Interventional Pulmonology Focus On Treatment ( Cryo...

Interventional Pulmonology Focus On

Treatment ( Cryo-Recanalization )

Achmad Mulawarman Jayusman

WORK CONFERENCE XVI

Indonesian Society Of Respirology

Surakarta, 11 – 14 September 2019

RS KANKER DHARMAIS

CRYO THERAPY

EXTERNAL : Thorax Surgeon

INTRA BRONCHIAL : Pulmonologist

EXTERNAL CRYO THERAPY

IN LUNG CANCER

DISCUSSION

STRATEGY

CRYO FUNCTION

BIOPSY TOOLS

INTRABRONCHIAL RECANALIZATION

( BOTH CONTACT )

PREPARATION

PATIENT STATUS :

Haematology

Cardiology

Anesthesiology

Lung Function

WHAT IS CRYOBIOPSY ?

Transbronchial cryobiopsy/cryobiopsy refers to the use of a cryoprobe to rapidly freeze samples of

peripheral lung tissue.

Cryobiopsy specimens are larger than those

obtained using traditional forceps (usually >5mm)

Initial use of this technique has focused on the

diagnosis of diffuse parenchymal lung diseases

(DPLDs)

Lentz A, Argento A, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung

disease: a state of the art review of procedural techniques, current evidence, and future challenges.2017

CRYOBIOPSY SAFETY CONSIDERATION

The principle risks of cryobiopsy : airway hemorrhage and pneumothorax

Pneumothorax results from a biopsy obtained

so distally that the visceral pleura is violated

Major hemorrhage is thought to be greater in

the more proximal region, where vessels have

branched less extensively and are larger but

still too distal to be protected by the

cartilaginous rings

Lentz A, Argento A, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung

disease: a state of the art review of procedural techniques, current evidence, and future challenges.2017

THE JOULE – THOMSON EFFECT

THE JOULE – THOMSON PRINCIPLE

The decrease in temperature that is observed during the

expansion of gas from a high pressure to a low-pressure

environment.

N2O/CO2 gas, which is stored at room temperature under high

pressure,

When N2O is released at the tip of the cryoprobe, the

temperature falls to –890C within several seconds.

Maiwand MO, Homasson JP. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427–443.

CRYOPROBES

Cryoprobes have been used since the late 1960s.

In the early 2000s, flexible

cryoprobes allowed for the

development of

cryoadhesion or

cryorecanalization

Lentz A, Argento A, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state of

the art review of procedural techniques, current evidence, and future challenges.2017

INDICATIONS OF CRYOBIOPSY

Interstitial lung diseases

Neoplastic diseases

Infectious diseases (Pneumocystis jiroveci)

Lung transplant surveillance – evaluation of allograft rejection

Babiak A, et al. Transbronchial cryobiopsy: a new tool for lung biopsies. Respiration. 2009

Pajares V, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014

TRANSBRONCHIAL CRYOBIOPSY TECHNIQUE

The cryoprobe is advanced through the working channel into the peripheral lung surrounding

parenchyma to rapidly freeze and adhere to the

cryoprobe tip

It rapidly expands and cools to a temperature of –79°C

(using carbon dioxide) or –89°C (using nitrous oxide)

within 3-5 seconds

Lentz A, Argento A, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung

disease: a state of the art review of procedural techniques, current evidence, and future challenges.2017

TRANSBRONCHIAL CRYOBIOPSY TECHNIQUE

The bronchoscope and cryoprobe with attached frozen

biopsy are then removed from

the airway because the

cryobiopsy is larger than the

working channel.

Resulting biopsies : 7–10 mm in greatest dimension (larger than

traditional forceps biopsies, and

lack crush artifact)

Lentz A, Argento A, Colby TV, Rickman OB, Maldonado F. Transbronchial cryobiopsy for diffuse parenchymal lung disease: a state of

the art review of procedural techniques, current evidence, and future challenges.2017

MOST ALL CASES TO DATE HAVE BEEN PERFORMED

UNDER FLUOROSCOPIC GUIDANCE

CRYOBIOPSY SPECIMEN

Transbronchial forcep biopsy Cryobiopsy sample

Kropski JA, Pritchett JM, Mason WR, Sivarajan L, Gleaves LA, et al. Bronchoscopic Cryobiopsy for the Diagnosis of Diffuse

Parenchymal Lung Disease. PLoS ONE. 2013

COMPARISON WITH OTHER TECHNIQUE Randomized trial published in 2014

Technique Specimen

size (mm2)

Histologic

Dx

Cryobiopsy 14.7 +/- 11 74 %

Forceps biopsy 3.3 +/- 4.1 34 %

Pajares V, et al. Diagnostic yield of transbronchial cryobiopsy in interstitial lung disease: a randomized trial. Respirology. 2014

Cryobiopsy

superior

than

forceps

biopsy

DEBULKING TECHNICS

ELECTROCAUTER

FORCEPS REMOVAL

RIGID BRONCHOSCOPE

LASER

CRYO THERAPY + ARGON PLASMA COAGULATION

INTRABRONCHIAL RECANALIZATION

WHAT IS CRYOTHERAPY ?

