11 #10. Planning EBUS-TBNA of subcarinal lymph node (station 7) Describe how the coronal view of a computed tomography scan can be used to help plan the

11

#10. Planning EBUS-TBNA of subcarinal lymph node (station 7)

► Describe how the coronal view of a computed tomography scan can be used to help plan the procedure.

► What is the yield of EBUS-TBNA versus conventional TBNA for Sarcoidosis.

► Describe the clinical implications of granulomatous inflammation detected on nodal histology.Bronchoscopy.org

2Bronchoscopy.org 2

Case description (practical approach # 10)

► A 72 year old male with a 25 pack-year history of smoking presents with cough.

► Past medical history: COPD (FEV1 40% predicted) and right toe amputation for melanoma 5 years earlier.

► Computed tomography shows a 2.5 X 2.7 cm subcarinal lymph node.

► PET scan = increased activity ( SUV max 6)

► Patient is referred for diagnosis.

3Bronchoscopy.org 3

Case description (practical approach #10)

Subcarinal lymph node on axial and coronal CT views

Axial CT view Coronal CT view

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Bronchoscopy.org4

The Practical Approach

Initial Evaluation Procedural Strategies

Techniques and Results

Long term Management

• Examination and, functional status

• Significant comorbidities

• Support system• Patient preferences and

expectations

• Indications, contraindications, and results

• Team experience • Risk-benefits analysis and

therapeutic alternatives• Informed Consent

• Anesthesia and peri-operative care

• Techniques and instrumentation

• Anatomic dangers and other risks

• Results and procedure-related complications

• Outcome assessment• Follow-up tests and

procedures• Referrals• Quality improvement

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Bronchoscopy.org5

Initial Evaluations►Exam

►Decreased air entry bilaterally and prolonged exhalation

►WHO functional status I

►Comorbidities►COPD

►Support system►Lives with wife at home

►Patient preferences►Desires diagnosis and treatment of his cough

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Procedural Strategies

►Indications Sample station 7(subcarina)

►Common differential diagnosis of mediastinal lymphadenopathy is:

►Metastatic primary lung carcinoma►Metastatic extrapulmonary carcinoma

►Lymphoma►Tuberculosis►Sarcoidosis

Bronchoscopy.org6

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Procedural Strategies► Contraindications:

►None► Experienced team and operator► Risks-benefits:

►No serious complications reported in the literature.

►Agitation, cough, and presence of blood at puncture site reported infrequently.**

►Benefits: accurate, safe and same day procedure.►Level 7 could be sampled by conventional TBNA

or Mediastinoscopy.

Bronchoscopy.org7

*Chest 2004; 125:322–325**Eur Respir J 2009; 33: 1156–1164

8 Bronchoscopy International

Techniques and results

► Previous malignancy: expected results► EBUS in PET positive lymph nodes

N=73 lymph nodes were tested by EBUS-TBNA on 48 consecutive patients, each patient underwent to mediastinoscopy or thoracoscopy immediately after needle aspiration for histological confirmation.

sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 97.4%, 100%, 100%, 87.5%, and 97.7% respectively.

Noscoti M, Surg Endoscopy, 2008


Techniques and results► Primary lung carcinoma: expected

results► Metanalysis: A total of 11 studies with 1299

patients, who fulfilled all of the inclusion criteria, were considered for the analysis. No publication bias was found. EBUS-TBNA had a pooled sensitivity of 0.93

(95% CI, 0.91–0.94) and a pooled specificity of 1.00 (95% CI, 0.99–1.00).

