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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 Presentation
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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– 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
• 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
Endobronchial Ultrasonound
-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
Endobronchial Ultrasound- EBUS TBNA Scope
-7,5-10 Mhz
-linear scanning
-Power Doppler
-Real-time monitoring the needle
• 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
Bronchial wall shows 5-7 ecographic layer
Bronchial Wall-ECHOENDOSCOPY
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
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 ?
EBUS- airway compression? infiltration?
• 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
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
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
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
• 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
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
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
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
< 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.
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
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
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
Endobronchial US- case
N. K, 40 y, F
Endobronchial US- case
X100 PAP
X400 PAP
EBUS in peripheral lesions
Radial probe
20 Mhz
With or without baloon
< 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
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
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
• 55 year old male patient.
• Biopsy: Adenocarcinoma
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
EMN and EBUS case
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?