Cryoablation

Prostate cryoablation is moderately effective but, as with any prostate removal process, also can result in impotence. Prostate cryoablation is used in three patient categories:

1. as primary therapy in patients for whom sexual function is less important or who are poor candidates for radical retropubic prostatectomy (RRP, surgical removal of the prostate);
2. as salvage therapy in patients who have failed brachytherapy (the use of implanted radioactive "seeds" placed within the prostate) or external beam radiation therapy (EBRT); and
3. focal therapy for smaller, discrete tumors in younger patients.

Cryoablation has been explored as an alternative to radiofrequency ablation in the treatment of moderate to severe pain in people with metastatic bone disease. The area of tissue destruction created by this technique can be monitored more effectively by CT than RFA, a potential advantage when treating tumors adjacent to critical structures.{{cite journal | vauthors = Callstrom MR, Dupuy DE, Solomon SB, Beres RA, Littrup PJ, Davis KW, Paz-Fumagalli R, Hoffman C, Atwell TD, Charboneau JW, Schmit GD, Goetz MP, Rubin J, Brown KJ, Novotny PJ, Sloan JA | title = Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial | journal = Cancer | volume = 119 | issue = 5 | pages = 1033–1041 | date = March 2013 | pmid = 23065947 | pmc = 5757505 | doi = 10.1002/cncr.27793 }}

Cryoablation has similar outcomes to radiofrequency ablation when treating renal cell carcinoma.{{cite journal | vauthors = El Dib R, Touma NJ, Kapoor A | title = Cryoablation vs radiofrequency ablation for the treatment of renal cell carcinoma: a meta-analysis of case series studies | journal = BJU International | volume = 110 | issue = 4 | pages = 510–516 | date = August 2012 | pmid = 22304329 | doi = 10.1111/j.1464-410x.2011.10885.x | doi-access = free | hdl = 11449/41070 | hdl-access = free }}

Cryoablation for breast cancer is typically only possible for small tumors.{{cite journal | vauthors = Sabel MS | title = Nonsurgical ablation of breast cancer: future options for small breast tumors | journal = Surgical Oncology Clinics of North America | volume = 23 | issue = 3 | pages = 593–608 | date = July 2014 | pmid = 24882353 | doi = 10.1016/j.soc.2014.03.009 }} Often surgery is used following cryoablation. As of 2014 more research is required before it can replace lumpectomy.

Another type of cryoablation is used to restore normal electrical conduction by freezing tissue or heart pathways that interfere with the normal distribution of the heart’s electrical impulses. Cryoablation is used in two types of intervention for the treatment of arrhythmias: (1) catheter-based procedures and (2) surgical operations.

A catheter is a very thin tube that is inserted into a vein in the patient’s leg and threaded to the heart where it delivers energy to treat the patient’s arrhythmia. In surgical procedures, a flexible probe is used directly on an exposed heart to apply the energy that interrupts the arrhythmia. By cooling the tip of a cryoablation catheter (cardiology) or probe (heart surgery) to sub-zero temperatures, the cells in the heart responsible for conducting the arrhythmia are altered so that they no longer conduct electrical impulses.

Cryoablation is also currently being used to treat fibroadenomas of the breast. Fibroadenomas are benign breast tumors that are found in approximately 10% of women (primarily ages 15–30).{{Cite web|url=https://medical-dictionary.thefreedictionary.com/fibroadenoma|title=fibroadenoma|via=The Free Dictionary}}

In this procedure which has been approved by the U.S. Food and Drug Administration (FDA), an ultrasound-guided probe is inserted into the fibroadenoma and extremely cold temperatures are then used to destroy the abnormal cells.{{Cite web|url=https://www.webmd.com/women/news/20031204/cryotherapy-shrinks-benign-breast-lumps|title=Cryotherapy Shrinks Benign Breast Lumps|website=WebMD}} Over time the cells are reabsorbed into the body. The procedure can be performed in a doctor's office setting with local anesthesia and leaves very little scarring compared to open surgical procedures.

Different catheter-based ablation techniques may be used and they generally fall into two categories: (1) cold-based procedures where tissue cooling is used to treat the arrhythmia, and (2) heat-based procedures where high temperature is used to alter the abnormal conductive tissue in the heart.

Cold temperatures are used in cryoablation to chill or freeze cells that conduct abnormal heart rhythms. The catheter removes heat from the tissue to cool it to temperatures as low as -75 °C. This causes localized scarring, which cuts undesired conduction paths.

