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Cryosurgery Description Reasons For Cryosurgery Advantages & Disadvantages Cryosurgery Procedure Description Cryosurgery Expected Outcome Cryosurgery Complications Cryosurgery Post Procedure Care Medication Activity Recommendations & Restrictions Diet & Nutrition Notify Your Health Care Provider Recommended Related Products
Cryosurgery, also known as cryotherapy, is the removal of abnormal or diseased tissue by freezing, usually with liquid nitrogen. The technique is used to treat cancerous tumors, control pain, control bleeding, and reduce brain tumors. Cryosurgery has been used to treat skin lesions for approximately 100 years. The first cryogens were liquid air and compressed carbon dioxide snow. Liquid nitrogen became available in the 1940's and currently is the most widely used cryogen.
The use of a cotton-tipped swab (called a dipstick method) using a liquid nitrogen application has been a popular choice for the management of common benign lesions. This method is being replaced by liquid nitrogen spray techniques since the liquid nitrogen spray equipment is easy to use for management of benign, pre-malignant and malignant lesions.
Cryosurgery works by taking advantage of the destructive force of freezing temperatures on cells. At low temperatures, ice crystals form inside the cells, which can tear them apart. More damage occurs when blood vessels supplying the diseased tissue freeze.
In the past, the most common method to freeze was using liquid nitrogen as the cooling solution. The super-cooled liquid may be sprayed on the diseased tissue or simply dabbed on with a cotton or foam swab. Another method is a tube called a cryoprobe. The cold is introduced through a cryoprobe which has liquid nitrogen circulating through it. Less frequently, health care providers use carbon dioxide "snow" formed into a cylinder or mixed with acetone to form a slush that is applied directly to the treated tissue. Recent advances in technology have allowed for the use of Argon gas to drive ice formation using a principle known as the Joule-Thompson effect. This gives health care providers excellent control of the ice, and minimizes complications using ultra-thin 17-gauge cryoneedles.
Liquid nitrogen, which boils at -196°C (-320.8°F), is the most effective cryogen for use in a clinical setting. To destroy diseased tissue, the tissue is cooled to -20°C to -30°C (-4°F to -22°F). Temperatures of -25°C to -50°C (-13°F to -58°F) can be achieved within 30 seconds if a sufficient amount of liquid nitrogen is applied by spray or probe. Irreversible damage in treated tissue occurs because of intracellular ice formations. The degree of damage is dependent on the rate of cooling and the minimum temperature achieved. Other procedures that control pain or bleeding are cooled to a lesser degree to prevent tissue damage. Slow thaw times and repeat freeze-thaw cycles produce more damage to tissue than a single freeze and thaw. Usually, several minutes are allowed between repeat freeze-thaw-cycles. Repeat freeze-thaw cycles are employed only in the treatment of malignancy (cancer). Continuous freezing at one location for more than 30 seconds beyond when an adequate free ball is achieved around the target area can result in disruption of the collagen matrix of the skin and possible scarring may occur.
Mild freezing leads to dermal-epidermal separation, which is useful in treating benign epidermal lesions. The more sensitive cells in the epidermis are destroyed while the dermis is left intact. Treatment may be complicated by an element of hypopigmentation (lack of skin color), but studies and clinical experience indicate that re-pigmentation (return of skin color) often occurs over several months because of undamaged melanocytes within hair follicles or the migration of melanocytes from the edge of the frozen zone. However, the predictability of re-pigmentation in individual patients is uncertain and they may have continued light skin pigmentation at the treatment site.
Inflammation develops during the 24 hours after treatment, further contributing to destruction of the lesion through immunologically mediated mechanisms.
Cryosurgery is a minimally invasive procedure, and is often preferred to more traditional kinds of surgery because of its minimal pain, scarring, and cost; however, as with any medical treatment, there are risks involved, primarily that of damage to nearby healthy tissue. Damage to nerve tissue is of particular concern.
Patients undergoing cryosurgery usually experience minor-to-moderate localized pain and redness, which can be alleviated by oral administration of an analgesic (such as acetylsalicylic acid (aspirin) or ibuprofen) and application of topical steroid cream. Blisters may form, but these usually scab over and peel away.
