High-frequency electric snare resection combined with cryoablation for tracheal myoepithelioma: a case report

High-frequency electric snare resection combined with cryoablation for tracheal myoepithelioma: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report High-frequency electric snare resection combined with cryoablation for tracheal myoepithelioma: a case report Shanting Chen, Ling Deng, Zhong Hu, Jin Wang, Meiyuan Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7690787/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Myoepitheliomas are rare, benign tumors that originate from myoepithelial cells. They represent a small proportion of all pulmonary salivary gland-type tumors (PSGTs).These tumors are extremely rare in the respiratory tract. Despite their benign nature, endotracheal myoepitheliomas frequently require interventions due to complications, including airway obstruction. Although surgical resection is the standard treatment for these benign tumors, some patients are unsuitable for surgery due to various factors. Bronchoscopic intervention has been used to restore pulmonary ventilation and temporarily relieve dyspnea in patients with central airway stenosis. Our findings suggest that this therapy can also provide effective and stable outcomes for this type of benign airway tumor. Furthermore, the study demonstrates the merits of minimal trauma, rapid recovery, and high accuracy, which are not possessed by traditional surgical operations. Case presentation We report the case of an 84-year-old male patient who initially presented with mild cough and hemoptysis. Two months later, the patient gradually developed severe dyspnea. The blood gas analysis indicated type I respiratory failure. Chest CT (CT) scans revealed a high density shadow in the left main bronchus, accompanied by complete atelectasis of the left lung and left-sided pleural effusion. Bronchoscopy confirmed complete obstruction of the left main bronchus due to a mass. The patient’s condition was critical and life-threatening.Given the patient’s poor cardiopulmonary function and comprehensive risk-benefit analysis, high-frequency electric snare resection combined with cryoablation was urgently performed to excise the mass and mitigate the risk of fatal respiratory failure. The patient’s dyspnea improved significantly after the interventions. A biopsy of the mass was performed, and the final pathological diagnosis was confirmed as endotracheal myoepithelioma. The patient achieved a favorable recovery following postoperative treatment. The subsequent follow-up demonstrated a satisfactory and stable outcome. Conclusions This case presents an effective treatment option for patients who are not eligible for surgery for various reasons. A comprehensive review of the literature on tracheal myoepithelioma was undertaken to deepen our understand ing of the disease and optimize personalized treatment strategies in view of the encouraging outcome of this case. Bronchoscopy Central airway obstruction Myoepithelioma Interventional treatment High-frequency electric snare resection Cryoablation Figures Figure 1 Figure 2 Figure 3 Introduction Primary PSGTs typically arise from the epithelium of the submucosal tracheobronchial glands and typically present as endoluminal lesions. PSGTs can be classified into six subtypes, one of which is myoepithelioma. Since Sheldon WH’s initial report of a benign myoepithelioma in 1943[ 1 ], numerous studies have documented myoepitheliomas in salivary glands and other anatomical sites[ 2 ]. However, reports of myoepitheliomas in the respiratory tract remain scarce, with Strickler JG documenting the first case of pulmonary myoepithelioma[ 3 ]. Despite their benign nature, these tumors can obstruct the airway, resulting in symptoms such as cough, wheezing, and shortness of breath[ 4 ]. Consequently, most patients require surgical intervention to prevent or manage complications. Although surgical resection is the standard treatment for these benign tumors[ 5 ],Surgery may not be possible for some patients due to their age or other health conditions. An effective and simple treatment modality is urgently needed to address this pressing clinical issue.We present a case of severe respiratory failure due to endotracheal myoepithelioma in a patient considered unfit for surgery due to advanced age and impaired cardiopulmonary function. Effective bronchoscopic interventions were employed to excise the mass, restore airway patency, and alleviate dyspnea. A stable and favorable therapeutic outcome was achieved by the patient. A comprehensive review of existing literature on tracheal myoepithelioma was undertaken based on this successful case to improve understanding of the disease and optimize treatment strategies for specific populations. Case report An 84-year-old male patient presented to the outpatient clinic with mild cough and hemoptysis as the primary clinical manifestations; however, physical examination and subsequent investigations revealed no significant findings. Two months later, the patient returned to the hospital with worsening cough, wheezing, and dyspnea. Aarte- rial blood gas (ABG) analysis indicated type I respiratory failure (Fig. 1 ). The patient’s condition was urgent, so he was admitted to the hospital for treatment immediately. A subsequent chest CT scan revealed left lung atelectasis, pleural effusion, and a dense shadow in the lumen of the left main bronchus(Fig. 2 ).Subsequent bronchoscopy confirmed a mass in the left main bronchus, completely