Safety and Performance of Transbronchial Cryobiopsy for Parenchymal Lung Lesions

Feasibility of a Modified Bronchoscopic Transparenchymal Nodule Access Technique ('Essen Tunnel') for Improving the Diagnosis of Intraparenchymal Pulmonary Lesions

BACKGROUND AND OBJECTIVE

Diagnosing intraparenchymal pulmonary lesions lacking a bronchus sign remains challenging. Bronchoscopic transparenchymal nodule access (BTPNA) for reaching such lesions has seen limited clinical adoption due to insufficient evidence and practical challenges. This study evaluates the feasibility and diagnostic yield of a modified BTPNA (mBTPNA) technique-referred to as the 'Essen tunnel'-which eliminates the need for a guide sheath.

METHODS

A retrospective analysis was conducted on patients undergoing virtual bronchoscopic navigation (VBN) incorporating the mBTPNA technique at our centre, from December 2019 to March 2024. The 'Essen tunnel' was created by a needle under virtual navigation guidance, enabling direct insertion of an ultrathin bronchoscope (UTB) or radial endobronchial ultrasound (R-EBUS) probe to biopsy intraparechymal lesions.

RESULTS

Among 266 lesions targeted via VBN, 37 (14%) intraparenchymal lesions (mean target length: 12.7 ± 4.1 mm) were accessed using mBTPNA. The tunnel was successfully created in 97.3% of cases with UTB intubation in 51.4%. R-EBUS was inserted into the tunnel in 83.8% of cases. Semicircular to circular patterns (SCP) were detected in 19.4% before and 61.3% after tunnel creation (p < 0.01). SCP presence on R-EBUS following mBTPNA was associated with a diagnostic accuracy of 66.7%, comparable to that observed in non-tunnel lesions exhibiting a bronchus sign (72.9%, p = 0.58). No severe complications were observed.

CONCLUSION

The mBTPNA technique is a feasible and safe method that enhances endosonographic lesion detection and achieves promising diagnostic accuracy for challenging intraparenchymal lesions.

The utility of transbronchial cryobiopsy performed under conscious sedation for interstitial lung diseases in a resource constrained setting

Background

Transbronchial biopsy (TBB) with a cryoprobe, also known as transbronchial lung cryobiopsy (TBLC), has become a well established modality for sampling lung parenchyma. TBLC is performed under general anaesthesia in the majority of centres, utilising rigid or flexible bronchoscopy. In resource-constrained settings, however, most diagnostic bronchoscopies, including TBB, are performed under conscious sedation with flexible bronchoscopy without the presence of a specialist anaesthetist.

Objectives

Given the paucity of evidence on TBLC performed under conscious sedation for interstitial lung diseases (ILD), specifically in a resource-constrained setting, we aimed to describe its utility in a pilot study.

Methods

We prospectively enrolled the first 20 patients who underwent TBLC for ILD at a large tertiary hospital in South Africa. All TBLCs were performed under conscious sedation using a cryoprobe. Patients were actively monitored for complications. The final diagnosis and decision regarding need for a surgical biopsy were made at a multidisciplinary meeting that included at least two specialist pulmonologists with an interest in ILD, a thoracic radiologist, and an anatomical pathologist with an interest in ILD.

Results

Three patients experienced complications. Two (10%) developed a pneumothorax (neither required any intervention). Bleeding that required 10 minutes of tamponade with the endobronchial blocker was observed in one case. This patient experienced no haemodynamic or respiratory compromise and was discharged the same day. There were no complications arising from the use of conscious sedation. A definitive diagnosis was made in 17/20 (85%) of the patients.

Conclusion

TBLC performed at an experienced bronchoscopy centre using a cryoprobe under conscious sedation with a dedicated sedationist was safe and well tolerated. Furthermore, it had a high diagnostic yield, and surgical lung biopsy was avoided in 85% of the patients.

Study synopsis

What the study adds. There is a paucity of evidence for the use of transbronchial lung cryobiopsy (TBLC) for the diagnosis of interstitial lung diseases (ILD) in resource-constrained settings, especially when performed under conscious sedation. In this pilot study, TBLC performed under conscious sedation was safe and well tolerated, and had a high diagnostic yield.Implications of the findings. TBLC under conscious sedation can safely be rolled out in resource-constrained settings as a first-line diagnostic procedure when lung tissue needs to be obtained in patients with ILD, as its yield is comparable to TBLC under general anaesthesia. It potentially avoids surgical lung biopsy in >80% of cases, together with the need for general anaesthesia.

Massive endobronchial hemorrhage leading to Cardiac arrest during EBUS-TBNA: a case of successful resuscitation

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used for diagnosing mediastinal lymphadenopathy. Despite a low complication rate, severe hemorrhage can occur which is reported in this literature, particularly in hypervascular conditions like Castleman disease.

METHODS

A 54-year-old male with idiopathic multicentric Castleman disease underwent EBUS-TBNA for mediastinal lymph node sampling. During the procedure, vascular invasion led to significant bleeding, requiring immediate interventions including suctioning and therapeutic bronchoscopy.

RESULTS

The patient experienced massive hemorrhage, resulting in airway obstruction, oxygen desaturation, and cardiac arrest. Aggressive resuscitation successfully restored cardiac rhythm after 15 min. The patient was then stabilized and transferred to the intensive care unit for monitoring.

CONCLUSIONS

This case underscores the risk of severe hemorrhage in hypervascular conditions during EBUS-TBNA. Pre-procedural imaging, careful planning, and immediate availability of hemostatic measures are crucial to reducing complications and improving outcomes in high-risk patients.

Safety and efficacy of transbronchial cryobiopsy for elderly lung cancer patients

BACKGROUND

The increasing prevalence of lung cancer in the elderly population necessitates a closer evaluation of diagnostic and therapeutic approaches. This study aimed to compare the safety and diagnostic efficacy of transbronchial lung cryobiopsy (TBLC) between patients ≥ 80 years and younger patients.

METHODS

A retrospective review was conducted of 96 patients diagnosed with peripheral lung cancer who underwent TBLC between April 2021 and October 2023. The patients were categorized into two groups: the elderly group (age ≥ 80 years, n = 20) and younger group (age < 80 years; n = 76). Data regarding the biopsy yield, complications, and feasibility of molecular analyses were collected and analyzed.

RESULTS

The diagnostic yield of TBLC was comparable between the elderly and younger groups (95% vs. 89.5%, p = 0.679). Biomarker testing, including programmed death-ligand 1 expression and genetic mutations, were feasible in all cases diagnosed with cancer using TBLC samples. No significant differences were observed in major complications such as pneumothorax or bleeding.

