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11 #8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L) Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Describe.

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Presentation on theme: "11 #8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L) Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Describe."— Presentation transcript:

1 11 #8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L) Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. Identify 4L and surrounding vascular structures using EBUS. Identify 4L and surrounding vascular structures using EBUS. Bronchoscopy.org

2 2 2 Case description (practical approach # 8) A 69 year-man with a 120 pack –year history of smoking presents with cough. A 69 year-man with a 120 pack –year history of smoking presents with cough. Computed tomography shows a 2.5 X 2 cm left upper lobe mass and a 1.5 cm left paratracheal lymph node. Computed tomography shows a 2.5 X 2 cm left upper lobe mass and a 1.5 cm left paratracheal lymph node. Patient is referred for diagnosis and staging Patient is referred for diagnosis and staging

3 3 Bronchoscopy.org 3 Case description (practical approach #8) 1.5 cm left paratracheal lymph node Axial CT viewCoronal CT view

4 4 Bronchoscopy.org 4 The Practical Approach Initial EvaluationProcedural Strategies Techniques and ResultsLong term Management Examination and, functional status Examination and, functional status Significant comorbidities Significant comorbidities Support system Support system Patient preferences and expectations Patient preferences and expectations Indications, contraindications, and results Indications, contraindications, and results Team experience Team experience Risk-benefits analysis and therapeutic alternatives Risk-benefits analysis and therapeutic alternatives Informed Consent Informed Consent Anesthesia and peri-operative care Anesthesia and peri-operative care Techniques and instrumentation Techniques and instrumentation Anatomic dangers and other risks Anatomic dangers and other risks Results and procedure-related complications Results and procedure-related complications Outcome assessment Outcome assessment Follow-up tests and procedures Follow-up tests and procedures Referrals Referrals Quality improvement Quality improvement

5 5 Bronchoscopy.org 5 Initial Evaluations Exam Exam Decreased air entry bilaterally and prolonged exhalation Decreased air entry bilaterally and prolonged exhalation WHO functional status II WHO functional status II Comorbidities Comorbidities COPD, Coronary artery disease COPD, Coronary artery disease Support system Support system Lives with wife at home Lives with wife at home Patient preferences Patient preferences Desires diagnosis and considers all available active treatment options. Desires diagnosis and considers all available active treatment options.

6 6 Procedural Strategies Indications Indications Invasive lymph node staging? Invasive lymph node staging? Invasive staging should be performed in patients with 1 or more risk factors for occult N2 disease* ** *** Invasive staging should be performed in patients with 1 or more risk factors for occult N2 disease* ** *** The patient in this case has clinically evident N2 disease (1.5 cm left paratracheal node) The patient in this case has clinically evident N2 disease (1.5 cm left paratracheal node) Bronchoscopic inspection can be performed at the time of EBUS-TBNA. Bronchoscopic inspection can be performed at the time of EBUS-TBNA. Diagnosis and staging can be performed during a single procedure. Diagnosis and staging can be performed during a single procedure. Bronchoscopy.org 6 *Ann Thorac Surg 2007;84: **J Thorac Cardiovasc Surg 2006;131: *** Eur J Cardiothorac Surg Jul;32(1):1-8

7 77 Procedural Strategies Indications Indications Obtain tissue diagnosis Obtain tissue diagnosis Sample 4L (left paratracheal node) for staging purposes Sample 4L (left paratracheal node) for staging purposes Mediastinal lymph node involvement is found in 26% of newly diagnosed lung cancer patients* Mediastinal lymph node involvement is found in 26% of newly diagnosed lung cancer patients* The presence of lymph node metastasis remains one of the most adverse factors for prognosis in NSCLC The presence of lymph node metastasis remains one of the most adverse factors for prognosis in NSCLC Mediastinal nodal involvement suggests stage IIIA or IIIB Mediastinal nodal involvement suggests stage IIIA or IIIB inoperability and/or inoperability and/or need for treatment by chemotherapy and/or radiotherapy need for treatment by chemotherapy and/or radiotherapy Bronchoscopy.org * Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med 2004; 350: 379–392.