REASONS FOR CRYOSURGERY PROCEDURE
Primary treatment of cervical dysplasia (low and high grade squamous intraepithelial lesion [SIL]).
Treatment of cervicitis (inflammation of the cervix).
Removal of skin lesions. Warts, moles, skin tags, solar karatoses, and small skin cancers are candidates for cyrosurgical treatment.
Internal disorders are also treated with cryosurgery, including liver cancer, prostate cancer, cervical disorders (see above), and more commonly in the past, hemorrhoids. Although found to be effective, this method of treatment is only appropriate for use against localized disease with no metastasis.
MoonDragon's Womens Health Disorders Information: Hemorrhoids
MoonDragon's Health & Wellness Disorders: Prostate Cancer
MoonDragon's Health & Wellness Disorders: Skin Cancer
MoonDragon's Health & Wellness Disorders: Warts
ADVANTAGES & DISADVANTAGES
CRYOSURGERY ADVANTAGES - SKIN LESIONS
Cryosurgery is best suited for use in patients with light skin and for treatment of lesions in most nonhair-bearing areas of the body. Spray methods include the timed spot freeze technique, the rotary or spiral pattern, and the paintbrush method. Benign skin lesions that are suitable for freezing include actinic keratosis, solar lentigo, seborrheic keratosis, viral wart, molluscum contagiosum, and dermatofibroma. Cryosurgery requires little time and fits easily into the health care provider's office schedule. Advantages of this treatment include a short preparation time, low risk of infection, and minimal wound care. In addition, cryosurgery requires no expensive supplies or injectable anesthesia, and the patient does not have to return for suture removal. The risk of infection is low and wound care is minimal.
CRYOSURGERY ADVANTAGES - CANCER TREATMENT
Cryosurgery offers advantages over other methods of cancer treatment. It is less invasive than surgery, involving only a small incision or insertion of the cryoprobe through the skin. Consequently, pain, bleeding, and other complications of surgery are minimized. Cryosurgery is less expensive than other treatments and requires shorter recovery time and a shorter hospital stay, or no hospital stay at all. Sometimes cryosurgery can be done using only local anesthesia.
Because health care providers can focus cryosurgical treatment on a limited area, they can avoid the destruction of nearby healthy tissue. The treatment can be safely repeated and may be used along with standard treatments such as surgery, chemotherapy, hormone therapy, and radiation. Cryosurgery may offer an option for treating cancers that are considered inoperable or that do not respond to standard treatments. Furthermore, it can be used for patients who are not good candidates for conventional surgery because of their age or other medical conditions.
CRYOSURGERY DISADVANTAGES - CANCER TREATMENT
The major disadvantage of cryosurgery is the uncertainty surrounding its long-term effectiveness. While cryosurgery may be effective in treating tumors the health care provider can see by using imaging tests (tests that produce pictures of areas inside the body), it can miss microscopic cancer spread. Furthermore, because the effectiveness of the technique is still being assessed, insurance coverage issues may arise.
Additional studies are needed to determine the effectiveness of cryosurgery in controlling cancer and improving survival. Data from these studies will allow physicians to compare cryosurgery with standard treatment options such as surgery, chemotherapy, and radiation. Moreover, health care providers continue to examine the possibility of using cryosurgery in combination with other treatments.
Cryosurgery is widely available in health care provider's offices for the treatment of cervical neoplasias. A limited number of hospitals and cancer centers throughout the country currently have skilled health care providers and the necessary technology to perform cryosurgery for other non-cancerous, pre-cancerous, and cancerous conditions. Individuals can consult with their health care providers or contact hospitals and cancer centers in their area to find out where cryosurgery is being used.
DESCRIPTION OF CRYOSURGERY PROCEDURE
The dose of liquid nitrogen and the choice of delivery method depend on the size, tissue type, and depth of the lesion. The area of the body on which the lesion is located and the required depth of freeze also should be considered. Other factors to consider include the thickness of the epidermis and underlying structures, the water content of the skin, and local blood flow. Liquid nitrogen spray methods for lesions of different sizes include the timed spot freeze or direct spray technique, the rotary or spiral pattern, and the paintbrush method.
