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From the Newsroom

GALIL MEDICAL LAUNCHES NEW FAMILY OF CRYOABLATION NEEDLES 07/10/15

GALIL MEDICAL LAUNCHES NEW FAMILY OF CRYOABLATION NEEDLES Arden Hills, MN—DATE October 5, 2015 — Galil Medical, the global leader in interventional oncology cryoablation technolo…

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I wanted it all out of the way as quickly as possible so that I could get back to work! I chose cryoablation because it was minimally invasive and there was a good chance that my renal [kidney] function could be preserved. .
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 Introduction | Patient Selection Guidelines | Treatments | Results

Frequently Asked Questions | Additional Resources

Prostate


1. Introduction

The prostate is a muscular gland about the size of a walnut, located in the pelvis below the urinary bladder and in front of the rectum. It is comprised of several small glands encased in the prostate capsule.

As cancer of the prostate is typically slower growing when compared to other forms, symptoms and signs of prostate cancer often do not appear until the cancer has spread within the prostate capsule and beyond to seminal vesicles and potentially other organs. Consequently, the potential for prostate cancer cures are high when detected early.

prostategland.jpg

Image Source: Galil Medical

a. Symptoms

Cancer growing inside the prostate usually causes no symptoms until the cancer grows large enough to begin affecting other organs, such as the bladder or urethra. Early symptoms of prostate cancer will likely not exist. This is why screening for prostate cancer is important.

The following symptoms of prostate cancer may occur:

  • Delayed or slowed start of urinary stream
  • Painful or burning urination
  • Painful ejaculation
  • Difficulty in having an erection
  • Blood in urine or semen

b. Tests, Diagnosis and Staging

When it comes to whether or not an individual is likely to receive a prostate cancer diagnosis during his lifetime, one should consider the following risk factors: age, family history, ethnicity, environment, diet, genes, and occupation.

Two initial tests are commonly used to screen for prostate cancer. When used together, these screening tests can detect abnormalities that might suggest prostate cancer.

Digital Rectal Exam (DRE): To perform a DRE, your doctor will insert a gloved finger into the rectum and feel along the back rectal wall for the presence of lumps, enlargements, or hard, coarse, jagged, or uneven areas that may indicate cancer or other prostatic diseases.

Prostate-Specific Antigen (PSA): Prostate-specific antigens are biomarkers that are found in the blood, fluids, and tissues. When an individual’s PSA level is considered elevated it can indicate the presence of prostate cancer. If the PSA level rises quickly over two or three tests, it may be a sign of a large or fast-growing tumor.

PSA testing combined with DRE helps screen prostate cancers at their earliest stage. If certain symptoms or the results of early detection tests – a PSA blood test and/or DRE – suggest that you might have prostate cancer, your doctor will recommend further testing.

Transrectal Ultrasound (TRUS): TRUS testing is utilized after PSA and DRE testing indicates the presence of possible cancer. The doctor will insert a lubricated ultrasound probe into the rectum behind the prostate. The TRUS probe creates sound waves and the patterns form a picture of the prostate and allow the doctor to see any abnormalities.

Needle Biopsy: Through a needle biopsy, multiple samples of tissue are extracted for pathological testing. The needle biopsy will be performed in conjunction with a TRUS, with the ultrasound images guiding the placement of the needle.

Saturation Biopsies or 3D Mapping Biopsies: If the initial needle biopsy does not indicate cancer, but your physician suspects cancer is present or the exact location of the cancer is needed, a saturation biopsy or 3D global mapping biopsy can be used for further diagnostic testing. Saturation biopsies generally mean that more than 20 different biopsies are taken. TRUS is used to guide the biopsy.

When a biopsy confirms the presence of prostate cancer, your doctor will determine the extent (stage) of the cancer. A staging system is a standard way for your doctor to describe how far a cancer has spread. The American Joint Committee on Cancer (AJCC) TNM system is a widely used staging system for prostate cancer.

Once testing is complete, your doctor assigns your cancer a stage. This helps determine your treatment options.

Prostate cancer staging:

Stage I: The cells closely resemble normal cells and the gland feels normal to the examining finger.

Stage II: More of the prostate is involved and a lump can be felt within the gland.

Stage III: The tumor has spread through the prostate wall and the lump can be felt on the surface of the gland.

