Fantastic. OK, I think we're live now, so welcome everybody who can be with us here today live. My name is Sylvia Janska.

I'm a veterinarian in the UK and I'll be your chair for today. As you already know, it's a pre-recorded webinar that we're doing today, but we do have with us Doctor Sam Nalla, so, there will be a chance to ask some questions at the end. So if you have any questions, please pop them into the Q&A box.

And, I'm not going to do too much of a, introduction because, the, the, the, the, the speakers do introduce themselves, on the, on the recorded session, but I would just like to thank Doctor Ned Bala, the founder and CEO of Cryo Concepts for being here today with us, so thank you very much, even though it's super early morning where you are. And I would also love to thank NWK Healthcare for sponsoring this webinar on cryosurgery for lic granulomas and other benign lesions in the vet, veterinary medicine. So, without further ado, I'm seeing a lot of people saying hello in the chat, so yes, thank you very much for coming.

Hello to everyone and let's dive into the webinar. Welcome everyone to this seminar and thank you for attending. Dr.

Mosby and I look forward to sharing some of our experiences, also the technical background around cryosurgery and some of the unique things that have been tried and some of the clinical situations we want to talk about today. But before we get started, let's do some housekeeping. So first, let's introduce ourselves and, and Doctor Mosby or Tim.

If you'd like to tell everybody about your background training so they have a framework around which to understand, you know, the instruction you'll give later. Sure. I'm a 2005 graduate of the University of Pennsylvania.

I've been in practise since then, 17 years now. Mainly general practise, also emergency medicine, have interest with surgery and dermatology and ultrasound, which doesn't apply here. But I got a, it's been doing cryosurgery for, I believe about 5 years now.

Was, was playing around with it some before I met Sam and cryoconcepts. And so we've worked over the last 5 years developing some of these techniques and, and helping us, figure out how to use them better in practise. But thanks, Tim.

And, and my name again is Doctor Sam Nabala. I'm a PhD, and so my role in the seminar this morning is really to facilitate as we go through it, but also to provide a lot of the technical background about how cryosurgery works, how the technologies, out there are used and how they're applied in veterinary medicine. And really just to kind of walk us through the the underpinnings that then Tim will guide us through the clinical utility and why it all makes sense in the practise.

So for today, I'm going to switch over to the slide deck now. Let me just do that. And we'll begin to walk through the seminar now.

We would encourage you that if you have questions to please send them in over the course of the lecture. We'll be in the background ready to answer what we can. If there's something we need to do a little more work on, we'll get back to you regardless.

So we would just encourage as we go to be sending those in. We'll also provide for you some references at the end of the, the, seminar that you can, look up or if you'd like copies, please let us know and we're happy to share those. And, also, again, you may have questions that relate to products, that I'll show.

Just full disclosure, I obviously work for. Cryo concepts. I'm CEO of the company, but I'm also a researcher, and so I've published a lot in the past and so I, I feel very compelled to educate and so in what we will discuss today, of course there's, there's products technologies that relate to us, but also I'll show you everybody else's technologies that are out there and some of the that will give you in performing cryosurgery in your practise will relate to whatever product you use.

Our goal here is to teach and to give you some better ways to perhaps do things that you've done in the past with cryosurgery or to expose you to the new ideas and maybe some of the applications that are possible if you've not been doing it in the past. So by all means, you know, we're trying to be an open book and talk through this, . Both from an academic as well as clinical perspective.

And so with that, let's get started and talking through some of our slides. So, first of all, we'd like to talk a little bit about why cryosurgery in the veterinary practise, the history, the principles. We'll talk about technologies and products and review.

Again, we're not gonna do live demonstrations of products. We have some videos that we'll share with you, . We'll also then dive in and look at some clinical cases and so various ways that the technology is used, how it's applied, how to consider the patient, their owner, etc.

Practise economics are also important because it's got to be efficient and timely. For you to perform these procedures and then we'll conclude and as I said there's references at the back end of this that you may find that you'd like to look up or like a copy, let us know. Of course the slides, everything else is there for you and also, you know, your ability to get the CE credit for attending the course.

Right, so now let's start to talk about cryosurgery. So definition, of course, is the use of extreme cold in order to destroy abnormal or diseased tissue, cryo meaning cold and surgery meaning hand work. We are typically focused only on benign lesions that are topical.

We are not doing any sort of internal or contact freezing that, and of course, Cancer as well. We, we leave that to other techniques, other technologies. We're really looking at the lumps and bumps that pet owners dislike and that, you know, can be attended to with the kind of technology and temperatures that we're talking about today.

And when you think about it in that framework, then you ask, OK, why cryo versus the alternatives? And, and really it's, it's a couple of things that fall out. Number one, it's tolerated by both the patient as well as the owners, and it's understood by them because for us as humans we also get cryosurgical treatments quite often either over the counter or in our physician offices.

So it's not. Technology that's foreign to individuals and, and understanding how to properly use it with companion animals or equine is really the challenge for the professional side, but I think conceptually everybody understands what we're doing and, and, and in general how it might work. Now the one thing that I'll come across throughout this lecture is that when you use cryosurgery to treat companion animals because of the physiology and design of the skin.

They have a different scenario or path that follows the cryopro. So, Number one is because you're freezing the local tissue that's targeted, you eliminate the risk, or I'm sorry, you eliminate the risks associated with general anaesthesia cause you primarily and as Tim will discuss, can use a local or in many cases nothing at all. So we know that our companion animals just like us as we get older, get the lumps and bumps and so with that comes a certain risk.

That we can avoid by not using general anaesthesia. Also, there's no wound that's produced, and this is different again compared to human use where we may often blister in what we'll describe today we don't see that with our companion animals. Also.

Because of the first couple things we described, there's generally no need for a cone leaving the office or the cone of shame, as it's often called, and there's a variety of indications and it's very simple to use. So when you compare cryo to the other alternatives, which may be just surgical. Excision or electrocautery, which definitely create wounds and definitely create other challenges.

Cryo negates a lot of that and as you'll see in the case studies, brings about some help, especially with the older patients. Now let's talk a little bit about history. You know, we're really not inventing something new here.

