Cryosurgery, cryoablation, and cryoextraction

Cryosurgery, cryoablation, and cryoextraction

Cryosurgery for malignant endobronchial tumors: analysis of outcome

https://www.ncbi.nlm.nih.gov/pubmed/15947313

Landmark Article 

Reference: Asimakopoulos G, Beeson J, Evans J, Maiwand MO. Cryosurgery for malignant endobronchial tumors: analysis of outcome. Chest. 2005;127(6):2007-14.

Background: A retrospective study which explores cryotherapy and cryosurgery for malignant endobronchial disease. It had a prospective data collection and follow-up at a thoracic surgery clinic.

PICO:

Populations:

  • Patients with malignant endobronchial lesions needing therapeutic intervention

Intervention:

  • Cryosurgery for endobronchial lesions in 1-2 sessions

Comparison:

  • Comparison using endobronchial cryosurgery as first line in 2 different groups.
  • Group A (2 sessions of cryosurgery 172 patients) vs Group B (1 session of cryosurgery 157 patients)

Outcome:

  • Symptoms of dyspnea, cough, and hemoptysis were significantly reduced in both groups after cryosurgery (P < 0.001), group A benefited more than group B.
  • Lung function test results improved significantly in group A.
  • The mean survival was 15 months (median, 11 months) for group A and 8.3 months (median, 6 months) for group B.

Take Home: Patients who had cryosurgery and external beam radiotherapy showed longer survival, and two sessions of cryosurgery trended toward greater benefit. Cryosurgery appears to be a safe method for palliation of endobronchial malignancies causing airway obstruction.


 The application of cryosurgery in the treatment of lung cancer

https://www.ncbi.nlm.nih.gov/pubmed/14969682

Landmark Article 

Reference: Maiwand MO, Evans JM, Beeson JE. The application of cryosurgery in the treatment of lung cancer. Cryobiology. 2004;48(1):55-61.

Background: One of the few large prospective studies evaluating cryosurgery for debulking in lung cancer.

PICO:

Populations:

  • 476 patients with central endobronchial obstruction in lung cancer stage II – IV

Intervention:

  • Use of cryosurgery debulking

Comparison:

  • None

Outcome:

  • Lung function tests before and after intervention
  • Symptoms before and after interventions
  • Karnofsky performance scale
  • Survival

Take Home: This study demonstrates the same results as the previous study by Maiwand et al with improvement of symptoms, spirometry values and performance scores after cryoablation. It showed a possible survival advantage when used for palliation compared to alternative palliative methods. Cryosurgery is a safe method for palliation of symptoms related to endobronchial malignancies with airway obstruction. Cryosurgery can be considered in patients with inoperable obstructive endobronchial carcinoma.


 Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis

https://www.ncbi.nlm.nih.gov/pubmed/19716140

Case Series 

Reference: Schumann C, Hetzel M, Babiak AJ, et al. Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis. J Thorac Cardiovasc Surg. 2010;139(4):997-1000.

Background: One of the few recent large studies which retrospectively explores cryotherapy using an ERBE flexible cryopobe for malignant endobronchial disease and associated airway stenosis.

PICO:

Populations:

  • 225 patients with malignant endobronchial stenosis needing therapeutic intervention using a flexible cryoprobe.

Intervention:

  • Use of cryosurgery using ERBE flexible cryoprobe for malignant endobronchial lesions and stenosis using rigid or flexible bronchoscopy.

Comparison:

  • None

Outcome:

  • Successful cryo recanalization was achieved in 205/225 patients (91.1%)
  • The flexible cryoprobe was used with all patients, primarily in combination with flexible bronchoscopy and only in a minority (n=31, 13.8%) in combination with a rigid bronchoscope.
  • Additional interventional techniques used were endobronchial stents (n=11, 4.9%) and APC (n=37, 16.4%).
  • Mild bleeding occurred in 9 (4.0%) patients, moderate bleeding occurred in 18 (8.0%) patients, and severe bleeding never occurred.

Take Home: Cryosurgery performed with a flexible cryoprobe can be safely used as a first line ablative modality through a rigid or flexible bronchoscope for therapeutic intervention of endobronchial stenosis and tumors. Bleeding requiring intervention subsequent to cryosurgery can occur, but is typically minimal and seldom moderate requiring intervention. Severe bleeding post endobronchial cryosurgery procedure was never encountered in this study.


