Cryosurgery and Electrosurgery

Adam O. Goldstein, MD

Associate Professor

UNC Dept Family Medicine

Chapel Hill, NC

aog@med.unc.edu

Objectives

Know indications and techniques for using cryotherapy to treat common dermatologic conditions

Know indications and techniques for using electrocautery to treat common dermatologic conditions

Know side effects of cryotherapy and electrosurgery

Cryosurgery

Purpose: For rapid treatment of common skin conditions

Benign lesions: warts, seborrheic keratoses

Premalignant lesions: actinic keratoses Malignant tumors: Basal cell/squamous

cell carcinomas MUST KNOW THE DIAGNOSIS

Cryosurgery

Tissue destruction: -10 to -20 C. Malignant cell kill: -40 to -50 C.

Chemical refrigerants -70 to -94 C. Cold cryoprobes -90 C. Liquid Nitrogen -196 C.

Chemical Refrigerants

Verruca-Freeze Low start-up costs Useful for satellite

offices Not approved treatment

for malignant lesions

Verruca Freeze

Speculum size (2-12 mm) that encompasses lesion

1 “freeze” cycle =

» Fill speculum with spray 1/8- 1/4 inch (3-6 seconds)

» Allow fluid to evaporate (20-25 sec.) 130 “freezes” per cannister $200 start-up costs Long shelf life- 4-5 years

Cryoprobes

Nitrous oxide cryoguns Tanks with cart, hand gun, pressure

gauge and regulator Useful if liquid nitrogen not available

Nitrous Oxide

Put water soluble gel to lesion Select probe size Apply activated cryogun probe tip to skin

Liquid Nitrogen

Advantages for clinician Cheap after set-up costs Easy to learn Multiple lesions at one time Do not need assistant to perform

Liquid Nitrogen

Advantages for patient No local anesthetic needed Pain tolerable No sutures Wound care relatively easy

Liquid Nitrogen

Disadvantages for clinician Start-up costs $1000 Storage facilities Filling canisters

Liquid Nitrogen

Boiling point -196 C. Cellular destruction d/t:

» ice crystal formation» cellular dehydration» protein and enzymatic denaturization

Destruction more pronounced with:» rapid freeze» slow thaw cycle

Liquid Nitrogen: Equipment

Liquid nitrogen Storage tank= Dewars 2-30 L, filled q 3-4 weeks Costs:

Tanks: Holding time Costs» 2 L 48 hrs $200» 10 L 6-8 weeks $475» 20 L 8-12 weeks $535» 30 L 14-16 weeks $620

Liquid Nitrogen: Equipment

Filling Dewars; pouring, ladles or devices Devices affixed to dewar:

Ladels Valve: $310 Tube: $150

Liquid Nitrogen: Equipment

Thermos bottle with hole and cotton tipped swab orCry-AC Spray/cryogun (C-tip, mini-gun)

10 oz 16 oz 12 oz $670 $670 $650 12 hr 24 hr 24 hr

Cryosurgery

Frozen areas turn white = “freezeball” or “iceball”

Depth of freeze should be 1 X radius of freeze

Lethal Zone» Tissue temp < -20 C.» 2-3.5 mm inward from outer margin iceball

Freeze 2-3 mm beyond lesion edge

Cryosurgery

Remember ….. Always best to underfreeze rather than

overfreeze Hold canister perpendicular to skin Usually 2-3 freeze/thaw cycles

Cryosurgery

Cotton tipped swabs

Informed consent-oral vs written

Cryosurgery: Freezeball Time

Freckles/lentigos: 3-5 seconds Small papules: 5-10 seconds Seborrheic Keratoses: 30-40 seconds Actinic keratoses: 40-60 seconds SCCa/BCCa: 80-90 seconds

Cryosurgery: Freezeball Size

1mm- freckles/lentigos 1-2 mm- most benign skin lesions 2-3 mm- most warts 3-4 mm- most actinic keratoses 4-6 mm- superficial SCCa, BCCa

Cryosurgery

Thermocouple

$500 for temperature monitor and thermocouple needle

Cryosurgery: Effectiveness

Low Vascular lesions: e.g. angiomas Achrochordans

Cryosurgery: Effectiveness

Medium Xanthelasma Dermatofibroma Keloid Molluscum Prurigo nodularis Sebaceous hyperplasia