Everybody learned about cryosurgery in school, and, and again, it's, it's part of normal life. But in the veterinary practise, it really goes all the way back to the 1970s and searching the literature and primarily Doctor Lane and a lot of the work being done in the UK with liquid nitrogen. And a couple of years ago, Doctor, Doctor Mosby and I were giving a A lecture on cryosurgery in I think it was at BMX or one of the larger shows and there was an old veterinarian that came up afterwards who said, oh, I, I did this way back when and we use liquid nitrogen.

The problem was the access to get it. And so, what you saw is a lot of work, a lot of like early establishment of what was going on and how best to practise, but it faded away because the access to liquid nitrogen is very different. The things we'll review today are all more or less mobile, able to be used around the office, and, really take care of that objection of the past.

So when you look at the literature, you can see the list here of various lesions that have been treated. A lot of them are the same that we're seeing today. It's just that we've refined the techniques to match the technologies that are readily available.

In terms of treatment, of course, a small animal, canine, feline, most companion animals, basically anything with circulation and moisture as far as tissue can be treated on large animal, equine is the. Focus, but or primary lesion that's asked about. But again, these can be extremely large and so that's more of a challenge.

Small animal, absolutely doable, and as you'll see in all the case studies, good examples of the various ways that it can be applied. OK. So now, now let's dive down a little bit in terms of the matching the physiology and the requirements for optimal cryosurgery.

So a number of years ago, I know when I first got involved with this, and in my experience it's mostly from the human side developing cryosurgical products, many of which you see over the counter or if you visit your physician's office. It was only later that I really picked up on the idea of veterinary cryosurgery, and we spent about a year and a half visiting offices, testing. That's when Tim and I met.

And really trying to understand what was the difference and for the longest time couldn't really dig deep enough to understand what was driving the difference in performance because what is typically done on a human in terms of time and temperature of a cryot treatment did almost nothing when we treated a companion animal. And what it really boiled down to was the basic difference in the physiology of the skin. And what you have to do in terms of treatment.

So with the dog and cat, for example, we have differences in the, in the structure that drive the requirement for really aggressive treatment. And aggressive to the point that it's so different from what you would do in the human case that we really are going to drive that point home all the way throughout this so that with the limited capillary flow, the increased fat content, and in some cases limited hydration, that then means the cryo portion of this has to be used more aggressively and work a little harder to make sure that the freeze is appropriate. The benefit in veterinary medicine is something I mentioned a slit or two ago, which is you do not create an open wound.

What you'll create is a scab and you will certainly kill the nerves that are local to the area being treated, but the benefit again compared to say human treatments is you do not have that danger of creating a wound when you follow what we're talking about. OK, so let me then move to the next slide. All right, so now let's talk about Principles of cryosurgical treatment.

So there'll be a, a test at the end of this on this equation. I'm sure you're gonna memorise this, it's, but no, it's really not gonna be that at all. What we really want you to understand from this is that when you Apply the, a cold spray, a cold tip, a cold liquid to the surface of the skin.

What you're actually doing is pulling the heat from the tissue beneath, and that is really the main action that's occurring in a cryosurgical treatment. What really follows on from this is what, what does that mean? How do I reach a temperature that's lethal enough to kill the target cells, but, but nothing more in an ideal world?

How long does that take and what, what temperature ultimately must I I reach to do that? And so once heat transfer has begun, then I get into the next question. And this is where I, I want to just pause because this is physiology, but also the physics of this.

So, if you look at A, B, C, D, from top to bottom, the first one is where I get a slow freeze. And what the image is showing is on the left, you know, the cells in, in before form, and then afterwards if I slowly freeze, what I do is dehydrate the, the cells. I drive out the, the water.

I'll increase the solutes that are surrounding. But what I basically do is create freeze dried tissue. Now, we know from the food industry, this is one of the main ways that you preserve.

Cells and you keep food basically edible. So when we're trying to destroy tissue, that doesn't work. What does work is B, which is a rapid freeze which causes change rapid changes in osmotic pressure, the production of ice crystals, and so we get this kind of destructive force that's physical from the ice.

We also get the chemical changes that occur and so a rapid freeze is going to give you the, the Best, destructive, tendencies. When you go to C and D, now we're talking about the other part, which is I want a rapid freeze, and the question is rapid thought or slow thought. And the answer is I want a slow thought because then what happens is, with the rapid freeze, I basically just called caused localised havoc among the cells and the tissue and the in inner cellular space.

As it slowly thaws, it remains disrupted and you get, basically, changes at membrane level that lead to further destruction and also changes in osmotic pressure. With a rapid thaw, what I get is almost an equilibrium that that can occur very quickly because I put energy back in. So, going to the bottom line with everything I do with cryosurgery, I want to do rapid freezes, which means I want to get as cold as I can, as quick as I can, and I want to then let the lesion come back to temperature, a, a message you will hear over and over.

And then, the second part to it is I want to do that multiple times in a treatment to give myself the best chance of success with one session. Now, what are some other clues and, and things we can add in here that will bring about further effectiveness? Well, number one, remember what I told you we're doing in cryo which is we're taking heat out of the tissue.

And so the first thing I can do is actually pre-cool the area. And so here I might use an ice pack or I might use an ice cube, I might use just a cool gel pack, something that will basically draw off some of the heat. As Tim will attest in a little bit, you know, again, you, and you, you likely know this as well when you put a companion animal up on the table and they start to shake, that the heat, they generate heat, when you pre-cool, you also acclimate them to the freezing that they're about to receive, when it's applied.

And so it, it, it has a number of benefits. The second one is to debride, and we have, we have a number of, of ways that people do that with a file, they may plan it off. They may use Adremel, but if you're treating something, something that's thickened, you want to remove whatever is dead tissue because honestly you always have to remember whatever you're going to freeze has to contain moisture.

If it doesn't, there's nothing to freeze. And then the last part of this, which is really important is you want something that's going to freeze to at least -50 °C. There's an interesting article that that actually drives this point home, and it is from, it was research done on the human side, but it was actually done with a canine model.

And what they did is experiment with how A temperature related to the cellular death rate that was seen and they started at -10 and went in 10 degree increments and then took biopsies and looked at the effect and once you reached -50 °C 100% of The cells were were killed. And so that's a great sort of line to draw on the sand. So any technology you may be using today or look at should at least attain those temperatures and tie up to what the literature has taught us in some of the early studies.

