Role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS- TBNA) in the respiratory diseases

Pulmonary Department, Shanghai Chest Hospital Respiratory Endoscopy Clinic Base ,The Ministry of Health

Han Baohui

Lung cancer has replaced liver cancer to become the first cause of death in China

Accurate staging of the disease is important not only to determine the prognosis but also to decide the most suitable treatment plan

During the staging process, mediastinal lymph node staging is one of the most important factors that affect the patient outcome

Background

The role of EBUS- TBNA in the diagnosis and staging of lung cancer

Fig. A :EBUS –TBNA conceptual diagram

BneedleA

Realtime EBUS-guided TBNA was developed in 2002.

Fig.B: a realtime puncture was performed under EBUS

C

Fig.C: EBUS-TBNA obtained histological specimens.

EBUS-TBNA indications :

• lymph node staging in lung cancer patients;

• diagnosis of intrapulmonary tumors;

• diagnosis of unknown hilar and/or mediastinal

lymphadenopathy;

• diagnosis of mediastinal tumors.

The pooled sensitivity of real-time EBUS － TBNA in lung cancer is

90% , but the false negative rate is 20%;The sensitivity of

conventional TBNA was only 65% in our experience

More than 60 cases were examined by EBUS-TBNA since June 11,

2009 in our hospital ,the sensitivity in the diagnosis of lung cancer

was above 90% after finishing learning curve• Sun Jiayuan, Wang Jianhua, Han Baohui （ corresponder ） et al. Significance of transbronchial needle

aspiration (TBNA) in the diagnosis of bronchogenic carcinoma .Journal of Shanghai Jiaotong university

（ medical science ） 2008,28(12):1597 － 1599.

• Sun Jiayuan, Zhaoheng, Han Baohui （ corresponder ） et al. Clinical analyses of initial 30 cases

examined by endobronchial ultrasound-guided transbronchial needle aspiration: a single institution's early

learning curve (to be published )

Comparison of EBUS-TBNA and noninvasive methods

The sensitivities of CT, PET, and EBUS-TBNA for the correct diagnosis of mediastinal and hilar lymph node staging were 76.9%, 80.0%, and 92.3%, respectively;

Specificities were 55.3 %, 70.1%, and 100%, and diagnostic accuracies were 60.8%, 72.5%, and 98.0%.

EBUS-TBNA was un -eventful, and there were no complications.Yasufuku K, Nakajima T, Motoori K, et al. Chest 2006;130(3):710–8

Comparison of EBUS-TBNA and invasive methods

2 Toloza EM, Harpole L, Detterbeck F, et al. Chest 2003; 123 (1 Suppl):157S–166S.

3 Detterbeck FC, Jantz MA, Wallace M, et al. Chest 2007; 132 (3 Suppl):202S–220S.

4 Cybulsky IJ, Bennett WF. Ann Thorac Surg 1994; 58:176–178.

Comparison of EBUS-TBNA and mediastinoscopy

Current conclusion :When the prevalence of N2 or N3 disease was high, existing data favour EBUS but when it is moderate then cervical mediastinoscopy appears superior.

EBUS-TBNA-systematic review and meta － analysis

Gu P, Zhao YZ, Han BH (Corresponder),et al. European Journal of Cancer,2009;45(8):1389-96.

EBUS-TBNA for LN staging. 11 studies (n=1299) Sensitivity =0.93 (95% CI, 0.91-0.94),Specificity =100 (95% CI , 0.99-1.00) Study sensitivity not related to prevalence of LN metastasis

Future directions

1. Evaluating the whole mediastinum LN by combining EBUS-TBNA and EUS-FNA

2.Comparing the gold standard mediastinoscopy and EBUS-TBNA forlymph node staging.

3. EBUS-TBNA restaging of the mediastinum after the introduction of chemotherapy.

4. EBUS-TBNA samples will possibly provide molecular biological information that will be useful for the treatment of lung cancer.

Other applications

Lymphoma ： the reported diagnostic sensitivity is 91%

； Sarcoidosis ： the demonstration of non-caseating

granulomatous inflammation range from 85 － 94% ； Paratracheal and peri-bronchial tumors ： with a

diagnostic sensitivity of 82 － 94% ； Drain mediastinal and bronchogenic cysts and

consequently relieve central airway obstruction;

Tuberculosis: could diagnose the tuberculous

mediastinal lymphadenitis and intrapulmonary mass in

our experience.

• EBUS-TBNA 在 2008 年引入中国投入临床使用，我院于 2009 年 6 月引进该项设备和技术，在完成 5 例学习曲线训练后于 2009 年 7 月 10

日至 2010 年 2 月 24 日共行 EBUS-TBNA 检查 95 例，其中经病理学检查和临床随访验证肺癌病人 60 例

• 临床诊断结果： 60 例肺癌患者中， 非小细胞肺癌 50 例：低分化癌 12 例，鳞癌 16 例，腺癌 21 例；小细胞癌 8 例；低分化伴小细胞癌 3 例。

• 2.2 穿刺结果： 60 例病人共穿刺 112 组LN （ 2R 组 5 例次， 4R 组 28 例次， 4 L 组 10例次， 7 组 34 例次， 10L 组 5 例次， 10R 组9 例次 , 11L 组 4 例次， 11R 组 12 例次， 12R组 4 例次 , 12L 组 1 例次），肺内肿块 11 例（右上肺肿块 8 例次，右下肺肿块 3 例次），每个部位共进行 1 － 4 次穿刺，平均 1.98 次

60个实时 EBUS-TBNA病人穿刺纵隔 /肺门 LN和肺内肿块的位置和结果Table 1 Results of real-time EBUS-TBNA in 60 patients with mediastinal/hilar lymph nodes and intrapulmonary mass by location.

LN station/intrapulmonary mass Nodes/masses(n)

Cell smears positive

(n)

Tissue specimens positive

(n)

Total positive (n)

Nodes/

masses

diagnosed (%)

2R 5 5 4 5 100.00

4R 28 23 18 23 82.14

4L 10 7 8 8 80.00

7 34 27 14 28 82.35

10L 5 4 2 4 80.00

10R 9 7 5 7 77.78

11L 4 3 3 3 75.00

11R 12 7 6 7 58.33

12R 4 2 2 3 75.00

12L 1 1 1 1 100.00

right upper lobe 8 7 5 8 100.00

right lower lobe 3 1 1 2 66.67

Total 123 94 69 99 80.49

60 个实时 EBUS-TBNA 病人穿刺纵隔 / 肺门 LN 和肺内肿块的位置和结果

总 结

• Yasufuku 报道应用 EBUS-TBNA 对 70 个病人纵隔和肺门 LN 进行穿刺，区分良恶性纵隔 LN 的敏感性、特异性、准确率分别为 95.7% 、 100% 、和 97.1% [5] ； Herth 报道 502 例纵隔或肺门 LN 肿大患者，经EBUS-TBNA 穿刺 572 个 LN ，诊断敏感性为 94% 、特异性为 100% 、阳性预测值为 100%, 无并发症出现[6] ；多个研究表 EBUS-TBNA 诊断肺癌的平均敏感性是 90 ％，假阴性率是 20 ％ [7] 。传统 TBNA 根据 CT定位进行盲穿，结果变动较大，我们既往的一项回顾性研究提示传统 TBNA 诊断肺癌的敏感性为61.11% [8] ，而本研究中 EBUS-TBNA 诊断肺癌的敏感性为 96.67 ％，高于传统 TBNA

•Represent cases

Thank Thank youyou ！！