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#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 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. Bronchoscopy.org

2Bronchoscopy.org 2

Case description (practical approach # 8)

►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.

►Patient is referred for diagnosis and staging

3Bronchoscopy.org 3

Case description (practical approach #8)

1.5 cm left paratracheal lymph node

Axial CT view Coronal CT view

4

Bronchoscopy.org4

The Practical Approach

Initial Evaluation Procedural Strategies

Techniques and Results

Long term Management

• Examination and, functional status

• Significant comorbidities

• Support system• Patient preferences and

expectations

• Indications, contraindications, and results

• Team experience • Risk-benefits analysis and

therapeutic alternatives• Informed Consent

• Anesthesia and peri-operative care

• Techniques and instrumentation

• Anatomic dangers and other risks

• Results and procedure-related complications

• Outcome assessment• Follow-up tests and

procedures• Referrals• Quality improvement

5

Bronchoscopy.org5

Initial Evaluations►Exam

►Decreased air entry bilaterally and prolonged exhalation

►WHO functional status II

►Comorbidities►COPD, Coronary artery disease

►Support system►Lives with wife at home

►Patient preferences►Desires diagnosis and considers all available

active treatment options.

6

Procedural Strategies► Indications

Invasive lymph node staging?►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)

Bronchoscopic inspection can be performed at the time of EBUS-TBNA.

Diagnosis and staging can be performed during a single procedure.

Bronchoscopy.org6

*Ann Thorac Surg 2007;84:177-181**J Thorac Cardiovasc Surg 2006;131:822-829*** Eur J Cardiothorac Surg. 2007 Jul;32(1):1-8

77

Procedural Strategies► Indications

Obtain tissue diagnosis Sample 4L (left paratracheal node) for staging purposes

► 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

► Mediastinal nodal involvement suggests stage IIIA or IIIB inoperability and/or 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.

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Procedural Strategies► Contraindications:

►None► Expected Results: ► 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%)*► Experienced team and operator► Risks-benefits:

►No serious complications reported in the literature.

►Agitation, cough, and presence of blood at puncture site reported infrequently.**

►Benefits: accurate, safe and same day procedure.

Bronchoscopy.org8

*Chest 2004; 125:322–325**Eur Respir J 2009; 33: 1156–1164

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Procedural Strategies

►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%)*

►EUS-FNA( esophageal ultrasound reaches 4L node; Sensitivity 81-97% Specificity 83-100% **

►Mediastinoscopy: considered gold standard. Bronchoscopic airway inspection would still be

required►VATS: most invasive of alternatives.

►Only provides access to ipsilateral nodes. 75% sensitivity***.

►Benefits include definitive lobar resection at same time if node negative.

9

*Chest. 2003; 123: 157-66 **Lung Cancer. 2003; 41: 259-67***Chest 2007;132;202-220

For station 4L, EBUS-TBNA and EUS-FNA have similar diagnostic rates

Bronchoscopy.org 10

Am J Respir Crit Care Med Vol 171. pp 1164-1167, 2005

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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;596-601****Lung Cancer 64 (2009) 127–128*****J Bronchol 2008; 15:127-128****** Southern Medical Journal 2008;101,No5;534-38

Bronchoscopy.org

12

Procedural Strategies

► Informed consent: ►There were no barriers to learning identified. Patient has

good insight into his disease and realistic expectations.

BI #. Practical Approach Title 12

Drawing from Herth FJ et al. J Bronchol Volume 13, Number 2, April 2006

EBUS image from patient.

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Bronchoscopy.org13

Procedural techniques and resultsAnesthesia and perioperative care

► Conscious (moderate) sedation►May be performed in bronchoscopy suite►Cost savings compared to general anesthesia.►Visualization and biopsy of smaller nodes technically more

difficult than with general anesthesia.

► General anesthesia with LMA (#4 or 4.5 )►Better visualization of higher nodes ( station 1 and 2)

compared with ET tube►May be performed in bronchoscopy suite►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)

►Usually performed in OR . ►EBUS scope directed more centrally in airway which may

make biopsies more difficultChest 2008;134;1350-1351

J Cardiothorac Vasc Anesth 2007; 21:892–896

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Procedural Techniques and Results

► Instrumentation EBUS scope- direct real time US imaging with

curved array ultrasound transducer incorporated in distal end of bronchoscope

Ultrasound processor►Adjustable gain and depth►B mode and Doppler capabilities

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

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Procedural Techniques and Results

►Anatomic dangers and other risks►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►“Minor” oozing of blood at puncture site was

reported in 1 study there have been no reports of major bleeding*

►Pneumothorax and pneumomediastinum**

►Have been reported with blind TBNA but no reports in literature with EBUS guided FNA.Bronchoscopy.org 15

Chest 2004;126;122-128**Eur Respir J 2002; 19:356–373

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Procedural Techniques and Results► Aspirate cytology

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* **

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****

*Am J Clin Pathol 2008;130:434-443**Chest 2008;134;368-374;***Chest 2004;126;1005-1006****Techniques in GI Endoscopy, Vol 2, No 3, 2000: pp 136-141

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Procedural Techniques and Results

► Number of aspirates* if ROSE not utilized 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.

