Is cryotherapy effective for basal cell carcinoma (BCC)?

Cryotherapy for Basal Cell Carcinoma

Cryotherapy should be reserved only for low-risk, superficial basal cell carcinomas when surgery or radiation therapy is contraindicated or impractical, as it has inferior cure rates and significantly worse cosmetic outcomes compared to surgical options. 1

Key Recommendation from Guidelines

The NCCN explicitly states that superficial therapies including cryotherapy should be reserved for patients for whom surgery or radiation therapy is contraindicated or impractical, because cure rates may be lower. 1

Efficacy Data

Recurrence Rates

• Prospective trials show highly variable recurrence rates ranging from 5% to 39% for cryotherapy-treated BCCs 1
• Systematic reviews of historical data report recurrence rates from 0% to 13%, with pooled mean recurrence rates of 3-4% 1
• The wide variability is attributed to patient selection, inconsistent follow-up durations, differences in technique, and operator skill 1
• One exceptional retrospective series by a single expert clinician reported a 99% 5-year cure rate in 415 BCCs, but this is not representative of typical practice 1

Comparison to Other Modalities

• Cryotherapy has similar efficacy to photodynamic therapy (PDT) but significantly worse cosmetic outcomes 1
• In a randomized trial comparing cryotherapy to PDT, the 5-year recurrence rate was 20% for cryotherapy versus similar rates for PDT, but excellent cosmetic outcomes occurred in only 16% with cryotherapy versus 61% with PDT (P=0.00078) 1
• Cryotherapy is inferior to radiation therapy in terms of recurrence rates 2

Appropriate Patient Selection

Low-Risk BCC Only

• Cryotherapy is most useful for low-risk, superficial BCCs on the trunk or extremities 1
• Double freeze-thaw cycles are generally recommended for facial BCCs, while superficial truncal lesions may require only a single treatment cycle 1

Contraindications

• High-risk BCCs should NOT be treated with cryotherapy alone 1
• Recurrent BCCs are poor candidates for cryotherapy 1
• Facial lesions have higher failure rates compared to trunk and limb sites 1

Expert Hands Exception

• In expert hands, cryotherapy combined with curettage may have a role for selected high-risk lesions, with one study reporting 8% recurrence at 5.2 years for 171 high-risk BCCs 1
• Selected periocular BCCs treated with double-cycle cryosurgery by experts showed 8% recurrence at 5 years, though careful lesion selection is crucial (excluding large size, morpheic histology, lid margin involvement) 1

Technical Considerations

Proper Technique Required

• Tissue temperatures of -50 to -60°C are required for adequate tumor destruction 1
• Double freeze-thaw cycles are standard for most BCCs 1
• Success relies heavily on careful lesion selection and operator experience 1

Major Limitations

Cosmetic Outcomes

• A key limitation of cryotherapy is poorer cosmetic outcomes compared with other treatment options, as demonstrated by prospective randomized trials 1
• Adverse cosmetic results include conjunctival hypertrophy and ectropion for periocular lesions, which may require corrective surgery 1

Lack of Histologic Confirmation

• Cryotherapy provides no tissue for confirming diagnosis or assessing adequacy of tumor removal 3

Clinical Algorithm

1. First, determine if the patient is a surgical candidate - if yes, surgery is preferred 1, 4, 5
2. If surgery/radiation contraindicated, assess BCC risk stratification:
   • Low-risk (small <2cm, well-defined, superficial, trunk/extremities): Consider cryotherapy as an option 1, 5
   • High-risk (≥2cm, poorly defined, facial, aggressive histology, recurrent): Do NOT use cryotherapy 1, 5
3. If proceeding with cryotherapy, ensure:
   • Operator has significant experience 1
   • Double freeze-thaw cycles to -50 to -60°C 1
   • Patient counseled about inferior cosmetic outcomes 1
   • Close follow-up for recurrence monitoring 1

Common Pitfalls to Avoid

• Do not use cryotherapy for nodular or infiltrative BCC subtypes - these require surgical excision 5, 6
• Do not use cryotherapy on facial high-risk lesions - recurrence rates are unacceptably high 1
• Do not assume all cryotherapy is equal - technique and operator skill dramatically affect outcomes 1
• Do not prioritize cosmesis over cure - if cosmetic outcome is important, choose PDT, imiquimod, or surgery instead 1