Experimental cryogenic injury of the palate: Observations pertinent to cryosurgical destruction of tumors

In experiments using cryosurgical apparatus to freeze the canine palate in situ, observations were made on techniques of producing tissue destruction. Several time-temperature schedules of freezing were studied. The results showed the great tolerance of palatal tissues to extremely low temperatures for short time periods. Melanocytes were extraordinarily sensitive to cold injury. Tissue necrosis increased with duration of freezing, but repeated freezing was lethal and obviously critical for successful cryosurgical destruction. Thermocouples must be used in clinical cryosurgery to insure that lethal tissue temperatures (colder than ?50 °C) are attained. The incidence of sequestration in the canine palate showed the need for use of proper technique and suitable precautions in the cryosurgical treatment of human palatal tumors.     

A call for more physiology at conservation conferences

Scientific conferences are more impactful when they foster novel ideas, create new networks, and promote inter-disciplinary collaboration. The field of conservation physiology is inherently cross-disciplinary, representing the application of physiological techniques and knowledge to address conservation issues. Ideally, knowledge transfer comes from both directions: conservation biologists seek input on physiological techniques that can contribute to the success of their programs, and physiologists collaborate with conservation biologists to plan relevant applications for their work. To assess whether the level of integration between conservation and physiology has been increasing since the formal naming of the discipline of conservation physiology in 2006, we reviewed abstracts from conferences of three societies: Society for Conservation Biology (SCB), Society for Integrative and Comparative Biology (SICB), and Society for Experimental Biology (SEB). Specifically, we searched for physiology-related keywords in abstracts from SCB meetings, and for conservation-related keywords in abstracts from SICB and SEB. Our results indicate that the percentage of presentations incorporating physiology at conservation meetings has remained relatively steady (2–3%). In contrast, the percentage of presentations citing conservation applications has been rising at both of the integrative biology societies’ meetings and has reached 4.4 and 7.9% at SICB and SEB, respectively. We provide suggestions for why there may be discrepancies between conference types and ways to encourage the presence of physiological topics at future conservation meetings.     

Advances in the design of special cryosurgical apparatus in China

Advances in the design of special cryobiomedical apparatus and a review of the trend of developments in the field of cryosurgery in China are discussed. The typical structure of two special cryoprobes for treatment deep in the body and the technology of designing these probes are presented in detail. Some cases which are treated successfully with the above cryoprobes will also be discussed. The experimental aspects of heat transfer in frozen tissue and of the temperature profiles both of a human brain during surgery and of the cryoprobe are described. Other improvements in the field of cryosurgical devices, e.g., four main ways of attaching freezing tips to cryoprobes during surgery and an LN2 transfer tube with high dexterity are also presented. Finally, the development of commercial cryosurgical apparatus in China is also discussed.     

An analytical study on the thermal effects of cryosurgery on selective cell destruction

The aim of cryosurgery is to kill cells within a closely defined region maintained at a predetermined low temperature. To effectively kill cells, it is important to be able to predict and control the cooling rate over some critical range of temperatures and freezing states in order to regulate the spatial extent of injury during any freeze-thaw protocol. The objective of manipulating the freezing parameters is to maximize the destruction of cancer cells within a defined spatial domain while minimizing cryoinjury to the surrounding healthy tissue. An analytical model has been developed to study the rate of cell destruction within a liver tumor undergoing a freeze-thaw cryosurgical process. Temperature transients in the tumor undergoing cryosurgery have been quantitatively investigated. The simulation is based on solving the transient bioheat equation using the finite volume scheme for a single or multiple-probe geometry. Simulated results show good agreement with experimental data obtained from in vivo clinical study. The calibrated model has been employed to study the effects of different freezing rates, freeze-thaw cycle(s), and multi-probe freezing on cell damage in a liver tumor. The effectiveness of each treatment protocol is estimated by generating the cell survival-volume signature and comparing the percentage of cell damaged within the ice-ball. Results from the model show that employing freeze-thaw cycles has the potential to enhance cell destruction within the cancerous tissue. Results from this study provide the basis for designing an optimized cryosurgical protocol which incorporates thermal effects and the extent of cell destruction within tumors.     

Long-term follow-up post-cryosurgery in a sheep breast model.