obstructing the airway and cor roborating the CT findings (Fig. 3 ). Given the patient’s advanced age and longstanding history of chronic obstructive pulmonary disease (COPD) and diabetes, his family opted to forgo surgical treatment. Bronchoscopic procedures were performed with the informed consent of the patient and his family to rapidly relieve airway obstruction and improve ventilation. The tumor was excised via a high-frequency electric snare, with precise guidance from an electronic bronchoscope (Fig. 3 ). The residual tumor stump was subsequently treated with cryoablation (Fig. 3 ). The procedure was carried out satisfactorily, with no evident bleeding. Dyspnea was significantly relieved after treatment, as evidenced by a significant reduction in the dyspnea score according to the American Thoracic Society criteria (Fig. 1 ). The patient’s respiratory failure was also resolved, as indicated by an ABG (Fig. 1 ). A bedside chest X-ray showed improved ventilation with re-expansion of the left lung(Fig. 2 ). The postoperative pathology confirmed the diagnosis of tracheal myoepithelioma, with positive immunohistochemical staining for cytokeratin, P63, and S-100 proteins. The patient was discharged with active support and exhibited good postoperative recovery without complications. One and three months after discharge, the patient returned for follow-up, with complete resolution of dyspnea and respiratory failure (Fig. 1 ). Chest radiographs revealed a stable condition of the left lung (Fig. 2 ). Subsequent electronic bronchoscopy revealed that the left main bronchus was completely patent, with no evidence of residual bronchial lesions or tumor recurrence(Fig. 3 ). Discussion and Conclusions Globally,minimally invasive surgery has emerged as a predominant trend in the evo- lution of surgical methodologies. This approach involves creating surgical channels through smaller incisions or natural cavities,employing instruments via medical endo- scopes, and executing interventions on diseased tissues. This case report highlights the innovative use of a combined approach involving high-frequency electric snare resection and cryoablation in the management of tracheal myoepitheliomas via electronic bronchoscopy, representing a successful intervention rarely reported in the literature. In contrast to previous studies that described surgical resection as the standard treatment, our approach offers a less invasive alternative, particularly suitable for elderly patients with comorbidities or those seeking to preserve airway function. Myoepitheliomas are a rare form of benign neoplasm that originates from myoep- ithelial cells. These neoplasms are characteristically located in glandular structures, including the salivary glands. Tracheal myoepitheliomas represent a rare subtype of myoepithelial neoplasm. Myoepithelial cells, which facilitate the contraction of glan- dular ducts, are susceptible to neoplastic transformation due to genetic mutations, environmental factors, or chronic irritation.However, no definitive risk factors have been established[ 6 , 7 ].Pulmonary myoepitheliomas typically occur in younger patients and are generally more indolent than other primary lung cancers[ 8 – 11 ]. The case reported in this article is the oldest tracheal myoepithelioma patient to date. It pro- vides valuable insights into the disease.Patients with tracheal myoepithelioma often exhibit atypical clinical manifestations in the early stages of the disease. Symptoms associated with airway obstruction, including dyspnea, persistent cough, hemoptysis, and wheezing, usually appear when the tumor is large enough to substantially nar row the airway.The case presented in this article highlights the obscured nature of the disease, a characteristic that has, to some extent, delayed diagnosis and inter- vention.The diagnosis of tracheal myoepithelioma typically involves imaging studies, such as chest CT scans or magnetic resonance imaging (MRI), which can detect a mass in the trachea[ 12 ]. Bronchoscopy is a crucial diagnostic instrument that enables direct visualization of the tumor and facilitates biopsy for histopathological analy- sis.Immunohistochemistry is a common diagnostic tool that is utilized to confirm a 5 diagnosis by detecting specific markers. Cytokereratins, P63, and S-100 proteins are characteristic of myoepithelial cells and are often used in pathological analysis[ 13 ].The prognosis for tracheal myoepitheliomas is generally favorable, particularly when complete resection is achieved. Surgical resection is considered a curative procedure, with a low rate of recurrence.Bronchoscopic interventions have been used to reduce the extent of resection, restore pulmonary ventilation, and relieve dyspnea in patients with central airway obstruction in patients who are unsuitable for surgery[ 14 , 15 ]. These interventions are generally performed under either local or general anesthesia. The available techniques include Nd:YAG laser ablation, microwave ablation, argon plasma coagulation (APC), electrocautery, cryoablation, radiofrequency ablation, and mechanical resection. However, these interventions are currently used primarily for diagnosing or temporarily alleviating airway obstruction. Case reports are the primary source of information[ 16 – 19 ].However, they have not yet become mainstream treatments for the disease. Moreover, there is a lack of reports on the application of combined, endoscopic therapeutic interventions for this disease. The high-frequency electric snare