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

#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.

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

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  1. #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. 1 Bronchoscopy.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. Bronchoscopy.org 2

  3. Case description(practical approach #10) Subcarinal lymph node on axial and coronal CT views Axial CT view Coronal CT view Bronchoscopy.org 3

  4. Initial Evaluation Procedural Strategies Techniques and Results Long term Management The Practical Approach • 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 Bronchoscopy.org 4

  5. 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 Bronchoscopy.org 5

  6. 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.org 6

  7. Procedural Strategies *Chest 2004; 125:322–325 **Eur Respir J 2009; 33: 1156–1164 • 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.org 7

  8. Techniques and results Noscoti M, Surg Endoscopy, 2008 • 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. Bronchoscopy International

  9. 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). Bronchoscopy International EUROPEAN JOURNAL OF CANCER ( 2 0 0 9 )

  10. Techniques and results • 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 Bronchoscopy International Kennedy MP, et al, Thorax. 2008 Apr

  11. Techniques and results Bilaceroglu S et al. Chest 2004;126:259-267 • 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

  12. 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

  13. Procedural Strategies Data from studies evaluating patients with suspected/confirmed lung cancer *Chest. 2003; 123: 157-66 **Lung Cancer. 2003; 41: 259-67 ***Chest 2007;132;202-220 • 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

  14. For station 7, EBUS-TBNA and EUS-FNA have similar diagnostic rates Am J Respir Crit Care Med Vol 171. pp 1164-1167, 2005 Bronchoscopy.org

  15. 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 difficult J Cardiothorac Vasc Anesth 2007; 21:892–896 15 Bronchoscopy.org Chest 2008;134;1350-1351

  16. 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

  17. Procedural Techniques and Results Chest 2004;126;122-128 **Eur Respir J 2002; 19:356–373 • 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

  18. Planning the procedure Lymph node Pulmonary vein Left Atrium Bronchoscopy.org

  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

  20. Procedural Techniques and Results 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

  21. 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 ClinPathol 2008;130:434-443 Bronchoscopy International

  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 Bronchoscopy.org 22

  23. Q 1: Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. Bronchoscopy.org

  24. 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. CT views http://en.wikipedia.org/wiki Bronchoscopy International 25

  26. CT views: coronal http://en.wikipedia.org/wiki • 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 Bronchoscopy International 26

  27. CORONAL http://en.wikipedia.org/wiki/ AXIAL 27 Bronchoscopy International

  28. Which CT view is most useful for planning EBUS-TBNA for 7? 12 9 Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006 Bronchoscopy from head of patient EBUS scope in the RMB with the probe facing medially towards 9 o’clock Bronchoscopy.org

  29. The coronal CT view identifies the EBUS scanning plane cephalad LN P. vein Left Atrium caudal Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006 Bronchoscopy International 29

  30. Simultaneous coronal CT view and EBUS image at station 7 Coronal The EBUS image at station 7 shows this pattern Subcarinal (station 7) lymph node on coronal CT view Bronchoscopy.org

  31. To understand the use of coronal CT view one must understand the reference points on the EBUS image caudal cephalad The EBUS image is projected on the monitor as if the scope is horizontal 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 This dot is by default towards the 1’o’clock position of the screen Bronchoscopy International 31

  32. While the coronal CT view is displayed as if the scope is vertical cephalad cephalad P. vein P. vein Left Atrium Left Atrium caudal caudal Several adjustments can be made to the coronal CT image in order to bring the scope to a horizontal position, the green dot cephalad (towards the 1 o’clock position on the screen) to match the EBUS image… Bronchoscopy International 32

  33. Step by Step cephalad cephalad P. vein P. vein Left Atrium Left Atrium caudal caudal 1. Print out a single frame of the CT image 2. Rotate the CT image clockwise in order to horizontalize the scope and bring the green dot cephalad towards the 1 o’clock position. Bronchoscopy International 33

  34. The two images now correlate and show all structures in the same locations cephalad caudal cephalad LN LN Left Atrium caudal Left Atrium See how easy it is to identify the anatomic structures now ! This is a characteristic EBUS view of the subcarinal node Bronchoscopy International 34

  35. Q 2: Describe the yield of EBUS-TBNA versus conventional TBNA for sarcoidosis. Bronchoscopy.org

  36. Conventional vs. EBUS TBNA for Sarcoidosis • EBUS-TBNA to standard 19-gauge TBNA in patients with mediastinaladenopathy 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% 36 Bronchoscopy International Tremblay A et al. Chest. 2009 Aug;136(2):340-6.

  37. EBUS-TBNA vs. Conventional TBNA for Sarcoidosis Bronchoscopy International 37 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

  39. Granulomatous inflammation can coexist with malignancy and may be an epiphenomenon Lymph nodes harboring both necrotizing and nonnecrotizinggranulomas 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. ClinDermatol. 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 SurgOncol. 2003;1:3. Bronchoscopy International

  40. Clinical implication of granulomatous inflammation on EBUS-TBNA specimens • N=153 patients with mediastinallymphadenopathy on CT imaging at a cancer institution and noncaseatinggranulomas 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 mediastinallymphadenopathy and no prior history of cancer had a clinical syndrome consistent with sarcoidosis. Bronchoscopy.org Kennedy MP et al. Journal of Cardiothoracic Surgery 2008, 3:8

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

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

  43. Bronchoscopy International: Practical Approach, an Electronic On-Line Multimedia Slide Presentation. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2009 (Please add “Date Accessed”). 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: Thank you Bronchoscopy.org 43

  44. Prepared with the assistance of SeptimiuMurgu M.D., University of California, Irvine www.bronchoscopy.org Bronchoscopy.org 44

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