8 8 Procedural Strategies Contraindications: Contraindications: None None Expected Results: Expected Results: The diagnostic rate of EBUS-TBNA for station 4L reportedly equal to conventional TBNA (72%vs. 71%) The diagnostic rate of EBUS-TBNA for station 4L reportedly equal to conventional TBNA (72%vs. 71%) Lymphocytes more often present on EBUS-TBNA specimens compared with conventional TBNA (82%vs. 71%)* Lymphocytes more often present on EBUS-TBNA specimens compared with conventional TBNA (82%vs. 71%)* Experienced team and operator Experienced team and operator Risks-benefits: Risks-benefits: No serious complications reported in the literature. No serious complications reported in the literature. Agitation, cough, and presence of blood at puncture site reported infrequently.** Agitation, cough, and presence of blood at puncture site reported infrequently.** Benefits: accurate, safe and same day procedure. Benefits: accurate, safe and same day procedure. Bronchoscopy.org 8 *Chest 2004; 125:322–325 **Eur Respir J 2009; 33: 1156–1164

9 9 Procedural Strategies Diagnostic alternatives: Diagnostic alternatives: CT-guided percutaneous needle aspiration of mass; high diagnostic rate (91%) but does not provide staging, and has increased risk for pneumothorax (5-60%)* CT-guided percutaneous needle aspiration of mass; high diagnostic rate (91%) but does not provide staging, and has increased risk for pneumothorax (5-60%)* EUS-FNA( esophageal ultrasound reaches 4L node; Sensitivity 81-97% Specificity % ** EUS-FNA( esophageal ultrasound reaches 4L node; Sensitivity 81-97% Specificity % ** Mediastinoscopy: considered gold standard. Mediastinoscopy: considered gold standard. Bronchoscopic airway inspection would still be required Bronchoscopic airway inspection would still be required VATS: most invasive of alternatives. VATS: most invasive of alternatives. Only provides access to ipsilateral nodes. 75% sensitivity***. Only provides access to ipsilateral nodes. 75% sensitivity***. Benefits include definitive lobar resection at same time if node negative. Benefits include definitive lobar resection at same time if node negative. 9 * *Chest. 2003; 123: **Lung Cancer. 2003; 41: ***Chest 2007;132;

10 For station 4L, EBUS-TBNA and EUS-FNA have similar diagnostic rates Bronchoscopy.org10 Am J Respir Crit Care Med Vol 171. pp , 2005

11 11 Procedural Strategies Risks-Benefits Cost effectiveness- no formal evaluations have been published In 2 separate decision-analytic models, both (EUS-FNA + EBUS-FNA) and (conventional TBNA + EBUS-FNA) were more cost-effective approaches than Mediastinoscopy for staging patients with NSCLC and abnormal mediastinal lymph nodes on non-invasive imaging* ** A strategy adding EUS-FNA to a conventional lung ca staging approach (mediastinoscopy thoracotomy) reduced costs by 40% per patient*** May actually increase health care costs if done in low volume centers by less experienced operators**** ***** Start up costs Cost of equipment ~100K******and training Physician reimbursement ~$280; facility reimbursement $257****** *Gastrointestinal Endoscopy 69, No. 2, Supp 1, 2009, S260 **J Bronchol 2008;15:17–20 ***Thorax 2004;59; ****Lung Cancer 64 (2009) 127–128 *****J Bronchol 2008; 15: ****** Southern Medical Journal 2008;101,No5; Bronchoscopy.org

12 12 Procedural Strategies Informed consent: Informed consent: There were no barriers to learning identified. Patient has good insight into his disease and realistic expectations. There were no barriers to learning identified. Patient has good insight into his disease and realistic expectations. BI #. Practical Approach Title12 Drawing from Herth FJ et al. J Bronchol Volume 13, Number 2, April 2006 EBUS image from patient.

13 13 Bronchoscopy.org 13 Procedural techniques and results Anesthesia and perioperative care Conscious (moderate) sedation Conscious (moderate) sedation May be performed in bronchoscopy suite May be performed in bronchoscopy suite Cost savings compared to general anesthesia. Cost savings compared to general anesthesia. Visualization and biopsy of smaller nodes technically more difficult than with general anesthesia. Visualization and biopsy of smaller nodes technically more difficult than with general anesthesia. General anesthesia with LMA (#4 or 4.5 ) General anesthesia with LMA (#4 or 4.5 ) Better visualization of higher nodes ( station 1 and 2) compared with ET tube Better visualization of higher nodes ( station 1 and 2) compared with ET tube May be performed in bronchoscopy suite May be performed in bronchoscopy suite May not be appropriate in severe obesity or severe untreated GERD May not be appropriate in severe obesity or severe untreated GERD General anesthesia with ET tube (#8.5 for female and #9 for male patients) General anesthesia with ET tube (#8.5 for female and #9 for male patients) Usually performed in OR. Usually performed in OR. EBUS scope directed more centrally in airway which may make biopsies more difficult EBUS scope directed more centrally in airway which may make biopsies more difficult Chest 2008;134; J Cardiothorac Vasc Anesth 2007; 21:892–896