generates heat at the tissue interface using elec- trical energy, facilitating precise excision and coagulation. This technique is widely employed in bronchoscopic procedures for tumor resection[ 20 ]. High-frequency electric snare resection offers several advantages, particularly in minimally invasive procedures, such as bronchoscopy and endoscopic resections. One of the key benefits is its ability to excise and coagulate tissue simultaneously, thereby minimizing bleeding and enhancing visibility during the procedure. The precision of the high-frequency electric snare enables controlled, targeted tumor excision, preserving surrounding healthy tissue and maintaining the structural integrity of vital organs. The aforementioned advantages of the technique make it particularly suitable for patients with advanced age, comorbidities, or poor general health who are not ideal candidates for surgery. In this case, the treatment approach was used to remove the tumor precisely,minimizing damage to the surrounding tissue. It facilitates the rapid removal of airway lesions, alleviates obstruction, restores airway patency, and improves clinical symptoms. However, this technology has limitations. For instance, residual tumor lesions may be observed in cases of deeply infiltrating tumors. This can lead to tumor recurrence. Addition ally, thermal damage can penetrate the bronchial wall, which can lead to bronchial fistula.Cryoablation is a therapeutic technique that employs extremely low temperatures to induce cellular destruction by freezing[ 21 ]. This process leads to the formation of ice crystals within cells, resulting in cellular injury, microvascular embolism, and eventual necrosis of the targeted tissue.This technology primarily targets the base of the tumor and deeply infiltrated regions. Cryoablation has been increasingly used after tumor resection to reduce recurrence rates[ 22 ]. In this case, cryoablation was used in an innovative manner following high-frequency electric snare resection. This approach was employed to ensure the complete eradication of residual tumor tissue and to reduce the risk of tumor recurrence.Ultimately, the patient achieved good, stable treatment results.A subsequent review of the extant literature was conducted to explore the potential mechanisms of combination therapy, which revealed that the efficacy of combination sequential therapy can be attributed to the following factors: 6 f irst, the electric loop rapidly reduces the tumor, and second, cryoablation eradicates residual lesions and stimulates systemic immunity[ 23 – 30 ]. The low incidence of PSGTs has impeded the establishment of a consensus on optimal treatment strategies. In the management of benign myoepitheliomas, a com prehensive risk-benefit evaluation is crucial to determine the necessity of treatment and to establish the most appropriate course of action. This evaluation should con- sider several factors, including clinical presentation, patient age, changes in lesion size, and overall physical condition.[ 31 ].Managing tracheal myoepitheliomas poses significant challenges due to their rarity and the potential for airway obstruction[ 32 ]. In summary, the present findings contribute to the mounting body of evidence support ing bronchoscopic techniques for managing tracheal myoepitheliomas.Given the rarity of the disease, case reports such as ours are invaluable in guiding clinical practice, particularly in high-risk patients for whom conventional surgery is not feasible. How ever, this study has some limitations. For example, as a single-center case report, the generalizability of the findings requires caution. Future research should concentrate on the combination of different mechanisms of endoscopic intervention techniques for the treatment of tracheal myoepithelioma, and optimize and standardize the treatment plan for better and wider clinical application. Abbreviations PSGTs Pulmonary salivary gland-type tumors CT Computed tomographyarterial ABG Blood gas analysis COPD Chronic obstructive pulmonary disease MRI Magnetic resonance imaging APC Argon plasma coagulation OI Oxygenation index PaO2 Pressure of oxygen in arterial blood PaCO2 Pressure of carbon dioxide in arterial blood Declarations Acknowledgements We would like to thank this patient for his participation. Clinical trial number Not applicable Author contribution SC: Writing– original draft,Data curation,Investigation,Operation and Management of the patient. LD: Writing– original draft,Operation and Management of the patient. ZH:Operation and Management of the patient. JW:Writing– review and editing, methodology, and supervision. MC: Writing– review and editing, methodology, and supervision. Funding This work was supported by the Chongqing Municipal Public Health Key Speciality Construction Project. Data availability All data generated or analysed during this study are included in this published article. Further inquiries can be directed to the corresponding authors. Conflict of interest The authors declare that the research was conducted in the absence of any com- mercial or financial relationships that could be construed as a potential conflict of interest. Competing interests The authors declare no competing interests. Ethics approval and consent to participate Not applicable: Ethical approval for this case report was not requested. All data in this case were derived from the patient’s routine course of treatment with trace ability and no experimental interventions or other manipulations beyond standard medical practice were performed. 