Stage IV: The tumor has invaded nearby tissue.


2. Patient Selection Guidelines

Cryotherapy, also known as Cryosurgery, Cryo, and Cryoablation, can be effective as a primary and/or salvage treatment for prostate cancer. To determine eligibility, patients generally meet certain criterion that are not fixed, but rather vary based on the physician performing the treatment.

Primary prostate cryoablation is a treatment option to men who have clinically organ-confined disease of any grade with a negative metastatic evaluation.

 

Dr. Tannenbaum discusses appropriate patient selection criteria for primary cryotherapy patients.

 

Patients who have undergone prostate cancer radiation therapy or another treatment for prostate cancer and have experienced a recurrence are left with limited treatment options. The patient may opt for a salvage radical prostatectomy that may cause significant side effects or hormone therapy that will reduce the size of the tumor but not offer a cure. Salvage prostate cryoablation is a treatment option with curative intent in men who have had a recurrence of their prostate cancer.

 

Dr. Waterhouse discusses why he recommends salvage cryotherapy to his patients.


a. Primary Prostate Cryoablation

Primary prostate cryoablation is recognized by both the American Urological Association (AUA) and the European Association of Urology (EAU) as a treatment for prostate cancer. A detailed patient selection criteria guideline is available from both associations.
 
Below are a few of the criteria.
 
AUA’s recommended guideline on primary prostate cryoablation includes:

  • Clinically organ-confined disease of any grade with a negative metastatic evaluation
  • A PSA level of ≤10
  • Gleason score 7 to <8 with a PSA level >10 to <20 ng/mL and/or clinical stage T2b

Patients with a prior history of transurethral resection of the prostate (TURP) are not recommended for primary prostate cryoablation.

 

Dr. Waterhouse discusses the benefits of primary cryotherapy over other treatment options.


b. Salvage Prostate Cryoablation

Salvage prostate cryoablation is recognized by the American Urological Association (AUA) as a treatment option for curative intent in men who have had a recurrence of prostate cancer.

 

Dr. Tannenbaum discusses why salvage cryotherapy is a good option for patients with recurrent prostate cancer.


AUA’s recommended guideline on salvage prostate cryoablation includes:

  • PSA <10 ng/mL
  • Gleason score of ≤ 8
  • Clinical stage of tumor T1 or T2 (before salvage therapy)
  • Pathologic evidence of locally recurrent disease without clinical evidence of metastatic disease
  • No evidence of seminal vesicle (SV) invasion
  • A life expectancy >10 years
  • A long PSA doubling time

c. Focal Prostate Cryoablation

The EAU 2012 Guidelines of Prostate Cancer provides the following criteria to help identify candidates for ongoing trials of focal prostate cryoablation treatment:

  • Patients should ideally undergo transperineal template mapping biopsies
  • Patients with a low to moderate risk
  • The clinical stage of the tumor should be < cT2a and the radiological stage < cT2b


Patients who have undergone radiation therapy of the prostate are not recommended for focal prostate cryoablation. Patients with previous prostate surgery should also be counseled with caution because no data on functional and oncological outcomes are available.
 
Patients must be informed that focal prostate cryoablation is still experimental and that there is a possibility of repeat treatment. 


3. Treatments

Cryotherapy, also known as Cryosurgery, Cryo, and Cryoablation, is a minimally invasive treatment (no incisions) that uses extremely cold temperatures to kill cancer tumors. Cryotherapy is widely used around the world and has over fifteen years’ reported clinical experience to support its safety and effectiveness. The treatment is also recognized by both the American Urological Association (AUA) and the European Association of Urology (EAU) as a treatment for prostate cancer.
 
To treat a patient with cryoablation, doctors generate ice utilizing specially designed thin needles which encompass the targeted area with iceballs. This ice is very precisely shaped and positioned to destroy all of the cancerous tissue. The process is carefully controlled by the doctor who uses ultrasound imaging and temperature monitors to help ensure that the healthy tissue surrounding the prostate is not affected by the cold temperatures.