► The subgroup of patients who were selected on the basis of CT or PET positive results had higher pooled sensitivity (0.94, 95% CI 0.93–0.96) than the subgroup of patients without any selection of CT or PET (0.76, 95% CI 0.65–0.85) (p < 0.05). EUROPEAN JOURNAL OF CANCER ( 2 0 0 9 )


►For lymphoma EBUS-TBNA has a: Sensitivity- 90.9% Specificity- 100% Positive predictive value- 100% Negative predictive value- 92.9% study of nodes > 5 mm and SUV max >

4

Kennedy MP, et al, Thorax. 2008 Apr



►Tuberculosis: expected results No published studies on the role of EBUS-

TBNA for tuberculosis as of 9/2009 Conventional TBNA, however, has a

sensitivity of 83%, specificity of 100%, positive predictive value of 100% and negative predictive value of 38%

Accuracy=85%

Bronchoscopy.org 11

Bilaceroglu S et al. Chest 2004;126:259-267

Techniques and results► Sarcoidosis: expected results

Oki M, Saka H, Kitagawa C et al. Real-time endobronchial ultrasound-guided Transbronchial needle aspiration is useful for diagnosing Sarcoidosis. Respirology 2007; 12(6):863-868.

Yield 93% Garwood S, Judson MA, Silvestri G et al. Endobronchial

ultrasound for the diagnosis of pulmonary sarcoidosis. Chest 2007; 132(4):1298-1304.

Yield 82% Wong M, Yasufuku K, Nakajima T et al. Endobronchial

ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J 2007; 29(6):1182 -1186

Yield 91.8%

Bronchoscopy.org 12

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Procedural Strategies

►Diagnostic alternatives:►EUS-FNA( esophageal ultrasound reaches station 7); ►Sensitivity 81-97% Specificity 83-100% **►Mediastinoscopy: considered gold standard.

Bronchoscopic airway inspection would still be required

►VATS: most invasive of alternatives. ►Only provides access to ipsilateral nodes. 75%

sensitivity***. ►Benefits include definitive lobar resection at same

time if node negative.

13

*Chest. 2003; 123: 157-66 **Lung Cancer. 2003; 41: 259-67***Chest 2007;132;202-220

Data from studies evaluating patients with suspected/confirmed lung cancer

For station 7, EBUS-TBNA and EUS-FNA have similar diagnostic rates

Bronchoscopy.org 14

Am J Respir Crit Care Med Vol 171. pp 1164-1167, 2005

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Bronchoscopy.org15

Procedural techniques and resultsAnesthesia and perioperative care

► Conscious (moderate) sedation►May be performed in bronchoscopy suite►Cost savings compared to general anesthesia.►Visualization and biopsy of smaller nodes technically more

difficult than with general anesthesia.

► General anesthesia with LMA (#4 or 4.5 )►Better visualization of higher nodes ( station 1 and 2)

compared with ET tube►May be performed in bronchoscopy suite►May not be appropriate in severe obesity or severe

untreated GERD

► General anesthesia with ET tube (#8.5 for female and #9 for male patients)

►Usually performed in OR . ►EBUS scope directed more centrally in airway which may

make biopsies more difficultChest 2008;134;1350-1351

J Cardiothorac Vasc Anesth 2007; 21:892–896

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Procedural Techniques and Results

► Instrumentation EBUS scope- direct real time US imaging with

curved array ultrasound transducer incorporated in distal end of bronchoscope

Ultrasound processor►Adjustable gain and depth►B mode and Doppler capabilities

Needle►22 gauge acrogenic needle with stylet►Needle guide system locks to scope►Lockable needle and sheath►Precise needle projection up to 4 cm

Bronchoscopy.org 16

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►Anatomic dangers and other risks►Major vascular structures

►Risk of canulating major vessel may be reduced with real time B mode and Doppler mode imaging

►“Minor” oozing of blood at puncture site was reported in 1 study; there have been no reports of major bleeding*

►Pneumothorax and pneumomediastinum**

►Have been reported with conventional TBNA but no reports in literature with EBUS guided FNA.

Bronchoscopy.org 17

Chest 2004;126;122-128**Eur Respir J 2002; 19:356–373

Bronchoscopy.org 18

Planning the procedure

Lymph node

Left Atrium

Pulmonary vein

19

Results

►Results and procedure-related complications EBUS-TBNA was performed under general

anesthesia using a 9.0 endotracheal tube. Subcarinal cytology showed

granulomatous inflammation Bronchoscopic inspection : normal airway

mucosa There were no complications.