This is a much newer treatment for supraventricular tachycardia (SVT) involving the atrioventricular (AV) node directly. SVT involving the AV node is often a contraindication for using radiofrequency ablation because of the risk of injuring the AV node, forcing patients to receive a permanent pacemaker. With cryoablation, areas of tissue can be mapped by limited, reversible, freezing (e.g., to -10 C). If the result is undesirable, the tissue can be rewarmed without permanent damage. Otherwise, the tissue can be permanently ablated by freezing it to a lower temperature (e.g., -73 C).

This therapy has revolutionized AV nodal reentrant tachycardia (AVNRT) and other AV nodal tachyarrhythmias. It has allowed people who were otherwise not a candidate for radiofrequency ablation to have a chance at having their problem cured. This technology was developed at The Montreal Heart Institute in the late 1990s. The therapy was successfully adopted in Europe in 2001, and in the US in 2004 following the "Frosty Trial".{{Cite web |url=http://www.cryocath.com/de/7.neuigkeiten/7.0.neuigkeiten.asp?id=385 |title=Neuigkeiten |access-date=2013-12-18 |archive-url=https://web.archive.org/web/20131219021118/http://www.cryocath.com/de/7.neuigkeiten/7.0.neuigkeiten.asp?id=385 |archive-date=2013-12-19 |url-status=dead }}

In 2004, the technology was pioneered in the midwest United States at Miami Valley Hospital in Dayton, Ohio, by Mark Krebs, MD, FACC, Matthew Hoskins, RN, BSN and Ken Peterman, RN, BSN. These electrophysiology experts were successful in curing the first 12 candidates in their facility.{{citation needed|date=May 2018}}

Cryoablation for AVNRT and other arrhythmias do have some drawbacks. A recent studyNov. 2010 German CYRANO study [http://circ.ahajournals.org/cgi/content/abstract/122/22/2239 (Cryoablation Versus Radiofrequency Energy for the Ablation of Atrioventricular Nodal Reentrant Tachycardia)] concluded that procedure times are slightly higher on average for cryoablation than for traditional radio-frequency (heat-based) ablations. Also, higher rate of equipment failures were recorded using this technique. Finally, even though short term success rate is equivalent to RF treatments, cryoablation appears to have a significantly higher long term recurrence rate.

Cryoanalgesia can be performed using various techniques, primarily categorized into percutaneous and intraoperative approaches. The percutaneous approach involves inserting a cryoprobe through the skin under imaging guidance (e.g., fluoroscopy, ultrasound, or CT) to precisely target the nerve. This is common for intercostal or occipital nerve blocks. The intraoperative approach involves direct visualization and application of the cryoprobe to nerves exposed during surgery, often utilized during thoracotomy or other procedures where nerves are easily accessible.

Cryotherapy is able to produce a temporary electrical block by cooling down the tissue believed to be conducting the arrhythmia. This allows the physician to make sure this is the right site before permanently disabling it. The ability to test a site in this way is referred to as site testing or cryomapping.

When ablating tissue near the AV node (a special conduction center that carries electrical impulses from the atria to the ventricles), there is a risk of producing heart block – that is, normal conduction from the atria cannot be transmitted to the ventricles. Freezing tissue near the AV node is less likely to provoke irreversible heart block than ablating it with heat.

As in catheter-based procedures, techniques using heating or cooling temperatures may be used to treat arrhythmias during heart surgery. Techniques also exist where incisions are used in the open heart to interrupt abnormal electrical conduction (Maze procedure). Cryosurgery involves the use of freezing techniques for the treatment of arrhythmias during surgery.

A physician may recommend cryosurgery being used during the course of heart surgery as a secondary procedure to treat any arrhythmia that was present or that may appear during the primary open-chest procedure. The most common heart operations in which cryosurgery may be used in this way are mitral valve repairs and coronary artery bypass grafting. During the procedure, a flexible cryoprobe is placed on or around the heart and delivers cold energy that disables tissue responsible for conducting the arrhythmia.