This study constitutes the advanced stage of an ongoing project for the development of cryosurgical devices and techniques for breast cryosurgery. The current study focuses on the long-term follow-up post-cryosurgery in a sheep breast model. Results of this study indicate that the cryotreatment site in a sheep breast model cannot be identified up to 5 months post-cryosurgery by means of ultrasound, mammography, or MRI. Histology findings of this study further indicate that there is no gross or microscopic difference between lesions that have been subject to one versus three freeze/thaw cycles. Under either cryosurgical protocol, there is a main cryoinjured region that has uniform destruction of epithelium and healing scar formation and a transition zone of damaged lobules without acini, surrounded by healthy tissues. The cryoinjured region at 5 months post-cryosurgery was found to be about half the diameter of the ultrasound-imaged frozen region during the cryoprocedure. This study shows that, in terms of recovery and regeneration, surgical excision appears to have an advantage over cryosurgery, which results in a more rapid healing process. Based on observations that the cryoinjured region is no smaller than the ultrasound-imaged ice-ball and that the typical thickness of the transition zone is up to 5 mm, a conservative use of the cryosurgical device developed for the current study in an ultrasound-monitored cryoprocedure requires at least 5 mm safety margins of the frozen region radius around the target region.     

Experimental cryosurgery on bone: A light and electron microscopical investigation

Three rabbits were treated with cryosurgery on the lateral surface of the mandible. Osteocytes with normal appearance were not detected in the cortex after 2 or 7 days following cryosurgery. In the marrow cavity, cells appeared more resistant and often showed a normal morphology as studied with both light and electron microscopy. The reason why cells survived in the marrow cavity is probably due to a combination of sheltering bone and the near proximity to an intact circulation due to a patent alveolar artery.The uncertain extension of the cold front beyond the cortex may indicate that cryosurgery alone is not suitable if a tumor has invaded the marrow cavity, while more superficially located tumors can be eradicated. However, tumor invasion itself destroys the cortex and thus the marrow cavity will be more readily exposed to the more extensive cryosurgical techniques used in clinical cryosurgery.     

Pre-conditioning cryosurgery: cellular and molecular mechanisms and dynamics of TNF-α enhanced cryotherapy in an in vivo prostate cancer model system

Cryosurgery is increasingly being used to treat prostate cancer; however, a major limitation is local recurrence of disease within the previously frozen tissue. We have recently demonstrated that tumor necrosis factor alpha (TNF-α), given 4h prior to cryosurgery can yield complete destruction of prostate cancer within a cryosurgical iceball. The present work continues the investigation of the cellular and molecular mechanisms and dynamics of TNF-α enhancement on cryosurgery. In vivo prostate tumor (LNCaP Pro 5) was grown in a dorsal skin fold chamber (DSFC) on a male nude mouse. Intravital imaging, thermography, and post-sacrifice histology and immunohistochemistry were used to assess iceball location and the ensuing biological effects after cryosurgery with and without TNF-α pre-treatment. Destruction was specifically measured by vascular stasis and by the size of histologic zones of injury (i.e., inflammatory infiltrate and necrosis). TNF-α induced vascular pre-conditioning events that peaked at 4h and diminished over several days. Early events (4-24 h) include upregulation of inflammatory markers (nuclear factor-κB (NFκB) and vascular cell adhesion molecule-1 (VCAM)) and caspase activity in the tumor prior to cryosurgery. TNF-α pre-conditioning resulted in recruitment of an augmented inflammatory infiltrate at day 3 post treatment vs. cryosurgery alone. Finally, pre-conditioning yielded enhanced cryosurgical destruction up to the iceball edge at days 1 and 3 vs. cryosurgery alone. Thus, TNF-α pre-conditioning enhances cryosurgical lesions by vascular mechanisms that lead to tumor cell injury via promotion of inflammation and leukocyte (esp. neutrophil) recruitment.     

Minimally Invasive Cryosurgery-Technological Advances

The technological advances which have caused renewed interest in cryosurgery are the development of intraoperative ultrasound to monitor the therapeutic process and the development of new cryosurgical equipment designed to use supercooled liquid nitrogen. The thin, highly efficient probes, available in several sizes, can be placed in diseased sites via endoscopy or percutaneously in minimally invasive procedures. The manner of use is to place the probe in the desired location in the diseased tissue with ultrasound guidance. If required by the size or location of the tumor, as many as five probes can be inserted and cooled to −195°C simultaneously. The process of freezing is monitored by ultrasound which displays a hypoechoic (dark) image when the tissue if frozen. Rapid freezing, slow thawing, and repetition of the freeze/thaw cycle are standard features of technique. Clinical applications which have become common in the past 4 years include the treatment of prostatic cancer and liver tumors. The cases selected for cryosurgery are generally those for which no conventional treatment is possible. However, especially in prostatic cancer, the operative morbidity is so low and the results of therapy are sufficiently good in the short term to merit consideration of use in earlier stages of the disease. Diverse tumors in other sites, such as the brain, bronchus, bone, pancreas, kidney, and uterus, have also been treated in small numbers by cryosurgery. Judging from this experience, further expansion in the use of cryosurgical techniques seems certain.     