14 14 Procedural Techniques and Results Instrumentation Instrumentation EBUS scope- EBUS scope- direct real time US imaging with curved array ultrasound transducer incorporated in distal end of bronchoscope Ultrasound processor Ultrasound processor Adjustable gain and depth B mode and Doppler capabilities Needle Needle 22 gauge acrogenic needle with stylet Needle guide system locks to scope Lockable needle and sheath Precise needle projection up to 4 cm Bronchoscopy.org 14

15 15 Procedural Techniques and Results Anatomic dangers and other risks Anatomic dangers and other risks Major blood vessels- Pulmonary Artery and Aortic arch Major blood vessels- Pulmonary Artery and Aortic arch Risk of canulating major vessel may be reduced with real time B mode and Doppler mode imaging Risk of canulating major vessel may be reduced with real time B mode and Doppler mode imaging Minor oozing of blood at puncture site was reported in 1 study there have been no reports of major bleeding* Minor oozing of blood at puncture site was reported in 1 study there have been no reports of major bleeding* Pneumothorax and pneumomediastinum** Pneumothorax and pneumomediastinum** Have been reported with blind TBNA but no reports in literature with EBUS guided FNA. Have been reported with blind TBNA but no reports in literature with EBUS guided FNA. Bronchoscopy.org 15 Chest 2004;126; **Eur Respir J 2002; 19:356–373

16 16 Procedural Techniques and Results Aspirate cytology Adequate/representative: in presence of frankly malignant cells, lymphocytes, lymphoid tissue, or clusters of anthracotic pigment-laden macrophages* Adequate/representative: in presence of frankly malignant cells, lymphocytes, lymphoid tissue, or clusters of anthracotic pigment-laden macrophages* Inadequate/nonrepresentative : if there are no cellular components, scant lymphocytes (defined as <40 per HPF) blood only, or cartilage or bronchial epithelial cells only* ** Inadequate/nonrepresentative : if there are no cellular components, scant lymphocytes (defined as <40 per HPF) blood only, or cartilage or bronchial epithelial cells only* ** A quantitative cut off value of at least 30% of cellularity composed of lymphocytes has been arbitrarily proposed by some experts*** A quantitative cut off value of at least 30% of cellularity composed of lymphocytes has been arbitrarily proposed by some experts*** Higher yield may be obtained by obtaining aspirates from the periphery of nodes**** Higher yield may be obtained by obtaining aspirates from the periphery of nodes**** *Am J Clin Pathol 2008;130: ** Chest 2008;134; ; *** Chest 2004;126; ****Techniques in GI Endoscopy, Vol 2, No 3, 2000: pp

17 17 Procedural Techniques and Results Number of aspirates* if ROSE not utilized Number of aspirates* if ROSE not utilized Best yield with 3 aspirates per station (see table) Best yield with 3 aspirates per station (see table) Two aspirations per LN station are acceptable when at least one tissue core specimen is obtained. Two aspirations per LN station are acceptable when at least one tissue core specimen is obtained. Sensitivity 91.7%, NPV 96.0%, and accuracy 97.2% Sensitivity 91.7%, NPV 96.0%, and accuracy 97.2% If operator believes targeting is inadequate or insufficient another aspirate should be performed If operator believes targeting is inadequate or insufficient another aspirate should be performed Bronchoscopy.org 17 * Chest 2008;134; ;

18 18 Maximum results after 3 aspirates Chest 2008;134; Rapid On Site Cytology may assure greater yield but potentially prolongs procedure time and costs. Bronchoscopy.org

19 19 Procedural Techniques and Results Results and procedure-related complications Results and procedure-related complications EBUS-TBNA was performed under general anesthesia using a 9.0 endotracheal tube. EBUS-TBNA was performed under general anesthesia using a 9.0 endotracheal tube. 4L nodal cytology diagnostic for non small cell carcinoma (adenocarcinoma). 4L nodal cytology diagnostic for non small cell carcinoma (adenocarcinoma). Bronchoscopic inspection : swelling and erythema distal left upper lobe bronchus. Washing positive for adenocarcinoma. Bronchoscopic inspection : swelling and erythema distal left upper lobe bronchus. Washing positive for adenocarcinoma. There were no complications. There were no complications. Bronchoscopy.org 19

20 20 Bronchoscopy.org 20 Long-term Management Plan Outcome assessment Outcome assessment Patient was referred for multidisciplinary evaluation to include cardiothoracic surgery, oncology, and radiation oncology for potential trial enrollment for neoadjuvant treatment of stage IIIA adenocarcinoma of the lung.* Patient was referred for multidisciplinary evaluation to include cardiothoracic surgery, oncology, and radiation oncology for potential trial enrollment for neoadjuvant treatment of stage IIIA adenocarcinoma of the lung.* 5 year survival for IIIA non-small cell lung ca is 23%. 5 year survival for IIIA non-small cell lung ca is 23%. Follow-up tests and procedures Follow-up tests and procedures Patient will follow up in 2 weeks to ensure involvement of above specialties. Patient will follow up in 2 weeks to ensure involvement of above specialties. Referrals Referrals See above. See above. Quality improvement Quality improvement Diagnosis and N2 metastasis identified by single procedure. Diagnosis and N2 metastasis identified by single procedure. *Chest 2007;132;243S-265S