Bronchoscopy.org 19

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►Aspirate cytology Adequate/representative: in presence of

frankly malignant cells, lymphocytes, lymphoid tissue, or clusters of anthracotic pigment-laden macrophages*

Inadequate/nonrepresentative: if there are no cellular components, scant lymphocytes (defined as <40 per HPF) blood only, or cartilage or bronchial epithelial cells only* **

*Am J Clin Pathol 2008;130:434-443**Chest 2008;134;368-374;***Chest 2004;126;1005-1006****Techniques in GI Endoscopy, Vol 2, No 3, 2000: pp 136-141


In some cases of nodal replacement by granulomatous or metastatic disease,

lymphoid tissue might not be seen

► In addition, the presence and quantity of bronchial cells may have no bearing on adequacy because these cells are found in the majority of samples, without correlation with the number of lymphocytes. Am J Clin Pathol 2008;130:434-443

22Bronchoscopy.org 22

Long-term Management Plan► Outcome assessment

Adequate specimen obtained but no specific diagnosis► Follow-up tests and procedures

Mediastinoscopy was deferred. Computed tomography was scheduled in 3 months to re-evaluate the mediastinal lymphadenopathy

Work up for sarcoidosis Fungal antibodies to rule out infection as a cause of the

granulomatous inflammation► Referrals

Oncology to re-evaluate for possible melanoma recurrence and potentially obtain full body PET/CT

► Quality improvement No confident diagnosis was made on EBUS-TBNA

23

Q 1: Describe how the coronal view of a computed tomography

scan can be used to help plan the procedure.

Bronchoscopy.org

Subcarina (Station 7): definition based on IASLC map

► Upper border: the carina of the

trachea

► Lower border: the upper border of

the lower lobe bronchus on the left;

the lower border of the bronchus intermedius on the right

(J Thorac Oncol. 2009;4: 568–577)

25

25Bronchoscopy International

CT views

http://en.wikipedia.org/wiki

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CT views: coronal

► A coronal (aka frontal) plane is perpendicular to the ground, which (in humans) separates the anterior from the posterior, the front from the back, the ventral from the dorsal

http://en.wikipedia.org/wiki


http://en.wikipedia.org/wiki/CORONAL

AXIAL

Which CT view is most useful for planning EBUS-TBNA for 7?

Bronchoscopy.org28

Bronchoscopy from head of patient

129

Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006

EBUS scope in the RMB with the probe facing medially towards 9 o’clock

29


The coronal CT view identifies the EBUS scanning

plane

Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006

LN

cephalad

caudal

P. vein

Left Atrium

Simultaneous coronal CT view and EBUS image at

station 7

Bronchoscopy.org 30

The EBUS image at station 7 shows this pattern

Coronal

Subcarinal (station 7) lymph node on coronal CT view


To understand the use of coronal CT view one must understand the reference points on the

EBUS image

1. The EBUS image is projected on the monitor as if the scope is horizontal

2. The green dot on the monitor represents the point where the needle exits the scope and corresponds to the superior (cephalad) aspect of the body

3. This dot is by default towards the 1’o’clock position of the screen

caudal cephalad


While the coronal CT view is displayed as if the scope is vertical

Several adjustments can be made to the coronal CT image in order to bring thescope to a horizontal position, the green dot cephalad (towards the 1 o’clock position on the screen) to match the EBUS image…

cephalad

caudal

P. vein

Left Atrium

cephalad

caudal

P. vein

Left Atrium


1. Print out a single frame of the CT image2. Rotate the CT image clockwise in order to horizontalize the scope and bring the green dot cephalad towards the 1 o’clock position.

Step by Stepcephalad

caudal

P. vein

Left Atrium

cephalad

caudal

P. vein

Left

Atrium


The two images now correlate and show all structures in the same

locations

See how easy it is to identify the anatomic structures now !

