EBUS Mediastinal Staging - Duke Surgery · EBUS – Mediastinal Staging 1 th2016 Duke Masters of...
Transcript of EBUS Mediastinal Staging - Duke Surgery · EBUS – Mediastinal Staging 1 th2016 Duke Masters of...
EBUS – Mediastinal Staging
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2016 Duke Masters of Minimally Invasive Thoracic Surgery Sep 15-17th, 2016
Kazuhiro Yasufuku MD, PhD
Director of Endoscopy, University Health Network
Director, Interventional Thoracic Surgery Program
Associate Professor of Surgery, University of Toronto
Division of Thoracic Surgery, Toronto General Hospital
Disclosure
• Industry-sponsored grants • Educational and research grants from Olympus Corporation
• Consultant • Olympus America Inc.
• Intuitive Surgical Inc.
• Covidien
• Johnson and Johnson
• Research Collaboration • Siemens
• Novadaq Corp.
• Veran Medical Systems
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Mediastinal Staging
• Non-invasive staging (Imaging) • CT, PET-CT
• Invasive staging (Tissue diagnosis) • Surgical biopsy (Med, VATS)
• Needle biopsy (TBNA, EBUS-TBNA, EUS-FNA, TTNA)
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Endoscopic Staging - EBUS-TBNA
• Access to all LN stations accessible by Med as well as N1 nodes
• A minimally invasive modality
• Sensitivity 85-96%
• Real time procedure
• Doppler mode enables differentiation of LN from vessels
• Adopted in over 2500 centers
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Hanna WC, Yasufuku K. Ther Adv Respir Dis. 2013; 7(2): 111-8
Convex Probe EBUS (Olympus)
Outer Diameter: 6.9 mm Scanning Range: 50 degrees Instrument Channel: 2.2 mm Optics: 35 degrees forward oblique
Division of Thoracic Surgery Toronto General Hospital
Convex Probe EBUS (Olympus)
Division of Thoracic Surgery Toronto General Hospital
EBUS-TBNA – Equipment (Olympus)
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EU-ME1
EU-C60 EU-ME2
EBUS - EB1970UK (Pentax Medical)
• 19 French
• 6.3mm Insertion Tube
• 2mm working channel
• Color CCD video images
• 45⁰ Forward Oblique
• Hitachi 5500 scanner
• 75⁰ Forward Oblique
• 5,6.5,7.5,9, 10 MHz options
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New Small Hitachi Linear Array Ultrasound Transducers
EBUS scope – EB-530US (FUJIFILM)
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Fujifilm Ultra Small Super CCD Chip
installed
10°forward oblique view
Wide Field of View: 120°
Φ6.3mm
Φ6.7mm
Φ2.0mm
NA-201SX-4022, 4021 (Olympus)
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21G and 22G needles
SonoTip EBUS Pro Flex (Medi-Globe)
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Dimensionally stable 22G Nitinol needle
Eliminates needle deformation
EchoTip ProCore EBUS Needles (Cook Medical)
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Core trap design to obtain tissue
22G and 25G
ExpectTM EBUS-TBNA Needles (Boston Scientific)
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22G and 25G
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Cell blocks often contain a “mini-core” of tumour.
Can be used for multiple immunohistochemical stains.
Can provide prognostic information (cell-cycle proteins, EGFR mutation).
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EBUS-TBNA
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Understanding the Mediastinum
Bronchoscopic Anatomy
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Carina
SVC
Esophagus
Azygos vein
Descending Aorta
Lt Upper Lobe Br
Lt Lower Lobe Br
Rt Upper Lobe Br
Tr Intermedius
PA
Ascending Aorta
A1,3
A3
A1+2 a,b
A1+2 c
A6
#3p #3p
#10
#10
#4L #4R
#10
#5
#6
#7
#4R
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Carina
#4R
#7
SVC
Azygos vein
Ascending Aorta
#4L #4R
PA
Descending Aorta
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Rt Main Bronchus
SVC
PA
Asc Aorta
Azygos Vein
#4R
#7
#10R
#11
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Rt Main PA
Rt SPV
Tr Intermedius
Rt Main Br
Rt Upper Lobe Br #7
Carina
#10R #12
#10R
#11
A1
A3
B1
B2
B3 V2
V3
V3
Rt Upper / Tr Intermedius
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Rt Upper / Tr Intermedius
#12R
#11R
#10R
Rt Upper Lobe Br
Rt Lower Lobe Br
Rt Main stem PA
SPV
A1 A2 A3
V1,2 V3
V4,5
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Rt Middle and Lower Lobe Br
Rt Main PA
A6b,c
A5
A4
A6a
Basalis PA
Rt IPV
V4,5
#12R
#12R
#10
#11R
#13
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Lt Main Br
Descending Aorta
Lt Lower Lobe Br
B1+2,3
Ascending Aorta
A3+A1+2a,b
A1+2 c
#10L #4L
#5
#6
#7
B4,5
A6
A4,5
Lt Main PA
#11
Basal A
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Lt Main Br
Aorta
Lt Main PA
#7
#4L
#10L
A3+A1+2a,b
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Lt Upper / Lower