Cryoablation has recently been used to treat low-flow vascular malformations such as venous malformations (VM) and fibroadipose vascular anomalies (FAVA). Cryoablation has proved effective for treating these disorders both as primary treatment and after sclerotherapy.{{cite journal | vauthors = Ramaswamy RS, Tiwari T, Darcy MD, Kim SK, Akinwande O, Dasgupta N, Guevara CJ | title = Cryoablation of low-flow vascular malformations | journal = Diagnostic and Interventional Radiology | volume = 25 | issue = 3 | pages = 225–230 | date = May 2019 | pmid = 31063139 | pmc = 6521903 | doi = 10.5152/dir.2019.18278 | publisher = Aves Yayincilik Ltd. STI. | doi-access = free }}

Cryoimmunotherapy is an oncological treatment for various cancers that combines cryoablation of tumor with immunotherapy treatment.{{cite journal | vauthors = Sidana A | title = Cancer immunotherapy using tumor cryoablation | journal = Immunotherapy | volume = 6 | issue = 1 | pages = 85–93 | year = 2014 | pmid = 24341887 | doi = 10.2217/imt.13.151 }} In-vivo cryoablation of a tumor alone can induce an immunostimulatory, systemic anti-tumor response, resulting in a cancer vaccine – the abscopal effect.With improvements in breast imaging and image-guided interventions, there is interest in ablative techniques for breast cancer. Cryosurgery initiates inflammation and leaves tumor-specific antigens intact, which may induce an anti-tumor immune response.{{cite journal | vauthors = Tarkowski R, Rzaca M | title = Cryosurgery in the treatment of women with breast cancer-a review | journal = Gland Surgery | volume = 3 | issue = 2 | pages = 88–93 | date = May 2014 | pmid = 25083502 | pmc = 4115762 | doi = 10.3978/j.issn.2227-684X.2014.03.04 }} However, cryoablation alone may produce an insufficient immune response, depending on various factors, such as high freeze rate. Combining cryotherapy with immunotherapy enhances the immunostimulating response and has synergistic effects for cancer treatment.{{cite journal | vauthors = Haen SP, Pereira PL, Salih HR, Rammensee HG, Gouttefangeas C | title = More than just tumor destruction: immunomodulation by thermal ablation of cancer | journal = Clinical & Developmental Immunology | volume = 2011 | pages = 160250 | year = 2011 | pmid = 22242035 | pmc = 3254009 | doi = 10.1155/2011/160250 | doi-access = free }}

The use of cold for pain relief and as an anti-inflammatory has been known since the time of Hippocrates (460–377 BC).{{cite journal | vauthors = Cooper SM, Dawber RP | title = The history of cryosurgery | journal = Journal of the Royal Society of Medicine | volume = 94 | issue = 4 | pages = 196–201 | date = April 2001 | pmid = 11317629 | pmc = 1281398 | doi = 10.1177/014107680109400416 }} Since then there have been numerous accounts of ice used for pain relief including from the Ancient Egyptians and Avicenna of Persia (AD 982–1070).{{cite journal | vauthors = Trescot AM | title = Cryoanalgesia in interventional pain management | journal = Pain Physician | volume = 6 | issue = 3 | pages = 345–360 | date = July 2003 | pmid = 16880882 | doi = 10.36076/ppj.2003/6/345 | doi-access = free }} Since 1899, Dr. Campbell White used refrigerants for treating a variety of conditions, including: lupus erythematosus, herpes zoster, chancroid, naevi, warts, varicose leg ulcers, carbuncles, carcinomas and epitheliomas. De Quervain successfully used of carbonic snow to treat bladder papillomas and bladder cancers in 1917. Dr. Irving S. Cooper, in 1913, progressed the field of cryotherapy by designing a liquid nitrogen probe capable of achieving temperatures of -196 °C, and utilizing it to treat of Parkinson's disease and previously inoperable cancer. Cooper's cryoprobe advanced the practice of cryotherapy, which led to growing interest and practice of cryotherapy. In 1964, Dr. Cahan successfully used his liquid nitrogen probe invention to treat uterine fibroids and cervical cancer. Cryotherapy continued to advance with Dr. Amoils developing a liquid nitrogen probe capable of achieving cooling expansion, in 1967.{{cite journal | vauthors = Gage AA | title = History of cryosurgery | journal = Seminars in Surgical Oncology | volume = 14 | issue = 2 | pages = 99–109 | date = March 1998 | pmid = 9492880 | doi = 10.1002/(sici)1098-2388(199803)14:2<99::aid-ssu2>3.0.co;2-1 }}{{cite journal | vauthors = Freiman A, Bouganim N | title = History of cryotherapy | journal = Dermatology Online Journal | volume = 11 | issue = 2 | pages = 9 | date = August 2005 | pmid = 16150217 | url = http://escholarship.org/uc/item/4f62h9vt }}{{cite journal | vauthors = Cooper SM, Dawber RP | title = The history of cryosurgery | journal = Journal of the Royal Society of Medicine | volume = 94 | issue = 4 | pages = 196–201 | date = April 2001 | pmid = 11317629 | pmc = 1281398 | doi = 10.1177/014107680109400416 }}