For small skin lesions (external tumors), liquid nitrogen is applied to a cotton-tipped applicator. The applicator is held to the skin lesions (directly to the cancer cells), until they are frozen and destroyed.
Sometimes, a spray can with pressurized liquid nitrogen is used to freeze skin lesions (external tumors).
Sun-Damaged Skin: Sun-damaged skin and related lesions are highly amenable to intervention with cryosurgical treatment. Localized small actinic keratosis, which is one of the most common solar-related skin abnormalities, usually requires only five to seven seconds of freeze time beyond initial appearance of a halo around the target lesion. Treatment requires only one freeze-thaw cycle and a margin of less than 1 mm.
Seborrheic Keratosis: Seborrheic keratosis, the most common benign neoplasm, is best treated with cryosurgery or shave excision/curettage. Cryosurgery is especially effective in patients with multiple lesions. Thin, flat lesions usually require only one five- to ten-second freeze-thaw cycle; larger, thicker lesions may need longer treatments times or, occasionally, two freeze-thaw cycles. In treating seborrheic keratosis, the health care provider should consider the potential for hair loss in treated areas when choosing a therapeutic modality. The other major side effect of cryosurgery for this lesion is hypopigmentation. This side effect is more likely to occur in patients with dark skin.
Viral Skin Infections: Warts that are resistant to over-the-counter topical agents commonly are treated with cryosurgery. However, response is variable and often depends on the size of the wart and the degree of hyperkeratosis. Several treatment sessions typically are required, and the overall success rate is approximately 75 percent. To avoid hypopigmentation, small flat warts may be treated with a light spray technique. Digital warts respond favorably to the timed spot freeze spray technique. Deep plantar or palmar warts present challenges, because pain may limit the patient's tolerance of freezing. However, favorable cure rates have been reported for initial pretreatment with keratolytics (salicylic acid). The wart then can be shaved, and the base can be frozen with or without multiple freeze-thaw cycles.
Cryosurgery has been found to be effective in the management of condyloma acuminatum, particularly when treatment with podophyllin (Podocon-25) has failed or the lesion is located in an area where use of this agent is undesirable.
Molluscum contagiosum, a common dermatologic problem in younger persons, is caused by a poxvirus. This lesion is amenable to cryosurgery, if indicated. Applying liquid nitrogen spray for a few seconds until the surface of the umbilicated papule turns white usually is adequate.
Dermatofibroma: Open spray or cryoprobe techniques may be used to improve the cosmetic appearance of dermatofibromas. Surgical excision of these deep, asymptomatic skin nodules may result in hypertrophic scar formation, because the fibrous lesions are thought to arise from skin microtrauma. A single 20- to 30-second freeze-thaw cycle is advised, and a 1- to 2-mm margin should be obtained. Re-treatment in eight weeks may be necessary. Significant clinical improvement, including visible flattening of raised dermatofibromas and lightening of pigmentation, has been reported in 80 to 90 percent of patients.
THE TIMED-SPOT-FREEZE TECHNIQUE OVERVIEW
This method allows greater standardization of liquid nitrogen delivery. It may be the most appropriate method for health care providers who are learning to perform cryosurgery. Use of this technique maximizes the ability to destroy a lesion with minimal cellular damage to surrounding tissue. The freezing time is adjusted according to variables such as skin thickness, vascularity, tissue type, and lesion characteristics. Timed spot freezing is performed with a small spray gun that typically holds 300 to 500 mL of liquid nitrogen. Nozzle sizes range from A through F, with F representing the smallest aperture. Nozzle sizes B and C are suitable for the treatment of most benign and malignant lesions.