The evolution of British Biology: Presidential Address to the Linnean Society delivered at the Anniversary Meeting, 24 May 1983

British biology is multiply divided between 115 national societies and 900 local ones, as well as divisions between amateurs and professionals, pure and applied, universities and research institutes. It is in fact composed of four strands, three of them (natural history, scientific biology and preservation/conservation) having arisen independently, and all having given rise to the fourth (international) strand. Natural history declined at the end of the nineteenth century with the growth of professional biology, government funding, and new techniques imported from abroad; it has recovered spectacularly since the 1939–45 war. Scientific biology grew mainly from continental science, and came of age as a professional discipline around 1900. Concern for conservation has risen as human pressures on the environment have increased.
The question asked is whether this serendipitous structure is the most efficient one, in a time when the conditions which gave rise to much of it have changed: personal motivation, the role of scientific meetings, ease of travel, accessibility of libraries, sources of funding, etc. The trends have always been to split, and virtually all attempts at co-ordination have failed. This process leads to long-term inefficiency, and for scientific, political and personal advantage, the future will almost inevitably require some foci for biologists beyond narrow subject societies. The Linnean Society is peculiarly fitted to become an active focus, perhaps catalysing an amalgamation or federal sybiosis along the lines of the Royal Society of Chemistry.     

Cryosurgery with pulsed electric fields

This study explores the hypothesis that combining the minimally invasive surgical techniques of cryosurgery and pulsed electric fields will eliminate some of the major disadvantages of these techniques while retaining their advantages. Cryosurgery, tissue ablation by freezing, is a well-established minimally invasive surgical technique. One disadvantage of cryosurgery concerns the mechanism of cell death; cells at high subzero temperature on the outer rim of the frozen lesion can survive. Pulsed electric fields (PEF) are another minimally invasive surgical technique in which high strength and very rapid electric pulses are delivered across cells to permeabilize the cell membrane for applications such as gene delivery, electrochemotherapy and irreversible electroporation. The very short time scale of the electric pulses is disadvantageous because it does not facilitate real time control over the procedure. We hypothesize that applying the electric pulses during the cryosurgical procedure in such a way that the electric field vector is parallel to the heat flux vector will have the effect of confining the electric fields to the frozen/cold region of tissue, thereby ablating the cells that survive freezing while facilitating controlled use of the PEF in the cold confined region. A finite element analysis of the electric field and heat conduction equations during simultaneous tissue treatment with cryosurgery and PEF (cryosurgery/PEF) was used to study the effect of tissue freezing on electric fields. The study yielded motivating results. Because of decreased electrical conductivity in the frozen/cooled tissue, it experienced temperature induced magnified electric fields in comparison to PEF delivered to the unfrozen tissue control. This suggests that freezing/cooling confines and magnifies the electric fields to those regions; a targeting capability unattainable in traditional PEF. This analysis shows how temperature induced magnified and focused PEFs could be used to ablate cells in the high subzero freezing region of a cryosurgical lesion.     

Progress in cryosurgery.

The Workshop on Cryosurgery at the 28th Annual Meeting of the Society for Cryobiology contained a diversity of papers which fairly represented the present state of cryosurgery in medical practice and which identified directions for future research. Emphasis was clearly on the development of visceral cryosurgery, which appears likely to become of increased clinical importance as a result of combination with ultrasound imaging techniques. This report reviews in brief the important new developments in cryosurgery and focuses on those presentations which were of special interest from the viewpoint of research in cryosurgery.     