Sensitivity 91.7%, NPV 96.0%, and accuracy 97.2%

If operator believes targeting is inadequate or insufficient another aspirate should be performed

Bronchoscopy.org17

* Chest 2008;134;368-374;

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Maximum results after 3 aspirates

Chest 2008;134;368-374

Rapid On Site Cytology may assure greater yield but potentially prolongs procedure time and costs.Bronchoscopy.org

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Procedural Techniques and Results

►Results and procedure-related complications EBUS-TBNA was performed under general

anesthesia using a 9.0 endotracheal tube. 4L nodal cytology diagnostic for non small

cell carcinoma (adenocarcinoma). Bronchoscopic inspection : swelling and

erythema distal left upper lobe bronchus. Washing positive for adenocarcinoma.

There were no complications. Bronchoscopy.org 19

20Bronchoscopy.org 20

Long-term Management Plan► 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.*

5 year survival for IIIA non-small cell lung ca is 23%.► Follow-up tests and procedures

Patient will follow up in 2 weeks to ensure involvement of above specialties.

► Referrals See above.

► Quality improvement Diagnosis and N2 metastasis identified by single

procedure.

*Chest 2007;132;243S-265S

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Q 1: Describe the yield of EBUS-TBNA versus conventional TBNA

at station 4L.

Bronchoscopy.org

22

22Bronchoscopy International

EBUS-TBNA vs. Conventional TBNA

CHEST 2004; 125:322–325

The yield of EBUS-TBNA for diagnosing malignancy in station 4L is as high as

96%

Bronchoscopy.org 23

Herth F et al. Thorax 2006;61;795-798

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Q 2: Describe how the coronal view of a computed tomography

scan can be used to help plan the procedure.

Bronchoscopy.org

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.

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26Bronchoscopy International

CT views

http://en.wikipedia.org/wiki

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27Bronchoscopy 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

http://en.wikipedia.org/wiki

28Bronchoscopy International

http://en.wikipedia.org/wiki/

AXIAL

CORONALSAGITTAL

Which CT view is most useful for planning EBUS-TBNA for station

4L?

Bronchoscopy.org29

To visualize the left paratracheal node (4L), the operator turns the bronchoscope laterally to the 9-o’clock position and scans the area of lymph node station 4 L.

9

12

Bronchoscopy from head of patient

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30Bronchoscopy 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

Simultaneous coronal CT view and EBUS image at

station 4L

Bronchoscopy.org 31

The EBUS image at station 4L shows this pattern

CORONAL

4L

32Bronchoscopy International

To understand the use of coronal CT view one must understand the reference points on the

EBUS image

cephaladcaudal

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 1’o’clock position of the screen

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 thescope to a horizontal position, the green dot cephalad (towards the 1 o’clock position on the screen) to match the EBUS image…

34Bronchoscopy International

1. Print out a single frame of the CT image2. Rotate the CT image clockwise in order to horizontalize the scope and bring the green dot cephalad towards the 1 o’clock position.

caudal

cephalad

Aorta

PulmonaryArtery

Lymph node caudal

cephalad

Aorta

Pulmonary

Artery

Lymph

node

cau

dal

cep

hala

d

Aorta

Pulm

onary

Artery

Lymph

node

Step by Step

35Bronchoscopy International

The two images now correlate and show all structures in the same

locations

PAAo

LN

cau

dal

cep

hala

d

Aorta

Pulm

onary

Artery

Lymph

node

See how easy it is to identify the anatomic structures now !

This is a characteristic EBUS view of level 4 L

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

Bronchoscopy.org

37

Characteristic image of lymph node station 4 L

Bronchoscopy.org

The lymph node is echogenic (circle) and vascular structures are

anechoic (arrows)

Bronchoscopy.org 38

Because the green dot corresponds to the more cephalad, and therefore proximal aspect

of the body)…

Bronchoscopy.org 39

The vascular structure at approximately 3 o’clock is the Aorta (proximal)while the vascular structure at 9 o’clock is the Pulmonary artery (distal)

PAAorta

Cephalad/proximal

Caudal/distal

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Bronchoscopy.org40

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. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2009 (Please add “Date Accessed”).

Thank you

41Bronchoscopy.org 41

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

www.bronchoscopy.org