For the standard spot freeze technique, the nozzle of the spray gun is positioned 1 to 1.5 cm from the skin surface and aimed at the center of the target lesion. The spray gun trigger is depressed, and liquid nitrogen is sprayed until an ice field (or ice ball) encompasses the lesion and the desired margin (Figure 5). The designated ice field may need to be delineated in advance with a skin marker pen, because freezing may blur pre-treatment lesion margins. The margin size depends primarily on the thickness of the lesion and whether the lesion is benign or malignant. Margins for most benign lesions can extend as little as 1 to 2 mm beyond the visible pathologic border. Pre-malignant lesions need margins of 2 to 3 mm, while malignant lesions require margins of 5 mm of clinically normal skin to ensure adequate removal. These margin sizes allow enough depth of freeze to ensure temperatures of -50°C to a depth of 4 to 5 mm. Once the ice field has filled the specified margin, the spray needs to be maintained, with the spray canister trigger pressure and, thus, the liquid nitrogen spray flow adjusted to keep the target field frozen for an adequate time. This time may vary from five to 30 seconds beyond the initial time for formation of the ice field. If more than one freeze-thaw cycle is required for lesion destruction, complete thawing should be allowed before the next cycle (usually two to three minutes). The timed spot freeze technique achieves temperatures that are adequate for tissue destruction in an ice field up to 2 cm in diameter. The best approach for lesions larger than 2 cm (including an adequate margin) is to use overlapping treatment fields.
OPEN SPRAY TECHNIQUE VARIATIONS
Variations on the open spray technique include the rotary or spiral pattern and the paintbrush method. These techniques can be useful for treating larger benign lesions. They are not well standardized for ensuring the temperatures that are required for the destruction of malignant lesions.
While the open spray technique can be used for the most easily accessible lesions, a cryoprobe attached to the liquid nitrogen spray gun can provide added versatility, depending on the site and type of the lesion. Various sizes and types of cryoprobes are available. The cryoprobe is applied directly to the lesions. A gel interface medium often is used between the probe and the skin surface. Cryoprobes frequently are used in the treatment of smaller facial lesions (e.g., on the eyelids), where scatter of liquid nitrogen is undesirable. Probes also are useful in the management of vascular lesions, where the pressure of the probe can be used to remove blood from the tissues thus allowing more adequate treatment.
Cryosurgery is also used to treat tumors inside the body (internal tumors and tumors in the bone). For internal tumors, liquid nitrogen or argon gas is circulated through a cryoprobe, which is placed in contact with the tumor. The health care provider uses ultrasound or MRI to guide the cryoprobe and monitor the freezing of the cells, thus limiting damage to nearby healthy tissue. (In ultrasound, sound waves are bounced off organs and other tissues to create a picture called a sonogram.) A ball of ice crystals forms around the probe, freezing nearby cells. Sometimes more than one probe is used to deliver the liquid nitrogen to various parts of the tumor. The probes may be put into the tumor during surgery or through the skin (percutaneously). After cryosurgery, the frozen tissue thaws and is either naturally absorbed by the body (for internal tumors), or it dissolves and forms a scab (for external tumors).
TYPES OF CANCER TREATED WITH CRYOSURGERY
Cryosurgery is used to treat several types of cancer, and some precancerous or non-cancerous conditions. In addition to prostate and liver tumors, cryosurgery can be an effective treatment for the following:
- Retinoblastoma (a childhood cancer that affects the retina of the eye). Health care providers have found that cryosurgery is most effective when the tumor is small and only in certain parts of the retina.
- Early-stage skin cancers (both basal cell and squamous cell carcinomas).
- Precancerous skin growths known as actinic keratosis.
- Precancerous conditions of the cervix known as cervical intraepithelial neoplasia (abnormal cell changes in the cervix that can develop into cervical cancer).
Cryosurgery is also used to treat some types of low-grade cancerous and non-cancerous tumors of the bone. It may reduce the risk of joint damage when compared with more extensive surgery, and help lessen the need for amputation. The treatment is also used to treat AIDS-related Kaposi's sarcoma when the skin lesions are small and localized.
Researchers are evaluating cryosurgery as a treatment for a number of cancers, including breast, colon, and kidney cancer. They are also exploring cryotherapy in combination with other cancer treatments, such as hormone therapy, chemotherapy, radiation therapy, or surgery.
CRYOSURGERY & PROSTATE CANCER
Cryosurgery can be used to treat men who have early-stage prostate cancer that is confined to the prostate gland. It is less well established than standard prostatectomy and various types of radiation therapy. Long-term outcomes are not known. Because it is effective only in small areas, cryosurgery is not used to treat prostate cancer that has spread outside the gland, or to distant parts of the body.