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02:05:08","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78770,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7690787/v1/2b16741b5d24549c6541cc6e.html"},{"id":93730580,"identity":"da6d795b-42d7-4761-b692-efb8ec5a01a0","added_by":"auto","created_at":"2025-10-17 02:21:08","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1120506,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in blood gas parameters and clinical manifestations before and after treatment. (A)Oxygenation index(OI)trend over time following bronchoscopic intervention.(B)Pressure of oxygen in arterial blood(PaO2)trend over time following bronchoscopic intervention.(C)Pressure of carbon dioxide in arterial blood(PaCO2)trend over time following bronchoscopic intervention.(D)Dyspnea score trend over time following bronchoscopic intervention. These line charts individually illustrate the changes in OI, PaO2, PaCO2, and dyspnea score measured at five time points: preoperation, postoperative(1 day), postoperative(1 week), postoperative(1 month), and postoperative(3 months). The data indicate a positive response to the procedure\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7690787/v1/2ad679698b44d9eb723c5207.jpeg"},{"id":93726802,"identity":"3e010f08-cb04-47b2-b4c6-fd5ec6715acc","added_by":"auto","created_at":"2025-10-17 02:05:08","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57145,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in chest images before and after treatment. (A)The preoperative chest X-ray showed complete atelectasis of the left lung. (B)The preoperative contrast-enhanced CT scan (lung window) showed an intraluminal mass in the left main bronchus (black arrow) and complete atelectasis of the left lung. (C)The postoperative(1 day) chest X-ray showed improved atelectasis of the left lung. (D)The postoperative(3 months) chest X-ray showed stable left lung fields. (E)The postoperative(3 months) contrast-enhanced CT scan (lung window) showed no significant residual mass in the left main bronchus and recovery of left lung atelectasis\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7690787/v1/3a807ff132ddf24edb42abb0.jpeg"},{"id":93726797,"identity":"a107045f-3ee1-4aec-8e1f-47d9f8e92abe","added_by":"auto","created_at":"2025-10-17 02:05:08","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":37917,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in bronchoscopic observations before and after treatment. (A)Bronchoscopy showed an intraluminal tracheal lesion obstructing the left main bronchus. (B)The tracheal lesion on closer inspection showed complete obstruction of the left main bronchus. (C)The high-frequency electric snare was used to excise the intraluminal mass of the trachea. (D)The mass originated from the supe rior segment (B6), and the tumor stump was treated with cryoablation. (E)Postoperative(3 months) bronchoscopy demonstrated airway patency. (F)A closer postoperative(3 months) view showed complete resolution of the tumor with no recurrence at the previously treated site (black arrow)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7690787/v1/c0c712a3b7de2b2c1d5321f5.jpeg"},{"id":93730600,"identity":"5bc2db5f-99ad-4123-a4b7-6e135746a677","added_by":"auto","created_at":"2025-10-17 02:21:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":657250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7690787/v1/48095489-3240-4e45-b808-97171af31171.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"High-frequency electric snare resection combined with cryoablation for tracheal myoepithelioma: a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary PSGTs typically arise from the epithelium of the submucosal tracheobronchial glands and typically present as endoluminal lesions. PSGTs can be classified into six subtypes, one of which is myoepithelioma. Since Sheldon WH\u0026rsquo;s initial report of a benign myoepithelioma in 1943[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], numerous studies have documented myoepitheliomas in salivary glands and other anatomical sites[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, reports of myoepitheliomas in the respiratory tract remain scarce, with Strickler JG documenting the first case of pulmonary myoepithelioma[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite their benign nature, these tumors can obstruct the airway, resulting in symptoms such as cough, wheezing, and shortness of breath[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, most patients require surgical intervention to prevent or manage complications. Although surgical resection is the standard treatment for these benign tumors[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e],Surgery may not be possible for some patients due to their age or other health conditions. An effective and simple treatment modality is urgently needed to address this pressing clinical issue.We present a case of severe respiratory failure due to endotracheal myoepithelioma in a patient considered unfit for surgery due to advanced age and impaired cardiopulmonary function. Effective bronchoscopic interventions were employed to excise the mass, restore airway patency, and alleviate dyspnea. A stable and favorable therapeutic outcome was achieved by the patient. A comprehensive review of existing literature on tracheal myoepithelioma was undertaken based on this successful case to improve understanding of the disease and optimize treatment strategies for specific populations.