SESSION TITLE: Bronchology Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Probe-based confocal laser endomicroscopy (pCLE) allows the bronchoscopist to visualize microscopic tissue architecture in vivo. Spray cryotherapy is an endoscopic treatment modality that, until recently, has only been approved for use in the gastrointestinal tract but has been demonstrated to be effective in the treatment of endobronchial malignancy. However, a new low-flow spray cryotherapy system has been approved for use in the tracheobronchial tree. We discuss the use of pCLE to guide the endobronchial application of low-flow spray cryotherapy.
CASE PRESENTATION: An 87 year old female with a significant smoking history was referred to pulmonary clinic for evaluation of exertional dyspnea and non-resolving RML infiltrate. Spirometry was consistent with severe obstruction (FEV1 47% predicted) and imaging revealed a enlarging, infiltrative mass extending peripherally from the right hilum into middle and lower lobes with small ipsilateral pleural effusion and mediastinal adenopathy. Diagnostic thoracentesis identified small cell carcinoma; subsequent PET-CT and CT brain identified metastases in the left adrenal, right breast, and brain. Videobronchoscopy demonstrated a mixed infiltrating and partially obstructing tumor in the right lower lobe. Further examination with pCLE identified abnormal tissue architecture that extended proximally beyond the visual abnormality. Low-flow spray cryotherapy was then applied to all areas of visual and endomicroscopic abnormality. Subsequent bronchoscopic examination demonstrated regression of the tumor.
DISCUSSION: Recent technological advances have greatly increased the variety of tools available for endobronchial treatment of malignancy. Spray cryotherapy has been demonstrated to be effective in the treatment of lung cancer, but there were concerns about significant rates of complications. The recent development of a low-flow cryotherapy system may alleviate these concerns. The concomitant use of pCLE may be able to identify microscopic extension of endobronchial malignancy not apparent on white light bronchoscopy and expand the target area for spray cryotherapy and other therapeutic modalities.
CONCLUSIONS: Use of pCLE to inspect for microscopic margins of endobronchial lesions in conjunction with low flow spray cryotherapy improves therapeutic coverage of malignant endoluminal disease and allows for earlier treatment of potential airway obstruction.
Reference #1: Thiberville L, Salaün M, Lachkar S, et al. Confocal Fluorescence Endomicroscopy of the Human Airways. Proc Am Thorac Soc 2009; 6:444-449.
Reference #2: Lee SH, Choi WJ, Sung SW, et al. Endoscopic cryotherapy of lung and bronchial tumors: a systematic review. Korean J Intern Med 2011; 26:137-144.
Reference #3: Shibuya K, Fujiwara T, Yasufuku K, et al. In vivo microscopic imaging an endo-cytoscopy system. Lung Cancer 2011; 72:184-190.
DISCLOSURE: The following authors have nothing to disclose: David Hostler, Scott Parrish, Robert Browning
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