CONCLUSIONS

TBLC was found to be a safe and effective diagnostic tool for peripheral lung cancer in elderly patients and provided adequate samples for molecular testing. Since the complication rates did not significantly differ between the two age groups, age alone should not be considered a contraindication for the procedure.

Feasibility of Cryobiopsy Specimen Retrieval Through Standard Guide Sheath for Peripheral Pulmonary Lesions Without Bronchoscope Removal

BACKGROUND

Transbronchial cryobiopsy is a promising technique for biopsy of peripheral pulmonary lesions (PPL). However, cryobiopsy specimen retrieval can pose problems due to the risk of bleeding during the blind period when the bronchoscope and cryoprobe are removed en bloc. Artificial airways and prophylactic balloon placement are risk-reducing measures, but the latter is challenging in upper lobe PPL. Specimen retrieval through standard guide sheath (GS) system without the need for bronchoscope removal may now be feasible with the ultrathin cryoprobe.

METHODS

Retrospective review of radial endobronchial ultrasound (rEBUS)-guided transbronchial cryobiopsy for PPL cases in which cryobiopsy specimen was retrieved through the GS over a 6-month period.

RESULTS

Twenty patients were included with an overall median age of 66.50 (IQR: 53.0 to 76.7). The median procedural time was 30 (IQR: 25.0 to 33.7) minutes. Median target size was 3.20 (IQR: 2.17 to 4.84) cm with 85% of lesions demonstrated "within" rEBUS orientation. Overall technical feasibility was 85% with median cryoactivation of 4.0 (IQR: 3.0 to 4.0) seconds. No specimen was retrieved in 3 patients. The diagnostic yield for forceps and cryobiopsy was 70% and 60%, respectively, and the combined diagnostic yield was 85% (P<0.01 vs. forceps biopsy). Median aggregate size for forceps and cryobiopsy was 8.0 (IQR: 5.3 to 10.0) and 4.5 (IQR: 2.3 to 7.0) mm respectively (P<0.01). No pneumothorax was reported and mild self-limiting bleeding was encountered in 30% of cases.

CONCLUSION

Retrieval of cryoprobe through standard GS appears to be a safe and feasible method that can simplify the transbronchial cryobiopsy procedure and complement forceps biopsy in specific cases.

Cryobiopsy for Secondary Pulmonary Alveolar Proteinosis

Secondary pulmonary alveolar proteinosis (SPAP) is one of the diffuse parenchymal lung diseases, and the utility and safety of transbronchial lung cryobiopsy (TBLC) for diagnosing SPAP are unknown. A case of SPAP diagnosed by TBLC is presented. Specimens that were useful for diagnosis were collected, and there was no adverse event following TBLC. The usefulness of TBLC for interstitial lung disease has been widely reported, but there are few reports of SPAP. We present the clinical course of TBLC in the diagnosis of SPAP.

Assessment of Advanced Diagnostic Bronchoscopy Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American College of Chest Physicians Research Statement

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

Analysis of clinical outcomes and prognosis of patients with early bronchogenic lung cancer after treatment of rigid bronchoscopy combining fiberoptic bronchoscopy: a single-center retrospective study

OBJECTIVES

To investigate the clinical value of rigid bronchoscopy combined with fiberoptic bronchoscopy in patients with early bronchogenic lung cancer who underwent sleeve lobectomy.

METHODS

A retrospective study was performed on 76 patients with early bronchogenic lung cancer admitted to our center from March 2016 to March 2017. Patients in the control group received conventional sleeve lobectomy (n = 38), while patients in the observation group underwent sleeve lobectomy by using rigid bronchoscopy combining fiberoptic bronchoscopy (n = 38). We compared perioperative period indicators and the recovery of pulmonary function indexes one month after the operation were compared in two groups. The prognosis of the patients were also analyzed.

RESULTS

Compared with the control group, the intraoperative blood loss, operation duration and airway reconstruction duration in the observation group were significantly reduced. The total incidence of perioperative complications was markedly lower in the observation group than in the control group. The percentage of DLCO% was significantly improved in the observation group. The relapse-free survival (RFS) in the observation group was remarkably longer than in the control group.

CONCLUSION

Rigid bronchoscopy combined with fiberoptic bronchoscopy is beneficial to improve the clinical outcome and prognosis of patients with early bronchogenic lung cancer more effectively.

Safety and risk factors for bleeding complications of radial probe endobronchial ultrasound-guided transbronchial biopsy

BACKGROUND

Radial probe endobronchial ultrasound (radial EBUS) is widely used to diagnose pulmonary lesions; however, the diagnostic value of radial EBUS-guided transbronchial biopsy (TBB) varies, and its complications (especially the risk of bleeding) are not properly understood.

OBJECTIVES

In this study, we evaluated the diagnostic performance and rate of complication of this procedure, and investigated the risk factors associated with the procedure-related bleeding events.

DESIGN

A retrospective cohort study.

METHODS

This was a retrospective study that included consecutive patients who underwent radial EBUS-guided TBB. Radial EBUS was performed under moderate sedation in inpatients or outpatients. The severity of bleeding was graded using the standardized definitions of bleeding.

RESULTS

Of 133 patients (median age, 69 years; men 57.1%) included, 41 were outpatients (30.8%). The diagnostic accuracy, sensitivity, and specificity for malignancy were 76.1% (89/117), 71.1% (69/97), and 100% (20/20), respectively. The diagnostic accuracy ranged from 66.9% to 79.0%, depending on the classification of undiagnosed cases as either false negatives or true negatives. Twenty-seven patients (20.3%) developed complications (pneumothorax, 3; pneumonia, 5; complicated pleural effusion, 2; bleeding event grade 2 or higher, 21). Of the 41 outpatients, two developed complications (pneumothorax without intervention, 1; grade 2 bleeding event, 1). Of the 21 patients (15.8%) with procedure-related bleeding events, 18 had grade 2, and three had grade 3 bleeding complications. In multivariate analysis, a large size of ⩾30 mm (adjusted odds ratio (OR), 5.09; p = 0.03) and central lesion (adjusted OR, 3.67; p = 0.03) were significantly associated with the risk of grade 2 or higher bleeding events.

CONCLUSION

Our results suggest that radial EBUS-guided TBB is an accurate and safe method for diagnosing pulmonary lesions. Clinically significant procedure-related bleeding was rare. The central location and larger size (⩾30 mm) of pulmonary lesions were risk factors for grade 2 or higher bleeding events.