Cryosurgery: Effectiveness

Medium-High Seborrheic keratosis Verruca * Condyloma acuminata Lentigo Freckles

Cryosurgery

Verruca: » Often resistant» Warts on hands» Plantar warts» Flat warts

Cryosurgery: Effectiveness

High Actinic keratosis Superficial Basal Cell Carcinoma Superficial Squamous Cell Carcinoma

Cryosurgery: Superficial BCCa/SCCa

Establish pathological diagnosis first Success rates > 95%

Cryosurgery: Special Populations

Children » In general avoid b/c pain» Use EMLA cream if needed

Useful modality for those on anticoagulants, those with pacemakers and those allergic to anesthetics

Cryosurgery

DO NOT FREEZE If you do not know diagnosis Recurrent skin cancers Melanoma or any possibility Morpheaform BCCA Lip neoplasms Nasolabial fold cancers Compromised circulation

Cryosurgery

BE CAREFUL ABOUT FREEZING Lesions on/near the eye Lesions on the fingers/elbows Lesions over shins, ears, genitals Lesions near nails

Cryosurgery

BE CAREFUL ABOUT FREEZING Patients with dark skin Patients with Raynaud’s disease Patients on chronic steroids Patients with diabetes Patients with cold induced

urticaria/cryoglobulinemia

Cryosurgery: Side Effects

Short term: Pain and erythema Blister formation Hemorrhage Infection Pyogenic granuloma

Cryosurgery: Side Effects

Long term Nerve damage Pigmentary changes Hypertrophic scar formation Permanent nail dystrophy Recurrence of lesion Multiple visits may be needed

Electrosurgery

Purpose:» Destroy tissue» Excise tissue» Coagulation

Often done with curettage

Electrosurgery

Electrocautery: Hot electrode (vs cold electrodes) Electrodessication: Electrode inserted into/on skin

(“dries out” skin; “epilation” = fine dessication)

Fulguration: Electrode held away from skin (“fulgur” = lightening; shallow destruction and eschar)

Electrocoagulation: Used for hemostasis Electrosection: Used to cut tissue Radiosurgery: Electrosx. with radio frequencies

Electrosurgery

Electricator Hyfrecator Bantam Bovie Ritter Coagulator Surgitron

Electrosurgery

Advantages: Easy to use, rapid, useful, hemostasis while cutting, less infection

Disadvantages: Electric shocks and burns/fires, hypertrophic scars, “channeling” nerves, viral shedding, delayed bleeding, slower healing, histological distortion

Costs: $1000-2000

Electrosurgery

Indications Procedure Cherry angiomas dessication Achrocordans dessication/fulguration Telangiectasias dessication Small verrucae on hands fulguration Pyogenic granulomas fulguration Seb Keratoses fulguration Small BCCa or SCCa fulguration and curettage

Resistant Wart

Electrosurgery

Start at low power and increase slowly Use lowest power needed for tissue

destruction/cutting

Electrosurgery

Local anesthesia: EMLA, lidocaine Avoid ethyl chloride, alcohol wipes, and

oxygen Keep field dry (Aluminum chloride) Mask and ventilation Fire extinguisher

Electrosurgery and Curettage (C&D)

Useful for small BCCa or SCCa Local anesthetic Sharp 2 mm, 3 mm curettes Scrape in different directions until “firm”

Electrosurgery and Curettage (C&D)

Electrodessicate base and 2 mm skin Repeat total of three times Control bleeding with Monsel’s solution Wound instructions and saucerization

Electrosurgery vs Cryosurgery

Verrucae and AK’s- Cryosurgery Condyloma- Electrosurgery

(Transmission of HPV through vapors)

Electrosurgery vs Excision

Excision preferred for histology and to minimize tissue destruction

Electrosurgical excision acceptable at times

Avoid both on feet if at all possible

Electrosurgery and ....

Pacemakers Metal pins Melanoma

Conclusions

Cryosurgery and elctrosurgery are safe, effective and can be done quickly

Know the diagnosis first Perform patient education before the

procedure

That….that…that….that’s...

That’s all folks!!!!!!!!!!!!!

THE END