INCREASING DIAGNOSTIC YIELD WITH ARGON PLASMA COAGULATION

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Endobronchial biopsy can often be complicated by bleeding. In certain cases, the procedure must be aborted due to bleeding complications. We present a case of using argon plasma coagulation to increase biopsy yield and allow for adequate tissue sampling and diagnosis CASE PRESENTATION: An 87-year-old woman presented to us with complaints of 15-pound weight loss along with worsening cough and night sweats. On initial workup her chest x-ray noted a nodular density in the left upper lung zone. She underwent computed tomography of her chest in which a large mass like density was seen in the left upper lobe. Bronchoscopy with bronchoalveolar lavage as well as brush biopsy was scheduled given the size and location of the lesions. On inspection, there was diffuse inflammation of the apicoposterior branch of the left upper lobe, along with severe obstruction. Brushing of the lesions was attempted, but copious amounts of bleeding occurred. Epinephrine was instilled to achieve hemostasis, and the procedure was aborted. Given the complications, the samples obtained were non-diagnostic. She was rescheduled for bronchoscopy, but in addition to brushing, and forceps biopsy we employed argon plasma coagulation (APC) as well as endobronchial ultrasound with transbronchial biopsy. Upon forceps biopsy, bleeding complications were encountered. However, multiple samples were obtained, and argon plasma was used to achieve hemostasis as well as tumor debulking. In addition, areas on inflammation seen on the left lower lobe were sampled with cytology brushing. Samples obtained from EBUS-TBNA, brushing, and biopsy was diagnostic for non-small cell lung cancer, and PDL-1 negative. She underwent palliative radiation therapy. Given her staging of IIIA, she opted to enroll in home hospice. DISCUSSION: Bleeding complications from both endobronchial to transbronchial biopsies have been well documented. A variety of methods to achieve hemostasis have also been listed methods to control post-biopsy bleeding. These include topicalized adrenaline, ice-cold saline, direct tamponade with the bronchoscope, and balloon tamponade. Bleeding complications are likely to occur especially in the setting of inflamed for vascular tissue. In addition, given the amount of tissue needed for both diagnosis and tumor markers, multiple samples are required; the ERS recently suggested as much as six samples. APC has been documented to achieve hemostasis, especially with regards malignancy. Argon plasma coagulation is a form on non-contact electrocoagulation, and allows rapid coagulation of target tissue. The European Respiratory society recently suggested APC may be used as an adjunct for post-biopsy bleeding and hemostasis. However, the data is limited in such cases. CONCLUSIONS: This case highlights the planned of APC to increase diagnostic yield, with the preparation of hemostasis after multiple biopsies. Reference #1: Bernasconi M, Koegelenberg CFN, Koutsokera A, et al. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ Open Res. 2017;3(2):00084-2016. Published 2017 Jun 21. https://doi.org/10.1183/23120541.00084-2016 Reference #2: Bolliger CT, Sutedja TG, Strausz J, Freitag L. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents. Eur Respir J. 2006;27(6):1258-71. Reference #3: Ofiara LM, Navasakulpong A, Ezer N, Gonzalez AV. The importance of a satisfactory biopsy for the diagnosis of lung cancer in the era of personalized treatment. Curr Oncol. 2012;19(Suppl 1):S16-23. DISCLOSURES: No relevant relationships by Danial Arshed, source=Web Response No relevant relationships by Christopher Lee, source=Web Response no disclosure on file for Lourdes Sanso; no disclosure on file for Anthony Smith