Primary Pulmonary Leiomyosarcoma Managed With Pazopanib: A Case Report and Literature Review

Primary pulmonary leiomyosarcoma (PPL) arises from pulmonary smooth muscle tissue, with less than 0.5% incidence among pulmonary malignancies and 30% among primary pulmonary sarcomas. Here, we present a case of PPL managed with pazopanib. Moreover, a brief review of relevant literature was conducted. A 65-year-old female presented with chronic cough, weight loss, and recurrent pneumonia, with a medical history including diabetes mellitus, hypertension, and hyperlipidemia, as well as past surgical colectomy and hysterectomy (due to abnormal uterine bleeding with normal pathology and no evidence of uterine leiomyosarcoma). Upon admission, she exhibited fever, cough, dyspnea, and decreased breath sounds over the upper lung lobe. Diagnostic workups revealed a large pulmonary mass, diagnosed as leiomyosarcoma via core needle biopsy and subsequent immunohistochemical staining. Neoadjuvant treatment with ifosfamide and adriamycin followed by chemoradiotherapy was attempted, but surgery for tumor resection was not feasible. Then, gemcitabine and docetaxel were chosen as the new treatment after ifosfamide and adriamycin were not effective. Imaging revealed tumor not reacting to latest treatment, either. Given the disease's persistence and the patient's diminished capacity for chemotherapy, the patient is presently undergoing pazopanib treatment, with ongoing monitoring of its effects. After 3 months of treatment with pazopanib (administered orally at 200 mg twice daily), the patient experienced a significant reduction in tumor size, with a notable decrease from 135 mm to 80 mm, approximating one-third of the initial size, indicating a positive therapeutic effect. This case report provides preliminary evidence suggesting that pazopanib, an oral multi-tyrosine kinase inhibitor, may be a promising therapeutic option for the management of PPL. However, further in-depth and long-term studies are warranted to evaluate the clinical efficacy and superiority of this treatment.

Endobronchial Ultrasound-guided Mediastinal Lymph Nodal Cryobiopsy in Patients With Nondiagnostic/Inadequate Rapid On-site Evaluation: A New Step in the Diagnostic Algorithm

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered the investigation of choice for sampling mediastinal nodes. A major drawback of EBUS-TBNA is its lower diagnostic yield for lymphoma and benign diseases. EBUS-guided mediastinal cryobiopsy (EBUS-MCB) is a novel technique that provides larger nodal biopsy samples, with an acceptable safety profile. In this study, we aimed to evaluate the diagnostic yield of EBUS-MCB in patients with an inconclusive rapid on-site evaluation (ROSE).

METHODS

This is a prospective study of patients who underwent EBUS-TBNA for undiagnosed mediastinal lymphadenopathy. Patients in whom ROSE did not yield a diagnosis (nondiagnostic ROSE) or ROSE revealed scanty atypical cells (inadequate ROSE) were subjected to EBUS-MCB. The diagnostic yield, adequacy, and complications of EBUS-MCB were analyzed.

RESULTS

Of the 196 patients undergoing EBUS-TBNA, 46 patients underwent EBUS-MCB. Thirty-two cases underwent EBUS-MCB for a nondiagnostic ROSE. EBUS-MCB confirmed the diagnosis in 19/32 (59.3%) cases. The additive diagnostic yield of EBUS-MCB over EBUS-TBNA was 43.7% (14/32 cases). In all 14 cases where EBUS-MCB was performed for an inadequate ROSE, the material obtained by EBUS-MCB was adequate for ancillary studies. The most common complication observed was a minor bleed in 13 cases.

CONCLUSION

EBUS-MCB has a diagnostic yield of 59.3% when performed in cases with a nondiagnostic EBUS-ROSE. The tissue obtained by EBUS-MCB is adequate for ancillary studies. We propose EBUS-MCB as an additional diagnostic step in cases with an inconclusive ROSE while performing EBUS-TBNA. Larger studies are, however, needed before EBUS-MCB can be incorporated in the diagnostic algorithm for the evaluation of mediastinal lesions.

[Navigational bronchoscopy with tranbronchial cryobiopsy in differential diagnosis of peripheral pulmonary lesions]

OBJECTIVE

To evaluate the efficacy and safety of tranbronchial cryobiopsy (TBCB) with 1.9-mm and 1.1-mm cryoprobes in patients with peripheral pulmonary lesions (PPLs).

MATERIAL AND METHODS

We analyzed 34 patients (mean age 60 years) with PPLs who underwent bronchoscopy with TBCB. Mean lesion size was 31.5 mm, upper lobe localization was predominant (47% of cases). CT signs of appropriate bronchus were identified in 79% (27/34) of cases. Manual branch tracking and virtual bronchoscopy (VB) were performed pre-procedurally, and radial endobronchial ultrasonography (rEBUS) was performed during bronchoscopy for accurate positioning of PPLs. TBCB was performed using 1.9-mm (n=19) or 1.1-mm (n=15) cryoprobes without fluoroscopic guidance. Incidence and severity of bleeding and pneumothorax were evaluated in all patients.

RESULTS

Total efficacy of TBCB was 76.5% (26/34): 78.9% (15/19) for 1.9-mm cryoprobe and 73.3% (11/15) for 1.1-mm cryoprobe (p=0.702). Efficacy depended on the presence of CT signs of bronchus (presence - 94%, absence 14.3%, p<0.001) and PPL size (94% for PPL >30 mm and 58.8% for PPL <30 mm, p=0.016). Central probe position during rEBUS was associated with 94.7% diagnostic efficacy (18/19), adjacent probe position - 72.7% (8/11) (p=0.088). Bleeding grade 3 (Nasville) occurred in 5.8% (2/34) of cases, and no pneumothorax was observed.

CONCLUSION

TBCB is an effective and safe diagnostic method for PPLs.

Exploring the optimal freeze time and passes of the ultrathin cryoprobe in transbronchial cryobiopsy of peripheral pulmonary lesions

In PPL-TBLC, quality of tissue matters more than quantity for accurate diagnosis. Comparable diagnostic yield with 1.1-mm cryoprobe can potentially be achieved in 6 s of freezing and three or more passes. https://bit.ly/49cbmbW.