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eAn 84-year-old male patient presented to the outpatient clinic with mild cough and hemoptysis as the primary clinical manifestations; however, physical examination and subsequent investigations revealed no significant findings. Two months later, the patient returned to the hospital with worsening cough, wheezing, and dyspnea. Aarte- rial blood gas (ABG) analysis indicated type I respiratory failure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient\u0026rsquo;s condition was urgent, so he was admitted to the hospital for treatment immediately. A subsequent chest CT scan revealed left lung atelectasis, pleural effusion, and a dense shadow in the lumen of the left main bronchus(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).Subsequent bronchoscopy confirmed a mass in the left main bronchus, completely obstructing the airway and cor roborating the CT findings (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Given the patient\u0026rsquo;s advanced age and longstanding history of chronic obstructive pulmonary disease (COPD) and diabetes, his family opted to forgo surgical treatment. Bronchoscopic procedures were performed with the informed consent of the patient and his family to rapidly relieve airway obstruction and improve ventilation. The tumor was excised via a high-frequency electric snare, with precise guidance from an electronic bronchoscope (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The residual tumor stump was subsequently treated with cryoablation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The procedure was carried out satisfactorily, with no evident bleeding. Dyspnea was significantly relieved after treatment, as evidenced by a significant reduction in the dyspnea score according to the American Thoracic Society criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient\u0026rsquo;s respiratory failure was also resolved, as indicated by an ABG (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A bedside chest X-ray showed improved ventilation with re-expansion of the left lung(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The postoperative pathology confirmed the diagnosis of tracheal myoepithelioma, with positive immunohistochemical staining for cytokeratin, P63, and S-100 proteins. The patient was discharged with active support and exhibited good postoperative recovery without complications. One and three months after discharge, the patient returned for follow-up, with complete resolution of dyspnea and respiratory failure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Chest radiographs revealed a stable condition of the left lung (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Subsequent electronic bronchoscopy revealed that the left main bronchus was completely patent, with no evidence of residual bronchial lesions or tumor recurrence(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eGlobally,minimally invasive surgery has emerged as a predominant trend in the evo- lution of surgical methodologies. This approach involves creating surgical channels through smaller incisions or natural cavities,employing instruments via medical endo- scopes, and executing interventions on diseased tissues. This case report highlights the innovative use of a combined approach involving high-frequency electric snare resection and cryoablation in the management of tracheal myoepitheliomas via electronic bronchoscopy, representing a successful intervention rarely reported in the literature. In contrast to previous studies that described surgical resection as the standard treatment, our approach offers a less invasive alternative, particularly suitable for elderly patients with comorbidities or those seeking to preserve airway function.\u003c/p\u003e\u003cp\u003eMyoepitheliomas are a rare form of benign neoplasm that originates from myoep- ithelial cells. These neoplasms are characteristically located in glandular structures, including the salivary glands. Tracheal myoepitheliomas represent a rare subtype of myoepithelial neoplasm. Myoepithelial cells, which facilitate the contraction of glan- dular ducts, are susceptible to neoplastic transformation due to genetic mutations, environmental factors, or chronic irritation.However, no definitive risk factors have been established[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].Pulmonary myoepitheliomas typically occur in younger patients and are generally more indolent than other primary lung cancers[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The case reported in this article is the oldest tracheal myoepithelioma patient to date. It pro- vides valuable insights into the disease.Patients with tracheal myoepithelioma often exhibit atypical clinical manifestations in the early stages of the disease. Symptoms associated with airway obstruction, including dyspnea, persistent cough, hemoptysis, and wheezing, usually appear when the tumor is large enough to substantially nar row the airway.The case presented in this article highlights the obscured nature of the disease, a characteristic that has, to some extent, delayed diagnosis and inter- vention.The diagnosis of tracheal myoepithelioma typically involves imaging studies, such as chest CT scans or magnetic resonance imaging (MRI), which can detect a mass in the trachea[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Bronchoscopy is a crucial diagnostic instrument that enables direct visualization of the