To the Editor, A 10-year-old presented with a 3-year history of fever and dry cough. Right mammary and infra-mammary areas were dull on percussion with diminished breath sounds. Chest imaging (Figure 1A,B) showed collapse of the right lower lobe. Flexible bronchoscopy (FB) identified a well-defined broad-based mass originating from the middle lobe bronchus (Figure 1C). We planned a cryobiopsy to secure adequate tissue sample. The patient was intubated with an endotracheal (ET) tube of internal diameter (ID) 6 mm under general anesthesia in the operation theater (OT). A cryoprobe (1.1 mm, 900 mm length, ERBE) was inserted through the pediatric flexible bronchoscope (Olympus BF-P190, 4.2 mm diameter, 2.0 mm working channel). Tissue samples were obtained after freezing for 3–5 s. A Fogarty balloon catheter (4 Fr), inserted through the ET tube alongside the FB and positioned in the right bronchus intermedius under vision, was inflated intermittently to control bleeding. The procedure lasted for 1 h. A total of 4 fragments were obtained, each measuring roughly 0.5 cm in diameter. The estimated blood loss was approximately 20–25 mL. Histopathological analysis confirmed a typical carcinoid tumor (Figure 1D). A positron emission tomography (PET) scan afterwards showed no metastasis. The patient underwent a right middle and lower lobectomy with regional lymph node dissection. He has no signs of recurrence to date, after 1 year. A 9-year-old presented with recurrent fever and wet cough for 4 months, and absent breath sounds over the left hemithorax. Imaging (Figure 1E) revealed collapse of part of the left lung, and an enhancing endobronchial lesion at the bifurcation of the left main bronchus (LMB). FB identified a friable bleeding mass almost completely obstructing the LMB (Figure 1F). The feeding bronchial artery was identified on CT and embolized, to reduce the risk of hemorrhage during further procedures. Cryobiopsy was performed in the pediatric intensive care unit (PICU). The patient was intubated with an ET tube of ID 6 mm, under intravenous sedation and neuromuscular paralysis. The cryoprobe (1.1 mm) was introduced via an FB of 4.2 mm diameter. A total of 4 tissue fragments, each measuring roughly 0.5 in diameter, were obtained. During the next attempt, the entire mass got avulsed from its base, resulting in a near complete debulking. It was then grasped using a wire basket and the entire assembly of the FB, wire basket holding the globular tissue mass (approximate diameter 1.5 cm) and the ET tube were removed together, while the patient was immediately re-intubated. (Figure 1G). Bleeding was controlled using a Fogarty balloon catheter (4 Fr). The estimated total blood loss was 25–30 mL while the procedure lasted for 45 min. Histopathological examination confirmed an intermediate-grade mucoepidermoid carcinoma (MEC) (Figure 1H). PET-CT showed no local invasion, or lymph node or distant metastases. The child subsequently underwent wedge resection of the secondary carina with bronchial reconstruction. The patient is well in follow up at 10 months. The use of forceps for sampling endobronchial masses often yields crushed specimens that may be inadequate for detailed histopathological evaluation. Cryotherapy allows extraction of larger, well-preserved tissue samples with minimal crush artifact. A systematic review comparing the efficacy and safety of cryobiopsy versus forceps biopsy found that the former was associated with a higher diagnostic rate (OR 3.58, 95% CI 2.60–4.93) and larger specimen size (SMD 2.97, CI 1.84–4.09) with respect to lung tumors, but with an increased risk of moderate to severe bleeding (OR 1.92, 95% CI 1.22–3.04) 1. Pediatric applications of cryotherapy are still evolving. Availability of cryoprobes as small as 1.1 mm has partly resolved this problem. In a prospective study reporting 30 cryobiopsy procedures in children from 10 centers, the diagnosis was carcinoid tumor in 3 cases. 28 out of 30 (93.3%) procedures were performed using FB 2. Out of 6 children with bronchial MEC in a series reported from China, 5 were managed solely using bronchoscopic interventions based on cryotherapy and argon plasma coagulation (APC). The procedures were conducted using rigid bronchoscope and FB in 3 patients each 3. In the second case, we accidentally removed the entire mass macroscopically. Bronchoscopic debulking is sometimes essential in malignant central airway lesions to restore airway patency and can be a life-saving procedure, or can be done with a palliative intent in untreatable disease. For malignancies without any distant metastases and invasion outside the airway wall, bronchoscopic removal of tumor can be definitive. However, the patient needs to be in regular follow-up for early detection of any recurrence 3. Possible complications of such a procedure include hemorrhage, immediate airway damage, perforation and air leak, delayed effects of cartilage injury including stenosis, and tumor spillover to the unaffected side causing hypoxia and respiratory failure. A bronchial artery embolization was performed in the second case, to lessen any chances of procedural bleeding and a Fogarty balloon catheter was employed in both the cases. Bleeding is reported as the commonest complication of using cryotherapy. Other commonly used measures to control bleeding include mechanical pressure with the tip of the bronchoscope, instillation of locally active agents including ice-cold saline, epinephrine and tranexamic acid, inflation of the balloon of a bronchial blocker to isolate the bleeding segment and also coagulation using APC 4. Our experience supports the expanding role of cryotherapy in pediatric airway diagnostics and therapeutics. We have reported using it through the FB in the PICU, but this may not be the advisable approach in all cases. The choice of conduit would depend upon the location of the lesion and extent of the procedure planned, with a lengthier procedure and a greater risk of hemorrhage warranting the use of a rigid bronchoscope. Similar concerns and the overall condition of the patient would govern the choice between an OT and ICU. Whatever be the initial choice of the treating team, meticulous pre-procedure planning, careful selection of patient, ensuring availability of all hemostatic modalities, readiness of multidisciplinary support and escalation strategies would go a long way towards ensuring patient safety and a successful procedure outcome. Ramakrishna Golla, Nisha Sahoo, Ketan Kumar, Krishna Mohan Gulla, Rashmi Ranjan Das, Manoj Kumar Panigrahi, and Sundeep M. C. Kisku were involved in the clinical care of the patient. Ranjan Kumar Patel, Mukund Namdev Sable, Pritinanda Mishra, and Kanishka Das contributed to various aspects of the diagnostic workup of the patient. Ramakrishna Golla wrote the first draft. Ketan Kumar, Krishna Mohan Gulla, and Rashmi Ranjan Das revised and approved the final manuscript. Ketan Kumar will act as the guarantor. All authors agree to be accountable for the article and to ensure that all questions regarding the accuracy or integrity of the article are investigated and resolved. The authors have nothing to report. Ethical approval is not applicable to this submission because this is a case report where the subject cannot be de-identified. The text or the figure does not contain any identifiable patient information. Informed consent was obtained from the caregivers for publication of the same. The authors declare no conflicts of interest. There are no prior duplicate or overlapping publications or presentations relevant to this article. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Golla et al. (Wed,) studied this question.