Selective bronchial occlusion for the prevention of pneumothorax after transbronchial lung cryobiopsy in a pulmonary alveolar proteinosis patient: a case report

The diagnosis of pulmonary alveolar proteinosis (PAP) is based on biopsies. Compared with other methods of taking biopsies, transbronchial lung cryobiopsy (TBLC) has a higher diagnostic rate and the likelihood of pneumothorax. Selective bronchial occlusion (SBO) is an effective technique for treating intractable pneumothorax. However, there are no data available about SBO for the prevention of pneumothorax after TBLC in a PAP patient. A 49-year-old man complained of recurrent cough and tachypnea, and his symptoms did not fully resolve until the diagnosis was confirmed, and he was treated with whole lung lavage. Our patient was ultimately diagnosed with PAP by TBLC but not multiple tests for the bronchoalveolar lavage fluid (BALF). The patient was discharged quickly after whole lung lavage due to the fact that he did not develop pneumothorax under SBO. This case illustrates that TBLC is a supplementary examination for PAP, especially for those in whom BALF results fail to confirm a diagnosis. Moreover, our report highlights that SBO is necessary to effectively prevent pneumothorax during and after multiple TBLCs in PAP patients.

A Multicenter, Single-Arm, Prospective Trial Assessing the Diagnostic Yield of Electromagnetic Bronchoscopic and Transthoracic Navigation for Peripheral Pulmonary Nodules

Rationale: Strict adherence to procedural protocols and diagnostic definitions is critical to understand the efficacy of new technologies. Electromagnetic navigational bronchoscopy (ENB) for lung nodule biopsy has been used for decades without a solid understanding of its efficacy, but offers the opportunity for simultaneous tissue acquisition via electromagnetic navigational transthoracic biopsy (EMN-TTNA) and staging via endobronchial ultrasound (EBUS). Objective: To evaluate the diagnostic yield of EBUS, ENB, and EMN-TTNA during a single procedure using a strict a priori definition of diagnostic yield with central pathology adjudication. Methods: A prospective, single-arm trial was conducted at eight centers enrolling participants with pulmonary nodules (<3 cm; without computed tomography [CT]- and/or positron emission tomography-positive mediastinal lymph nodes) who underwent a staged procedure with same-day CT, EBUS, ENB, and EMN-TTNA. The procedure was staged such that, when a diagnosis had been achieved via rapid on-site pathologic evaluation, the procedure was ended and subsequent biopsy modalities were not attempted. A study finding was diagnostic if an independent pathology core laboratory confirmed malignancy or a definitive benign finding. The primary endpoint was the diagnostic yield of the combination of CT, EBUS, ENB, and EMN-TTNA. Measurements and Main Results: A total of 160 participants at 8 centers with a mean nodule size of 18 ± 6 mm were enrolled. The diagnostic yield of the combined procedure was 59% (94 of 160; 95% confidence interval [CI], 51-66%). Nodule regression was found on same-day CT in 2.5% of cases (4 of 160; 95% CI, 0.69-6.3%), and EBUS confirmed malignancy in 7.1% of cases (11 of 156; 95% CI, 3.6-12%). The yield of ENB alone was 49% (74 of 150; 95% CI, 41-58%), that of EMN-TTNA alone was 27% (8 of 30; 95% CI, 12-46%), and that of ENB plus EMN-TTNA was 53% (79 of 150; 95% CI, 44-61%). Complications included a pneumothorax rate of 10% and a 2% bleeding rate. When EMN-TTNA was performed, the pneumothorax rate was 30%. Conclusions: The diagnostic yield for ENB is 49%, which increases to 59% with the addition of same-day CT, EBUS, and EMN-TTNA, lower than in prior reports in the literature. The high complication rate and low diagnostic yield of EMN-TTNA does not support its routine use. Clinical trial registered with www.clinicaltrials.gov (NCT03338049).

Utility and Safety of Bronchoscopic Cryotechniques-A Comprehensive Review

Cryosurgical techniques are employed for diagnostic and therapeutic bronchoscopy and serve as important tools for the management of pulmonary diseases. The diagnosis of interstitial lung disease requires multidisciplinary team discussions after a thorough assessment of history, physical exam, computed tomography, and lung-function testing. However, histological diagnosis is required in selected patients. Surgical lung biopsy has been the gold standard but this can be associated with increased morbidity and mortality. Transbronchial lung cryobiopsy is an emerging technique and multiple studies have shown that it has a high diagnostic yield with a good safety profile. There is wide procedural variability and the optimal technique for cryobiopsy is still under investigation. There is emerging data that demonstrate that cryobiopsy is safe and highly accurate in the diagnosis of thoracic malignancies. Furthermore, cryorecanalization procedures are a useful adjunct for the palliation of tumors in patients with central airway obstruction. One should keep in mind that these procedures are not free from complications and should be carried out in a specialized center by a trained and experienced bronchoscopy team. We present a review of the literature on the diagnostic and therapeutic utility of bronchoscopy-guided cryosurgical procedures and their safety profile.

Identification of microbial markers associated with lung cancer based on multi-cohort 16 s rRNA analyses: A systematic review and meta-analysis

BACKGROUND

The relationship between commensal microbiota and lung cancer (LC) has been studied extensively. However, developing replicable microbiological markers for early LC diagnosis across multiple populations has remained challenging. Current studies are limited to a single region, single LC subtype, and small sample size. Therefore, we aimed to perform the first large-scale meta-analysis for identifying micro biomarkers for LC screening by integrating gut and respiratory samples from multiple studies and building a machine-learning classifier.

METHODS

In total, 712 gut and 393 respiratory samples were assessed via 16 s rRNA amplicon sequencing. After identifying the taxa of differential biomarkers, we established random forest models to distinguish between LC populations and normal controls. We validated the robustness and specificity of the model using external cohorts. Moreover, we also used the KEGG database for the predictive analysis of colony-related functions.

RESULTS

The α and β diversity indices indicated that LC patients' gut microbiota (GM) and lung microbiota (LM) differed significantly from those of the healthy population. Linear discriminant analysis (LDA) of effect size (LEfSe) helped us identify the top-ranked biomarkers, Enterococcus, Lactobacillus, and Escherichia, in two microbial niches. The area under the curve values of the diagnostic model for the two sites were 0.81 and 0.90, respectively. KEGG enrichment analysis also revealed significant differences in microbiota-associated functions between cancer-affected and healthy individuals that were primarily associated with metabolic disturbances.

CONCLUSIONS

GM and LM profiles were significantly altered in LC patients, compared to healthy individuals. We identified the taxa of biomarkers at the two loci and constructed accurate diagnostic models. This study demonstrates the effectiveness of LC-specific microbiological markers in multiple populations and contributes to the early diagnosis and screening of LC.

