Endobronchial ultrasound-guided intralesional cryobiopsy: a case series

SESSION TITLE: Tales in BronchoscopySESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: Linear endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is a minimally invasive modality to sample mediastinal and parabronchial lymph nodes and masses for a variety of clinical scenarios. It has been recently shown that intra-lesional cryobiopsy can improve diagnostic yield, particularly for uncommon thoracic tumors and benign disorders. We present our experience with intra-lesional cryobiopsy thus far.CASE PRESENTATION: We performed intra-lesional cryobiopsy on nine (n=9) patients. Patients were selected for reasons such as suspected granulomatous disease, bulky mediastinal lymphadenopathy or anticipated need for additional tissue sampling. Eight cases involved lymph nodes and one case involved a mediastinal mass. All patients underwent mediastinal evaluation with linear EBUS and TBNA using a 19-gauge needle. Cryobiopsies were then obtained using a 1.1 mm flexible cryoprobe through the existing TBNA puncture. Antibiotics were given in seven cases (77.8%). An average of 2.56 lesions per case were sampled with TBNA and an average of 1.56 lesions per case were sampled with cryobiopsy. With combination TBNA and cryobiopsy specimens, a diagnosis was obtained in all nine cases (100%). Diagnoses were as follows: sarcoidosis (44.4%), lung adenocarcinoma (22.2%), melanoma (11.1%), lymphoma (11.1%), infection (11.1%). Diagnostic TBNA was observed in seven cases (77.8%) with diagnostic cryobiopsy in five (55.6%); concordance was observed in five cases (55.6%). In one case of sarcoidosis, cryobiopsy was diagnostic whereas TBNA was not. In two cases, both TBNA and cryobiopsy were negative, but TBNA of an additional node revealed the diagnosis. Rapid on-site evaluation (ROSE) was obtained on one cryobiopsy, and the specimen was considered adequate. No immediate complications, such as pneumothorax, pneumomediastinum, mediastinitis, other procedure related infections or massive bleeding, were observed.DISCUSSION: We observed fair diagnostic yield with the method described here, which did not require any additional intervention to access tissue. Additionally, no significant adverse events occurred. The sample size is too small to compare differences in the diagnostic abilities of TBNA and cryobiopsy alone, but our data suggests that a protocolized, combined approach can enhance diagnostic accuracy. The array of diagnoses, both benign and malignant, also suggests that cryobiopsy provides adequate specimen for various pathologies. While cryobiopsy may not be needed for all patients undergoing EBUS-TBNA, it may be useful in the setting of lymphoproliferative disorders, granulomatous disease such as sarcoidosis and other rare tumors.CONCLUSIONS: Intra-lesional cryobiopsy should be considered as an additional modality for mediastinal sampling and more studies are needed to define its utility.Reference #1: Zhang J, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial. Eur Respir J 2021;58:2100055.DISCLOSURES: No relevant relationships by Rodrigo Garcia TomeNo relevant relationships by Tao HeFaculty for fellows’ education project relationship with Medtronic Please note: Current Added 12/02/2021 by Catherine Oberg, value=Consulting feeNo relevant relationships by Scott Ohno disclosure on file for Reza Ronaghi;No relevant relationships by Miki Ueoka SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Linear endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is a minimally invasive modality to sample mediastinal and parabronchial lymph nodes and masses for a variety of clinical scenarios. It has been recently shown that intra-lesional cryobiopsy can improve diagnostic yield, particularly for uncommon thoracic tumors and benign disorders. We present our experience with intra-lesional cryobiopsy thus far. CASE PRESENTATION: We performed intra-lesional cryobiopsy on nine (n=9) patients. Patients were selected for reasons such as suspected granulomatous disease, bulky mediastinal lymphadenopathy or anticipated need for additional tissue sampling. Eight cases involved lymph nodes and one case involved a mediastinal mass. All patients underwent mediastinal evaluation with linear EBUS and TBNA using a 19-gauge needle. Cryobiopsies were then obtained using a 1.1 mm flexible cryoprobe through the existing TBNA puncture. Antibiotics were given in seven cases (77.8%). An average of 2.56 lesions per case were sampled with TBNA and an average of 1.56 lesions per case were sampled with cryobiopsy. With combination TBNA and cryobiopsy specimens, a diagnosis was obtained in all nine cases (100%). Diagnoses were as follows: sarcoidosis (44.4%), lung adenocarcinoma (22.2%), melanoma (11.1%), lymphoma (11.1%), infection (11.1%). Diagnostic TBNA was observed in seven cases (77.8%) with diagnostic cryobiopsy in five (55.6%); concordance was observed in five cases (55.6%). In one case of sarcoidosis, cryobiopsy was diagnostic whereas TBNA was not. In two cases, both TBNA and cryobiopsy were negative, but TBNA of an additional node revealed the diagnosis. Rapid on-site evaluation (ROSE) was obtained on one cryobiopsy, and the specimen was considered adequate. No immediate complications, such as pneumothorax, pneumomediastinum, mediastinitis, other procedure related infections or massive bleeding, were observed. DISCUSSION: We observed fair diagnostic yield with the method described here, which did not require any additional intervention to access tissue. Additionally, no significant adverse events occurred. The sample size is too small to compare differences in the diagnostic abilities of TBNA and cryobiopsy alone, but our data suggests that a protocolized, combined approach can enhance diagnostic accuracy. The array of diagnoses, both benign and malignant, also suggests that cryobiopsy provides adequate specimen for various pathologies. While cryobiopsy may not be needed for all patients undergoing EBUS-TBNA, it may be useful in the setting of lymphoproliferative disorders, granulomatous disease such as sarcoidosis and other rare tumors. CONCLUSIONS: Intra-lesional cryobiopsy should be considered as an additional modality for mediastinal sampling and more studies are needed to define its utility. Reference #1: Zhang J, et al. Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial. Eur Respir J 2021;58:2100055. DISCLOSURES: No relevant relationships by Rodrigo Garcia Tome No relevant relationships by Tao He Faculty for fellows’ education project relationship with Medtronic Please note: Current Added 12/02/2021 by Catherine Oberg, value=Consulting fee No relevant relationships by Scott Oh no disclosure on file for Reza Ronaghi; No relevant relationships by Miki Ueoka