ENDOBRONCHIAL ULTRASOUND

Associate Professor Erdoğan Çetinkaya

Yedikule Hospital of Chest Diseases and Thoracic Surgery

Presentation • Introduction to endobronchial ultrasound• Endobronchial ultrasound equipment

– EBUS-RP– EBUS-CP

• Indications for endobronchial ultrasound– Evaluating the invasion of bronchial wall– Diagnostic value of EBUS-guided TBNA in mediastinal

and hilar lymph nodes– Role of EBUS-guided TBNA in staging of lung cancer– Results of our study– EBUS-guided transbronchial lung biopsy in peripheral

lesions• Summary

• Ultrasound imaging depends on the the capacity of tissues with different impedans according to variations in transmitting ,absorption, and reflecting the ultrasound waves

Endobronchial Ultrasonound

Endobronchial Ultrasonound

-2.8 mm inner diameter bronchoscope

-2 mm diameter balloon-tipped catheter

-Miniprobe 20 Mhz rotating 360 degree

-Axial scanning

-Penetration depth 4 cm

Endobronchial Ultrasound- EBUS-RP

Endobronchial Ultrasound- EBUS TBNA Scope

-7,5-10 Mhz

-linear scanning

-Power Doppler

-Real-time monitoring the needle

• Defining the infiltration of the airway

• Viewing mediastinal structures or lesions adjacent to the air way

• Guiding the transbronchial needle aspiration

• Guiding transbronchial lung biopsy in peripheral lesions

Endobronchial Ultrasound (EBUS)Indications

Bronchial wall shows 5-7 ecographic layer

Bronchial Wall-ECHOENDOSCOPY

Showing the depth of invasion in early stage cancer

Pathological correlation > 95 %

Kurimoto N. Chest 1999; 115:1500-1506

Insitu carsinoma-EBUSInsitu carsinoma-EBUS

In carcinoma insitu , addition of EBUS in evaluation of airway defines the best

patient group whom benefits from treatment

EBUS CT

Sensitivity 89% 28%Specifity 100 % 80% Accuracy 0,94 0,51

EBUS is highly accurate diagnostic tool and superior to chest CT evaluating

the question of airway involvement by central intrathoracic tumor

n=105

Herth F et al. Chest 2003; 123:458-462

EBUS- airway compression? infiltration ?

EBUS- airway compression? infiltration?

• In 2446 interventional bronchoscopy patients EBUS was used in 1174– %29 mechanical debridement– %20 stent application– %13 Nd-YAG laser– %23 Argon Plasma Coagulation– %11 brachitherapy– %2 foreign body removal– %2 endoscopic abcess drainage

• EBUS guided and changed treatment in 43% of the patients

Herth et al. Eur Respir J. 2002;20:118-121

Interventional Bronchoscopy-EBUS

1, 2R, 2L, 3, 4R, 4L, subcarinal 1, 2R, 2L, 3, 4R, 4L, subcarinal mediastinal lymph nodesmediastinal lymph nodes

10, 11 hilar lymph nodes10, 11 hilar lymph nodes

EBUS TBNA scope

EBUS TBNA scope

EBUS-RPEBUS-RP

EBUS-guided TBNA in mediastinal and hilar lymph nodes and in staging of lung cancer

100

50 EBUS-guided 50 conven.

40 diagnostic 36 diagnostic

(80 %) (72 %)ns

TBNA subcarinal

Herth et al., Chest, 2004;125:322-325

Conventional & EBUS-guided TBNA

TBNA paratracheal 100

50 EBUS-guided 50 conven.

42 diagnostic 29 diagnostic

(74 %) (56 %)p < 0,001

Herth et al., Chest, 2004;125:322-325

EBUS-guided TBNA compared with conventional method, decreased the number of needle puncture and increases the diagnostic value in paratracheal lymph nodes

Conventional & EBUS-guided TBNA

• 55 patients

• Randomized 30 EBUS-CP TBNA 25 EBUS-RP

• The diagnostic accuracy rate of EBUS-CP (97%) and EBUS-RP(76%) were statistically significantly different

• The mean number of penetrations was 1.24 in the EBUS-CP group and 1.36 in the EBUS-RP group.