ProstateCyroblation.jpg
Image Source: Galil Medical

a. Primary Prostate Cryoablation

  1. The patient is placed in the dorsal lithotomy position.
  2. An ultrasound probe is inserted into the rectum to create an image of the prostate which allows the doctor to view the placement of cryoablation needles and the entire freezing process during the cryoablation treatment.
  3. The number of 1.5 mm cryoablation needles and their configuration depends upon the type of cryoablation needle used, and the shape and size of the prostate.
  4. Galil Medical's 1.5 mm Multi-Point Thermal Sensors™ (MTS) are inserted within the prostate and adjacent tissue to monitor the lethal temperature throughout the target tissue, while avoiding damage to the rectal wall and the urethra.
  5. A warming catheter is used to protect the urethra from freezing.
  6. Under real-time ultrasound imaging and temperature monitoring, two freeze/thaw cycles are employed, ensuring a minimum temperature of -40⁰ Celsius throughout the prostate tissue.

b. Salvage Prostate Cryoablation

The process of salvage prostate cryoablation treatment is similar to primary prostate cryoablation treatment, with only minor differences. Most men, but not all, who undergo salvage prostate cryoablation treatment have had some type of previous radiation treatment for their prostate cancer.
 
Salvage prostate cryoablation has been proven to be just as effective as salvage prostatectomy, also known as surgery, with notable reductions in rectal injury and incontinence.

c. Focal Prostate Cryoablation

Focal prostate cryoablation follows similar principles as standard prostate cryoablation. Focal prostate cryoablation only freezes a portion of the prostate as opposed to the entire gland. Focusing on the specific areas where the physician believes the cancer resides allows doctors to preserve other regions of the prostate – in particular the nerves associated with potency (the ability to obtain and maintain an erection suitable for sexual intercourse) and the urinary sphincter which controls continence.
 
Focal prostate cryoablation is a relatively new technique but initial evidence supports that most men receiving the treatment remain potent and only a very small percentage become incontinent (lose the ability to control their urine flow). It is important that patients understand that focal prostate cryoablation may only be a temporary solution. Because focal prostate cryoablation focuses on a specific area of the prostate, at least half of the gland will go untreated. This may mean that small, developing tumors are not destroyed.
 
All patients undergoing focal prostate cryoablation should have very regular follow-up care to carefully monitor any changes. Focal prostate cryoablation does not exclude any treatment options for the future – including a repeat focal prostate cryoablation or primary prostate cryoablation.

d. Side Effects

 

Dr. Waterhouse discusses what patients need to know about primary cryotherapy before making their decisions.

 

Some patients may experience the following side effects after cryoablation treatments:

  • Swelling of the penis or scrotum. The gland swells, preventing urine from leaving the bladder. As a result, a catheter is often required for a couple of weeks until swelling subsides. The perineum (the area between the anus and scrotum) may also swell or feel sore.
  • Freezing may affect the bladder and intestines, which can lead to pain, burning sensations, and the need to empty the bladder often. Most men recover normal bladder function in a matter of weeks.
  • Any damage to the urethra from the cryoablation freezing may cause obstruction or sloughing of the urethra. This side effect has been greatly decreased with the use of a warming catheter during the prostate cancer treatment process to protect the urethra from freezing.
  • In very rare cases, a fistula, an unnatural join between two hollow organs, occurs between the rectum and urethra. The fistula occurs as a result of tissue damage from freezing. This allows urine to leak into the rectum and may require surgery to repair. This rare side effect affects about one percent of cryosurgery patients.
  • One potential side effect of all prostate cancer treatments, including cryosurgery, is incontinence; the inability to control urine flow. If incontinence occurs, there are varying types of urinary incontinence and differing degrees of severity.
  • Another side effect of cryoablation is impotence. Impotence is the inability to maintain an erection. Sexual impotence is one of the most common side effects of cryoablation. The freezing process during cryoablation may affect nerve bundles near the prostate that are associated with an erection.

 

Dr. Waterhouse explains post salvage cryotherapy procedure.

e. Follow Up

Follow-up care after any prostate cancer treatment remains extremely important. A doctor may choose to regularly examine a prostate cancer patient to be sure the cancer has not returned or progressed. You should consult with your doctor on your follow-up schedule post-cryoablation.

 

How quickly were you able to resume your normal activities after primary prostate cryotherapy?

 

4. Results

a. Primary Prostate Cryoablation

The effectiveness of cancer therapies is measured in terms of the number of years patients enjoy being disease-free after treatment. The graph below shows the percentage of patients who are cancer free a number of years after treatment. It demonstrates that cryoablation is at least as effective as any other therapy – including surgery – at giving patients a life free from cancer.