Some advantages of cryosurgery are that the procedure can be repeated, and it can be used to treat men who cannot have surgery or radiation therapy because of their age or other medical problems.
Cryosurgery for the prostate gland can cause side effects. These side effects may occur more often in men who have had radiation to the prostate.
- Cryosurgery may obstruct urine flow or cause incontinence (lack of control over urine flow); often, these side effects are temporary.
- Many men become impotent (loss of sexual function).
- In some cases, the surgery has caused injury to the rectum.
CRYOSURGERY & LIVER CANCER
Cryosurgery may be used to treat primary liver cancer that has not spread. It is used especially if surgery is not possible due to factors such as other medical conditions. The treatment also may be used for cancer that has spread to the liver from another site (such as the colon or rectum). In some cases, chemotherapy and/or radiation therapy may be given before or after cryosurgery. Cryosurgery in the liver may cause damage to the bile ducts and/or major blood vessels, which can lead to hemorrhage (heavy bleeding) or infection.
CRYOSURGERY & CERVICAL TREATMENT
Cervical cryosurgery or cryotherapy is a gynecological treatment that freezes a section of the cervix. Cryosurgery of the cervix is most often done to destroy abnormal cervical cells that show changes that may lead to cancer. These changes are called precancerous cells. Your health care provider will probably use the term cervical dysplasia.
Cryosurgery is done only after a colposcopy confirms the presence of abnormal cervical cells. Cyrotherapy is also used for the treatment of cervicitis or inflammation of the cervix. Cryosurgery is not a treatment for cervical cancer.
Cryosurgery is performed in your health provider's office while you are awake. It is similar to a pelvic exam: you will be asked to undress from the waist down, lay on an exam table with your feet in stirrups, a speculum is inserted into your vagina to hold the vaginal canal open so that your cervix can be seen. However, that is where the similarity ends.
For surgery on the cervix, a special cryoprobe instrument is used. Liquid nitrogen circulates in the tip of this instrument causing it to become almost as cold as the liquid nitrogen. During cryosurgery the cyroprobes are inserted into your vagina until they firmly cover the abnormal areas of cervical tissue. Next, liquid nitrogen begins to flow through the cryoprobes at a temperature of approximately -50°C. This causes the metal probes to freeze and the instrument tip is held on the affected areas until the abnormal tissue is frozen and the superficial abnormal cervical tissue is destroyed.
The most effective treatment result is obtained by freezing for three minutes, letting the cervix thaw, and repeating the treatment for three more minutes. You may feel some slight cramping and experience either a sensation of cold or of heat.
You can return to most normal activities the day after cryosurgery; however, there are a few things you should take note of for the first two to three weeks following treatment:
- It is normal to experience a watery discharge for the first few weeks. This is caused by the sloughing of dead cervical tissue.
- Do not insert anything into the vagina for at least two to three weeks. This means no tampons, no douches, and no sexual intercourse.
You should call your health care provider if any of the following occur:
- Fever. Your health care provider should inform you before you leave the office what amount of fever is cause for alarm following cryosurgery.
- Vaginal bleeding that is heavier than you normally experience during your menstrual cycle.
- Pain. Some slight cramping is normal, however, any severe or increasing pelvic pain should be reported to your health care provider immediately.
- Foul smell or yellowish vaginal discharge. These can indicate an infection which may need immediate treatment.
Cryosurgery is relatively risk-free, producing fewer complications than any other gynecological procedure. After cryosurgery you will need Pap tests every three to six months for a period of time. Once you have had several normal Pap smears in a row, your health care provider will discuss with you how often you need future screening for cervical cancer.
CRYOSURGERY EXPECTED OUTCOME
For Skin Lesions: Initial swelling and redness become a blister in 2 or 3 days. The blister will rupture by itself about 2 weeks after surgery. It will leave a scab, but little or no scar after complete healing.
For Surgery of the Cervix: Expect complete healing without complications. There may be mild uterine cramping and facial flushing. Vaginal discharge is common and may be profuse, foul-smelling and last for 7 to 10 days or longer. Allow about 3 weeks for recovery from surgery.
