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Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer Staging: How EBUS Became a Game Changer
 

Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer Staging: How EBUS Became a Game Changer

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EBUS-TBNA, EUS-FNA or their combination have finally gained acceptance as the tests of first choice in mediastinal staging. In suspected non-small cell lung cancer, endobronchial ultrasound may be ...

EBUS-TBNA, EUS-FNA or their combination have finally gained acceptance as the tests of first choice in mediastinal staging. In suspected non-small cell lung cancer, endobronchial ultrasound may be preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy

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    Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer Staging: How EBUS Became a Game Changer    Endobronchial Ultrasound Guidance of TBNA. Current Approach To Lung Cancer Staging: How EBUS Became a Game Changer Presentation Transcript

    • Endobronchial Ultrasound Guidance of TBNA Current Approach To Lung Cancer Staging - How EBUS Became a Game Changer Bassel Ericsoussi, MD Pulmonary and Critical Care Consultant Franciscan Medical Specialists
    • Types of EBUS
    • Spatial Difficulties with Transbronchial Biopsy Using Monoplanar Fluoroscopy Only
    • Radial EBUS for Peripheral Pulmonary Lesions • Utilizes radial ultrasound probe • 1.7mm probe inserted through the working channel of a therapeutic bronchoscope • Frequency is 20Mhz
    • Radial EBUS
    • Radial EBUS
    • Washington University Experience with Radial EBUS • 446 of 467 (96%) nodules located using radial EBUS only • Overall diagnostic yield 69% • Diagnostic yield 84% when a concentric view was obtained vs 31% when an eccentric view was obtained
    • Radial EBUS Things to Look For
    • Combining Radial EBUS with ENB will Increase the Diagnostic Yield Am J Respir Crit Care Med 2007; 176:36-41
    • Radial EBUS Summary • Radial probe EBUS can be used to target peripheral nodules • Provides real-time feedback about location relative to peripheral nodules • Radial probe EBUS can complement existing methods of sampling peripheral nodules
    • Convex Probe EBUS Bronchoscope
    • Real-time Guidance of Transbronchial Needle Aspiration (EBUS-TBNA)
    • Understand the Orientation
    • Understand the Orientation
    • How EBUS Became a Game Changer • Minimally invasive • Ability to access nearly all nodal stations • Ability to combine diagnosis and staging in a single procedure • Equivalent (if not better) yield when c/w mediastinoscopy • Ability to provide adequate tissue for molecular analysis Ernst et al, J Thorac Oncol 2008; 3:577 Annema et al, JAMA 2010; 304: 2245
    • Conventional vs EBUS-TBNA • Randomized trial 200 patients • Level 7 nodes : no significant difference in diagnostic yield • Other mediastinal nodal stations: 58% vs 84% diagnostic yield ( conventional vs ebus ) Chest 2004; 125: 322-325
    • Conventional vs EBUS-TBNA Herth,Ernst. Chest 2004; 125:322-325
    • EBUS Vs. Standard TBNA In Patients With Suspected Sarcoidosis Tremblay et al, Chest 2009; 136:340-346
    • ABILITY TO ACCESS NEARLY ALL NODAL STATIONS
    • Lymph Node Map Update The International Association for the Study of Lung Cancer (IASLC) Lymph Node Map 2009 Accurate assessment of lymph node involvement is essential for staging and treatment of lung cancer.
    • Naruke Lymph Node Map Mountain-Dressler Japan Lung Cancer Society Modification of ATS Map
    • Conventional Mediastinoscopy Does not access : 1R and 1L: supraclavicular nodes 3A: prevascular nodes 5-6: Subaortic (AP window), para-aortic nodes 7 posterior 8: paraesophageal nodes 9: pulmonary ligaments nodes • 2R and 2L: right and left upper paratracheal nodes • 4R and 4 L: right and left lower paratracheal nodes • Station 7: subcarinal nodes (but not 7 posterior) Morbidity 2% Mortality 0.08%
    • Extended Mediastinoscopy Left Anterior Mediastinoscopy Chamberlain Procedure • Station 5: subaortic (AP window) LN • Station 6: paraaortic nodes • Contraindications: Far less easy and therefore less routinely performed than conventional mediastinoscopy - Mobidity 8% - Mortality < 1% – Calcified aorta – Post operative aorta
    • Endoscopic Ultrasound with Fine Needle Aspiration EUS-FNA Lower mediastinum LN • Station 7: subcarinal, including posterior subcarinal • Station 8: paraesophageal • Station 9: Pulmonary ligament • 3P: prevertebral • Left adrenal gland • Left liver lobe
    • Endobronchial Ultrasound Transbronchial Needle Aspiration EBUS-TBNA UIC Bassel Ericsoussi, MD 30
    • EQUIVALENT (IF NOT BETTER) YIELD WHEN C/W MEDIASTINOSCOPY
    • EBUS-TBNA VS. Mediastinoscopy • Prospective, crossover trial 66 patients • Biopsy results of paratracheal and subcarinal lymph nodes were compared • The prevalence of malignancy was 89% (59/66 cases) Ernst et al JTO 2008
