Cryosurgery and Electrosurgery

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Cryosurgery and Electrosurgery

• Adam O. Goldstein, MD
• Associate Professor
• UNC Dept Family Medicine
• Chapel Hill, NC
• aog_at_med.unc.edu

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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

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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

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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.

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Chemical Refrigerants

• Verruca-Freeze
• Low start-up costs
• Useful for satellite
  offices
• Not approved treatment for
  malignant lesions

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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

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Cryoprobes

• Nitrous oxide cryoguns
• Tanks with cart, hand gun, pressure gauge and
  regulator
• Useful if liquid nitrogen not available

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Nitrous Oxide

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

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Liquid Nitrogen

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

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Liquid Nitrogen

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

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Liquid Nitrogen

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

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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

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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

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Liquid Nitrogen Equipment

• Filling Dewars pouring, ladles or devices
• Devices affixed to dewar
• Ladels Valve 310
  Tube 150

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Liquid Nitrogen Equipment

• Thermos bottle with hole and cotton tipped swab
  or
• Cry-AC Spray/cryogun (C-tip, mini-gun)
• 10 oz 16 oz
  12 oz 670
  670 650
  12 hr
  24 hr 24 hr

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Cryosurgery

• Frozen areas turn white freezeball or
  iceball
• Depth of freeze should be
  1 X radius of freeze
• Lethal Zone
• Tissue temp lt -20 C.
• 2-3.5 mm inward from outer margin iceball
• Freeze 2-3 mm beyond lesion edge

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Cryosurgery

• Remember ..
• Always best to underfreeze rather than overfreeze
• Hold canister perpendicular to skin
• Usually 2-3 freeze/thaw cycles

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Cryosurgery

• Cotton tipped swabs
• Informed consent-oral vs written

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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

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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

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Cryosurgery

• Thermocouple
• 500 for temperature monitor
  and thermocouple needle

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Cryosurgery Effectiveness

• Low
• Vascular lesions e.g. angiomas
• Achrochordans

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Cryosurgery Effectiveness

• Medium
• Xanthelasma
• Dermatofibroma
• Keloid
• Molluscum
• Prurigo nodularis
• Sebaceous hyperplasia

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Cryosurgery Effectiveness

• Medium-High
• Seborrheic keratosis
• Verruca
• Condyloma acuminata
• Lentigo
• Freckles

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Cryosurgery

• Verruca
• Often resistant
• Warts on hands
• Plantar warts
• Flat warts

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Cryosurgery Effectiveness

• High
• Actinic keratosis
• Superficial Basal Cell Carcinoma
• Superficial Squamous Cell Carcinoma

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Cryosurgery Superficial BCCa/SCCa

• Establish pathological diagnosis first
• Success rates gt 95

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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

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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

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Cryosurgery

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

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Cryosurgery

• BE CAREFUL ABOUT FREEZING
• Patients with dark skin
• Patients with Raynauds disease
• Patients on chronic steroids
• Patients with diabetes
• Patients with cold induced urticaria/cryoglobuline
  mia

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Cryosurgery Side Effects

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

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Cryosurgery Side Effects

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

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Electrosurgery

• Purpose
• Destroy tissue
• Excise tissue
• Coagulation
• Often done with curettage

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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

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Electrosurgery

• Electricator
• Hyfrecator
• Bantam Bovie
• Ritter Coagulator
• Surgitron

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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

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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

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Resistant Wart
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Electrosurgery

• Start at low power and increase slowly
• Use lowest power needed for tissue
  destruction/cutting

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Electrosurgery

• Local anesthesia EMLA, lidocaine
• Avoid ethyl chloride, alcohol wipes, and oxygen
• Keep field dry (Aluminum chloride)
• Mask and ventilation
• Fire extinguisher

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Electrosurgery and Curettage (CD)

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

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Electrosurgery and Curettage (CD)

• Electrodessicate base and 2 mm skin
• Repeat total of three times
• Control bleeding with Monsels solution
• Wound instructions and saucerization

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Electrosurgery vs Cryosurgery

• Verrucae and AKs- Cryosurgery
• Condyloma- Electrosurgery
• (Transmission of HPV through vapors)

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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

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Electrosurgery and ....

• Pacemakers
• Metal pins
• Melanoma

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Conclusions

• Cryosurgery and elctrosurgery are safe, effective
  and can be done quickly
• Know the diagnosis first
• Perform patient education before the procedure

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That.thatthat.thats...
THE END

• Thats all folks!!!!!!!!!!!!!