 Safety and Clinical Utility of Flexible Bronchoscopic Cryoextraction in Patients With Non-neoplasm Tracheobronchial Obstruction: A Retrospective Chart Review

https://www.ncbi.nlm.nih.gov/pubmed/26439016

Case Series  

Reference: Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY. Safety and Clinical Utility of Flexible Bronchoscopic Cryoextraction in Patients With Non-neoplasm Tracheobronchial Obstruction: A Retrospective Chart Review. J Bronchology Interv Pulmonol. 2015;22(4):288-93.

Background: This is a small study; however, it demonstrates the use of cryotherapy for cryoextraction and for treatment of non-malignant tracheobronchial obstructions.

PICO:

Populations:

  • Patients with non-malignant tracheobronchial obstructions of the airway

Intervention:

  • Use of flexible cryoprobe with flexible bronchoscopy for relieving non-malignant tracheobronchial obstructions caused by foreign bodies, clots, mucus plugs

Comparison:

  • None

Outcome:

  • 38 cryotherapy sessions performed on 30 subjects. Cryoprobe extraction was successful in reestablishing airway patency in 32/38 (84%) sessions.
  • 24/26 (92%) for blood clots, 4/6 (67%) for mucous plugging, 2/4 (50%) for foreign bodies, and 2/2 (100%) for plastic bronchitis.
  • 21/31 (68%) sessions resulted in improvement in oxygenation or ventilation. There was 1 complication related to sedation.

Take Home: Cryoprobe is a very safe and useful tool for cryoextraction and relieving non-malignant tracheobronchial obstructions with flexible bronchoscopy.


 Airway spray cryotherapy: initial outcomes from a multiinstitutional registry

https://www.ncbi.nlm.nih.gov/pubmed/22516831

Clinical Trial 

Reference: Finley DJ, Dycoco J, Sarkar S, et al. Airway spray cryotherapy: initial outcomes from a multi-institutional registry. Ann Thorac Surg. 2012;94(1):199-203.

Background: Multi-institutional study analyzing feasibility of endobronchial spray cryotherapy for treatment of malignant airway tumors.

PICO:

Populations:

  • Patients with endobronchial malignant airway disease needing therapeutic intervention.

Intervention:

  • Rapid freezing and thawing using a noncontact system to deliver liquid nitrogen (2 to 4 psi) through an endoscopic catheter Spray cryotherapy (SCT) for treatment of endobronchial malignant airway disease obstruction.

Comparison:

  • None

Outcome:

  • 80 patients (45 males [56%]) underwent 114 treatments. All patients were treated with minimal blood loss. Airway obstruction exceeded 75% in most of the lesions treated. All but 1 patient had airway patency after treatment. There were 21 intraoperative events (19%) including 3 pneumothoraces, one requiring chest tube placement.

Take Home: SCT can be used in patients with highly vascular tumors, with reduced bleeding complications and a low overall complication rate. Caution is needed before SCT is used on a widespread basis, given the intraoperative complications.


 Treatment of Benign Tracheal Stenosis Using Endoluminal Spray Cryotherapy

https://www.ncbi.nlm.nih.gov/pubmed/27532803

Case Series

Reference: Bhora FY, Ayub A, Forleiter CM, et al. Treatment of Benign Tracheal Stenosis Using Endoluminal Spray Cryotherapy. JAMA Otolaryngol Head Neck Surg. 2016;142(11):1082-1087.

Background: Use of SCT in treatment of benign tracheal and subglottic stenosis to evaluate if it helped with decreasing recurrence of this debilitating disease.

PICO:

Populations:

  • Patients with benign tracheal stenosis requiring treatment

Intervention:

  • Use of SCT for treatment of tracheal stenosis. Delivery of 4, 5-second SCT cycles and 2 balloon dilatations.

Comparison:

  • None

Outcome:

  • 26 patients underwent 48 SCT sessions. 23 patients (88%) had grade III or IV stenosis. Spray cryotherapy was successfully used without any substantial intraoperative or postoperative complications.
  • Median (range) follow-up of 11 (1-26) months.
  • All patients had improvement in symptoms before the institution of SCT. However, at the last evaluation after induction of SCT, 4 (15%) had grade III or IV stenosis compared to the 23 (88%) prior to SCT.
  • Patients with GPA required significantly fewer SCT procedures during the study period. Mean (SD) intervention rate decreased from 3.8 (3.4) per year prior to induction of SCT to 1.6 (0.8) per year after the institution of SCT.

Take Home: Spray cryotherapy was a safe adjunct modality to accomplish airway patency in patients with benign tracheal stenosis. Although efficacy evidence is limited for SCT, it may be useful for patients who have experienced treatment failure with conventional modalities. Additional trials are warranted for further evaluation of this modality in terms of its treatment sustainability and long term side effects in this population of patients.