Advanced Bronchoscopy at PRMC

an evidence based practice

Yashvir Sangwan

Current Status• Advanced Diagnostic Bronchoscopy– Linear EBUS – Radial EBUS– Thin Bronchoscopy– Electromagnetic Navigational Bronchoscopy– Cryobiopsy

• Therapeutic Bronchoscopy• Pleural Procedures• Critical Care Procedures

Current Status• Advanced Diagnostic Bronchoscopy

• Therapeutic Bronchoscopy– Electrocautery and APC– Cryo-recanalization– Balloon Bronchoplasty– Airway Stenting with SEMS– Airway Valves– Bronchial Thermoplasty

• Pleural Procedures• Critical Care Procedures

Current Status• Advanced Diagnostic Bronchoscopy• Therapeutic Bronchoscopy

• Pleural Procedures– VATS– Chest tube– Pleurodesis including blood patch– Pleur-X indwelling pleural catheter

• Critical Care Procedures

Current Status• Advanced Diagnostic Bronchoscopy• Therapeutic Bronchoscopy• Pleural Procedures

• Critical Care Procedures– Tracheostomy– Advanced Critical Airway management

If we had Rigid Bronchoscopy we would be an Interventional Pulmonary Program.

Advanced Diagnostic Bronchology-

Techniques forthe peripheral lung nodule

Bronchoscopy FirstReason #1 - Pneumothorax

The pneumothorax rate for bronchoscopy techniques = 1.5% with 0.6 % requiring chest tube. J Wang Memoli et al. Meta-Analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. CHEST 2012; 142(2): 385-93.

The pneumothorax rate for CT guided TTNA is 27% with 5% requiring chest tube.Huanqi L et al. Diagnostic accuracy and safety of CT –guided percutaneous aspiration biopsy of the lung. AJR Am J Roentgenol. 1996; 167: 105-9.Ohano Y et al. CT-guided transthoracic needle aspiration biopsy of small solitary pulmonary nodules. Am J Roentgenol. 2003; 180:1665-9.

Bronchoscopy FirstReason #2- mediastinal staging

Bronchoscopy FirstReason #2- mediastinal staging

The only time you don’t do EBUS is when a patient has a lung nodule (<3 cm) in the peripheral 1/3rd of the lung with negative CT and negative PET.Eur J Cardiothorac Surg. 2014 May;45(5):787-98. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.

Bronchoscopy FirstReason #2- mediastinal staging

• If tumor size > 3 cm – full mediastinal staging is needed (even if CT + PET negative).

• If tumor (any size) is central – full mediastinal staging is needed (even if CT + PET negative).

• If even 1 N1 lymph node is suspected involved – full mediastinal staging is needed. (The new lymph node cut –off is > 0.5 cm.)

• Eur J Cardiothorac Surg. 2014 May;45(5):787-98. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer.

EBUS• EBUS sensitivity for positive mediastinum is

90-100% . Mediastinoscopy 90%. PET 80%. CT 75%. Conventional TBNA 58-78%.

• Negative Predictive value – EBUS 91-97.4 %. Mediastinoscopy 91%. PET 85.2-91.5%. CT Scan 80-85%. Conventional TBNA 40-78%.– Herth F. Chest 2004; 125: 322-5.– Wallace MB. JAMA 2008; 299:540-6.– Holty JC et al. Thorax 2005;60:949-55.– Toloza EM et al. chest 2003; 123 : 157S-66S– Mol Clin Oncol. 2014 Jan;2(1):151-155. Epub 2013 Oct 23. A meta-analysis by Zhu T et al.– Lee BE et al. J Thorac Cardiovasc Surg 2012; 143: 585-90.– Yasufuku et al. J Thorac Cardiovasc Surg 2011; 142: 1393-400. E 1391. – Chest. 2014 Aug;146(2):389-97. Liberman M et. Al.– Herth FJ et al. EBUS in radiological and PET normal mediastinum. Chest 2008; 133:887-91.

EBUS• Conventional TBNA is not recommended for

lymph nodes < 1 cm in short axis.–Harrow E et al. Chest 1991; 100: 1592-6. – Oki M et al. Respiration 2004; 71: 523-7.

• Conventional TBNA best for LN> 2 cm in 7 or 4r position.

• EBUS staging followed by mediastinoscopy if EBUS negative is the most effective method.– JAMA. 2010 Nov 24;304(20):2245-52. Mediastinoscopy vs endosonography for

mediastinal nodal staging of lung cancer: a randomized trial. Annema JT et al.– Health Technol Assess. 2012;16(18):1-75, Sharples LD et al.– J Thorac Oncol. 2010 Oct;5(10):1564-70. Steinfort DP et al.– Chest. 2014 Aug;146(2):389-97. Liberman M et. Al.