tumor and facilitates biopsy for histopathological analy- sis.Immunohistochemistry is a common diagnostic tool that is utilized to confirm a 5 diagnosis by detecting specific markers. Cytokereratins, P63, and S-100 proteins are characteristic of myoepithelial cells and are often used in pathological analysis[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].The prognosis for tracheal myoepitheliomas is generally favorable, particularly when complete resection is achieved. Surgical resection is considered a curative procedure, with a low rate of recurrence.Bronchoscopic interventions have been used to reduce the extent of resection, restore pulmonary ventilation, and relieve dyspnea in patients with central airway obstruction in patients who are unsuitable for surgery[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These interventions are generally performed under either local or general anesthesia. The available techniques include Nd:YAG laser ablation, microwave ablation, argon plasma coagulation (APC), electrocautery, cryoablation, radiofrequency ablation, and mechanical resection. However, these interventions are currently used primarily for diagnosing or temporarily alleviating airway obstruction. Case reports are the primary source of information[\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].However, they have not yet become mainstream treatments for the disease. Moreover, there is a lack of reports on the application of combined, endoscopic therapeutic interventions for this disease.\u003c/p\u003e\u003cp\u003eThe high-frequency electric snare generates heat at the tissue interface using elec- trical energy, facilitating precise excision and coagulation. This technique is widely employed in bronchoscopic procedures for tumor resection[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. High-frequency electric snare resection offers several advantages, particularly in minimally invasive procedures, such as bronchoscopy and endoscopic resections. One of the key benefits is its ability to excise and coagulate tissue simultaneously, thereby minimizing bleeding and enhancing visibility during the procedure. The precision of the high-frequency electric snare enables controlled, targeted tumor excision, preserving surrounding healthy tissue and maintaining the structural integrity of vital organs. The aforementioned advantages of the technique make it particularly suitable for patients with advanced age, comorbidities, or poor general health who are not ideal candidates for surgery. In this case, the treatment approach was used to remove the tumor precisely,minimizing damage to the surrounding tissue. It facilitates the rapid removal of airway lesions, alleviates obstruction, restores airway patency, and improves clinical symptoms. However, this technology has limitations. For instance, residual tumor lesions may be observed in cases of deeply infiltrating tumors. This can lead to tumor recurrence. Addition ally, thermal damage can penetrate the bronchial wall, which can lead to bronchial fistula.Cryoablation is a therapeutic technique that employs extremely low temperatures to induce cellular destruction by freezing[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This process leads to the formation of ice crystals within cells, resulting in cellular injury, microvascular embolism, and eventual necrosis of the targeted tissue.This technology primarily targets the base of the tumor and deeply infiltrated regions. Cryoablation has been increasingly used after tumor resection to reduce recurrence rates[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In this case, cryoablation was used in an innovative manner following high-frequency electric snare resection. This approach was employed to ensure the complete eradication of residual tumor tissue and to reduce the risk of tumor recurrence.Ultimately, the patient achieved good, stable treatment results.A subsequent review of the extant literature was conducted to explore the potential mechanisms of combination therapy, which revealed that the efficacy of combination sequential therapy can be attributed to the following factors: 6 f irst, the electric loop rapidly reduces the tumor, and second, cryoablation eradicates residual lesions and stimulates systemic immunity[\u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe low incidence of PSGTs has impeded the establishment of a consensus on optimal treatment strategies. In the management of benign myoepitheliomas, a com prehensive risk-benefit evaluation is crucial to determine the necessity of treatment and to establish the most appropriate course of action. This evaluation should con- sider several factors, including clinical presentation, patient age, changes in lesion size, and overall physical condition.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].Managing tracheal myoepitheliomas poses significant challenges due to their rarity and the potential for airway obstruction[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In summary, the present findings contribute to the mounting body of evidence support ing bronchoscopic techniques for managing tracheal myoepitheliomas.Given the rarity of the disease, case reports such as ours are invaluable in guiding clinical practice, particularly in high-risk patients for whom conventional surgery is not feasible. How ever, this study has some limitations. For example, as a single-center case report, the generalizability of the findings requires caution. Future research should concentrate on the combination of different mechanisms of endoscopic intervention techniques for the treatment of tracheal myoepithelioma, and optimize and standardize the treatment plan for better and wider clinical application.