And the, the, the next one to add in here is what we mentioned a moment ago, which is the lesion should be rapidly frozen and slow thawed. So again, some very simple things that you can follow up with and then that last one about doing multiple freeze thaw cycles, and you'll hear that again as we talk about case studies. The last one on here is you generally also will get a small margin, maybe a 0.5 millimetre to 1 millimetre of healthy tissue around the lesion to freeze it as well.

And again, we're trying to get you the maximum benefit in a single session. OK, so let's talk about technologies a little bit. So the delivery of the cryogen can be done in one of three ways.

It could be an open spray. It could be what's termed a cone, and there's a couple different designs of cones or there can be an applicator and a bud. So I'll tell you the bottom line story here in veterinary medicine.

The open spray and the cone are the most efficient at heat transfer. The applicator, while it brings certain conveniences, is going to be more limited in its heat transfer because the, the, the bud itself has a limited capacity for the heat to transfer and the cold will be. Basically extinguished over a period of time.

So the two that you'll see most in clinical studies used that we present and, and the cases that follow are open spray and cone. Applicator is good. If I, if I need to reach something that's very difficult, as long as it's small and contains moisture, it's viable, but you may have to treat it a couple of times as we had mentioned.

OK, so what happens when I apply? So this is, this is actually a 3D model that looks at applying a cryosurgical treatment in the middle at zero, and then how the heat transfer propagates out sideways freezing. And so you can see over 5, 1015, 20, all the way up to 32 seconds, the degree in which it travels and propagates sideways as well as down.

So the idea is that time and temperature are the two things that are going to drive this the most. So if a very small lesion, I can go pretty short. If I have a larger lesion, then I need to apply for longer periods of time.

And while applying the energy and and performing the heat transfer, you'll See in a moment when we look at some of the comparative technologies why 1 may work versus another in achieving maximum effect. But this, this is just so that you picture as you're doing a treatment creating that cone that's basically inverse and under the tissue to maximise the treatment efficiency. So some of the considerations as we look at technologies, one of course is efficacy and efficacy.

We said you should have at least a cryogen gas that's going to be below -50 degrees, and those temperatures are really critical. It's too warm, there's very little that's going to happen or you have to treat for much longer. .

The other one is the ease of use and delivery. You'll see some devices that require two hands. Obviously in veterinary medicine, it's not always possible to both have the patient still enough and to be using two hands to do applications.

So that's important. Flexibility, there are technologies. That we'll look at in a moment that use both buds or cones.

There's also spray technologies that have to be in certain positions, can't be sprayed from an upside down angle as an example. All of those build into what you will like ultimately to use in your practise. The third one, which we talk about more and more.

Now is environmentally friendly. These are cryogen gases, but they also create a certain amount of waste and there is packaging and containers. So, we now include the idea and consideration for asking whether a product is returnable, reusable, you know, resulting in a lower impact on the environment in terms of waste.

And also the global warming potential because some of the gases that are out there are very old technologies that really need to be upgraded and, and there are alternatives available. So I think now we can begin to ask those questions and be responsible to sweat. OK.

So let's talk about the Variations among products and then we'll move on to the clinical portion of this. So cryosurgical gases are certainly part of it. But then the three main ways that we talked about doing this open spray, applicators or cones are what we want to now take a look at.

So when we look at open spray technologies, the image at the top treating the lesion is what you would expect. These are technologies that don't touch the surface of the skin but rather are just a little bit away and are delivering the gas consistently. Now, the one thing I'll say, and it'll make more sense when we look at cones, the energy or the heat transfer is only occurring when I'm spraying.

So these always require you to move from spot to spot to continually spray. They're the coldest portable gases. These, these all contain.

Liquid nitrogen on the right or nitrous oxide on the left. Now, nitrous oxide can be sprayed, but again, nitrous ox I'm sorry, liquid nitrogen has the issue of storage, whereas nitrous oxide can be stored in containers that are small cylinders or in the middle you see the product cryoabb that which has about a 20 ounce cylinder providing about 90 minutes of freeze time. So open spray technologies are the coldest that you can get.

There's reasonable portable versions of that with nitrous oxide and the most aggressive that are available. So here's the example I was referring to where on the left you see if I. Apply nitrous oxide by this product cryomega, there's instantly this taking of the heat from the material underneath and you see it's a very sharp band.

But if I stop over a period of a couple seconds, it very quickly dissipates outward and then if we looked at a second or two later, it would warm right back up the skin temperature. So in a spray, you must continually deliver it to the surface to get effect. If you look at cone-based technologies and in the top right you'll see an image of one of the styles of cones.

It goes over the lesion and then into the cone is delivered the cryogen. The cryogen will bubble for whatever period of time heat transfer is occurring or if it's evaporating into the atmosphere. So on the left is a product called Verucafreeze, which has been around a very long time.

And you can see the cones along the, in the image and the different size openings of those cones. On the left, on the right is the cryomegavat and that has a different style cone, which is shown in the picture above. The difference in these is the, cryomega dual delivery.

The cone is closed and so the blue line shows the delivery of the gas and then the period of time it's bubbling in the cone, heat transfer occurring, and the steadiness that happens, whereas the open cone, kind of the older design, which some of you may have seen in the past, the moment I deliver the gas into this open funnel design. It begins to do the heat transfer step, but it's also evaporating into the environment. So I have to very quickly add in more to keep that going.

So it's, you know, different generations of product at this point and just making you again aware of the comparisons. But between open spray and comb, these are the two most efficient ways for performing veterinary cryosurgery. Applicator-based technologies really there's a couple of examples here.

So the Veruca freeze in the middle and the cryomegadual delivery each have a a bud-like applicator. The one on the right, the histta freezer, is also sometimes. I'm seen in veterinary practises, but again, in all of these cases, the applicators have a limited capacity, and we know that for companion animal lesion effectiveness, we need to be much more aggressive.

So in small areas around the eye, anywhere where it's difficult to get in with a cone, you would use an applicator, but you can expect that you'll have to do multiple treatments because of the limited capacity for the cryogen. So Gives us a sense then for the different technologies, the different ways that the gases are, are used, the types of cryogens that are available. And so it brings us to start to move towards the clinical side to this.