CRYOSURGERY POTENTIAL COMPLICATIONS
Surgical-wound infection. Surgical-wound bleeding. Cervical stenosis (narrowing).
CRYOSURGERY SIDE EFFECTS
Cryosurgery does have side effects, although they may be less severe than those associated with surgery or radiation therapy. The effects depend on the location of the tumor. Cryosurgery for cervical intraepithelial neoplasia has not been shown to affect a woman's fertility, but it can cause cramping, pain, or bleeding. When used to treat skin cancer (including Kaposi's sarcoma), cryosurgery may cause scarring and swelling; if nerves are damaged, loss of sensation may occur, and, rarely, it may cause a loss of pigmentation and loss of hair in the treated area. When used to treat tumors of the bone, cryosurgery may lead to the destruction of nearby bone tissue and result in fractures, but these effects may not be seen for some time after the initial treatment and can often be delayed with other treatments. In rare cases, cryosurgery may interact badly with certain types of chemotherapy. Although the side effects of surgery may be less severe than those associated with conventional surgery or radiation, more studies are needed to determine the long-term effects.
CONTRAINDICATIONS TO CRYOSURGERY
The relatively few contraindications to cryosurgery generally are related to concomitant illnesses in which excess reactions to cold may occur or delayed healing may be anticipated (Table 2). Some relative contraindications may make alternative treatment modalities more suitable. Health care providers often do not perform cryosurgery in the pretibial areas, especially in elderly patients, because of slow wound healing.
CONTRAINDICATIONS TO CRYOSURGERY
Lesion for which tissue pathology is required.*** Lesion located in an area with compromised circulation. Melanoma. Patient unable to accept possibility of pigmentary changes. Proven sensitivity or adverse reaction to cryosurgery. Sclerosing basal cell carcinoma or recurrent basal cell or squamous cell carcinoma, particularly when located in a high-risk area e.g., temple, nasolabial fold),
Cold intolerance. Cold urticaria. Collagen disease or autoimmune disease. Concurrent treatment with immunosuppressive drugs. Cryoglobulinemia. Heavily pigmented skin. Lesions located in pretibial areas, eyelid margins, nasolabial fold, ala nasi, and hair-bearing areas. Multiple myeloma. Pyoderma gangrenosum. Raynaud's disease.
*** Biopsy must be performed before cryosurgery is considered.
CRYOSURGERY POST PROCEDURE CARE
For cervical therapy, discuss your care for you particular situation with your health care provider when you should be seen for a follow-up examination to be sure healing is complete and to assure that the treatment was effective.
Bathe and shower as usual. If appropriate, keep any skin wounds dry with bandages for the first 2 or 3 days after surgery. If a bandage gets wet, change it promptly.
You may use non-prescription drugs, such as acetaminophen, to relieve minor pain.
ACTIVITY RECOMMENDATIONS & RESTRICTIONS
DIET & NUTRITION
No special diet. However, you should follow a healthy, balanced nutritional program for a healthy immune system and to assist in a rapid recovery from your surgery.
MoonDragon's Nutrition Information: Adult Regular Diet
MoonDragon's Nutrition Information, Guidelines, Dietary Recommendations
NOTIFY YOUR HEALTH CARE PROVIDER
If pain, swelling, redness, drainage or bleeding increases in the surgical area. If you develop signs of infection: headache, muscle aches, dizziness, or a general ill feeling and fever and/or chills. If vaginal discharge increases or changes. If any unusual or unexpected signs or symptoms.
American Family Physician: Cryosurgery for Common Skin Conditions
Cancer News: Cryosurgery in the Treatment of Prostate Cancer
E-Medicine: Gynecologic Cryosurgery
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MoonDragon's Womens Health Disorders Information: Cervical Cancer
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MoonDragon's Womens Health STD Disorders Information: Genital Warts
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MoonDragon's Health & Wellness Disorders Information: Prostate Cancer
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MoonDragon's Womens Health Procedures Information: Vulvar Lesions
MoonDragon's Health & Wellness Disorders Information: Warts
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