Lt Lower Lobe Br
B1+2 A3+A1+2a,b
#12L
#12L #13
#10L
B4
A6
A4,5
Lt Main PA
#11L
Basal PA
B3
B5
#13
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Lt Upper / Lower
Lt Main PA
Lt SPV
Lt IPV
#10L
#10
#11L
#12
#12L
#13
A6
A4,5
A1+2c
A8
A3+A1+2a,b
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Trachea
#2L #4R
#2L
#2R
SVC Rt BCV
Lt BCV Rt BCA
Lt SCA
Aorta Azygos vein
#2R
Understanding the Mediastinum
EBUS Anatomy
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Stations 4R and 4L
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#4R
#7
SVC
Azygos vein
#4L #4R
PA
#10R
Stations 4R and 10R
Stations 4R, 2R and 2L
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Stations 7 and 11R
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EBUS-TBNA for Lung Ca Staging
• EBUS-TBNA Systematic Review and Meta-analysis • 22 studies
• >2000 patients
• Sensitivity: 0.88-0.93 (95% CI 0.79-0.94)
• Specificity: 1 (95% CI 0.92-1)
• Equivalent to Mediastinoscopy sensitivity, NPV, diagnostic accuracy
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Gu P. et al. Eur J Ca. 2009;45:11389-96 Adams K. et al. Throax. 2009;64:757-62
Zhang R. et al. Eur J Ca. 2013;49:1860-67
Lung ca staging (EBUS vs Med)
• Prospective cross-over trial (Ernst et al)
• Disagreement in the yield for #7 (24%; p=0.011)
• Prospective controlled study (Yasufuku et al)
• No difference between EBUS and Med
• Prospective controlled study (Um et al)
• EBUS superior to Med in sensitivity, accuracy and NPV (p<0.005)
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Ernst et al. J Thorac Oncol. 2008; 3: 577-82 Yasufuku et al. J Thorac Cardiovasc Surg. 2011 142: 1393-1400
Um SW et al. J Thorac Oncol. 2015; 10(2): 331-7
Sensitivity NPV
Study Year Number Prevalence of N2/N3 EBUS Med EBUS Med
Ernst et al 2008 66 89 87 68 78 59
Yasufuku et al 2011 153 32 81 79 91 90
Um et al 2015 127 59 88 81 85 79
Lung ca staging (EBUS vs VAM) – meta-analysis
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Ge Xet al. Lung. 2015; [Epub ahead of print]
• Quantitative meta-analysis of EBUS-TBNA (n=10) and VAM (n=7)
• Meta-regression applied after adjusting quality score, study design and LN station number
• Sensitivity
• EBUS 0.84 (95% CI 0.79-0.88) vs VAM 0.85 (95% CI 0.82-0.88)
• More procedural complications and fewer false negatives with VAM than EBUS
• EBUS-TBNA should be performed first, followed by VAM in the case of a negative needle result
Cost Effectiveness
• A decision-tree analysis to compare downstream costs of EBUS-TBNA, conventional TBNA and mediastinoscopy.
• EBUS-TBNA (-ve results surgically confirmed) most cost-beneficial approach (AU$2961)
• EBUS-TBNA (-ve results not surgically confirmed) ($3344)
• Conventional TBNA ($3754)
• Mediastinoscopy ($8859)
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Steinfort et al. J Thorac Oncol. 2010;5: 1564–1570
Changes of ACCP Guidelines – Mediastinal Staging
• 2007 ACCP Guidelines
• Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes
• A non-malignant result from a needle technique (eg, EUS-NA, TBNA, EBUS-NA, or TTNA) should be further confirmed by mediastinoscopy
• 2013 ACCP Guidelines
• In patients with high suspicion of N2,3 involvement, a needle technique (EBUS-NA, EUS-NA or combined EBUS/EUS-NA) is recommended over surgical staging as a best first test (Grade 1B)
• Remark: In cases where the clinical suspicion of mediastinal node involvement remains high after a negative result using a needle technique, surgical staging (eg, mediastinoscopy, VATS, etc) should be performed
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Advantages of EBUS over Med
• Outpatient setting under local anesthesia • Absence of neck scar • Access to N1 nodes • Less risk of morbidity • Less healthcare costs • Potential to streamline thoracic surgical capacity • Avoids unnecessary surgery in pts with infiltrating
mediastinal disease
Hanna W, Yasufuku K . Curr Respir Care Rep 2013
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De Leyn P et al. Eur J Cardiothorac Surg 2014;45:787-798
Revised ESTS guidelines for mediastinal staging
Summary • Accurate staging of the mediastinum remains essential for
management of patients with NSCLC
• The value of EBUS-TBNA as a diagnostic tool for LN staging of NSCLC has been established
• Understanding the anatomy of the mediastinum and the hilum is essential for performing a successful EBUS-TBNA
• EBUS-TBNA may be considered the first line procedure for pts with NSCLC with radiologic evidence of mediastinal adenopathy
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Thank you
Division of Thoracic Surgery
Toronto General Hospital
University Health Network
Kazuhiro Yasufuku, MD, PhD, FCCP