    • EBUS-TBNA VS. Mediastinoscopy • Diagnostic yield: – EBUS 91% – Mediastinoscopy 78% – p = 0.007 • EBUS the sensitivity, specificity, and negative predictive value were 87, 100, and 78%, respectively • Mediastinoscopy the sensitivity, specificity, and negative predictive value were 68, 100, and 59%, respectively Ernst et al JTO 2008
    • EBUS-TBNA VS. Mediastinoscopy In suspected non-small cell lung cancer, endobronchial ultrasound may be preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy Ernst et al JTO 2008
    • ABILITY TO PROVIDE ADEQUATE TISSUE FOR MOLECULAR ANALYSIS
    • Adequacy Of Sample For Molecular Studies • EBUS-TBNA samples of enlarged mediastinal and hilar nodes obtained are Adequate in quantity and quality for genetic and molecular subtyping in upwards of 90% and 77% of samples respectively. • Samples collected with this technique were found to be just as good as other sampling meth-ods such as mediastinscopy. Nivani N et al:Am J Respir Crit Care Med. 2012;185 (12):1316-132 Nakajima T et al. Ann Thorac Surg. 2012; 94:2097-2101
    • EBUS for Mutation Analysis • Retrospective analysis of 209 cytology specimens from patients with lung cancer at MD Anderson – 99 EBUS samples – 67 TTNA samples – 27 body fluid samples – 10 ultrasound-guided FNA of superficial sites • DNA sequencing for EGFR and KRAS performed on all specimens Billah S, et al. Cancer Cytopathol. 2011;119(2):111-117
    • EBUS for Mutation Analysis • EGFR found in 19% (29% of adeno) • kRAS in 24% • Overall specimen insufficiency rate was low: 6.2% – Body fluid: 3.7% – EBUS: 4% – TTNA: 7.5% – US-guided superficial FNA: 10% Billah S, et al. Cancer Cytopathol. 2011;119(2):111-117
    • EBUS for Multi-Gene Mutational Analysis • Review of 156 EBUS cases – 22ga needle – formalin fixed core split for cytopath analysis & Alloprotect Tissue Reagent – needle flushed with NS for cytology / cell block – EGFR: PCR – kRAS & p53: direct sequencing Nakajima T, et al. Chest 2011; 140: 1319
    • EBUS for Multi-Gene Mutational Analysis • EGFR analysis was possible in 98.7% – + in 26.9% (46% of female, non-smokers w/adeno) – gefitinib  PR of 54%, disease control (PR + stable disease 86%) • kRAS: + in 3.5% (all male, smokers) • p53: + in 41.6% (70% had adenoCA) – associated w/significant chemoresistance Nakajima T, et al. Chest 2011; 140: 1319
    • Does Needle Size Matter • Nakajima: 33 patients – no difference in yield – better histologic preservation w/21ga – more blood contamination • Saji: 56 patients – 21 is better • Yarmus / Aquire: 1299 patients – no difference in adequacy or yield • Above are for Dx, no data on markers (yet) Saji et al, J Bronchol & Intervent Pulmol 2011; 18:239 Nakajima et al, Respirology 2011; 16:90 Yarmus et al, CHEST 2013; 143:1036
    • EBUS Strategy • Sample from more than one nodal station • Choose most advanced nodal station ( N3 vs N2 vs N1) • Lymphnodesize > 1cm • Non-necrotic appearing • Number of passes : range of 3 - 5
    • EBUS-TBNA: How Many Aspirates Per Lymph Node? • A study of EBUS-TBNA in 163 Mediastinal LN stations in 102 NSCLC patients • Sample adequacy was: – 90.1% for one aspiration – 100% for three aspirations – The sensitivity for differentiating malignant from benign LN stations was 69.8%, 83.7%, 95.3%, and 95.3% for one, two, three, and four aspirations, respectively. – Maximum diagnostic values were achieved in three aspirations Lee. H.S. CHEST 2008; 134:368–374
    • # of Passes • For diagnosis: 3 needle passes • For markers: – 90 patients diagnosed with adenoCA via EBUS – 94% adequacy for mollecular analysis with 5 needle passes Seok Lee et al, Chest 2008; 134:368 Yarmus etl al, Ann Am Thorac Soc [in press]
    • EBUS Number of Passes • Plateau in yield at 7 passes Am J Respir Crit Care Med 2002,166: 377-381 • ** 3 transbronchial needle passes established a tissue diagnosis • ** 4 – 5 passes for lung cancer staging Eur Respir J 2007; 29: 112-116
    • Conclusions • Histologic subtyping and mutation analysis are critical steps in the evaluation of patients with NSCLC • Communication between oncologist, pathologist, and pulmonologist is a key to effective use of molecular analysis. • As the majority of patients with NSCLC are not surgical candidates, EBUS FNA is a less invasive means of tissue acquisition for molecular analysis.
    • The American College of Chest Physicians Lung Cancer Guidelines (3rd Ed) Editorial • EBUS-TBNA, EUS-FNA or their combination have finally gained acceptance as the tests of first choice in mediastinal staging. • More complete staging improves outcomes. • Safer and cheaper than mediastinoscopy without compromising accuracy (pooled sensitivities of 89%, 89%, and 91% (for EUS, EBUS, and combined EUS/EBUS respectively).
    • Talk to Your Patient • Discuss the risks and benefits of alternative management strategies and elicit patient preferences