At first it seemed like a lingering cold. No surprise there: although she was just 18, Erin Forrister had what she called a “weak immune system,” after all.

Six weeks later, the fever, the shortness of breath and the drained vitality made clear that something else was going on. The diagnosis in July 2018: pneumonia.

She was familiar enough with pneumonia. The University of Colorado sociology major from Boulder had just wrapped up her freshman year, during which she worked part-time at the Carillon at Boulder Creek senior living community. She associated pneumonia more with age 81 than 18, though.

The antibiotics helped. But a month later, Forrister was back at her doctor in Lafayette for a second round of them. By September, a summer typically highlighted by hiking and horseback riding had passed with little of either. With the third round of antibiotics that month, her doctor ordered a CT scan.

The mass the scan found in her left lung was diagnosed as a rare carcinoid tumor. It was slow-growing and not cancerous, but it blocked a major section of airway – hence the difficulty breathing. Often, removing such a tumor involves surgery to remove a large section of lung. In Forrister’s case, the surgery might have reduced her overall lung capacity 20 percent or more, permanently. That’s not good when you’re 81; when you’re 18, it’s a life sentence of diminished physical capability. But there was another option. Her doctors referred her to Dr. Ali Musani at UCHealth University of Colorado Hospital (UCH) at the Anschutz Medical Campus.

Skip the surgery

Musani, who works under the aegis of UCHealth’s Comprehensive Lung and Breathing Program, is a board-certified interventional pulmonologist – one of fewer than a handful in Colorado and perhaps 400 in the United States. A week later, Forrister and her mom, Mimi Turnipseed, met with Musani. He told them that most patients with Forrister’s tumor would end up having part of the lung removed. But he had the skills and UCH had the tools to do minimally invasive bronchoscopies. Musani could thread bronchoscopes, balloons, stents, laser-ablation and other tools into the lung via the windpipe and remove the tumor without taking a lot of the lung with it. He told her up-front that it would take two or three procedures. There was also a chance that, if he couldn’t remove the tumor bronchoscopically, some of the lung would end up being surgically removed anyway.

Despite Musani’s confidence that the minimally invasive procedure would work, Forrister prepared for the worst.

“I took the most pessimistic approach,” she recalled. “That there was no way they’re going to be able to get this. Why did I have to go through three scopes and then get part of my lung taken out?”

Her pessimism was well-founded. Carcinoid tumors such as Forrister’s were benign as far as cancer is concerned, but nasty to deal with using the tools of bronchoscopy. They bleed much more than other tumors, for one thing. Patients have died after biopsies by pulmonologists lacking the skills and tools to stop the bleeding quickly, Musani says. And in Forrister’s case, the carcinoid had grown into the lung wall and was dangerously close to her heart’s left ventricle. Hers was a high-risk case of the sort Musani often receives as referrals. He planned for multiple procedures because he wanted to be sure he was scraping and ablating only the tumor.

“Which is why I often do these cases in a serial or stepwise fashion,” Musani said. “Why not just blast it off with a laser? Better to bring them back than perforate the airway, and if you don’t stop at the right time, you could be lasering the left ventricle.”

One, two, three

The first and second procedures happened two weeks apart in October 2018. Using tools ranging from a flexible bronchoscope, balloons to open up her airway, large forceps for debulking the tumor, and a laser to ablate the tumor, he confirmed that Forrister’s was a typical carcinoid (nine out of 10 carcinoids are typical; atypical carcinoids grow faster and are more likely to spread) and then worked to remove it. Forrister spent the night at UCH after the first procedure and was home the same day after the second. Yet despite Musani assuring her that much of the tumor was now gone, she didn’t feel much better.

The third procedure happened the second week in November. Forrister was among the first patients whose bronchoscopy was done in UCH’s new, state-of-the art bronchoscopy suite in UCH’s Anschutz Outpatient Pavilion. The suite is capable of combining both the negative air pressure required for bronchoscopy and the positive air pressure needed for ear, nose and throat and thoracic surgery cases. That allows joint procedures for patients who need both bronchoscopy and surgery, which Musani says often happens with complex cases such as lung cancers. For bronchoscopy cases such as Forrister’s, the new suite includes an array of bronchoscopic and imaging tools that speed up and enhance the precision of procedures while ensuring patient safety.

In Forrister’s case, the surgical side of the suite stayed dormant. She was back home later that day and went hiking and was hanging out with friends the next day.

“I felt way better,” she said.

A week later she was off to London for a Thanksgiving-week trip with her mom and dad, Dirk Forrister. They were on their feet a lot, and more than once found themselves hustling to catch a London Underground train. Over the holidays a month later, the trio traveled to Thailand. Either would have been tough before Musani’s work.

“I’m glad I’m not still struggling, because it’s a huge inhibitor,” Forrister said.

A December CT scan showed a small, calcified remnant and some changes to Forrister’s surrounding lung as a result of the tumor’s growing presence over the years, but Musani says things look good. He’ll continue to monitor her in the years ahead.

“That’s the gratification we get in this occupation,” Musani said. “This kid who was having difficulty climbing stairs and walking long distances was running around London catching the tube and everything else.”

Forrister is grateful.

“Dr. Musani is so lighthearted and easy to talk to, but also really excellent at his work. I put a lot of trust in him from the very beginning,” she said. “It was definitely the best care I could have asked for.”