With the technological cryoprobe advancements in the 1960s came wider acceptance and practice of cryotherapy. Since the 1960s, liver, prostate, breast, bone, and other cancers have been treated with cryoablation in many parts of the world. Japanese physician Dr. Tanaka began treating metastatic breast cancer with cryoablation in 1968.{{cite journal | vauthors = Ablin RJ | title = The use of cryosurgery for breast cancer | journal = Archives of Surgery | volume = 133 | issue = 1 | pages = 106 | date = January 1998 | pmid = 9438770 | doi = 10.1001/archsurg.133.1.106 | doi-broken-date = 23 December 2024 }} For the next three decades, Dr. Tanaka successfully treated small and localized as well as advanced and unresectable breast cancer with minimally invasive cryoablation. All of Dr. Tanaka's breast cancer cases were considered incurable: advanced, unresectable, and resistant to radiotherapy, chemotherapy, and endocrine therapy. At the same time, physicians, including Dr. Ablin and Dr. Gage, started utilizing cryoablation for the treatment of prostate and bone cancer.{{cite journal | vauthors = Marcove RC, Miller TR | title = The treatment of primary and metastatic localized bone tumors by cryosurgery | journal = The Surgical Clinics of North America | volume = 49 | issue = 2 | pages = 421–430 | date = April 1969 | pmid = 5774987 | doi = 10.1016/s0039-6109(16)38799-0 }}{{cite journal | vauthors = Alblin RJ, Soanes WA, Gonder MJ | title = Prospects for cryo-immunotherapy in cases of metastasizing carcinoma of the prostate | journal = Cryobiology | volume = 8 | issue = 3 | pages = 271–279 | date = June 1971 | pmid = 5570410 | doi = 10.1016/0011-2240(71)90050-2 }} Dr. Paul J. Wang MD and Dr. Peter L. Friedman MD, PhD invented cryoablation for the heart and cardiac arrhythmia in 1988. Their patents were for the cryoablation catheter and cryogenic mapping (US Patents 5147355A and 5423807A).

The 1980s and 1990s saw dramatic advancement in apparatus and imaging techniques, with the introduction of CMS Cryoprobe, and Accuprobe.{{cite book | year = 2012 |title = Management of Medical Technology: Theory, Practice and Cases | url=https://books.google.com/books?id=SBYDCAAAQBAJ&pg=PA281 | page=281|isbn = 9781461555193 | vauthors = Geisler E, Heller O |publisher = Springer }} CT-, MRI-, and ultrasound-guided cryoprobes became available and improved the capabilities of cryoprobes in treatment. Excited by the latest advancements in cryotherapy, China embraced cryotherapy in the 1990s to treat many oncological conditions.Tumor treatment through cryotherapy was first invented by Americans in the 1960s. Aimed at promoting the new technology, the ISC was founded in Austria in 1972. The technology matured with each passing day after over 30 years of development. In recent years, in particular, China, with its greater economic development and scientific and technological progress, has been playing a leading role in the world in terms of both theoretical research and clinical application of cryotherapy. As an efficient medical method for treating tumors, cryotherapy has been adopted by more and more medical institutions in China and has achieved remarkable cancer-treating effectiveness.{{cite web | year = 2015 | title = China: New Chair of the International Society of Cryosurgery (ISC) | url = http://www.fudacancerhospital.org/fudanews/20150723185.html | access-date = 2016-10-23 | archive-url = https://web.archive.org/web/20161020041210/http://www.fudacancerhospital.org/fudanews/20150723185.html | archive-date = 2016-10-20 | url-status = usurped }} With the benefits well-established, the FDA approved the treatment of prostate cancer with cryoablation in 1998.{{cite web |title = Center for Devices and Radiological Health U.S. Food and Drug Administration. | website=Food and Drug Administration| url=https://www.fda.gov/ohrms/dockets/ac/03/briefing/3973b1_summary.htm| archive-url=https://web.archive.org/web/20030921195159/http://www.fda.gov/OHRMS/DOCKETS/AC/03/briefing/3973b1_summary.htm| url-status=dead| archive-date=September 21, 2003}}

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