118 Cryodestruction of regionally metastatic cutaneous melanoma (in-transit metastases) is effective therapeutic method in terms of survival: A series of cases report

Abstract

Introduction: Cutaneous melanoma of the limb, treated primarily with surgical resection and sentinel node biopsy followed by lymphadenctomy if necessary can recur as multiple in-transit metastases localised within the skin of the extremity. This feature means poor prognosis, although patients with such spread of disease still have a chance for a long-therm survival, so they should be treated further with curative intent. There are several options of treatment in this setting: surgical resection of small number of lesions or isolated limb perfusion in hiperthermia or even limb amputation in very select cases. There is some morbididity associated with each of the methods and melanoma usually continues to progress despite of therapy applied. Cryodestruction is a method which obtains good and sometimes excellent local control in this setting of recurrent melanoma. According to Neel (Vet Clin North Am 1980) cryoablation can stimulate immunological response against the antigens of tumor treated with this kind of therapy. Materials and methods: 3 patients treated previously with surgery and selective groin lymphadenectomy with in-transit metastases as recurent disease which occurred 6 and 12 months after first surgery within skin of lower extremities. The number of tumors was uncountable. There were no distant metastases found in imaging studies in any case tumors were treated with cryodestruction performed with Kriomed device (liquid nitrogen used as a cryogen). There were three freeze-thaw cycles performed for every tumor. Each freeze cycle lasted 60 seconds from the point when cryoprobe reached the temperature −180 °C to the point of 0 °C, the depth of freezing was not measured; thawing lasted until the temperature of cryoprobe reached the temperature of 36 °C. The probe was applied at room temperature in the first cycle, then 36 °C within the next two of three cycles. One of the patients was treated with our own method: hypothermic syringe cut and filled with 5–10 cm 2 of liquid nitrogen was placed with the opened end directly over the tumor allowing direct contact of the cryogen with tumors surface. Results: All of the metastases treated with cryosurgery were destroyed. Usually there were consecutive phases of edema and serous blister formation replaced by crust. In one patients we noticed disappearence of the tumors that were not treated with cryodestruction, as a symptom of systemic response to cryotherapy – this patient has stayed alive free of disease for 48 months. Overall survivall is 12–98 months. There were other recurrent tumors noticed during follow up control at two other patients, which were treated again with cryosurgery. None of the patients obtained systemic therapy (i.e. chemotherapy). There were no distant metastases in any case observed. There were no major comorbidities noted. Conclusions: Cryodestruction performed on patients with in transit metastases of skin melanoma can be an effective, cost-effective method of paliative treatment and allows good local control. Besides the direct ablative effect on frozen tissues there is perhaps another mechanism enhancing effectiveness of the method: stimulation of the immunological response due to presentation of the antigens of the cryodestroyed metastatic tumors. Source of funding: Own sources. Conflict of interest: None declared. rt@tarkowski.eu