And I put this slide in here. This was a survey that was done just over the second half of 2021. Because as we get into the clinical indications, the question becomes, well, OK, we knew what they did back in the 1970s, but in 2021, what were they doing?

And I, I apologise for the typo that's there. The, and so the message after surveying about 30 vets that were using open spray cryosurgery is to see that they were first and foremost treating warts, eyelid tumours. But notice the skin tags, papillomass, and then all the way at the bottom, there were, there was just one using it for lick granulomas, which is gonna be one of our topics for today.

But you can see these are the, the normal, benign. Bumps and bumps, the things that are happening day to day on the animals that are coming in for other treatments. And, so it gives you some perspective as we look now at the case studies, how to consider these as treatment options and what others are doing.

Tim, do you have any comments on, on this in terms of your practise? And that pretty much fits with what we use it for most of the time, kind of warts, adenoma, skin tags are, are the vast majority of what we do. Eyelid tumours, you can certainly find cases that it will work well for papillomas again, when they pop up, yeah, they're easy to use cryoon.

And, no, that I wasn't part of the survey, but one lick granuloma I think is, is what I had treated up until into 2021 at that point. So, no, that's, that pretty much fits with, what we use it for. Good, good.

And we wanted, you know, clinicians to understand this is what everybody's generally using cryo for if they're using it routinely in their practise. OK, so let's start to navigate them through case studies, and, and we do this in a couple of ways. We, we certainly have indications and, but we also do it by the methodology.

So some open spray, some cone, and, and again, we're going to focus a little bit more today on lick granuloma and whether or not this is a viable alternative to other things that you may have as clinicians in your bag to use. So what we typically do in each one of these. Is now Tim comes into the picture.

You now know your background, you've chosen whatever technology you're going to use, and now we start to see real life what happens and, you know, this picture is one good example of the kinds of things you guys may see, hopefully not every day, but it's out there. So, some of the questions that we'll look to Tim for now, the answer is, you know, how do you decide if prior is appropriate. You know, how would you freeze, in this case, this tag?

How many freeze thaws do you do? Let's, let's get very practical about this. What do you tell the client?

How would you send them home and how do you follow up? Typical questions I think every one of you may have, and we'll just try and cover these as we go through this. So, Tim, you want to take this one to start with?

Sure, definitely. Now, obviously this, this is, this is overall. Big mass.

Why cryo could be appropriate for this is basically how narrow it is at the base. That thing is probably no more than 1 centimetre, centimetre and half down at the base. So despite the overall mass of it, you know, where its actual attachment is, where it's getting its, its blood supply from, is overall pretty narrow, and we can freeze pretty well with, with cryosurgery.

Freezing it would focus really, at this point, we use, I used to freeze the entire thing. Having done a few of these now, usually focus down at the base. That's where I do majority of the freezing now.

If you're doing it right, you'll find that whole pendulous mass really, really blanches and gets very cold just when you freeze the, the base of it. So, something this big, do wanna give it a, a good long, freeze cycle. I'd go at least 30 seconds, probably if, if the patient tolerates it 40, 50, maybe even 60 down at the base of it.

And we'll come out from the base too, at least a couple of centimetres down that stock. I'd probably something this big. You need to be aggressive on.

So I would usually do 3 freeze, freeze stall cycles, to try and make sure we damage as much of that, that stock as we can. Generally, these, I've seen one of two things happens with them either one, that, that base gets very narrow, the mass shrinks down and really sometimes falls off or you get back for a recheck. And you can just, there's a scab you pick off and it's gone.

Sometimes they have, and I don't know exactly the difference why, they will just slowly shrink down and you may need to do 2323 treatments to get it totally resolved. You, my big thing when I would, for clients is I usually tell them, it may look a little more red, a little more irritated for a couple of days, that kind of initial, Frostbite, you give it, you do get some increased blood flow that comes back. It generally does not seem to be painful.

Even patients who may have been bothering it when they come in. Once they go home, once it's been frozen once, it seems to really kind of, dull the, the nerve sensation and they usually leave them alone. Patient dependent, of course, if it's something that, it's, it's gnawing at it or it's painful, can certainly use pain medication, you know, non-steroidal or, or gabapentin, and, you know, if you really needed to, a covering or a cone, but I find that that's really rare even with something this big.

So my biggest thing for the client is usually I tell them, leave it alone. Don't look at it, don't touch it. Usually, you don't need to do anything with it.

We'd like to see them back in, in about 2 to 3 weeks with something this size, or depending on, on the patient or client, maybe just have them send me a picture in 2 weeks. We can kind of decide how much resolution we've had, if we need to treat it again, or how many times we might need to treat it again. Smaller ones usually I just have to send pictures.

Something this big, I'd have them come back, in, in 2 to 3 weeks cause I, I assume something this big. We'll probably need to, to freeze it at least one more time. Mhm.

OK, perfect. So let's now, we'll walk through some other clinical indications and see how we would do with this. OK, so adenomas are next.

You know, this is one that you really treat a lot, so. If you would describe this particular patient, how you evaluated what you did here. Yeah, this was a little old shih-tzu who had, she probably had 20 of these, and the owners didn't want to go in surgically and make her look like Frankenstein with with stitches everywhere afterwards.

So we, we, this was early on, we, we were starting doing cryotherapy and adenomas are, that's our bread and butter. If you, if, if you buy a cryo unit and do nothing but adenomas, you'll probably pay for it pretty quickly. You probably don't need to do a lot else just for that, but there's a lot more you can do with it.

But these things, no. You know, we did a few of these, I think two of these we have pictures of here. One of them less than 1 centimetre.

We did 32nd freezes on that. Anything up to 1 centimetre, you can, you can generally freeze kind of all at once, as far as you can freeze the whole lesion at once. So I believe we did 30 seconds.

I like to try and do 3 freeze fall cycles. Most of the way, we can, most of the time, we could probably get away with 2. The one on the right was a little bigger one.

I think that one was closer, about 2 centimetres. So, Kind of turn that into hemispheres, froze one half of them for 30 seconds, switch over, freeze the other half of it for another 30, and then let it slow tha before, before repeating the cycle. Mhm.

The question that will likely come up is how many lesions or how, how many, yeah, how many lesions might you freeze in a, in one session? Very patient tolerant dependent. I think I've probably done.