This is a characteristic EBUS view of the subcarinal node

cephalad

caudal

Left Atrium

LN

caudal cephalad

LN

Left Atrium

35

Q 2: Describe the yield of EBUS-TBNA versus conventional TBNA

for sarcoidosis.

Bronchoscopy.org


Conventional vs. EBUS TBNA for Sarcoidosis

►EBUS-TBNA to standard 19-gauge TBNA in patients with mediastinal adenopathy and a clinical suspicion of sarcoidosis.

►N= 50 ( 24 EBUS, 26 conventional)►The primary outcome measure of

diagnostic yield was 53.8% versus 83.3% in favor of the EBUS-TBNA group an absolute increase of 29.5%

Tremblay A et al. Chest. 2009 Aug;136(2):340-6.

37


EBUS-TBNA vs. Conventional TBNA for Sarcoidosis

Tremblay A et al. Chest. 2009 Aug;136(2):340-6.

38

Q3:Describe the clinical implications of granulomatous

inflammation detected on EBUS-TBNA specimens

Bronchoscopy.org


Granulomatous inflammation can coexist with malignancy and may

be an epiphenomenonLymph nodes harboring both necrotizing

and nonnecrotizing granulomas and metastatic malignancies have been reported:

Laurberg P. Sarcoid reactions in pulmonary neoplasms. Scand J Respir Dis. 1975;56:20-27.

Cohen PR, Kurzrock R. Sarcoidosis and malignancy. Clin Dermatol. 2007;25:326-333.

Pandey M, Abraham EK, Chandramohan K, et al. Tuberculosis and metastatic carcinoma coexistence in axillary lymph node: a case report. World J Surg Oncol. 2003;1:3.

Clinical implication of granulomatous inflammation on

EBUS-TBNA specimens► N=153 patients with mediastinal

lymphadenopathy on CT imaging at a cancer institution and noncaseating granulomas seen on EBUS-TBNA

► Non-caseating granuloma in 17/153 (11%) patients in patients w/o any evidence of cancer 8/153 (5.2%) had sarcoid like lymphadenopathy

mimicking cancer recurrence (5/5 PET positive) 8/153 (5.2%) patients with new mediastinal

lymphadenopathy and no prior history of cancer had a clinical syndrome consistent with sarcoidosis.

Bronchoscopy.org 40

Kennedy MP et al. Journal of Cardiothoracic Surgery 2008, 3:8

Clinical implication of granulomatous inflammation on

EBUS-TBNA specimens► The diagnosis of sarcoidosis or sarcoid like

lymphadenopathy was made if clinico-radiological findings were supported by histopathologic findings from EBUS-TBNA appropriate exclusion of other granulomatous

diseases ►a composite of clinical history, follow-up and

laboratory results including tissue staining for fungi and acid fast bacilli (AFB), fungal and mycobacterial cultures and serum fungal antibody titers

Bronchoscopy.org 41

Kennedy MP et al. Journal of Cardiothoracic Surgery 2008, 3:8

Take home messages► Attributing radiographic findings such as

mediastinal lymphadenopathy without tissue confirmation as cancer recurrence can lead to unnecessary and toxic therapy1.

► If granulomatous inflammation is identified by EBUS-TBNA in a patient with suspected cancer recurrence, a reasonable clinical approach is to follow the patient radiographically without additional invasive testing, unless there is radiographic progression2

Bronchoscopy.org 42

(1). Kok TC et al. Cancer 1991, 68:1845-7.(2). Kennedy MP et al. Journal of Cardiothoracic Surgery 2008, 3:8

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Bronchoscopy.org43

All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide

shows, streaming videos, and essays can be cited for reference as:

Bronchoscopy International: Practical Approach, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2009 (Please add “Date Accessed”).

Thank you

44Bronchoscopy.org 44

Prepared with the assistance of Septimiu Murgu M.D., University of California, Irvine

www.bronchoscopy.org

Documents

11 #10. Planning EBUS-TBNA of subcarinal lymph node (station 7) Describe how the coronal view of a computed tomography scan can be used to help plan the