Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Belgrade, Serbia
Wednesday May 21st, 8.30 15.00
NON-MELANOMA SKIN CANCER: A HOLISTIC
APPROACH & STATE OF THE ART
Treatment of NMSC
Cryosurgery: when and how
Pasquali, Paola
Pius Hospital de Valls (TA)
Spain
MASTER CLASS
Belgrade, Serbia
Wednesday May 21st, 8.30 15.00
NON-MELANOMA SKIN CANCER: A HOLISTIC
APPROACH & STATE OF THE ART
Treatment of NMSC
Cryosurgery: when and how
Basic Concepts
C
R
Y
O
G
E
N
AIR
WATER
ICE
METAL
CRYOLESION
MECHANISM
DIRECT INJURY
VASCULAR INJURY
APOPTOSIS
IMMUNOLOGICAL
TIME of CYCLE
LOCATION
Extra- and
Intracellular ice
crystal formation
+ coagulation
necrosis
Freezing phase
Center of the
cryoinjury
Microcirculatory
failure+
Ischemic necrosis
Thawing phase
Periphery of the
cryoinjury
Cell death by
apoptosis
Up to 8 hours
after rewarming
Periphery of the
cryoinjury
T-cell response
mediated by
dendritic cells
Late event
Whole body
Pasquali P. Cryosurgery. In: Rigel D et al. (Eds.) Cancer of the Skin. 2nd Ed. 2011
Cryoimmunology
Tumor remains in situ upon cryosurgery procedure
After cryosurgical injury, there is release of tumoral
antigens
Tumoral antigens induce anti-tumoral response
First response is related to inflammation and it is a
short-lived, non-specific innate immune response
Balance between necrosis (inflammatory: neutrophils,
macrophages, and lymphocyte) and apoptosis (non
inflammatory)
Adaptive Immune
Response
1
.
Abs
5
. Cytotoxic
Tumor
CD8+ T-cell
IFN
TNF
IL-1
IL-6
2
.
Th1
Antige
ns
4
to lymph.
APC
s
(+ IL-12)
MHC
node
PMN
3
s
. Macrophag
es
Bcell
mature
APC
Blood
Vessel
Th2
TCR
TCell
Minimal
Consent forms
Non invasive imaging
Confirm diagnosis
Pre operative conditions
of relevance
Post operative cures
Pre operative
Equipment
General
Sterile gloves
Antiseptic agents
Local anesthesia and syringes
Minor surgery equipment with suture kit/set; curettes
Cauterizing agent
Biopsy jars
Specific
LN Storage and Withdrawal /Gloves/ Base
Units
Tips/Probes/Chambers
Others
Photographic camera
HFUS
Software
Hand-held unit
Techniques
OPEN
Flat lesions or elevated
Irregular surface
Large or small
Ideal for superficial BCC
CLOSE
Ideal for nodular tumors
INTRALESIONAL
Invasive
Needs US
For large
tumors/Metastasis
Indications
Cryobiopsy
Basal cell carcinoma: except
morpheiform/sclerodermiform/
not well defined margins
Squamous cells carcinoma:
Kerathoacantomas/Well to
moderately differentiated SCC
Palliative treatment
Cryobiopsy
Anatomical location
Ear
Nose
Eyelid
Earlobe
Eyelid
Nose
HFUS: 22 MHz
100
R 16 m
P 0.8-1.5 mm
Resolution 48 m
Resolution 210 m
Resolution 72 m
Penetration: 4-6 mm
Penetration: 8-10 mm
Resolution 31m Penetration: 50-70 mm
Penetration: 3-5 mm
Resolution 158 m
Penetration: 35 mm
Resolution 210 m
Penetration: 50-70 mm
Trans Cryosurgery
773x6133
797x 9767
1180 x 4767
IV
859x5400
523x8133
HHI Treatment
9 cm
Palliative treatment
Initial lesion
Segmental cryosurgery
Initial lesion
Final lesion
Freezing
spot
Fractional cryosurgery
After Goncalves JC. Fractional cryosurgery. A new technique for basal cell carcinomas of the eyelids and periorbital
area. Dermatol Surg 1997;23:475-481.
Cryoimmunology
C
R
Y
O
5 week imiquimod
Gaitanis G, Bassukas ID. Immunocryosurgery for non-superficial basal cell carcinoma: a prospective, openlabel phase III study for tumours 2 cm in diameter. Acta Derm Venereol. 2014 Jan;94(1):38-44.
Future considerations
Reflectance
Confocal
Microscopy
RCM is a noninvasive in vivo imaging technique
It relays on the natural variation of refractive indices in
tissue structures at different depths of the skin to
reconstruct the images.
In cryosurgery, it can be used a non-invasive
determination of lesion margins as well as a non-invasive
therapy monitoring
Optical Coherence
Tomography
OCT is a noninvasive in vivo imaging technique
OCT provides real-time, cross-sectional skin images to a depth
of up to 2 mm. It is based on an interferometric technique that
detects reflected or backscattered light from tissue
In cryosurgery, it can be used a non-invasive determination of
lesion margins as well as a non-invasive therapy monitoring
MASTER CLASS
Belgrade, Serbia
Wednesday May 21st, 8.30 15.00
NON-MELANOMA SKIN CANCER: A HOLISTIC
APPROACH & STATE OF THE ART
Treatment of NMSC
Cryosurgery: when and how
Pasquali Paola, MD
Pius Hospital de Valls (TA)
Spain
pasqualipaola@gmail.com