5.9%) pathologic fractures, three (2.9%) cases of partial skin necrosis, and two (1.9%) significant degenerative changes. Overall function was good to excellent in 94 patients (92.2%), moderate in seven patients (6.9%), and poor in one patient (0.9%). Cryosurgery has the advantages of joint preservation, excellent functional outcome, and low recurrence rate when compared with other joint preservation procedures. For these reasons, it is recommended as an adjuvant to curettage for most giant cell tumors of bone. | DOWNLOAD FULL ARTICLE

Conservative surgery for giant cell tumors of the sacrum. The role of cryosurgery as a supplement to curettage and partial excision

Cancer. 1994 Aug 15;74(4):1253-60
Marcove RC, Sheth DS, Brien EW, Huvos AG, Healey JH

BACKGROUND. Giant cell tumors (GCTs) of the sacrum are a difficult clinical problem. Wide excision (total sacrectomy) is associated with high morbidity and pelvic/spinal instability. Curettage with or without supplemental radiotherapy is associated with a high recurrence rate. In view of the proven effectiveness of cryosurgery as an adjunct to curettage for extremity GCT, cryosurgery was used for treatment of GCTs of the sacrum. METHODS. Seven patients with GCTs of the sacrum were treated at our institution by conservative surgery from 1973 to 1992. Four patients presented with recurrent tumors after failing previous radiation treatment (dose, 5040 cGy). Four patients were treated with curettage with cryosurgery and three with limited excision with cryosurgery. In the latter procedure after limited excision of the caudal (below S2) part of the tumor, the upper sacral segments were treated with curettage and cryosurgery. This spared the important upper sacral roots and maintained the skeletal integrity. RESULTS. At a median follow-up of 12.25 years (range, 2-14.2 years), all patients were disease free. Local recurrence developed in two patients. Both of these underwent repeat curettage and cryosurgery and have since remained disease free. Two patients had positive second look biopsy with microscopic tumor. Both of these were treated with repeat cryosurgery and have remained disease free. Two patient who developed solitary pulmonary metastases, underwent wedge resection and are alive without disease. No patient suffered neurologic deterioration. CONCLUSION. Conservative surgery (curettage or partial excision) with adjunct of cryosurgery is our preferred technique for the treatment of GCT of the sacrum. Satisfactory local control could be obtained by close observation, second look biopsy and repeat cryosurgery. The chief advantages of this method include preservation of pelvic and spinal continuity, speed and ease of surgical procedure and less potential blood loss. We recommend it over more radical sacrectomy due to low morbidity and less resultant neurologic deficits. | DOWNLOAD FULL ARTICLE

Cryosurgery and acrylic cementation as surgical adjuncts in the treatment of aggressive (benign) bone tumors. Analysis of 25 patients below the age of 21

Clin Orthop Relat Res. 1991 Jan;(262):42-57.
Malawer MM, Dunham W

This article reviews the clinical experience with cryosurgery (use of liquid nitrogen) and acrylic cementation (polymethylmethacrylate; PMMA) in the treatment of aggressive, benign bone sarcomas and the biologic basis of this technique. The results of 25 patients below the age of 21 treated by cryosurgery, with an average follow-up period of 60.8 months, are reported. Three approaches to surgical reconstruction were used: Group 1 (four patients) had cryosurgery with no reconstruction, Group 2 (13 patients) had bone graft reconstruction alone, and Group 3 (eight patients) had composite osteosynthesis with internal fixation, bone graft, and/or PMMA. The overall control rate was 96% (one recurrence). The tumor types were giant-cell tumor, chondroblastoma, aneurysmal bone cyst, and malignant giant-cell tumor. Nineteen lesions involved the lower extremity, and six lesions were located in the upper extremity. There were two secondary fractures (8%), one local flap necrosis, and one synovial fistula. There were no infections. Two epiphyseodeses were performed. The functional results were excellent (83%), good (13%), and fair (4%). The technique of composite osteosynthesis is recommended for all large tumors of the lower extremity. Cryosurgical results compare favorably with those obtained by en bloc resection and demonstrate the ability of cryosurgery to eradicate tumors while avoiding the need for extensive resections and reconstructive procedures. | DOWNLOAD FULL ARTICLE

Cryosurgical treatment of sacrococcygeal chordoma. Report of four cases

Cancer. 1986 Nov 15;58(10):2348-54
de Vries J, Oldhoff J, Hadders HN

Sacrococcygeal chordoma is a rare malignant neoplasm situated in a location adjacent to important structures. Distant metastases are usually rare and occur late. The treatment of choice usually consists of radical surgery, sometimes followed by radiotherapy. Extensive surgical resection is difficult and often causes bladder and/or bowel dysfunction, and the local recurrence rate remains high. In an attempt to diminish both risks, the authors introduced cryosurgery in situ as a new treatment modality for chordoma in the sacrococcygeal region. From 1974 to 1980, four patients (two male, two female) with sacrococcygeal chordoma were treated with cryosurgery without resection. Two patients had extensive tumors (greater than 10 cm) and could be treated only palliatively. Two other patients with smaller tumors (less than 10 cm) had radical cryosurgical treatment. Both patients are disease-free 10 and 7 years after cryosurgical treatment. One of the palliatively treated patients is alive with local recurrence 4 years after cryosurgery, the other died of tumor after 5 years. In a cryosurgical lesion, the tissue is completely devitalized; however, the architecture of the tissue in peripheral nerves, large vessels, and bone is preserved and remains as a perfect autograft. Frozen tissue is very susceptible to the hematogenous spread of infection. Therefore, infection prevention is of utmost importance. The authors believe that cryosurgery should have a place in the treatment of sacrococcygeal chordoma. | DOWNLOAD FULL ARTICLE

Cryosurgery in the treatment of giant cell tumors of bone: a report of 52 consecutive cases

Clin Orthop Relat Res. 1978 Jul-Aug;(134):275-89
Marcove RC, Weis LD, Vaghaiwalla MR, Pearson R

Fifty-two cases of giant cell tumor of bone have been treated by cryosurgery--an extensive freezing of residual tumor after curettage. Cryosurgery is performed by direct pouring of liquid nitrogen into the tumor cavity through a funnel. The cavity is filled with methylmethacrylate and corticocancellous onlay grafts until peripheral bone regeneration occurs to provide bone stability and prevent postoperative pathologic fracture. Patients with lesions in a weight bearing bone are placed in a long leg ischial weight bearing brace until sufficient healing has taken place. Rebiopsy (a second stage diagnostic procedure) is performed 3-6 months after the original cryosurgery. By comparison of pathology, results and complications between our first series of 25 cases and the additional 27, we have observed only one frank malignant giant cell tumor (1.9% incidence). This is much lower than the previously reported 16% fully malignant complication rate, and may be the result of the rapid elimination of the giant cell tumor by cryosurgery. | DOWNLOAD FULL ARTICLE

Videos

Dr. James Wittig narrates a video illustrating the surgical technique for resection of a sacrococcygeal chordoma, using cryosurgery as an adjuvant therapy. | WATCH VIDEO