Graph1.png

Since prostate cancer treatments have similar survival rates, side effects and quality of life are important considerations when choosing your treatment.

Graph2.png

Graph3.png

 

Primary prostate cryoablation offers many advantages over other treatment options, including:

  • A minimally invasive (no incisions), curative treatment.
  • 15-year clinical data supports safety and effectiveness in treating prostate cancer.
  • Single treatment, performed on outpatient basis or requiring just one overnight stay.
  • Short hospital stay reduces risk of hospital-acquired infection.
  • Short recovery time permits rapid return to everyday life.
  • Lower risk of incontinence (leaking urine) than with any other therapy.
  • May improve urinary function in patients experiencing problems prior to cryoablation.
  • Minimal or no pain.
  • No need for radiation or radioactive substances and risk of associated side effects (e.g. secondary cancer).
  • Low risk of rectal damage or irritation.
  • Can be used when other treatments, such as intensity modulated radiation therapy (IMRT), external beam radiotherapy (EBRT) and brachytherapy have failed to cure prostate cancer.

 

Why did I choose prostate cryotherapy?

b. Salvage Prostate Cryoablation

Cryotherapy performed on patients who have recurrent prostate cancer, having failed radiation therapy or some other type of primary treatment, is referred to as salvage prostate cryoablation. Unlike hormonal therapy, salvage prostate cryoablation is a curative treatment for prostate cancer recurrence.
 
Most patients who failed radiation are put on hormonal therapy. Hormonal therapy cannot cure prostate cancer – it can only delay the progress of the cancer. Hormonal therapy also has many unpleasant side effects. Recently, the US Food and Drug Administration has warned about a link between heart disease and diabetes in prostate cancer patients treated with hormones.
 
Other salvage treatment options include salvage prostatectomy (surgical removal of the prostate) or additional radiation therapy.

 

How did Dr. Waterhouse help you in making the final treatment decision?

 

Salvage prostate cryoablation offers many advantages over other salvage treatment options, including:

  • Curative therapy
  • Single-treatment session
  • Compared to surgery and radiation, low rates of incontinence (leaking urine)
  • Minimally invasive (no incisions)
  • No radiation or hormones
  • None of the side effects associated with hormones
  • Short hospital stay and quick recovery
  • Can be repeated, if necessary

SalvageGraph1.png

 

SalvageGraph2.png

 

c. Focal Prostate Cryoablation

FocalGraph.png


5. Frequently Asked Questions

a. Primary Prostate Cryoablation

What is primary prostate cryoablation?


Cryotherapy, also known as Cryosurgery, Cryo, and Cryoablation, is a minimally invasive treatment (no incisions) that uses extremely cold temperatures to kill cancer tumors. Cryotherapy is widely used around the world and has over fifteen years’ clinical experience to support its safety and effectiveness. It is also recognized by both the American Urological Association (AUA) and the European Association of Urology (EAU) as a treatment for prostate cancer.
 
Primary prostate cryoablation is a treatment option to men who have clinically organ-confined disease of any grade with a negative metastatic evaluation and have not had any other type of prostate cancer treatment.
 
To treat a patient with cryoablation, doctors create iceballs using compressed gas and specially designed thin hollow needles which create ice in the targeted areas. These iceballs are very precisely shaped and positioned to freeze the prostate and destroy all of the cancerous tissue. The process is carefully controlled by your doctor who uses ultrasound imaging and temperature monitors to help ensure that the healthy tissue surrounding the prostate is not affected by the cold temperatures or ice.
 
Will primary prostate cryoablation cure my cancer?
 
If your doctor considers you to be suitable for prostate cryoablation, it is very likely that the procedure will cure your prostate cancer. The effectiveness of cancer therapies is measured in terms of the number of years patients enjoy being disease-free after treatment. The graph shows the percentage of patients who are cancer free a number of years after treatment. It demonstrates that cryoablation is at least as effective as any other therapy – including surgery – at giving patients a life free from cancer.
 
Since prostate cancer treatments have similar survival rates, side effects and quality of life are important considerations when choosing your treatment.
 
What are the benefits of primary prostate cryoablation?
 