Diagnostic Utility and Safety of Non-Intubated Cryobiopsy Technique Using a Novel Ultrathin Cryoprobe in Addition to Conventional Biopsy Techniques for Peripheral Pulmonary Lesions

BACKGROUND

Transbronchial cryobiopsy enables high-quality sample collection around the probe tip. Meanwhile, existing cryoprobes have less flexibility and a higher risk of bleeding. The ultrathin cryoprobe with a 1.1-mm diameter addresses these problems and allows specimens to be directly retrieved through the working channel of a thin bronchoscope.

OBJECTIVE

This study evaluated the diagnostic utility and safety of non-intubated cryobiopsy using an ultrathin cryoprobe added to conventional biopsy for diagnosing peripheral pulmonary lesions (PPLs).

METHODS

The data of patients who underwent conventional biopsy followed by non-intubated cryobiopsy to retrieve specimens through the thin bronchoscope's working channel for diagnosing PPLs at Osaka Metropolitan University Hospital from July 2021 to June 2022 were retrospectively collected. They were analyzed to evaluate the diagnostic utility and safety of adding non-intubated cryobiopsy to conventional biopsy for PPLs. The characteristics of PPLs that obtain additional diagnostic benefits from cryobiopsy over conventional biopsy were also investigated.

RESULTS

The analysis included 113 patients. The diagnostic yields of conventional biopsy and non-intubated cryobiopsy were 70.8% and 82.3%, respectively (p = 0.009). The total diagnostic yield was 85.8%, higher than conventional biopsy alone (p < 0.001). Although one moderate bleeding occurred, no severe complications developed. The additional diagnostic benefits of non-intubated cryobiopsy over conventional biopsy were demonstrated when the radial endobronchial ultrasound (R-EBUS) showed "adjacent to" (60.3% vs. 82.8%, p = 0.017).

CONCLUSIONS

Non-intubated cryobiopsy using an ultrathin cryoprobe has high diagnostic utility and safety for diagnosing PPLs, with additional diagnostic benefits over conventional biopsy depending on the R-EBUS image.

Using cryobiopsy with Radial EBUS in high-bleeding-risk, peripheral pulmonary lesions (PPL): description of cases and technique

Cryobiopsy is an emerging tool in the diagnosis of peripheral pulmonary lesions (PPL) and becoming an important tool in the toolbox. Anecdotally the data on cryobiopsy use in the lung was extrapolated from the use of transbronchial cryobiopsy (TBCB) in Interstitial Lung disease (ILD). Similar to ILD data, cryobiopsy in PPL also provided larger tissue compared to forceps biopsies. Yet, unlike TBCB in ILD, the safety profile for cryobiopsy in PPL seems much more favourable, yet the number of publications on cryobiopsy in PPL remains sparse. Some PPL, both malignant and non-malignant are considered to be of a high bleeding risk due to vascularity of the tumour and/or inflammation of the blood vessels and surrounding tissue. The use of cryobiopsy and the risk of bleeding in this type of PPL have not been described. This paper describes four patients with PPL, undergoing cryobiopsy with radial EBUS for suspected lung cancer, and later diagnosed to have a PPL, deemed to be of a high bleeding risk. The use of cryobiopsy with radial ultrasonic examination for the vasculature of the PPL, bronchial blocker use, and airway protection as well as an expert team preserved the safety of the procedure.

Transbronchial lung cryobiopsy and pulmonary fibrosis: A never-ending story?

Background

The diagnostic process of pulmonary fibrosis (PF) is often challenging, requires a collaborative effort of several experts, and often requires bioptic material, which can be difficult to obtain, both in terms of quality and technique. The main procedures available to obtain such samples are transbronchial lung cryobiopsy (TBLC) and surgical lung biopsy (SLB).

Objective

The purpose of this paper is to review the evidence for the role of TBLC in the diagnostic-therapeutic process of PF.

Methods

A comprehensive review was performed to identify articles to date that addressed the role of TBLC in the diagnostic-therapeutic process of PF using the PubMed® database.

Results

The reasoned search identified 206 papers, including 21 manuscripts (three reviews, one systematic review, two guidelines, two prospective studies, three retrospective studies, one cross-sectional study, one original article, three editorials, three clinical trials, and two unclassifiable studies), which were included in the final review.

Conclusions

TBLC is gaining increasing efficacy and improving safety profile; however, there are currently no clear data demonstrating its superiority over SLB. Therefore, the two techniques should be considered with careful rationalization on a case-by-case basis. Further research is needed to further optimize and standardize the procedure and to thoroughly study the histological and molecular characteristics of PF.

Diagnostic efficacy of cryobiopsy for peripheral pulmonary lesions: A propensity score analysis

OBJECTIVES

Recently introduced cryobiopsy can provide quantitatively and qualitatively excellent specimens. However, few studies have directly compared the diagnostic yield of cryobiopsy for peripheral pulmonary lesions (PPLs) with that of conventional sampling methods.

MATERIAL AND METHODS

We retrospectively reviewed data from consecutive patients who underwent diagnostic bronchoscopy using radial endobronchial ultrasound and virtual bronchoscopic navigation for PPLs (October 2015 to September 2020). Patients who underwent cryobiopsy were assigned to the cryo group, whereas those who did not undergo cryobiopsy were assigned to the conventional group. The diagnostic outcomes of both groups were compared using propensity score analyses.

RESULTS

A total of 2,724 cases were identified, including 492 and 2,232 cases in the cryo and conventional groups, respectively. Propensity scoring was performed to match baseline characteristics, and 481 pairs of cases were selected for each matched group (m-group). The diagnostic yield was significantly higher in the m-cryo group than in the m-conventional group (89.2% vs. 77.6%, odds ratio [OR] = 2.36 [95% confidence interval [CI] = 1.65-3.38], P < 0.001). Propensity score stratification (OR = 2.35 [95% CI = 1.71-3.23]) and regression adjustment (OR = 2.54 [95% CI = 1.83-3.52]) also demonstrated the diagnostic advantages of cryobiopsy. The subgroup analysis revealed that cryobiopsy was notably effective for lesions in the middle lobe/lingula, right/left lower lobe, lesions with ground-glass opacity, and lesions invisible on chest radiography. Although there were more cases of grade 2 and 3 bleeding in the m-cryo group than in the m-conventional group (38.0% vs. 10.2% and 1.5% vs. 0.8%, respectively; P < 0.001), no grade 4 bleeding was observed.

CONCLUSION

The propensity score analyses revealed that cryobiopsy was associated with a higher diagnostic yield for PPLs than conventional sampling methods. However, increased bleeding risk should be noted as a potential complication.