CRYOTHERAPY

Freeze – thaw cycles using extreme cold to destroy tissue

and tumor.

Physical effect is immediate, and results from the freezing

and recrystal lization of cellular water on thawing, as well

as cellular dehydration.

Vascular effects result in tissue ischemia from

vasoconstriction, platelet aggregation, and increased

blood viscosity.

Produces beneficial effects on the immune system.

Maiwand et.al - Induce proliferation of a natural killer

cells.

Increase in lymphocyte activation in the peripheral

circulation .

Maiwand MO, Homasson JP. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427–443. Maiwand MO, Mathur PN. Endobronchial cryotherapy. Semin Respir Crit Care Med 1997;18:545–554. Alblin RJ, Soanes WA, Gonder MJ. Prospects for cryo-immunotherapy in cases of metastasizing carcinoma of the prostate. Cryobiology 1971; 8:271–279. Tanaka S. Immunological aspects of cryosurgery in general surgery. Cryobiology 1982;19:247–262.

PREPARATION

EQUIPMENTS

Case by case :

- Rigid Bronchoscope

- Small Bronchoscope

- Endo Tracheal Tube (ETT)

ANATOMY

CRYO EQUIPMENT

CARDIO-RESPIRATORY MONITOR

VIDEO MONITOR

N2O / CO2 GAS

TV MONITOR & BRONCHOSCOPY

TX BEFORE CRYOTHERAPY

CT Scan Thoraks 30/05/2012 Massa paru kanan Irreguler Pembesaran KGB Hilus kanan Karina, Paratrakeal, Supraklavikula ka/ ki

MSCT BEFORE CRYOTHERAPY

MSCT VIRTUAL BRONCHOSCOPY

TEAM WORK

As the size of the probe tip is

proportional to tissue injury, many

authors recommend rigid

bronchoscopy.

Flexible bronchoscopy is certainly more accessible to the majority,

and good results can also be

obtained with the flexible

cryoprobe.

Flexible bronchoscope, it is crucial

to have the probe protrude several

millimeters from the distal tip of the

scope, so as not to freeze the video

chip.

Maiwand MO, et.al. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427–443. Mathur PN, et.al. Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction. Chest 1996;110:718–723.

RIGID & FLEXIBLE BRONCHOSCOPY

VISUAL BRONCHOSCOPE

STENOSIS INFILTRASI

INTRABRONCHIAL CRYOTHERAPY

TX POST CRYOTHERAPY

MSCT BEFORE & AFTER CRYOTHERAPY

BEFORE AFTER

ATTENTION

LARYNGEAL CARCINOMA

ATTENTION LARYNGEAL CARCINOMA

Eliminating hemoptysis due to malignant disease in up to 93% of

pts,

Synergistic effects with chemotherapy or radiation.

Vergnon – 38 pts with unresectable NSCLC with a combination of

cryotherapy and external beam radiation therapy.

26 pts (65%) who had favorable results had a median survival of

397 days.

17 pts in this group had no evidence of residual tumor after

irradiation, and experienced a median survival of 560 days.

Marasso A, et.al. Cryosurgery in bronchoscopic treatment of tracheobronchial stenosis: indications, limits, personal experience. Chest 1993;103:472–474. Homasson JP, et.al . Tumor fixation of bleomycin labeled with 57-cobalt before and after cryotherapy of bronchial carcinoma. Cryobiology 1992;29:543–548. Vergnon JM, et.al. Initial combined cryotherapy and irradiation for unresectable non–small cell lung cancer: preliminary results. Chest 1992;102: 1436–1440.

SYNERGIC EFFECTS

Remove foreign bodies and blood clots in the airways.

As freezing and recrystallization depend on cellular water

content, cartilage and fibrous tissue are relatively cryoresistant.

The incidence of airway perforation is therefore markedly

reduced.

Bleeding tends to be less common because of the hemostatic

effects.

No risk of airway fires, electrical accidents, or radiation exposure.

Maiwand MO, et.al. Cryotherapy for tracheobronchial disorders. Clin Chest Med 1995;16:427–443. Marasso A, et.al. Cryosurgery in bronchoscopic treatment of tracheobronchial stenosis: indications, limits, personal experience. Chest 1993;103:472–474. Homasson JP. Bronchoscopic cryotherapy. J Bronchol 1995;2:145–149.

SYNERGIC EFFECTS CONT’

BLEEDING CONDITION

ARGON PLASMA COAGULATION

(Non Contact)

ARGON PLASMA COAGULATION (APC)

NEXT TREATMENT

HIGH CARE UNIT

EXTERNAL RADIOTHERAPY

TYROSINE KINASE INHIBITOR /

CHEMOTHERAPY

EXTERNAL RADIOTHERAPY

Continue with……….

SUMMARY

CRYOBIOPSY CAN BE USED TO GET SAMPLE

FROM PERIPHERAL LESSION & BIGGER TISSUE

CRYOTHERAPY AS A TOOL AND DIAGNOSIS

OF LUNG CANCER

GUARANTEED THERAPEUTIC TOOL IN TERMS

OF SAFETY

Thank you

Kepulauan Labengki, Desember 2018