10 to 12 max was an old Airedale who had just covered with, with adenomas, and he could tolerate 10 to 12 at once before, before he lost, lost his patience with us. We're just, we're just standing still in the office. I'd say that most patients aren't that extreme.

I'd, I'd say usually you can, most patients, they can get away treating 3 to 4, at once, and, and that's usually time-wise and, and patient tolerance wise, a, a good number. Right. So the other question I, I could just imagine is about to be typed is are you using any sort of anaesthetic?

Usually not. And again, this comes down to the patient. A lot of them, no, you, you don't need anything anesthetic-wise.

If you have a, a, a patient who's already pretty anxious in the office, those, I will usually try to, to come in on, on prem oral pre-meds, gabapentin or trazodone. Well, if it is something sort of sensitive, one that might be a bit inflamed, usually do try to pre-cool with an ice pack, for 5 to 10 minutes and just to kind of hopefully numb the area and, make it a little faster, easier freeze cycle. .

Really, really sensitive ones certainly can do local anaesthesia, lidocaine just under the lesion or actually last, last time we spoke with VMX, one of the attendees had told us about a topical lidocaine, Prilocaine cream. I think the trade name is ELA. That works well too.

It takes a little longer to work, apply it topically. Usually need to give it about 30 minutes, but that numbs things really well too. Mm, OK.

Good. All right. So again, adenoma, and another one that you'll see.

Here's another version. I don't know if, if there would be anything different that you would add in terms of this particular patient. No, it's pretty much, this is pretty, once you get the adenomas down, they're pretty standard.

Freeze them, freeze them at least a good 30 seconds, you know, do a couple of cycles and, they usually respond really well. Size-wise, you know, this one. I think again, size-wise, this one was not too bad.

And it looked a little narrower at the base, which those usually freeze better too. But certainly, I would say when you get to 12 centimetres or, or more, it's not unusual. A lot of times, I will have them come ready to come back in 23 weeks to, to freeze it again to try and make sure it's, it's totally resolved.

Good. OK. So let's, all right.

So this is now an eyelid treatment. And so, you know, a patient presents with this, would you consider using cryo? If you did, how might you use it?

Yeah, that definitely I consider cryo for this one. It's, it's a relatively small mass. It's pretty narrow at the base.

This one, hopefully you can tell from the picture, it's not really down into the eyelid margin causing an expansion down there. This is a really, you know, kind of fairly pedunculated small eyelid mass, and this is a pretty, a really good option for, for cryosurgery. Treatment wise, always protect the eye.

Some people like to use a tongue depressor. I usually find that I, I can use a gauze square to kind of block the eye off. .

If you're worried about sometimes, depending with open spray, especially, we get these little snowflakes that, that come off of the, the freeze, adding a little, eye lubricant, kind of just a little extra protective layers and a bad idea. I've, I've never had any eye problems, but I try to be cognizant that we don't want to cause any damage to, to, especially the, the ocular tissue. The eyelid tumours, they're generally a little more vascular, more moisture containing, fine, especially on the size, you probably don't need to freeze it as long.

I think we've heard some feedback, some people will do them for 10 seconds. I still like to do 20. I don't like things, I don't like them not to resolve.

So, I'd probably do two cycles of the 22nd freeze on, on something like that. Mhm. OK, perfect.

And here's a, the video of actually this treatment. So if you want, if you want to narrate, by all means, you know, add colour in, but this is a good example of this kind of treatment. Yeah, again, it's a, it's, you know, a pretty small mass at the medial campus using a tongue depressor to, to keep it isolated.

And now I think you can see that was only a 5-second freeze. So some of these small ones and especially vascular areas like the mouth or eyelids, you, you don't have to freeze as long as you do. You know, out on the body with, with adenomas.

And that being such a small mass, 5, 10 seconds may, may well be enough to, to freeze it. Yup. Yeah.

You, you can see also when the patient felt, hey, what was that? And notice the, the white still there showing that it's a good freeze. So again, when we talk about freeze thaw, you want the freeze to look white, and then when it thaws, it should turn back to flesh colour.

And that's probably good as far as do, how do we know, you know, obviously, we don't have tissue temperature gauges telling us we've gotten to -50. But yeah, it should be, should look like a little, it should look like ice when you, when you finish freezing. It should be an ice cube.

And it should take a, you know, if that fall cycle, if it, if it's thawing quickly afterwards, I would try and freeze longer on your next cycle, to try and to make that, that, thaw process slower and, and cause more damage to those cells. Yep, yup. I think with each priests thaw, it takes longer to thaw because you've actually frozen it.

So there's, you know, you've already sucked heat out of it. So with each thaw cycle, it just takes a little bit longer, but when you're patient, you, you get into the cadence of that, and we'll see that a little bit more. Here's one I know that we've looked at before, Epous.

This is I don't know if you want to comment on this. Yeah, this was, you know, gingival tissue, obviously a lot more moisture, a lot more vascular. So something like this that again, a small pedunculated, little mass, pretty easy to freeze if it's something the owners don't want to surgically remove and biopsy.

I believe this was done at the time of a, of a dental. Yeah, they like to to freeze it rather than surgically remove it and, and biopsy it. And now, these kind of things, they freeze really well.

Something like this. Not exactly a giant aggressive looking lesion, Easy thing to freeze and and monitor afterwards and And make sure it resolved. Obviously, these things, things come back not behaving as they normally do at that point.

I, I often will say, hey, go back, biopsy. Make sure you've, make sure you've got your diagnosis right, if it's not responding the way it's supposed to. All right.

And, and again, these are all examples of open sprays. Now we'll go in the direction of some cone-based treatments and we can, we can talk about this for a moment. So again, here's an adenoma.

This was Just a few days really for the, I'm sorry, this was a really nice sequence. You can see the, the lesion on the left hand picture and again cone treatments, you dispense the gas typically for 3 to 5 seconds or in the case of the verruca freeze, you fill the cone to a certain level and then you let it boil. During the boiling, the heat transfer takes place.