21 21 Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Q 1: Describe the yield of EBUS- TBNA versus conventional TBNA at station 4L. Bronchoscopy.org

22 22 Bronchoscopy International EBUS-TBNA vs. Conventional TBNA CHEST 2004; 125:322–325

23 The yield of EBUS-TBNA for diagnosing malignancy in station 4L is as high as 96% Bronchoscopy.org23 Herth F et al. Thorax 2006;61;

24 24 Q 2: Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. Bronchoscopy.org

25 25 Station 4L (left lower paratracheal) definition based on IASLC map Includes nodes to the left of the left lateral border of the trachea, medial to the ligamentum arteriosum. Upper border: upper margin of the aortic arch. Lower border: upper rim of the left main pulmonary artery. (J Thorac Oncol. 2009;4: 568–577) Both axial and coronal CT views are useful to define the borders of station 4L.

26 26 Bronchoscopy International CT views

27 27 Bronchoscopy International CT views: coronal A coronal (aka frontal) plane is perpendicular to the ground, which (in humans) separates the anterior from the posterior, the front from the back, the ventral from the dorsal A coronal (aka frontal) plane is perpendicular to the ground, which (in humans) separates the anterior from the posterior, the front from the back, the ventral from the dorsal

28 28 Bronchoscopy International AXIAL CORONAL SAGITTAL

29 Which CT view is most useful for planning EBUS-TBNA for station 4L? Bronchoscopy.org 29 To visualize the left paratracheal node (4L), the operator turns the bronchoscope laterally to the 9-oclock position and scans the area of lymph node station 4 L Bronchoscopy from head of patient

30 30 Bronchoscopy International The coronal CT view identifies the EBUS scanning plane Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006 cephalad caudal Ao PA LN The aortic arch is proximal and the left pulmonary artery is distal

31 Simultaneous coronal CT view and EBUS image at station 4L Bronchoscopy.org31 The EBUS image at station 4L shows this pattern CORONAL 4L

32 32Bronchoscopy International To understand the use of coronal CT view one must understand the reference points on the EBUS image cephalad caudal 1.The EBUS image is projected on the monitor as if the scope is horizontal 2.The green dot on the monitor represents the point where the needle exits the scope and corresponds to the superior (cephalad) aspect of the body 3.This dot is by default towards the 1oclock position of the screen

33 33Bronchoscopy International While the coronal CT view is displayed as if the scope is vertical cephalad caudal Ao PA LN Several adjustments can be made to the coronal CT image in order to bring the scope to a horizontal position, the green dot cephalad (towards the 1 oclock position on the screen) to match the EBUS image…

34 34Bronchoscopy International 1. Print out a single frame of the CT image 2. Rotate the CT image clockwise in order to horizontalize the scope and bring the green dot cephalad towards the 1 oclock position. caudal cephalad Aorta Pulmonary Artery Lymph node caudal cephalad Aorta Pulmonary Artery Lymph node caudal cephalad Aorta Pulmonary Artery Lymph node Step by Step

35 35 Bronchoscopy International The two images now correlate and show all structures in the same locations PA Ao LN caudal cephalad Aorta Pulmonary Artery Lymph node See how easy it is to identify the anatomic structures now ! This is a characteristic EBUS view of level 4 L

36 36 Identify 4L and surrounding vascular structures using EBUS. Q3: Identify 4L and surrounding vascular structures using EBUS. Bronchoscopy.org

37 37 Characteristic image of lymph node station 4 L Bronchoscopy.org

38 The lymph node is echogenic (circle) and vascular structures are anechoic (arrows) Bronchoscopy.org38

39 Because the green dot corresponds to the more cephalad, and therefore proximal aspect of the body)… Bronchoscopy.org39 The vascular structure at approximately 3 oclock is the Aorta (proximal) while the vascular structure at 9 oclock is the Pulmonary artery (distal) PA Aorta Cephalad/ proximal Caudal/ distal

40 40 Bronchoscopy.org 40 All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Practical Approach, an Electronic On- Line Multimedia Slide Presentation. Published 2009 (Please add Date Accessed). Thank you

41 41 Bronchoscopy.org 41 Prepared with the assistance Septimiu Murgu M.D., University of California, Irvine


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