– Verhagen AFT et al. Lung Cancer 2004; 44 : 175-81.– Detterbeck FC et al. Chest 2007; 132 : 202S-20S– Leyn PD et al. Eur J Cardiothoracic surgery 2007; 32: 1-8.– Hwangbo B et al. Chest 2009; 135:1280-7.– Yasufuku .Chest 2006; 130:710-8.– Clin Lung Cancer. 2012 Mar;13(2):81-9. Wang J et al. – Clin Lung Cancer. 2014 Aug 15. Robson JM et al.– Ann Thorac Surg. 2014 Aug 19. Shingyoji M ET al. – Kerr KM. Thorax 1992; 47: 337-41; – Gomez-Caro A et al. Eur J Cardiothoracic Surg 2010; 37 : 1168-74.– Ernst A et al. J Thoracic Oncol 2008;3: 577-82. – Adams K – meta-analysis and systematc review- Thorax 2009; 64- 757-62.– Gu P et al. Eur J cancer 2009; 45: 1389-96.– Varela-Lema L. Eur Respir J. 2009; 33:1156-64.– JAMA. 2010 Nov 24;304(20):2245-52. Mediastinoscopy vs endosonography for

mediastinal nodal staging of lung cancer: a randomized trial. Annema JT et al.– Health Technol Assess. 2012;16(18):1-75, Sharples LD et al.– J Thorac Oncol. 2010 Oct;5(10):1564-70. Steinfort DP et al.

Reason #3 – Bronchoscopy is effectiveTraditionalBroncho-scopy

CT guidedTTNA

Thin Scope with radial EBUS + GS

EMNSuper D

Combined EMN + Radial EBUS

Lesion <2 cm 34% 74% 73% 74% 76%

Lesion >=2 cm 63% 90% 80% 84% 88%

• Rivera et al. CHEST 2007; 132:131S-48• Kurimoto et al. CHEST 2004; 126:959-65.• Asano t al. Lung Cancer 2008; 60: 366-73.• Gildea et al. AJRCCM 2006;174: 982-9.• Eberhardt et al. AJRCCM 2007; 176: 36-41.• Ishida et al. Thorax 2011; 66:1072-7.

Lesion >3 cm with bronchus sign - Tbbx

• Diagnostic yield is highest (78%)when used with correct size alligator forceps, fluoroscopy with C arm rotation technique, combined with peripheral TBNA, Brush and BAL and 6-10 specimens are taken.

– Cox ID et al. Relationship of radiologic position to the diagnostic yield of fiberoptic bronchoscopy in bronchial carcinoma. Chest 1984; 85: 519-22.

– Smith LS et al. Comparison of forceps used for transbronchial lung biopsy. Chest 1985;87:574-6.

– Descombes E et al. Transbronchial lung biopsy : an analysis of 530 cases. Monaldi Arch Chest Dis. 1997; 52:324-9.

– Rivera MP, Mehta AC. Initial Diagnosis of lung cancer. ACCP evidence based clinical practice guidelines Chest 2007; 132:131S-48.

Lesion < 3 cm : Radial EBUS

– Kurimoto N et al. Endobronchial US using a guide sheath Chest 2004; 126:959-65.

– Paone G et al. Endobronchial US driven biopsy in diagnosis of peripheral lung lesion. Chest 2005; 128 :3551-7.

Lesion < 3cm : EMN

EMN• Electromagnetic Navigation uses a board

below the patient to generate a magnetic field around the patient’s thorax.

• Sensors on the patient’s chest and in the bronchoscope are used to match patient’s airway to a CT scan.

• Once the match happens the computer guides us to the lesion.

– Gildea TR et al. EMN bronchoscopy A prospective study . Am J respir Crit Care Med 2006; 174:982-9.

– Eberhardt R et al. Multimodality bronchoscopic diagnosis of peripheral lung lesions. Am J Respir Crit Care Med 2007; 176:36-31.

EMN

Cryobiopsy

Summary

• A majority of patients with suspected lung cancer need EBUS/ mediastinal staging.

• The bronchoscopic yield of peripheral lesions has significantly improved.

• Exceptions to bronchoscopy first – (a) advanced stage disease (b) non-surgical candidate and (c ) the < 3 cm peripheral nodule with negative PET and CT.