The difference between the open spray and the cone treatments is, is, during the open spray you are continuously, you know, turning on the spray of the gas to do your treatment in the cone you deliver into the cone and while it's boiling, it's doing its work. So you sort of turn off and just let it go through its evaporation heat transfer process, . Tim, I believe this one was treated 3 times again with the freeze to cycle using the cone and again, the, the resolution you can see as it goes along the scabbing and then of course the clearance some days later.

Oh, sorry. OK. OK, so this is another case of adenoma, and this is Doctor Cantamesa and peanut on the right.

So this is one of the first treatments we had done, and we're gonna show you now the, the cone treatment to give you an idea of how this was done. So some oohing and ahhing in the background that goes on, and Peanut was a great patient. Now, I know, Tim, you don't use the, the cone method as much in your practise.

You're really an open spray guy for the most part. Yeah, I've been using the cone a little bit more, especially for things like this. And sometimes, again, depending on how mobile the patient is, I feel like sometimes the cone is a little easier.

But no, so I usually open spray, but I have found the cone can, it's effective and it can be really nice. . So for everybody watching, you, you notice the gas bubbling inside the cone.

Now watch as the camera comes around and you'll see the spot, basically a perfect circle that was frozen. And that's a great exa that's a good freeze. Yes, right, right there, you got a good freeze around the lesion and we'll come back and treat it again, but what we're waiting for is the thaw cycle.

And again, we're, we're trying to drive home certain points for you. In teaching. So again, whatever cryotechnology you're using, you want the freezing to be adequate to get to this level, and then, and rapidly freeze, so below -50.

And then you can see, and that's what the pen is pointing out at this point, cause we were all oohing and ahhing in the background. You can see the redness coming back, the blood flow back into the tissue, thawing it. This is, you know, really a good example of maximum damage.

Peanut was very calm throughout, . And so you can see it kind of melting back in as we, we get ready to do yet another free cycle here. Very good example.

OK, so you noticed there's a little bit of edoema almost immediately. But this never progresses to the point of a blister. This, this, that's about the worst you will see and then this will transform in a period of time to a scab.

The scab then will remain for some weeks. When we also surveyed, Veterinarians, as part of what I showed you earlier, we asked about how long is it between treatments, and generally it's 2 to 4 weeks until the scab, will, will fall off. Again, they're not, you can, you can add some moisture to it with a damp cloth to try and help a little along, but really on its own, it's going to take about that long a time.

Tim, do you agree or do you observe anything different? No. Every once in a while you get that 7 to 10 days, especially a smaller one that might be pretty much resolved, but no, most of these, yeah, 2 to 4 weeks is generally when it happens.

OK, so let's talk then about lick granuloma because this is a little different. We've never really included this before in any of our lectures and it's, you know, it's one of these kind of common sense where you're like, you know, this is very easy to think about cause the one point we've made all along as well is that we know that when you freeze even without anaesthetic, most animals are just fine. There's an initial like, hey, what was that?

But then when you deaden the nerves in the local area, you know, you can go back and treat multiple times and do your freeze paws without that requirement for a topical and certainly not a general anaesthetic. So here's a case study in granuloma, with a 10 year old Labrador, had a history of food aller allergies, . Previously had been managed with oral and topical antibiotics and nothing had worked.

So let's, Tim, let's, let's play this out. So this is now a client that's been dissatisfied with where they went, came to you and said, here's my my Labrador. What might you have typically done in this case?

Yeah, I mean, we already have the history of food allergies, so hopefully we've got the overall allergy issue well managed. Certainly, if not, we, we've got to work on that in addition. And depending on how this thing looks, and, and, you know, when this one came in, it was actually, it was pretty good.

The actual like level of infection was, was pretty much resolved. It was the leftover granuloma, that was still bothering the patient. And so if it comes in, obviously, you've got this really extra of moist, ugly lesion.

Now, get the infection under control too. So you manage those two things, in this case, get it to where we're kind of left with just the granuloma as they left over, Lesion, then, then we can go ahead and and start trying to freeze it. So now let's sort of step back and you know, we're going to go back to school for a moment here with you.

So this is the image of what was presented and now let's talk about lick granuloma facts. So again, you know, we know that And this is going to be seen primarily in large attention seeking breeds. Males are 2 times more likely to have it than females.

In most cases are those less than 3 years of age. Is that all consistent with your experience, Tim? It is for the most part.

It's funny when, when we, you sent me the article and I was reading through it, I was like, Hadn't really thought about these things, but it's true. It's like, it's retrievers, it's Dobermans, most of the time. Not that you don't see the exceptions or large mixed breed.

Yeah, I saw the male thing. I was like, is that right? And I started thinking back.

I'm like, yeah, no, it's, it's probably I've seen more male dogs than females. The age thing, I do wonder if that's more like the first time it occurs is less than 3 years of age. I, I feel like most of the cases that I can think of lately were more middle aged, and I have a feeling they probably started with their initial lesion early, earlier in life and, you know.

Three years of, of, of kind of partially resolving, eventually, I guess I have seen them more around like 4 to 6 years of age. But now, overall, I think that that fits. And in your practise, and again, everybody's probably sitting out there thinking the same thing, how often are you seeing this during the week?

I'm, I'm gonna say luckily for I, I'm on a good stretch and not very often. I think probably, luckily I've been pretty lucky, probably only seeing one every, every couple of months. But no, you know, it's like everything, they come in bunches, and next thing you know, you'll have 4 or 5 in one month.

So, they vary, they vary. All right, so let's talk about then what was done here. So, you know, your therapeutic options.

You know, and again, this, this is literature-based, you know, prevent or eliminate infection, control behaviour, prevent patients from licking the area during treatment. Is there really anything else you typically can do? No, that is that.

Without going, the, the whole concept of the, the whole pathology of like granulomas is probably is well beyond what we're going to cover here, but no, those are the basics, you know, get rid of the infection, control the behaviour, but usually there is some level of compulsive behaviour involved here too on top of the, the underlying problem and, and then, yeah, breaking the, the lick cycle is, is, of course, necessary to keep this from, from perpetuating. Right. And, and again, we're really trying to position this for the general practitioner, not the specialist.

I mean they have, they have a whole different bag that they would probably pull out. So, so now you get to, you know, what was done in this particular case. So there was a plan discussed with the owner about using cryo.