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePSGTs \u0026nbsp; \u0026nbsp; \u0026nbsp; Pulmonary salivary gland-type tumors\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Computed tomographyarterial\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eABG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Blood gas analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOPD \u0026nbsp; \u0026nbsp; \u0026nbsp; Chronic obstructive pulmonary disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Magnetic resonance imaging\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Argon plasma coagulation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Oxygenation index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePaO2 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pressure of oxygen in arterial blood\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePaCO2 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pressure of carbon dioxide in arterial blood\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank this patient for his participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSC: Writing\u0026ndash; original draft,Data curation,Investigation,Operation and Management of the patient. LD: Writing\u0026ndash; original draft,Operation and Management of the patient. ZH:Operation and Management of the patient. JW:Writing\u0026ndash; review and editing, methodology, and supervision. MC: Writing\u0026ndash; review and editing, methodology, and supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Chongqing Municipal Public Health Key Speciality Construction Project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article. Further inquiries can be directed to the corresponding authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any com- mercial or financial relationships that could be construed as a potential conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable: Ethical approval for this case report was not requested. All data in this case were derived from the patient\u0026rsquo;s routine course of treatment with trace ability and no experimental interventions or other manipulations beyond standard medical practice were performed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSheldon WH. So-called mixed tumors of the salivary glands. Arch Pathol. 1943;35(1):1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaunders H, Abia-Trujillo D, Khoor A, Patel NM, Fernandez-Bussy S. Air way Myoepithelioma: A Misplaced Salivary Gland\u0026rsquo;s Tale. J Bronchol Interv Pulmonol. 2021;28(3):e39\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStrickler JG, Hegstrom J, Thomas MJ, Yousem SA. Myoepithelioma of the lung. Arch Pathol Lab Med. 1987;111(11):1082\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMardani P, Ebrahimi K, Shahriarirad R, Geramizadeh B, Kamran H, Niknam T, Khosravi MB, Vatankhah P. Tracheal myoepithelioma resected by using rigid bronchoscopy: a case report and review of the literature. J Cardiothorac Surg. 2022;17(1):125.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePandey D, Garg PK, Jakhetiya A, Pandey R, Bhoriwal S, Nath D, Kumar S. Surgical experience of primary salivary gland tumors of lung: A case series. Int J Surg. 2015;21:92\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFalk N, Weissferdt A, Kalhor N, Moran CA. Primary Pulmonary Salivary Gland type Tumors: A Review and Update. Adv Anat Pathol. 2016;23(1):13\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYanagawa N, Sato A, Nishiya M, Suzuki M, Sugimoto R, Osakabe M, Uesugi N, Saito H, Sugai T. Pulmonary epithelial-myoepithelial carcinoma without AKT1, HRAS or PIK3CA mutations: a case report. Diagn Pathol. 2020;15(1):105.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoden AC. Recent updates in salivary gland tumors of the lung. Semin Diagn Pathol. 2021;38(5):98\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorio Y, Kuroda H, Masago K, Matsushita H, Sasaki E, Fujiwara Y. Current diagnosis and treatment of salivary gland-type tumors of the lung. Jpn J Clin Oncol. 2024;54(3):229\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMolina JR, Aubry MC, Lewis JE, Wampfler JA, Williams BA, Midthun DE, Yang P, Cassivi SD. Primary salivary gland-type lung cancer: spectrum of clinical presentation, histopathologic and prognostic factors. Cancer. 2007;110(10):2253\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQin BD, Jiao XD, Liu K, Wu Y, He X, Liu J, Zang YS. Clinical, pathological and treatment factors associated with the survival of patients with primary pulmonary salivary gland-type tumors. Lung Cancer. 2018;126:174\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonzen Y, Fukushima N, Fukuhara T. Myoepithelioma and malignant myoep ithelioma arising from the salivary gland: computed tomography and magnetic resonance findings. Australas Radiol. 2007;51(Suppl):B169\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePlaza JA, Brenn T, Chung C, Salim S, Linos KD, Jour G, Duran Rincon J, Wick M, Sangueza M, Gru AA. Histomorphological and immunophenotypical spectrum of cutaneous myoepitheliomas: A series of 35 cases. J Cutan Pathol. 2021;48(7):847\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim BG, Lee K, Um SW, Han J, Cho JH, Kim J, Kim H, Jeong BH. Clinical outcomes and the role of bronchoscopic intervention in patients with primary pulmonary salivary gland-type tumors. Lung Cancer. 