Ultrathin bronchoscopic cryobiopsy of peripheral pulmonary lesions

BACKGROUND AND OBJECTIVE

Ultrathin bronchoscopy aids in the diagnosis of peripheral pulmonary lesions. However, both the working channel and the specimens are small. A 1.1-mm ultrathin cryoprobe that can enter the working channel of the ultrathin bronchoscope is now available, which may overcome the limitations of small specimen size. The aim of this study was to evaluate the feasibility, efficacy and safety of ultrathin bronchoscopic cryobiopsy using an ultrathin cryoprobe for diagnosing peripheral pulmonary lesions.

METHODS

Patients with peripheral pulmonary lesions ≤30 mm in diameter were prospectively enrolled in the study. All patients underwent forceps biopsy followed by cryobiopsy using a 3.0-mm ultrathin bronchoscope under radial probe endobronchial ultrasound guidance, virtual bronchoscopic navigation and fluoroscopic guidance. The primary endpoint was the feasibility of cryobiopsy.

RESULTS

In total, 50 patients with peripheral pulmonary lesions were enrolled in the study; the median longest diameter on computed tomography was 17.9 mm. Cryobiopsy was performed successfully in 49 patients (98%). Forceps biopsy, cryobiopsy and the combination of these two methods provided a specific diagnosis in 54% (27/50), 62% (31/50) and 74% (37/50) of patients, respectively. The median size of specimens obtained via cryobiopsy was significantly larger than the median size obtained via forceps biopsy (7.0 vs. 1.3 mm² , respectively, p < 0.001). Mild bleeding during cryobiopsy occurred in 47 patients (94%). No moderate/severe bleeding or pneumothorax occurred.

CONCLUSION

Ultrathin bronchoscopic cryobiopsy is feasible, effective and sufficiently safe for the diagnosis of peripheral pulmonary lesions.

Diagnostic performance of cryobiopsy guided by radial-probe EBUS with a guide sheath for peripheral pulmonary lesions

OBJECTIVE

Transbronchial lung cryobiopsy (TBCB) has developed rapidly and has become one of the research hotspots of lung biopsy technology. The present study sought to evaluate the efficacy of TBCB guided by radial-probe EBUS (RP-EBUS) and a guide sheath (GS) without fluoroscopy for peripheral pulmonary lesions.

METHODS

In this retrospective study, McNemar's test was used in order to compare TBCB and transbronchial forceps biopsy (TBFB) in terms of diagnostic performance. A multivariate logistic regression model was designed to explore the association between predictive variables and the diagnostic yield of TBCB.

RESULTS

A total of 168 patients underwent GS-guided RP-EBUS. Of those, 157 had lesions that were visible and 11 had lesions that were not. Of those 157 patients, 24 were excluded because of missing data or an unclear final diagnosis. Therefore, 133 patients underwent RP-EBUS-GS-guided TBFB and TBCB. The pooled diagnostic yield of RP-EBUS-GS-guided TBCB without fluoroscopy was 71.5% (103/144). In 133 patients, the diagnostic yield of TBCB was significantly higher than that of TBFB (77.4% vs. 59.4%; p < 0.05). Multivariate analysis indicated that lesion size and site were independently associated with the diagnostic yield of TBCB (OR = 2.8, p = 0.03 and OR = 4.1, p = 0.01, respectively), although cryoprobe size was not. There was no significant difference between the 1.1-mm cryoprobe and the 1.9-mm cryoprobe in terms of diagnostic performance (78.4% vs. 76.8%; p > 0.05).

CONCLUSIONS

GS-guided RP-EBUS is regarded as a practical option for guiding cryobiopsy, although it may not be able to replace fluoroscopy. Peripheral pulmonary lesions not located in the upper lobes or larger than 30 mm are significantly associated with a higher diagnostic yield of cryobiopsy.

Diagnosis of pulmonary leiomyosarcoma extending into the main bronchus using repeated transbronchial cryobiopsy

The diagnosis of pulmonary leiomyosarcoma using bronchoscopy is difficult, and surgical resection is often performed for definitive diagnosis and curative therapy. We report a case of pulmonary leiomyosarcoma, successfully diagnosed using repeated transbronchial cryobiopsy (TBCB). A 69-year-old-woman was found to have an oval mass in the left hilar region extending into the left main bronchus on computed tomography (CT). All transbronchial biopsy specimens were necrotic, but repeated TBCB removed the necrotic tissue from the tumour and finally led to the diagnosis of pulmonary leiomyosarcoma. Proton therapy was administered, which caused shrinkage of the tumour. Thus, TBCB is useful for definitive diagnosis of leiomyosarcoma without surgical biopsy. Repeated TBCB can reduce tumour volume, eliminate atelectasis, and reduce the extent of radiotherapy exposure.

Air embolism after transbronchial lung cryobiopsy: A case report

A 76-year-old woman underwent transbronchial lung cryobiopsy (TBLC) and transbronchial lung biopsy (TBLB) for examination of interstitial infiltrates. After the examination, the patient's consciousness became clouded, and head computed tomography showed an air embolus. She was started on 100% oxygen, and her consciousness improved, but she remained hemiplegic on the left side and dysphagic. Vascular air embolism (VAE) is a rare but serious complication. Although cases of VAE have been reported with conventional transbronchial forceps biopsy, cases of VAE after TBLC are quite rare, and thus this case is reported.

Design of a flexible robot toward transbronchial lung biopsy

Transbronchial lung biopsy is an effective and less-invasive treatment for the early diagnosis of lung cancer. However, the limited dexterity of existing endoscopic instruments and the complexity of bronchial access prevent the application of such procedures mainly for biopsy and diagnosis. This paper proposes a flexible robot for transbronchial lung biopsy with a cable-driven mechanism-based flexible manipulator. The robotic system of transbronchial lung biopsy is presented in detail, including the snake-bone end effector, the flexible catheters and the actuation unit. The kinematic analysis of the snake-bone end effector is conducted for the master-slave control. The experimental results show that the end effector reaches the target nodule through a narrow and tortuous pathway in a bronchial model. In conclusion, the proposed robotic system contributes to the field of advanced endoscopic surgery with high flexibility and controllability.

Thin bronchoscopic cryobiopsy using a nasobronchial tube

BACKGROUND

Transbronchial lung cryobiopsy is useful when diagnosing lung lesions. However, prevention of associated bleeding complications is essential. This study aimed to evaluate the safety and efficacy of our novel bronchoscopic cryobiopsy technique, which uses a long nasobronchial tube to prevent blood flooding the central airway.