In, in, in, with this particular case, again, there was the use of a topical lidocaine. They treated stepwise around the lesion using a 12 millimetre tip, and that's just the size of the cone tip and the surface area that it covers. And what was noticed immediately is the patient stopped licking the area post treatment.

And was retreated 3 weeks later. So again, consistent with this 2 to 4 weeks post-treatment and, and what had happened. And, and in this case then, the lesion.

basically the outcomes, I should say with the Labrador, where the patient continued not to lick the area and you can see already some of the resolution that was occurring. Sorry for a little fuzziness in the picture, but you could see right away the reduction. So Tim, what would be your assessment of this, you know, kind of from as the cryo guy here?

I mean, it says as far as, as far as resolution, I'm happy with any granuloma that responds to anything. It looks like this after a few weeks, like. No, I, I think overall the, the process, these things are sensitive.

So yeah, some sort of, I've, when I've treated them, I've usually had them come on, on gabapentin, little bit of pain control, a little bit of sedation, to help treat. And, since getting the, using the topical lidocaine creams, it definitely helps reduce, sensitivity during treatment so that you can get a good freeze. .

Yeah, I, I think the first one I treated did still, we, we did end up using the, the cone of shame or a boot to keep it covered, for the 1st, 1st couple of weeks. After that, the, it, it did. The, the whole lick cycle, really, really seemed to resolve and, retreated and this, you know, it's a little blurry.

I don't, I don't, I didn't see this case in particular. Are you done? Should you freeze it again?

I don't expect these dogs. I mean, this guy was 10, he probably had this thing for at least a few years. I don't expect your hair is gonna totally come back, that that skin's gonna totally be normal afterwards as far as how it looks.

But if it's comfortable, the infection's gone, you know, it's not recurring, I'd be, I'd be very happy with this. Right, so it really is the message that the, the cryo itself rather than you know, some of the other applications we've talked about, this is one where we're really just attenuating the local nerve senses, and that alone is enough to change the behaviour and I think as you said to me many It doesn't mean they're not going to go somewhere else, because we're not, we're not at a root cause here. We're treating some of the symptoms.

Yeah, and this is, you know, you have with like granulomas, you have to under most 70%, I think the literature said are, are allergy related, so you need to manage the, the, the the dermatologic disease. This may help the behaviour part of it. Some of these do just become, I think.

Compulsive at this, at this area. And I think if you, you decrease that sensation, you may help with the behaviour part of things. But yeah, this one is gone.

It looks great, but you know, like granulomas are frustrating and, and, certainly the, the owner needs to be vigilant. So when we get these things earlier, I think you have a much better shot of, of cryosurgery also helping them out. Right, so for everyone watching, we really, you know, we wanted to give you this particular case study and the addition of lick granuloma to the list of things that might be treatable using cryo and again, just to give you another option perhaps you hadn't thought of or really had the opportunity to, to implement.

So let's keep going here then. And so let's now recap, OK, we're going to begin to roll towards our conclusions. So, Tim, if you'd like to, comment on these now and establishing the, the owner's expectations when you use a cry treatment.

Yeah, the, you know, there's no sutures, nothing that the dog can lick out and, and open up an incision. So generally, you don't need the cone post-treatment. The lick granuloma might be one exception to keep them from, from, doing the whole lick cycle.

A lot of the, whether the lesion was gonna resolve in, in one treatment or not is, is often size dependent. Other types of things, maybe if you do have a heavy keratinized lesion or a really fibrous lesion, those also are something that, that is probably gonna take more than, more than one treatment. There's never anything that looks like an open wound on these things.

So it, it covers up with a scab pretty much immediately once, once the cell destruction starts. And I haven't, and I don't think of any of the other veterinarians we've worked with. I, I haven't had one that ever got an infection in the area afterwards.

Nothing we ever needed to treat antibiotics. It was something that came in very infected, all right, may go ahead and, and treat that. But generally, the, the procedure itself, no, we, we don't see any infection associated with it.

. And it's, it's obviously manage the expectation of this isn't going away right away. Sometimes I have owners came in who, who, either we didn't communicate or they didn't listen, and we come back with a pet and there's still lesions. No, this doesn't, this doesn't, this wasn't surgery.

We don't take it off right. This is't an incision. So it does take a couple of weeks and yeah, some of these, some of these may need to be treated again depending on the, the lesion or how well you were able to freeze it the first time.

Mhm. Great. OK.

And again, I think that's important to know. Are there any other, you know, that we have this post-treatment instructions and again, people will start to ask who, who are watching. So any comments on this and and other things you do?

Yeah, leave it alone is the big part. Unless it's getting a lot of crusting scabbing, I usually don't even have them clean it or, or hydrated. Usually the, the leave it alone is my one big instruction to them, and, usually send me a picture in 2 weeks, so let me see what it looks like.

Yeah, I always think that's really interesting that they don't even have to come back. They send you a picture. You can generally look at it and go, OK, we're good.

Keep going. Yeah, most of the time it's, it's helpful, frees up the appointment time. We've all been busy lately.

Yeah, your time's very happy to not have to come back in. They don't have to. Yeah, true.

OK, so just a quick comment on revenue and cost. So you know, the Cost per treatment really varies depending on which of the technologies that you, you pick, but it's really gonna be somewhere around $4 in, in, in treatment costs because you're going to do a lot of, freeze thaw cycles. So this is really an average, but it could be anywhere from a couple dollars to say $10.

You know, again, depending on which. Technology you pick most practises, and I know, Tim, we're not going to talk with you about how your practise prices, but anywhere from $50 to $300 lesion, depending on what it is, you know, eyelid tumours, etc. Tend to be more expensive, whereas, you know, straightforward, papilloma, adenomas, maybe a lot less.

So, This is one of these things that, again, because you're not using a general anaesthetic or required to wait for one, you can treat on a routine basis. And I, I think from that perspective, Tim, you've adopted that into your practise now. So are you talking actively to the owners about the things you can, you, you might be able to treat during routine visits, or how are you approaching it?

Yeah, especially the adenoma thing. I mean, every small breed dog over 10, you can probably find at least one. So it's usually at our wellness exams is when those first come up.

That's probably the majority of cases that we do those sort of things are things that come up during a routine exam. And no, I mean, occasionally you have that the owner presents for the lump and we do it that way. But no, these are things you can definitely, another thing you can find and do on a, on a wellness exam to, to generate revenue and make the client happier.