2020;146:58\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChaddha U, Hogarth DK, Murgu S. Bronchoscopic Ablative Therapies for Malig nant Central Airway Obstruction and Peripheral Lung Tumors. Ann Am Thorac Soc. 2019;16(10):1220\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScarlata S, Graziano P, Lucantoni G, Battistoni P, Batzella S, Dello Jacono R, Antonelli Incalzi R, Galluccio G. Endoscopic treatment of primary benign cen tral airway tumors: Results from a large consecutive case series and decision making flow chart to address bronchoscopic excision. 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Life Sci. 2024;349:122718.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChand M, Mann JM, Sabayev V, Luo JJ, Cohen PR, Travis WD, Lee PC, Paul S. Endotracheal myoepithelioma. Chest. 2011;140(1):242\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuibert N, Mhanna L, Droneau S, Plat G, Didier A, Mazieres J, Hermant C. Techniques of endoscopic airway tumor treatment. J Thorac Dis. 2016;8(11):3343\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bronchoscopy, Central airway obstruction, Myoepithelioma, Interventional treatment, High-frequency electric snare resection, Cryoablation","lastPublishedDoi":"10.21203/rs.3.rs-7690787/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7690787/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMyoepitheliomas are rare, benign tumors that originate from myoepithelial cells. They represent a small proportion of all pulmonary salivary gland-type tumors (PSGTs).These tumors are extremely rare in the respiratory tract. Despite their benign nature, endotracheal myoepitheliomas frequently require interventions due to complications, including airway obstruction. Although surgical resection is the standard treatment for these benign tumors, some patients are unsuitable for surgery due to various factors. Bronchoscopic intervention has been used to restore pulmonary ventilation and temporarily relieve dyspnea in patients with central airway stenosis. Our findings suggest that this therapy can also provide effective and stable outcomes for this type of benign airway tumor. Furthermore, the study demonstrates the merits of minimal trauma, rapid recovery, and high accuracy, which are not possessed by traditional surgical operations.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e\u003cp\u003eWe report the case of an 84-year-old male patient who initially presented with mild cough and hemoptysis. Two months later, the patient gradually developed severe dyspnea. The blood gas analysis indicated type I respiratory failure. Chest CT (CT) scans revealed a high density shadow in the left main bronchus, accompanied by complete atelectasis of the left lung and left-sided pleural effusion. Bronchoscopy confirmed complete obstruction of the left main bronchus due to a mass. The patient\u0026rsquo;s condition was critical and life-threatening.Given the patient\u0026rsquo;s poor cardiopulmonary function and comprehensive risk-benefit analysis, high-frequency electric snare resection combined with cryoablation was urgently performed to excise the mass and mitigate the risk of fatal respiratory failure. The patient\u0026rsquo;s dyspnea improved significantly after the interventions. A biopsy of the mass was performed, and the final pathological diagnosis was confirmed as endotracheal myoepithelioma. The patient achieved a favorable recovery following postoperative treatment. The subsequent follow-up demonstrated a satisfactory and stable outcome.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis case presents an effective treatment option for patients who are not eligible for surgery for various reasons. A comprehensive review of the literature on tracheal myoepithelioma was undertaken to deepen our understand ing of the disease and optimize personalized treatment strategies in view of the encouraging outcome of this case.\u003c/p\u003e","manuscriptTitle":"High-frequency electric snare resection combined with cryoablation for tracheal myoepithelioma: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:05:03","doi":"10.21203/rs.3.rs-7690787/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-31T22:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36144781552598598506956333594083963726","date":"2026-03-20T08:21:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183482695357492811629285214369066134283","date":"2026-03-18T13:00:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105690207489370382715588183584887710959","date":"2026-01-28T05:42:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T12:56:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25828277446225564188234386104377149468","date":"2025-10-05T07:20:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-03T03:31:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-26T01:33:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-26T01:31:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-09-23T06:59:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec487d2a-2501-43bc-b1b9-0e0a85e95ec7","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T02:05:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:05:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7690787","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7690787","identity":"rs-7690787","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}