Pre-conditioning cryosurgery: Cellular and molecular mechanisms and dynamics of TNF-α enhanced cryotherapy in an in vivo prostate cancer model system

Cryosurgery is increasingly being used to treat prostate cancer; however, a major limitation is local recurrence of disease within the previously frozen tissue. We have recently demonstrated that tumor necrosis factor alpha (TNF-α), given 4 h prior to cryosurgery can yield complete destruction of prostate cancer within a cryosurgical iceball. The present work continues the investigation of the cellular and molecular mechanisms and dynamics of TNF-α enhancement on cryosurgery. In vivo prostate tumor (LNCaP Pro 5) was grown in a dorsal skin fold chamber (DSFC) on a male nude mouse. Intravital imaging, thermography, and post-sacrifice histology and immunohistochemistry were used to assess iceball location and the ensuing biological effects after cryosurgery with and without TNF-α pre-treatment. Destruction was specifically measured by vascular stasis and by the size of histologic zones of injury (i.e., inflammatory infiltrate and necrosis). TNF-α induced vascular pre-conditioning events that peaked at 4 h and diminished over several days. Early events (4–24 h) include upregulation of inflammatory markers (nuclear factor-κB (NFκB) and vascular cell adhesion molecule-1 (VCAM)) and caspase activity in the tumor prior to cryosurgery. TNF-α pre-conditioning resulted in recruitment of an augmented inflammatory infiltrate at day 3 post treatment vs. cryosurgery alone. Finally, pre-conditioning yielded enhanced cryosurgical destruction up to the iceball edge at days 1 and 3 vs. cryosurgery alone. Thus, TNF-α pre-conditioning enhances cryosurgical lesions by vascular mechanisms that lead to tumor cell injury via promotion of inflammation and leukocyte (esp. neutrophil) recruitment.     

Professional societies and industry support: what is the quid pro quo?

Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.     

Late appearance of resistance to tumor rechallenge following cryosurgery: A study in an experimental mammary tumor of the rat

Resistance to tumor challenge following surgical and cryosurgical eradication of the tumor was studied, using an experimental mammary tumor of the rat, MRMT-1. It was revealed that rejection rate of the challenged tumor increased gradually following cryosurgery and reached its peak at 10 weeks after cryosurgery. No such phenomenon was observed after surgical excision of the tumor. Decreased incidence of lymph node metastases and decreased tumor weights in “take” cases also suggested an increased immunological activity against the tumor at 10 weeks after cryosurgery.     

Real time ultrasonic monitoring of hepatic cryosurgery

Cryosurgery has a number of advantages that make it particularly appealing in the treatment of liver cancer. However, a major problem in the clinical application of hepatic cryosurgery is the lack of a precise means of monitoring the freezing process in situ. Preliminary investigations on simulated tissue have shown that standard ultrasonography is capable of accurately determining the amount of frozen material during a cryosurgical procedure. To extend these results to living tissue, cryosurgery was performed, in vivo, on the livers of four mongrel dogs. An ultrasound imaging device using a new intraoperative ultrasound transducer monitored the entire process in real time. The results indicate that the entire freezing and thawing cycle can be monitored easily using real time ultrasound. During freezing, the solidification interface can be seen to move through the tissue allowing clear imaging of the cryolesion. After complete thawing, the cryolesion became less echogenic than before freezing and was therefore distinguishable under ultrasound. Postsurgical pathologic examination showed excellent correlation between the lesion size and its ultrasonic image.     

Cancer cryotherapy: evolution and biology

Since the inception of cryosurgery in the 1850s, landmark advances in chemistry, physics, materials science, and biology have culminated in the sophisticated cryosurgical devices currently in use. Effective cryosurgical tissue injury depends on four criteria: 1) excellent monitoring of the process; 2) fast cooling to a lethal temperature; 3) slow thawing; and 4) repetition of the freeze-thaw cycle. Meeting these criteria depends on understanding the imaging technology used to visualize the iceball, the type of cryogen used, the size of the probe, and probe arrangement. Third-generation cryosurgical equipment offers advantages over previous designs. These machines rely on argon for freezing but also use helium to warm probes and accelerate the treatment process, and they offer additional safety by being able to rapidly arrest iceball formation. Metallurgic advances have led to the development of thinner probes, which have been easily adapted to perineal templates similar to those used for prostate brachytherapy.     