METHODS

Patients with localized or diffuse lung lesions were prospectively enrolled and underwent cryobiopsy using a 1.9 mm diameter cryoprobe and a 4.0 mm diameter thin bronchoscope under conscious sedation. For cryobiopsy, a long silicone tube (inner diameter, 5.0 mm) was advanced through the nose to the target bronchus, then wedged to drain blood under thin-tube bronchoscopic control. The primary endpoint was the frequency of bleeding complications.

RESULTS

Of the 80 patients initially enrolled, 73 that underwent at least one cryobiopsy were ultimately included. Mild bleeding during cryobiopsy occurred in 58 patients (79.5%), but there was no moderate or severe bleeding. Other complications occurred in four patients (two pneumothorax, one pneumomediastinum, and one pneumonia). Tube dislocation was noted in eight patients (11%). Cryobiopsy specimens were significantly larger than forceps biopsy specimens (9.0 mm² vs. 2.7 mm², P < .001) and allowed specific diagnoses in 50 patients (68.5%).

CONCLUSIONS

Thin bronchoscopic cryobiopsy using a nasobronchial tube in consciously sedated patients is safe and effective. Trial registration Date of registration: 24/06/2019. UMIN-Clinical Trials Registry; Identifier: UMIN000037156 https://www.umin.ac.jp/ctr/index.htm.

Clinical Utility of Rapid On-Site Evaluation of Touch Imprint Cytology during Cryobiopsy for Peripheral Pulmonary Lesions

Simple Summary

With increasing interest in precision medicine for lung cancer, cryobiopsy is expected to improve the success rate not only for histological diagnosis, but also for next-generation sequencing. Rapid on-site evaluation (ROSE) is an immediate cytological evaluation performed during bronchoscopy. However, little is known about its clinical utility during cryobiopsy. We retrospectively reviewed the data of 63 consecutive patients who underwent cryobiopsy with ROSE of touch imprint cytology (ROSE-TIC) for solid peripheral pulmonary lesions. When the results of ROSE-TIC of each patient were compared directly with the histological findings of the corresponding specimen, the sensitivity, specificity, and positive and negative predictive values were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. Therefore, we believe that ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Abstract

Cryobiopsy enables us to obtain larger specimens than conventional forceps biopsy despite the caution regarding complications. This study aimed to evaluate the clinical utility of rapid on-site evaluation of touch imprint cytology (ROSE-TIC) during cryobiopsy of peripheral pulmonary lesions (PPLs). We retrospectively reviewed the data of consecutive patients who underwent cryobiopsy for solid PPLs between June 2020 and December 2021. ROSE-TIC was performed on the first specimen obtained via cryobiopsy and assessed using Diff-Quik staining. The results of ROSE-TIC for each patient were compared with the histological findings of the first cryobiopsy specimen. Sixty-three patients were enrolled in this study. Overall, 57 (90.5%) lesions were ≤30 mm in size and 37 (58.7%) had positive bronchus signs. The radial endobronchial ultrasound findings were located within and adjacent to the lesion in 46.0% and 54.0% of the cases, respectively. The sensitivity, specificity, and positive and negative predictive values of the ROSE results for histological findings of the corresponding specimens were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. In conclusion, ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Applications of cryobiopsy in airway, pleural, and parenchymal disease

INTRODUCTION

:Cryobiopsy is a novel diagnostic technique for thoracic diseases which has been extensively investigated over the past 20 years. It was originally proposed for the diagnosis of endobronchial lesions and diffuse parenchymal lung disease due to limitations of conventional sampling techniques including small size and presence of artifacts.

AREAS COVERED

:We will review recent evidence related to the expanding use of cryobiopsy in thoracic diseases. To identify references, the MEDLINE database was searched from database inception until May 2022 for case series, cohort studies, randomized controlled trials, systematic reviews and meta-analyses related to cryobiopsy.

EXPERT OPINION

Cryobiopsy has expanding applications in the field of thoracic diseases. Evidence to support transbronchial cryobiopsy as an alternative to surgical lung biopsy is increasing and was recently endorsed as a conditional recommendation by the latest American Thoracic Society guideline update for Idiopathic Pulmonary Fibrosis. Developments in technology and technique, in particular the availability of a 1.1 mm flexible cryoprobe, have extended applications to pulmonary diseases, including diagnosis of interstitial lung diseases, peripheral pulmonary lesions, and lung transplant rejection.

Does transbronchial lung cryobiopsy improve diagnostic yield of digital tomosynthesis-assisted electromagnetic navigation guided bronchoscopic biopsy of pulmonary nodules? A pilot study

INTRODUCTION

Bronchoscopic biopsies have limited sensitivity for small, peripheral lung nodules. Electromagnetic navigation guided bronchoscopy (ENB) with fluoroscopic digital tomosynthesis and a 1.1 mm cryoprobe for transbronchial lung cryobiopsy (TBLC) may improve diagnostic yield. We evaluated the diagnostic yield and safety of this approach.

METHODS

42 patients (45 nodules) underwent sequential biopsies by transbronchial needle aspiration (TBNA), then forceps biopsy (FB), and finally TBLC. Demographic data, nodule characteristics, biopsy results, and procedural complications were recorded.

RESULTS

Nodules were predominantly solid (n = 35, 78%), without a bronchus sign (n = 30, 67%), and 33% (n = 15) were <2 cm in all dimensions (mean axial: 25.7 ± 15.3 mm, coronal: 21.0 ± 10.1 mm, sagittal 25.5 ± 16.5 mm). TBNA was the most informative biopsy modality (31/45 diagnoses total, five unique, 69% modality diagnostic yield (MDY)) compared to FB (27/45, one unique, 60% MDY) or TBLC (27/45, six unique, 60% MDY). FB contributed four additional diagnoses, improving diagnostic yield to 80% (36/45). TBLC contributed six additional diagnoses for a final diagnostic yield of 93% (42/45). No bleeding that required intervention or pneumothoraxes occurred. In unadjusted logistic regression models, solid nodules had increased odds of obtaining a diagnosis with TBNA (OR: 5.06; 95% CI: 1.14-22.49) and increased axial dimension nodule size had increased odds of obtaining a diagnosis with TBLC (OR: 1.10; 95% CI: 1.02-1.19).

CONCLUSION

ENB guided TBLC of lung nodules appears safe and may increase the final diagnostic yield when combined with other modalities. Future studies identifying nodule characteristics and comparing biopsy tools may clarify the most efficacious approach to maximize yield and minimize risk.

