Endobronchial Ultrasound Guidance of TBNA
Current Approach To Lung Cancer Staging
- How EBUS Became a Game Changer Bassel ...
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...
Radial EBUS
Radial EBUS
Washington University Experience
with Radial EBUS
• 446 of 467 (96%) nodules located using radial
EBUS only
• Overall diag...
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 locat...
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 dia...
Conventional vs EBUS-TBNA
• Randomized trial 200 patients
• Level 7 nodes : no significant difference in
diagnostic yield
...
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 ass...
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 ...
Extended Mediastinoscopy
Left Anterior Mediastinoscopy
Chamberlain Procedure
• Station 5: subaortic (AP
window) LN
• Stati...
Endoscopic Ultrasound with Fine Needle Aspiration

EUS-FNA
Lower mediastinum LN
• Station 7: subcarinal,
including posteri...
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
l...
EBUS-TBNA VS. Mediastinoscopy
• Diagnostic yield:
– EBUS 91%
– Mediastinoscopy 78%
– p = 0.007

• EBUS the sensitivity, sp...
EBUS-TBNA VS. Mediastinoscopy
In suspected non-small cell lung cancer,
endobronchial ultrasound may be preferred in
the hi...
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...
EBUS for Mutation Analysis
• Retrospective analysis of 209 cytology
specimens from patients with lung cancer at
MD Anderso...
EBUS for Mutation Analysis
• EGFR found in 19% (29% of adeno)
• kRAS in 24%
• Overall specimen insufficiency rate was low:...
EBUS for Multi-Gene Mutational Analysis
• Review of 156 EBUS cases
– 22ga needle
– formalin fixed core split for cytopath ...
EBUS for Multi-Gene Mutational Analysis
• EGFR analysis was possible in 98.7%
– + in 26.9% (46% of female, non-smokers w/a...
Does Needle Size Matter
• Nakajima: 33 patients
– no difference in yield
– better histologic preservation w/21ga
– more bl...
EBUS Strategy
• Sample from more than one nodal station
• Choose most advanced nodal station ( N3 vs
N2 vs N1)
• Lymphnode...
EBUS-TBNA: How Many Aspirates Per
Lymph Node?
• A study of EBUS-TBNA in 163 Mediastinal LN
stations in 102 NSCLC patients
...
# of Passes
• For diagnosis: 3 needle passes
• For markers:
– 90 patients diagnosed with adenoCA via EBUS
– 94% adequacy f...
EBUS Number of Passes
• Plateau in yield at 7 passes
Am J Respir Crit Care Med 2002,166: 377-381

• ** 3 transbronchial ne...
Conclusions
• Histologic subtyping and mutation analysis are
critical steps in the evaluation of patients with
NSCLC
• Com...
The American College of Chest
Physicians Lung Cancer Guidelines
(3rd Ed) Editorial
• EBUS-TBNA, EUS-FNA or their combinati...
Talk to Your Patient
• Discuss the risks and benefits of alternative
management strategies and elicit patient
preferences
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
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
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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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 preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy

Published in: Health & Medicine

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

  1. 1. 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
  2. 2. Types of EBUS
  3. 3. Spatial Difficulties with Transbronchial Biopsy Using Monoplanar Fluoroscopy Only
  4. 4. 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
  5. 5. Radial EBUS
  6. 6. Radial EBUS
  7. 7. 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
  8. 8. Radial EBUS Things to Look For
  9. 9. Combining Radial EBUS with ENB will Increase the Diagnostic Yield Am J Respir Crit Care Med 2007; 176:36-41
  10. 10. 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
  11. 11. Convex Probe EBUS Bronchoscope
  12. 12. Real-time Guidance of Transbronchial Needle Aspiration (EBUS-TBNA)
  13. 13. Understand the Orientation
  14. 14. Understand the Orientation
  15. 15. 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
  16. 16. 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
  17. 17. Conventional vs EBUS-TBNA Herth,Ernst. Chest 2004; 125:322-325
  18. 18. EBUS Vs. Standard TBNA In Patients With Suspected Sarcoidosis Tremblay et al, Chest 2009; 136:340-346
  19. 19. ABILITY TO ACCESS NEARLY ALL NODAL STATIONS
  20. 20. 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.
  21. 21. Naruke Lymph Node Map Mountain-Dressler Japan Lung Cancer Society Modification of ATS Map
  22. 22. 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%
  23. 23. 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
  24. 24. 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
  25. 25. Endobronchial Ultrasound Transbronchial Needle Aspiration EBUS-TBNA UIC Bassel Ericsoussi, MD 30
  26. 26. EQUIVALENT (IF NOT BETTER) YIELD WHEN C/W MEDIASTINOSCOPY
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. ABILITY TO PROVIDE ADEQUATE TISSUE FOR MOLECULAR ANALYSIS
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. # 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]
  40. 40. 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
  41. 41. 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.
  42. 42. 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).
  43. 43. Talk to Your Patient • Discuss the risks and benefits of alternative management strategies and elicit patient preferences

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