Antitumor immunologic reactivity in the relatively early period after cryosurgery: Experimental studies in the rat

An experimental investigation was performed on antitumor immunity in the relatively early postoperative period after cryosurgery, using a metastasizing rat's mammary tumor, MRMT-1. Two weeks after its inoculation, surgical excision of the tumor, cryosurgery, surgical excision plus inoculation with freezing-thawing produced vaccine, or surgical excision plus fasting for 72 hr was performed, and postoperative follow-up was done on incidences of metastases, those of metastatic death, etc. Specific immunologic reactivity was examined in the surgical excision (SE) and cryosurgery (CR) groups.The FTV and fasting groups showed more metastatic deaths as compared with the SE group. The CR and SE groups did not differ significantly from each other in incidences of lung and lymph node metastases.Specific footpad reactivity at 2 and 3 weeks after treatment was lower in the CR group than in the SE group.Winn's neutralization assay showed an inhibition of tumor growth at 1 and 3 week(s) after treatment both in the SE and in the CR groups, the inhibitory effect tending to be lower in the latter.Inactivated serum obtained at 1 week after treatment showed a facilitation of tumor growth in the SE group and a tendency of tumor suppression in the CR group, showing a significant difference between them.A mild reduction in antitumor immunity seen in the relatively early postoperative period following cryosurgery probably was not due to a blocking effect by superfluous antigens. Rather it was considered to be due to activation of suppressor cells, consequent on cryosurgical stress, and/or slow and steady absorption of antigens.     

Cryosurgery of pulmonary metastases.

Indications and results of 33 cryosurgical interventions for metastatic tumors in the lung are presented. Regression of local and metastatic pulmonary growth on the contralateral side was observed in four cases. Nine cases showed temporary halt of metastatic pulmonary tumor growth. The technique of cryosurgery for pulmonary metastases is reviewed. The procedure of cryosurgery of pulmonary metastases was found to be an innocuous method to attempt both tumor destruction and eventually specific immunologic stimulation. Preliminary observations with the lymphocytes and sera indicate that cryosurgery of pulmonary metastases induces an increase in specific cell mediated immune response without producing blocking serum factors and may give rise to specific, complement dependent cytotoxic antibodies. In one case both mechanisms were observed after cryotherapy. In three cases with progressive disease, lymphocyte mediated cytotoxicity alone was stimulated.     

A novel approach to improve the efficacy of tumour ablation during cryosurgery

Freezing tumours and ablating it using cryosurgery is becoming a popular surgical procedure for treatment of carcinomas. In order to improve the efficiency of the cryosurgical procedure different approaches have been implemented till now, e.g., injecting high thermal conductivity fluid inside the tumour, low latent heat fluids inside the tumour prior to cryosurgery etc. These techniques improve the cryosurgical process to some extent but lack in minimising the damage to the surrounding healthy tissues. In this study, a novel concept is proposed which advocates the use of solutions with specific thermophysical properties around the interface of tumour. Numerical modelling has been done to determine the location of the ice fronts in the presence of this solution around the boundary of the tumour. It is noticed that in the presence of solution layer, owing to its distinct thermophysical properties like low thermal conductivity, not only the cellular destruction is enhanced but also the damage to the surrounding healthy tissue is minimised. Further, results indicate that this strategy leads to a faster ablation rate reducing the surgical time immensely. Also, an optimal offset, the minimum distance between the tip of cryoprobe and the boundary of the tumour, is identified for a given tumour radius with a given active length which gives maximum tumour necrosis in less time. This optimal offset which has been identified for each case will help the surgeons in proper planning of cryosurgery and improving the effectiveness of this technique greatly, making it a better treatment modality than its counterparts in many ways. It is also observed that for a 2 mm increase in activelength of the cryoprobe, the decrease in optimal offset is approximately 1 mm, i.e. optimal offset decreases linearly with an increase in the activelength for a given radius of the tumour. Also, for tumour with different radii, ranging between 10 mm to 15 mm, with same active length, the time taken for complete ablation by the larger tumour is nearly 2.7 times the time taken by the smaller one for every 2.5 mm increase in the tumour radius.     

Wound healing and scarring after cryosurgery

There are many references in the surgical literature to apparent lack of scarring after cryosurgery. This has been investigated experimentally by comparing the effects on the skin of four freeze-thaw schedules commonly used in clinical practice with those of maximal cryosurgical injury. Absence of damage to collagen is described, and it is proposed that this is an important factor in the often cited lack of scarring. Changes in skin thickness over a 6-month period are described, and obvious scarring after severe injury and long-term dermis thinning after less severe injury are reported. Evidence is presented that epidermal cells and fibroblasts differ in their susceptibility to low-temperature damage.