Evaluation of Ultrathin Probe Transbronchial Cryobiopsy

What this case study demonstrates

• CelTivity offers real-time intraprocedural tissue acquisition feedback, in the form of rapid on-site evaluation (ROSE) of tissue biopsy, FNA (fine needle aspiration), and cryobiopsy.
• Cryobiopsy specimens are adequate for reliable CelTivity imaging and intraprocedural analysis.
• CelTivity imaging process does not affect tissue integrity or interfere with pathological assessment.
• UP-TBLCB may confer an incremental diagnostic yield by providing a spherical or 360-degree tissue acquisition of challenging eccentric or laterally-adjacent nodules.
  

Case Presentation:

‍Patient is a 64-year-old female active lifelong smoker with a history of stage IV B-cell lymphoma status post chemotherapy completed in 2019 and subsequently diagnosed with stage IV a supraglottic squamous cell carcinoma in March 2021 for which she completed chemoradiation therapy. Upon comparison of surveillance computerized tomographies (CT) between February 2022 and September 2022, an enlarging left upper lobe (LUL) from 2 mm to 1.2mm solid nodule was identified (Figure 1). Given her clinicoradiographic presentation, diagnostic bronchoscopy was recommended to evaluate for the possibilities of a metastatic process versus a new bronchogenic carcinoma.

Management and Outcome

‍Under general anesthesia via an endotracheal tube, robotic assisted bronchoscopy (Monarch™, J&J) was performed with a virtual approximation to the targeted LUL by 10-15mm. Radial probe endobronchial ultrasonography (RP-EBUS; Olympus Medical) followed with an initial view strongly suggestive and encouraging of an adjacent bronchoscopic relation to the nodule in which echogenic features of the nodule are observed whilst the radial probe is visualized outside the perimeter of the nodule. At this location, sequential tissue acquisition methods were employed starting with a 19-gauge fine needle aspiration (FNA), followed by transbronchial forceps biopsies (TBBX). These samples were imaged via CelTivity which did not demonstrate any signs of lesional cells, hence non- diagnostic tissue. Additional TBBXs were obtained after additional maneuvers attempted to obtain an optimal concentric (ie. probe within the nodule) localization. This was unsuccessful and these additional specimens were also non-diagnostic.

Therefore, the decision to reinitiate navigational bronchoscopy was taken which yielded a more encouraging eccentrically oriented view (ie. radial probe visualized within the perimeter of the nodule) of the LUL nodule (Figure 2).

Based on the nodule’s ultrasonographic eccentric localization and prior non-diagnostic sampling methods, a 1.1 mm ultrathin cryoprobe (Erbecryo™ 2) transbronchial lung cryobiopsy was obtained at this location.

The cryobiopsy specimen was imaged by CelTivity confirming adequate representative tissue suspicious for malignancy (Figure 3). Final histopathology described tissue integrity and adequacy of the cryospecimen, confirming metastatic laryngeal Squamous cell carcinoma, consistent with the intraprocedural assessment from CelTivity (Figure 4).

Discussion

Despite the convincing navigational bronchoscopy and real-time RP-EBUS findings for appropriate nodule localization, initial CelTivity images of samples at this location did not identify representative lesional tissue. This in turn prompted further bronchoscopic investigation of the targeted nodule until diagnostic tissue was identified based on subsequent cryobiopsy specimens imaged by CelTivity. All specimens deemed non-diagnostic during bronchoscopy based on CelTivity imaging were confirmed as such by final histopathological evaluation.

In summary, by offering instrumental intraprocedural feedback at different stages of the diagnostic bronchoscopy, CelTivity delivered valuable rapid on-site cytological evaluation (ROSE) as well as rapid on-site pathological evaluation (ROPE), a novel concept. This ultimately empowered the proceduralist with information that made the difference between a diagnostic and a non-diagnostic bronchoscopy. Lastly, the utilization of cryobiopsy during this and other subsequent diagnostic bronchoscopies confirms CelTivity’s ability to determine adequacy in these types of samples.