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Peripheral Lung Lesions a Bronchoscopists view

Peripheral Lung Lesions a Bronchoscopists view. Thomas R. Gildea MD MS FCCP gildeat@ccf.org Respiratory Institute Cleveland Clinic. Hot Topic National Cancer Institute. 53,000 Heavy Smokers (>30 PK /yrs) Annual Low Dose CT CT screening reduces Cancer mortality 20%. Courtesy PJM.

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Peripheral Lung Lesions a Bronchoscopists view

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  1. Peripheral Lung Lesions a Bronchoscopists view Thomas R. Gildea MD MS FCCP gildeat@ccf.org Respiratory Institute Cleveland Clinic

  2. Hot TopicNational Cancer Institute • 53,000 Heavy Smokers (>30 PK /yrs) • Annual Low Dose CT • CT screening reduces Cancer mortality 20%

  3. Courtesy PJM Apples and Oranges on CT 1mm cuts-high resolution 5mm cuts-standard CT Fischbach, Eur Radiol 2003.

  4. Courtesy PJM Prevalence

  5. Clinical Overview Tobacco Lung Cancer: A growing problem In U.S.: • #1 cause cancer-related death1 • More than the next 4 cancers combined • #2 death behind heart disease1 • 87% of lung cancer deaths related to tobacco2 1. Jemal A, et al., CA Cancer J Clin 2007;57;43-66 2. American Cancer Society, 2006

  6. Fleischner Society Guidelines

  7. Options I N V A S I V E • Thoracotomy • VATS • CT-guided needle aspiration • FB • TBBX • EBUS • Virtual guidance • SuperDimension • Sputum cytology • Gene promoter hypermethylation

  8. Diagnostic Bronchoscopy for Peripheral Lesions • Essentially a blind procedure • Less then ideal yield • Localization does not guarantee sampling success • The journey is as important as the destination • Instruments limitations

  9. Clinical Overview Transthoracic Needle Aspiration • Cannot be used in all cases due to co-morbidities • Overall sensitivity 90% • False-negative rate 20-30% • Complications • Pneumothorax up to 30%* • 4% necessitate chest tube insertion • Hemoptysis and hemorrhage (up to 10%) *Manhire A, Charig M, Clelland C, et al. Guidelines for radiologically guided lung biopsy. Thorax. 2003;58:920–936

  10. Pneumothorax Risk of TTNA • Increases with # passes -37% one pass, 57% five passes • Increases with distance from pleura • 15% 0cm (pleural based), 50% 0-5cm • Decreases with increase in lesion size • 0-2cm 50%, 2-4cm 35%, >4cm 15% • Increases with presence of emphysema • With 50% (chest tube 27%), • Without 35% (chest tube 9%)

  11. Surgery Limitations • Higher cost, higher risk • Highly Invasive procedure • Associated with higher morbidity and mortality • Non-therapeutic Thoracotomy in 20-45%* * Alain Bernard, MD The Thorax Group. Resection of Pulmonary Nodules Using Video-Assisted Thoracic Surgery. Ann Thorac Surg 1996;61:202-204 MJ Mack, SR Hazelrigg, RJ Landreneau and TE Acuff. Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule. The Annals of Thoracic Surgery, Vol 56, 825-830 Hoffmann H, Dienemann H. Der pulmonale Rundherd. Dt Arztebl. 2000;97:A-1067-1071 Cardillo G, Regal M, Sera F, Di Martino M, Carbone L, Facciolo F, Martelli M. Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases. Ann Thorac Surg. 2003 May;75(5):1607-11; discussion 1611-2

  12. Standard Bronchoscopy • Fluoroscopic guidance • > 30 years • 20-84% • <2cm in diameter • 14% for peripheral lesions • Outer third of the chest • 31% • Proximal • 53% - in the most recent study with PET Baaklini WA, et al.Chest2000; 117:1049-1054. Chhajed PN, et al. Chest. 2005;128:3558-3564.)

