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

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: Electromagnetic navigational bronchoscopy (ENB) has been utilized as a technique for improving diagnostic yield from peripheral pulmonary lung lesions (1). However, the current ENB tools can be limiting in the volume of tissue biopsy obtained. Cryobiopsy (CB) has become an increasingly popular adjunct to traditional biopsy techniques due to the ability to extract tissue circumferentially, allowing for large, low artifact samples (2). However, current systems limit the ability to combine ENB with CB. In this case series, we report a novel technique to combine ENB-guided cryobiopsy (ENB-CB) and achieve improved bronchoscopic biopsy sampling. CASE PRESENTATION: Three patients with lesions suspicious for lung cancer ranging from 1.2 to 5.3 cm were referred to our interventional pulmonary program for biopsy. ENB was performed using the Medtronic SuperDimension System (Minneapolis, MN, USA) with fluoroscopy. Needle aspirate, brushing, and biopsies were performed with Medtronic tools and reviewed by rapid onsite cytology. 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 then passed and guided to the same fluoroscopic location. Using 4-5 second freeze times, two to three CBs were obtained. The CBs were then fixed in formalin and reviewed. DISCUSSION: In two of three cases, ENB-CB had diagnostic yield when conventional-biopsy tool cytology and histology did not. In the third case, ENB-CB allowed for better immunohistochemical and molecular marker analysis. In all cases, ENB-CB improved diagnostic yield. Current lung cancer therapeutics relies on high quality biopsies for molecular marker testing. ENB has high rates of sampling target peripheral lesions. CB is an established high yield tool for endobronchial lesions that is frequently being expanded to peripheral lesions with excellent results. ENB-CB blends two current bronchoscopic techniques. There was no incidence of major bleeding or pneumothorax in any of the cases. CONCLUSIONS: In this proof of concept case series, we have shown that using ENB-CB with fluoroscopic alignment can achieve large biopsy samples with a low complication rate. Ideally, new tools would allow cryoprobes to be passed through navigational extended working channels mitigating the need for fluoroscopic alignment. While only a small series, a larger trial would need to be performed to see if this technique improves yield over either technique alone. 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: Robert Greer, Robert Babkowski, Michael Bernstein No Product/Research Disclosure Information