Primary prostate cryoablation offers many advantages over other treatment options, including:
 

  • A minimally invasive (no incisions), curative treatment.
  • 10-year clinical data supports safety and effectiveness in treating prostate cancer.
  • Single treatment, performed on outpatient basis or requiring just one overnight stay.
  • Short hospital stay reduces risk of hospital-acquired infection.
  • Short recovery time permits rapid return to everyday life.
  • Lower risk of incontinence (leaking urine) than with any other therapy.
  • May improve urinary function in patients experiencing problems prior to cryoablation.
  • Minimal or no pain.
  • No need for radiation or radioactive substances and risk of associated side effects (eg secondary cancer).
  • Low risk of rectal damage or irritation.
  • Can be used when other treatments, such as intensity modulated radiation therapy (IMRT), external beam radiotherapy (EBRT) and brachytherapy have failed to cure prostate cancer.

 
What are the risks and side effects of primary prostate cryoablation?
 
Your doctor will advise you that any medical procedure has risks associated with it. However, cryoablation avoids many of the risks and complications of other therapies. The potential side effects of curative prostate cancer treatments include incontinence (although the risk of this is very low with cryotherapy) and erectile problems.

RiskGraph.png

 

How long does a primary prostate procedure take?
 
A prostate cryoablation procedure usually takes approximately 90 minutes.

How long will I need to be in hospital?

Prostate cryoablation can be performed on an outpatient basis. This means that you do not need to stay in hospital for more than a few hours after your treatment, and no overnight stay is required. Sometimes one overnight stay is preferred, but this is dependent on local arrangements or the individual case.

 

Would you recommend primary prostate cryotherapy to other patients?

 

How will I feel after a primary prostate procedure?
 
You may feel some slight discomfort immediately after the procedure, but you will be given pain medication for this and it will improve very quickly. You will have a drainage catheter left in place for a few days until you are able to urinate. You will be shown how to manage the catheter before you return home.
 
Most patients feel a great sense of relief that their cancer has been treated and some feel quite emotional as a result of this.
 
How long before I can return to work?
 
Your doctor will advise you on the time you should plan to take off. Because cryoablation does not involve open surgery, most patients are able to return to work and an active lifestyle once they no longer need their catheter – typically a week or less.
 
What about other activities, such as sports?
 
Your doctor will advise you on when it is appropriate to resume active hobbies and sports, but usually this will be a week or two after your procedure.

Will primary prostate cryoablation impact my sex life?

Your doctor may have explained to you that all curative treatments for prostate cancer can affect a man’s ability to obtain and maintain an erection. This risk can seem daunting, but it is important to remember that there have been significant advances in medication and other aids to help men whose natural ability to obtain an erection is lost or reduced. This condition – called impotence or erectile dysfunction (ED) – is very common among middle-aged men (including those who have not had prostate cancer) and today there is lots of help available to ensure they are still able to lead a fulfilling sex life.

 

b. Salvage Prostate Cryoablation


Are you pleased with your decision to have salvage cryotherapy?

 

What are the criteria for salvage cryoablation treatment?

  • PSA <10 ng/mL
  • Gleason score of ≤ 8
  • Clinical stage of tumor T1 or T2 (before salvage therapy)
  • Pathologic evidence of locally recurrent disease without clinical evidence of metastatic disease
  • No evidence of seminal vesicle (SV) invasion
  • A life expectancy >10 years
  • A long PSA doubling time


What are the advantages of salvage prostate cryoablation?

  • Curative therapy
  • Single-treatment session
  • Compared to surgery and radiation, low rates of incontinence1 (leaking urine)
  • Minimally invasive (no incisions)
  • No radiation or hormones
  • None of the side effects associated with hormones
  • Short hospital stay and quick recovery
  • Can be repeated, if necessary

 

How has salvage cryotherapy changed your life?

 

What are the disadvantages of hormone therapy?

  • Delays the progression of the cancer but does not cure it
  • Potential health risks include:
  • Bone fracture due to reduction in bone density
  • Reduced cardiovascular function (heart disease)
  • Reduced cognitive function (mental agility)
  • Poor insulin/glucose regulation (diabetes)
  • Unpleasant side effects include:
  • Hot flashes/flushes
  • Reduced sex drive
  • Breast enlargement


6. Additional Resources

a. Definitions

Ablation: The destruction of tissue by the application of extreme cold, heat or light (laser).
 