ERS International Congress 2021: highlights from the Clinical Techniques, Imaging and Endoscopy Assembly

This article summarises the highlights from the European Respiratory Society's “Clinical techniques, imaging and endoscopy” Assembly 14 presented at the virtual 2021 European Respiratory Society International Congress. Cutting-edge innovative developments in both diagnostic approaches and therapeutic strategies in patients with lung cancer, interstitial lung disease, obstructive airway disorders and infectious diseases were presented on this year's interactive congress platform. In this article, the Assembly 14 subgroups summarise the key take home messages given new research outcomes and place them in the context of the current knowledge.

Diagnostic Yield of Transbronchial Cryobiopsy Guided by Radial Endobronchial Ultrasound and Fluoroscopy in the Radiologically Suspected Lung Cancer: A Single Institution Prospective Study

Transbronchial cryobiopsy (TBCB) is being studied in the diagnosis of peripheral lung lesions; however, there are only a few clinical studies around the world. The aim of our study was to evaluate the diagnostic values and safety of transbronchial cryobiopsy for radiologically suspected peripheral lung cancer. The prospective clinical study was executed from September 2019 to September 2021 at a tertiary clinical centre in Lithuania. A total of 48 patients out of 102 underwent combined procedures of transbronchial forceps biopsy (TBFB) and TBCB. Diagnostic values and safety outcomes of TBFB and TBCB were analysed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were 72.9%, 100%, 100%, 7.7%, and 88.0% for TBFB, 85.1%, 100%, 100%, 12.5%, and 93% for TBCB, as well as 91.5%, 100%, 100%, 20.0% and 96.7% for the combined procedures, respectively, with a significantly higher accuracy for cryobiopsies compared to forceps biopsies (p < 0.05). The diagnostic values for transbronchial cryobiopsies were similar, irrespective of the radial mini probe endobronchial ultrasound (RP-EBUS) position, lesion size or bronchus sign, however, the sensitivity of the combined procedures in cases with RP-EBUS adjacent to the target was significantly higher compared to TBFB (86.2% vs. 64.3%, p = 0.016). Samples of cryobiopsies were significantly larger than forceps biopsies (34.62 mm2 vs. 4.4 mm2, p = 0.001). The cumulative diagnostic yield of transbronchial cryobiopsy was 80.0% after the second biopsy and reached a plateau of 84.1% after four biopsies. No severe bleeding, pneumothorax, respiratory failure or death was registered in our study. TBCB is a potentially safe procedure, which increases diagnostic values in diagnosing peripheral lung lesions compared to TBFB.

Efficacy and Safety of Cryobiopsy vs. Forceps Biopsy for Interstitial Lung Diseases, Lung Tumors, and Peripheral Pulmonary Lesions: An Updated Systematic Review and Meta-Analysis

Background

Cryobiopsy has emerged as a novel alternative to conventional forceps biopsy for the diagnosis of interstitial lung diseases (ILDs), lung tumors, and peripheral pulmonary lesions (PPLs). This study aims to compare cryobiopsy and forceps biopsy for the diagnosis of these lung pathologies with respect to efficacy and safety by performing a meta-analysis of updated evidence.

Methods

A number of databases, such as PubMed, Embase, Web of Science, the Cochrane Library, OVID, CNKI, and Wanfang database, were searched for eligible studies. Randomized and non-randomized comparative studies investigating the efficacy and safety of cryobiopsy vs. forceps biopsy for lung pathologies were included. Pooled results were calculated as an odds ratio (OR) or standardized mean difference (SMD) with 95% CI.

Results

A total of 39 studies, such as 9 RCTs with 3,586 biopsies (1,759 cryobiopsies and 1,827 flexible forceps biopsies) were analyzed. Cryobiopsy was associated with a significant increase in the diagnostic rates of ILDs (OR, 4.29; 95% CI, 1.85–9.93; p < 0.01), lung tumors (OR, 3.58; 95% CI, 2.60–4.93; p < 0.01), and PPLs (OR, 1.70; 95% CI, 1.23–2.34; p < 0.01). Cryobiopsy yielded significantly larger specimens compared with flexible forceps biopsy (SMD, 3.06; 95% CI, 2.37–3.74; p < 0.01). The cryobiopsy group had a significantly higher (moderate to severe) bleeding risk than the forceps group (OR, 2.17; 95% CI, 1.48–3.19; p < 0.01). No significant difference was observed in the incidence of pneumothorax between the groups (OR, 0.90; 95% CI, 0.44–1.85; p = 0.78).

Conclusion

Our results demonstrate that cryobiopsy is a safe and efficacious alternative to conventional forceps biopsy.

Alternative methods for local ablation-interventional pulmonology: a narrative review

OBJECTIVE

To discuss and summarise the background and recent advances in the approach to bronchoscopic ablative therapies for lung cancer, focusing on focal parenchymal lesions.

BACKGROUND

This series focusses on the challenges highlighted by increasing recognition of the prognostically more favourable oligometastatic disease rather than the more frequent, but prognostically poor, high tumour burden metastatic disease. While surgery, stereotactic body radiation therapy (SBRT), and trans-thoracic percutaneous ablative techniques such as microwave (MWA) and radiofrequency ablation (RFA) are well recognised options for selected cases of pulmonary oligometastasis, bronchoscopic approaches to pulmonary tumour ablation are becoming realistic alternatives. An underlying tenet driving research and implementation in this domain is that percutaneous ablative techniques are obliged to traverse the pleura leading to a high rate of pneumothorax, and risks also goes up for peri-vascular lesions. Historically low yield bronchoscopic targeting of isolated peripheral tumors have significantly improved by incorporating multi-modality high resolution imaging and processing, including navigation planning and real-time image guidances (ultrasound, electromagnetic navigation, cone-beam CT). Combining advanced image guidance with ablative technology adaptations for bronchoscopic delivery opens up the options for high dose local ablative therapies that may reduce transthoracic complications and provide palliative to curative options for limited stage primary and oligometastatic diseases.

METHODS

We conduct a narrative review of the literature summarizing the history of bronchoscopic tumor ablation approaches, technical details including biologic rational for their uses, and current evidence for each modality, as well as investigations into future applications. Because of the relative paucity of prospective studies, we have been very inclusive in our inclusion of experiences from the published clinical databases.

CONCLUSIONS

Whilst surgical resection and SBRT remain the current mainstay of curative therapies for peripheral cancers, in the foreseeable future, developments and further research will see bronchoscopic ablative therapies become viable lung sparing alternatives in those deemed suitable. The future is bright.