Kanoh et al.Chest 2005; 128:388–393

EBUS-RP&

EBUS-CP TBNA scope

year number diagnosis

of cases

Herth 2003 242 %71(RP)

Krasnik 2003 35 %92(CP)

Yasufuku 2003 17 %89(CP)

Yasufuku 2004 67 %91(CP)

Rintoul 2004 39 %90(CP)

Herth 2005 502 %92(CP)

Oki 2007 14 %93(CP)

Diagnostic value of EBUS-guided TBNA in mediastinal and hilar lymph nodes

Sensitivity specifity PPV NPV Accuracy

% % % % %

CT 76.9 55.3 37 87.5 60.8PET 80. 70.1 46.5 91.5 72.5

Comparison of EBUS-TBNA, CT and PET in staging of lung cancer

n:102

Yasufuku et al. Chest 2006;130:710-718

EBUS-TBNA 92.3 100 100 97.4 98.0

EBUS TBNA

Mediastinoscopy

EUS-TBNA &VATS

CT >10 mm lymph node&PET (+) lymph node _

CT>10 mm lymph node

&PET (+) lymph

node5,8,9

2R, 2L, 4R, 4L,Subcarinal, hilar

< 10 mm lymph node in CTPET (-) EBUS-TBNA• N=100 NSLC, • mean lymph node 7.9 mm (156 lymph node 5-10 mm)• lymph node positive in 8 cases(1 case N3, 5 cases N2,

2 cases N1)

Sensitivity Specifity NPV

EBUS-TBNA %89 %100 %98.9

Felix H et al.Chest 2008;133:887-891

Pathological lymph nodes in CT (-/+) and mediastinal invasion in PET(-/+) All NSLC patients should be evaluated with EBUS-TBNA for preoperative staging.

EBUS-TBNA after neoadjuvant chemotherapy

• 83 patients treated with neoadjuvant chemotherapy due to N2 disease

Sensitivity Specifity

EBUS-TBNA %70 %100

EBUS-TBNA to is a suitable method to evaluate mediastinal lymph nodes after neoadjuvant chemotheraphy.

Herth et al., ATS 2006

Probe year number of

cases

Sens%

Spec%

PPV NPV Accuracy%

Okamoto RP-EBUS 2002 37(16) 67 92 88Rintoul CP-EBUS

TBNA2005 18 85 100 89

Yasufuku CP-EBUS TBNA

2005 105 94.6 100 100 89.5 96.3

Faber CP-EBUS TBNA

2006 20 100 100 100 100 PET(+)

olgular

Plat RP-EBUS 2006 33 25/33(%76) surgical staging wasnt needed PET(+)

olgular

Vincet CP-EBUS TBNA

2008 117 98.7 100 97

Felix CP-EBUS TBNA

2008 100 89 100 98.9 PET(-), CT(-)

stage I NSLC

Role of EBUS-guided TBNA in staging of lung cancer

n:57%97 adequate material

35 diagnostic 22 staging(%77) 15 (%68) sarcoidosis%84.6

EBUS-guided EBUS-guided TBTBNANA

No need for further invasive staging

methodsdiagnostic

First experience in EBUS-guided TBNA

Endobronchial US- case

N. K, 40 y, F

Endobronchial US- case

X100 PAP

X400 PAP

EBUS in peripheral lesions

Radial probe

20 Mhz

With or without baloon

  

< 3 cm > 3 cm

Patients (n)(50) 21 29 EBUS n, (%) 17 (% 80) 23 (%79) Fluorosc n, (%) 12 (% 57) 26 (%89)

n.s.p < 0,001

Herth et al., Eur Respir J, 2002;20:972-974

EBUS & Fluoroscopy guided

Transbronchial biopsy

EBUS guided Brushing and TBB

• 150 patients• Peripheral pulmonary lesions

– < 3cm 124 , – >3 cm 26

• Fluoroscopy assisted

• 136/150 (76%) patients’ lesions could be visualized by EBUS

• 116/150 (77%) diagnostic value– < 3cm 92/124 , %74– >3 cm 24/26, 92 %

Kurimoto et al. Chest 2004;126:956-965

Transbronchial biopsy using EBUS and Virtual Bronchoscopic Assisted

• 29 patients with 30 lesions

• Peripheral pulmonary lesions mean 1.86 cm

• Virtual bronchoscopy assisted

• 24/30 (%80) patients’ lesions could be visualized by EBUS

• 19/30 (63.3%) diagnostic value

Asahina et al.Chest 2005;128:1761-1765

• 55 year old male patient.

• Biopsy: Adenocarcinoma

Eberhardt R Am J Respir Crit Care Med 2007;176(1):36-41

Multimodality approach to peripheral lung lesions EMN/EBUS

EBUS EMN EMN+EBUS

N=118 %69 %59 %88

EMN and EBUS case

ENDOBRONCHIAL ULTRASOUND Summary

• A New and attractive method.• Used in diagnosis ,staging and

interventional treatment .• Useful method in evaluating the

parabronchial area• Has a important effect on decisions about

treatment• Difficult anatomy, learning time?