Navigational Bronchoscopy-Guided Cryobiopsy for Interstitial Lung Disease: Combining the Best of Two Techniques

Abstract

SESSION TITLE: Bronchoscopy and Associated Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Lung biopsies are often used in the evaluation of patients with interstitial lung disease (ILD). For many ILDs, bronchoscopic biopsy (BB) has limited utility due to small biopsy size and the complexity of sampling heterogeneous lung disease, which is the hall mark of ILD. These limited biopsies prove diagnostically challenging to all pathologists. Electromagnetic navigational bronchoscopy (ENB) has been utilized as a technique for improving diagnostic yield from peripheral pulmonary lung lesions (1). However, ENB biopsy samples are often limited due to small tissue size and crush artifact. Cryobiopsy (CB) has become a popular adjunct BB method secondary to larger sample size (2). However, current systems limit the ability to combine ENB with CB. In this case series, we report a novel technique used to combine ENB and cryobiopsy (ENB-CB) and achieve greater tissue yield in BB for patients with ILD. CASE PRESENTATION: Three patients with heterogeneous ILDs were referred to our Interventional Pulmonology Service for biopsy. ENB was performed using the Medtronic SuperDimension System (Minneapolis, MN, USA) with fluoroscopy. Transbronchial biopsies were performed with Medtronic tools. Fluoroscopic images were then saved. The extended working channel from the ENB was removed and the bronchoscope was firmly fixed in a flexed position. A 1.9 mm ERBE cryoprobe (Tubingen, Germany) was passed and guided to the same fluoroscopic location (Figure 1). Using 4-5 second freeze times, two to three CBs were obtained. The CBs were placed in 10% neutral buffered formalin. DISCUSSION: In all 3 cases, ENB-CB resulted in diagnostic material suitable for evaluation and accurate classification of ILD; the amount of tissue allowed for appropriate stains to be performed to establish a pathologic diagnosis and classify the ILD (Figure 2). One patient was diagnosed with hypersensitivity pneumonitis and two patients with cryptogenic organizing pneumonia. There was no incidence of major bleeding; one biopsy was complicated by a pneumothorax that did not require a chest tube. In all cases, ENB-CB provided quantitatively better diagnostic material. ENB-CB blends two current bronchoscopic techniques. Ideally, new tools would allow cryoprobes to be passed through navigational working channels mitigating the need for fluoroscopic alignment. CONCLUSIONS: In this proof of concept case series, we have shown that using ENB-CB with fluoroscopic alignment can achieve large biopsy samples without complications to help direct biopsies for heterogeneous ILDs. A larger trial needs to be conducted to further support the assertions made. Reference #1: Wang Memoli JS, Nietert PJ, Silvestri GA. Met-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest (2012) 142(2): 385-393 Reference #2: Ganganah O et al. Efficacy and safety of cryobiopsy versus forceps biopsy for interstitial lung diseases and lung tumors: A systemic review and meta-analysis. Respirology (2016) 21: 834-841 DISCLOSURE: The following authors have nothing to disclose: Pankil Desai, Robert Greer, Robert Babkowski, Michael Bernstein No Product/Research Disclosure Information