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
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