Good. OK. So again, to give everybody who's watching just some idea of how to think, you know, how do I integrate this into the practise, there's a slide in here that you can have access to afterwards that's a general, you know, here's how you go about performing a treatment.

We don't have to revisit this one, at this point it's really there for everybody to look at later if they need a refresher. And, and so this last part becomes more general, you know, when to use which technology spray cones or applicators, and I think we said a couple of times the, the, the spray is the coldest, and again, you know, for some of the larger units like the cryolab, which, which, Tim is using, you can spray from any angle. It works in all situations.

It's, you know, but every time you're spraying is when you're actually performing action. You know, to do heat transfer and destroy the target tissue. So that's how it works.

Cones also allow for longer freezing, which we know we have to be more aggressive in veterinary cryo treatments and so cones meet the the bar in terms of temperature and all the other things. They're just more difficult because of the cone is a liquid, so I can't treat from underneath. I can only, even when you saw peanuts, .

You know, a little while ago, you'll notice we're about a 45 degree angle and you could see the liquid to the bottom, but I certainly can't treat from underneath. So it's got some physical limitations. And then the applicators and buds have a limited capacity in terms of heat transfer, so they'd be recommended for, you know, smaller lesions or where there's limited access.

So you have to step back if you're thinking about this and, and you, you'll see we have some links to different websites for you to look at. The technologies, but this would be a simple overview of, of, you know, which technology might work best and the pluses and minuses of that. So Tim, would you add anything else to the evaluation of somebody's thinking?

I think, no, I, the only, I think one thing we, we may not have hammered home like we did our last time we did this lecture was freeze time. It's your, your success is very, is, is the longer you freeze, the more success you're gonna have. I think we, we may have said ad nauseam last time we lectured, maybe I'll mention it.

A few times this time. That's, that's the one thing for success is, is freeze time. Yeah, absolutely.

The aggressiveness has to be there. You're really, as Tim has said, you're not going to produce a wound. So, you know, you're using molecules.

They're just cold molecules. Go ahead, you know, freeze off and, and do multiple free cycles, cycles to get the maximum effectiveness in that single session. OK, so, again, just to start to conclude now with our last slides, you know, companion animals require, here it is, Tim, long treatment times and low temps.

So we'll, we've said it over and over and drive it home in our conclusions. Cryosurgery is easy. It's, it, you can use it routinely.

It is, there's just a few hints that you need to, to understand and apply to get maximum effectiveness. And again for the practise, if it's something I don't have to wait for a dental to perform, if it's something that's safe for all my elderly patients, then it really becomes a benefit that I can bring out of the cabinet or from the desktop, whichever technology I've chosen, and use on a routine basis. So I know for Tim and I we want to say thank you for attending the webinar.

And also if you have questions, you can email them to us and we'll make sure they get answered again feel free to send them as well. You know, if you watch this again or you have a colleague that watches, but we'll be here to, to, to reply to whatever your questions may be. There's also some, couple of websites that have the different products that we've mentioned throughout and those that carry them.

And then the last part is some references. So again, if you would like some of these, so there's some basic ones about cryosurgery and the history of it in veterinarian medicine as well as a few on the granuloma and some of the articles and the different treatment modalities that have been used, including cryosurgery along with the others. So Tim, are there any last comments you would have?

No, I certainly any questions, welcome. You know, if you're doing cryosurgery and even if there's cases you have questions on, we, we, we haven't come across every situation yet, so it would help us learn too, and we can hopefully help you with cases, certainly, no, send us any questions. Yeah, so I'll close again with a big thank you for attending.

Hopefully that this was helpful to your practise and maybe give you some new ways to think about alternatives for some of the bumps, lumps, and now lick granulomas that you're seeing. And again, send us questions. We're happy to help.

And again, a final thank you. Bye-bye. Fantastic.

Great. I hope you'll enjoyed the webinar, and obviously, as we said before, it is, it was pre-recorded, but we do have Doctor Nirva here with us and thank you so much for answering all the questions that have been that that have been popping up throughout the presentation, but I think there's some that are unanswered and so I just wanted to sort of hand over to you. I think you can see the questions as well.

Is that right? Yes, thanks for that. A couple of these questions, I need to consult with Doctor Mosby on it.

Again, I'd rather not, try and answer these myself. One question that did come up was about relapse and, how often is that seen. And really, obviously, that's, that's lesion dependent, but for the most part, what you treat, as long as you've treated it adequately, you will remove that lesion and, wouldn't expect relapse, to occur or to not occur for Very long time.

Now, here's where it gets interesting. If you undertreat, then what will happen is you'll get some of the lesion removed and some will remain. And this is why over and over we keep saying be aggressive.

You're really, you're really not going to create too much damage or run the risk of, a blister. That's what makes this really unique and a good alternative. The other thing which, Doctor Mosby pointed out in the way he manages these crowd treatments, post-treatment is he sends the patient home and oftentimes rather than the patient having to come back to be looked at, he has the, the, owner.

Send pictures or to FaceTime with them, because again, it's, it's a nice safe procedure for them to manage from the home office. And like many during the pandemic, you know, the practises have just been so busy that time is precious. And this is where, cryottreatments have really kind of taken hold and become a nice go to for a lot of these benign lesions.

So, Sylvia, let's do this. There'll be, as I said, some of these questions we can't answer right away, but people know how to get to us and then we'll get back to them with specific answers. And thank you everybody for attending, by the way.

Fantastic. Thank you very much. Yes, there are two email addresses that you can email your questions to, which is one directly to Dawn at the webinar vet and obviously the email address that popped up on that one of the last slides that's directly to cryo concepts oh and Dawn has just posted her email address again in the chat, so if you all can sort of note that down and .

And ask your questions there and I think best thing as you said, Doctor Nar is, is, is obviously we have the email addresses of all our all of our delegates so we can get back to them with the answers via email. Fantastic, I think, unless you have any closing words, I will, I will bring it to an end because we've obviously overrun the one hour already, but thank you very much, for joining us, everybody. Thank, thank you to Doctor Ned Bala for coming and answering the questions and of course thank you to NWK Healthcare for even just sponsoring this webinar and this this opportunity.

Thank you, everybody.