Abstract Introduction Peripheral pulmonary lesions in children present unique diagnostic challenges. In adults, cone beam computed tomography (CBCT) enhances bronchoscopic biopsy accuracy by confirming tool-in-lesion positioning. Its use in pediatrics remains largely unreported. This case series illustrates the feasibility of CBCT-guided transbronchial lung cryobiopsy (TBLC) for diagnosing pediatric lung lesions. Case Descriptions Case 1: An 18-year-old male with relapsed Hodgkin lymphoma post-peripheral stem cell transplant (PSCT), radiation, and pembrolizumab immunotherapy developed enlarging PET-avid pulmonary nodules. Radial endobronchial ultrasound (EBUS) and CBCT identified a large left lower lobe pulmonary nodule. CBCT confirmed tool-in-lesion for transbronchial needle aspiration (TBNA) and cryobiopsy. Pathology showed interstitial pneumonitis and organizing pneumonia, consistent with immune checkpoint inhibitor pneumonitis. Follow-up CT revealed new ground glass opacities with PET-avid regions. Radial EBUS-guided TBLC and linear EBUS-guided transbronchial lymph node biopsy redemonstrated interstitial pneumonitis and organizing pneumonia, confirming immune checkpoint inhibitor pneumonitis. Symptoms resolved after a 9-week prednisone taper. Case 2: A 12-year-old male was found to have an incidental PET-avid right upper lobe pulmonary nodule. Radial EBUS localized the lesion, and CBCT confirmed tool-in-lesion for TBNA and TBLC. Pathology revealed granular cells and associated S100-positive spindle cells, consistent with granular cell tumor. The lesion was subsequently removed via wedge resection. Case 3: A 9-year-old male with X-linked inhibitor of apoptosis protein (XIAP) deficiency post-PSCT complicated by neutropenia and recurrent febrile illnesses, developed a right upper lobe opacity. Radial EBUS identified the lesion, and CBCT confirmed tool-in-lesion for TBNA and TBLC. Pathology demonstrated organizing pneumonia with cocci-shaped bacteria, and bronchoalveolar lavage culture grew methicillin resistant Staphylococcus aureus. He was treated with 10 days of clindamycin, resulting in interval improvement. In all procedures, mobile CBCT (GE OEC 3D) was used. TBNA was followed by TBLC using a 1.1 mm cryoprobe with 5-second freeze times and specimens removed en bloc. Tissue samples ranged from 3-9 mm in diameter. No serious bleeding events or pneumothoraces occurred. Discussion CBCT-guided TBLC enabled accurate localization and adequate tissue acquisition for histopathologic evaluation in all cases. The procedure demonstrated a favorable safety profile. These cases support the feasibility of CBCT-guided TBLC in children and support use of real-time imaging to enhance diagnostic precision for peripheral pulmonary lesions. This abstract is funded by: None
Haskett et al. (Fri,) studied this question.