endobronchial ultrasound
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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ENDOBRONCHIAL ULTRASOUND
Associate Professor Erdoğan Çetinkaya
Yedikule Hospital of Chest Diseases and Thoracic Surgery
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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
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• 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
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Endobronchial Ultrasonound
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-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
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Endobronchial Ultrasound- EBUS TBNA Scope
-7,5-10 Mhz
-linear scanning
-Power Doppler
-Real-time monitoring the needle
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• 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
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Bronchial wall shows 5-7 ecographic layer
Bronchial Wall-ECHOENDOSCOPY
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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
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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 ?
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EBUS- airway compression? infiltration?
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• 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
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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
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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
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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
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• 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
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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
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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
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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
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< 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.
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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
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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
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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
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Endobronchial US- case
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N. K, 40 y, F
Endobronchial US- case
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X100 PAP
X400 PAP
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EBUS in peripheral lesions
Radial probe
20 Mhz
With or without baloon
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< 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
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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
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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
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• 55 year old male patient.
• Biopsy: Adenocarcinoma
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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
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EMN and EBUS case
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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?