Anaesthesia: The loss of sensation and usually of consciousness artificially produced by the administration of one or more agents that block the passage of pain impulses along nerve pathways to the brain.
 
Benign Prostatic Hyperplasia/Hypertrophy (BPH): A non-cancerous condition that can affect PSA levels and cause enlargement of the prostate. This growth of the prostate can press on the urethra and cause urination and bladder problems (urinary symptoms).
 
Biopsy: The removal and examination of a sample of tissue for diagnostic purposes.
 
Brachytherapy: A procedure in which radioactive material sealed in needles, seeds, wires, or catheters is placed directly into or near a tumor.Cancer: A malignant and invasive growth or tumor.

Catheter: A tube inserted into the bladder to temporarily drain urine into a plastic bag. Depending upon your doctor’s recommendation, a catheter is normally kept in place 1-2 weeks after prostate cryoablation.

Cryotherapy or Cryoablation or Cryosurgery: The destruction of tissue by the application of extremely cold temperatures.

Erectile Dysfunction (ED): The loss of the ability to produce and/or sustain an erection. Often referred to as “impotence”. In many cases, an erection can be achieved with assistance.

External Beam Radiation Therapy (EBRT): See Radiation therapy.

Fistula: An abnormal passage from a hollow organ to the body surface or from one organ to another.

Gleason Score: A system of grading prostate cancer cells based on how they look under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread.Impotence: See erectile dysfunction.

Incontinence: See Urinary incontinence.

Intensity-Modulated Radiation Therapy (IMRT): See Radiation therapy.

Perineum: The area of skin between the scrotum and the anus through which the doctor inserts the ultra-thin cryoablation probes. After the procedure, a dressing is applied and the tiny holes heal rapidly.

Prostate: A gland in the male reproductive system just below the bladder. The prostate surrounds part of the urethra, the canal that empties the bladder, and produces a fluid that forms part of semen.

Prostate cancer staging:
Stage I: The cells closely resemble normal cells and the gland feels normal to the examining finger.
Stage II: More of the prostate is involved and a lump can be felt within the gland.
Stage III: The tumor has spread through the prostate wall and the lump can be felt on the surface of the gland.
Stage IV: The tumor has invaded nearby tissue.

Prostatectomy: Surgical removal of the prostate.

PSA: Prostate specific antigen, a protein produced by the prostate.

PSA Test: The PSA test measures levels in the blood and is used to help detect prostate cancer as well as to monitor the results of treatment.Elevated PSA may be an indicator of prostate cancer.

Radiation Therapy (Radiotherapy): Uses high-energy radiation to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external beam or intensity modulated radiation therapy) or from materials placed inside the body (internal radiation therapy, implant radiation, or brachytherapy).

Radical Prostatectomy: The surgical removal of the entire prostate gland, the seminal vesicles and nearby tissue.

Rectum: The short tube located at the end of the large intestine, which connects the intestine to the anus.

Robotic Radical Prostatectomy: Instead of directly moving the instruments, the surgeon uses a computer console to manipulate the instruments attached to multiple robot arms. The computer translates the surgeon’s movements, which are then carried out on the patient by the robot.

Stage: The extent of a cancer. See also Prostate cancer staging.

Transrectal Ultrasound (TRUS): the use of sound waves to create a picture of the prostate on a screen to help examine the condition of the prostate and guide insertion of the cryoablation probes.

Urethra: The tube that carries urine from the bladder to the outside of the body.

Urinary Incontinence: Involuntary loss of urine associated with a sudden strong urge to urinate.

Urinary Symptoms: Problems associated with obstruction to flow of urine, usually caused by BPH.

 

b. Patient Education Brochures

c. Clinical Publications

i. Primary Prostate Cryoablation
ii. Salvage Prostate Cryoablation
iii. Focal Prostate Cryoablation

CGG14-PST143-01

Galil Medical is a global leader in delivering innovative cryotherapy solutions. We focus primarily on the ablation of solid tumor cancers and nerve ablation for pain management. Our products address a range of cancers including kidney, lung, bone, liver and prostate as well as several local pain and nerve conditions. Our customers include multiple physician specialties — primarily Interventional Radiologists, Interventional Oncologists and Urologists.

 

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