  13. New technologies are evolving • Electomagnetic Navigation Bronchoscopy (ENB) • Endobronchial Ultrasound (EBUS) • Virtual CT guided ultra-thin bronchoscopy • Multimodality

  14. Transbronchial Diagnosis of A Pulmonary Peripheral SmallLesion Using an Ultrathin Bronchoscope with VirtualBronchoscopic Navigation Asano et al, 2002 Journal of Bronchology 9:108–11

  15. An example of bronchi seen on VB images (left), and images of actual bronchi seen using ultrathin bronchoscopy (right) Shinagawa, N. et al. Chest 2004;125:1138-1143

  16. CT-Guided Transbronchial Biopsy Using an Ultrathin Bronchoscope With Virtual Bronchoscopic Navigation* • 30 patients • 1 resolved • 3 had no “bronchus sign”- abandoned • 17 diagnosed (65%) • primary lung cancers, 13; atypical adenomatous hyperplasia, 1; metastatic cancer, 1; sarcoidosis, 1; and nontuberculous mycobacteriosis • 5/9- cancer at surgery – 4 others followed Shinagawa N, et al.Chest. 2004;125:1138-1143.

  17. A Virtual Bronchoscopic NavigationSystem for Pulmonary Peripheral Lesions • 37 patient • Lesion <30mm • Ultrathin bronchoscope/modified CT scanner in the room • 94.7% navigation success • Biopsy forceps reached 86.8% • Diagnostic 81.6% • Median procedure time 24.9 min • 28 with “bronchus sign” forceps reach 96.4% and the diagnosis was made in 89.3%. Asano et al, 2006 Chest 130(2) 559

  18. Virtual bronchoscopy/ultra-thin bronchoscopy-summary • CT scanner/bronchoscopy suite/Endotracheal tube • Ultrathin bronchoscope • Even with all real-time CT confirmation and guidance the yield is about 82% in the most current study • Limited by poor tissue yield and/or biopsy instruments

  19. EBUS Peripheral Probe

  20. Equipment U-30 Processor UM-2R UM-BS20-26R BF-UM40 UM-S20-20R UM-3R

  21. Technique • Routine bronchoscopy • Place bronchoscope into segment/subsegment of interest • Advance EBUS probe distally • View “snowstorm” • Abnormalities • Density • Homogeneous • Bright outline

  22. Normal lung Normal vessels

  23. Technique • Probe placed through catheter • Olympus guide sheath • Not yet FDA approved • Extended Working Channel-EWC • FDA approved-SuperDimension • Curette to guide to location

  24. Curette

  25. Peripheral EBUS NSCLC: Squamous cell carcinoma

  26. EBUS TBBX Eligible 144 Recruited 97 Analyzed 87 Definitive Dx 75.8% 9.8 min TBBX Eligible 149 Recruited 124 Analyzed 119 Definitive Dx 52.1% 8.1 min Endobronchial Ultrasound-Driven Biopsy in the Diagnosis of Peripheral Lung Lesions Paone et al, Chest , 2005;128;3551-3557

  27. Endobronchial Ultrasound-Driven Biopsy in the Diagnosis of Peripheral Lung Lesions • >3 cm • No difference • <3 cm • Improved diagnostic yield EBUS • 31% vs 75% • <2 cm • Improved diagnostic yield EBUS • 23% vs 71% Paone et al, Chest , 2005;128;3551-3557

  28. Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy in Fluoro Invisible Solitary Pulmonary Nodules • Prospective cross-over 138 pts for eval of SPN • 54 lesions were fluoroscopically invisible • 2.2cm (1.4-3.3) mean diameter • 48/54 (86%) lesion localized • 38/54 localized and diagnosed (70%) • 10/54 localized lesion, no Dx • 6/54 lesion not localized • 4 RUL and 2 LUL Herth et al, Chest, 2006;129;147-150

  29. A scene of bronchoscopy using this system Asano, F. et al. Chest 2006;130:559-566

  30. Bronchoscope insertion guidance system combined with EBUS with a guide sheath • virtual images to a median of fifth- (third- to seventh-) order bronchi • thin bronchoscope guided along the planned route • 93.8% visualized by EBUS, 84.4% pathologically diagnosed • lesions < 30mm EBUS visualization 91.7% diagnostic yield was 79.2% Asano F et al- Lung Cancer. 2008 Jun;60(3):366-73.

  31. Peripheral EBUS-Summary • Despite real-time precise localization not all lesions are reachable • Even with localization of 89% the yield was 70% (Herth) • Only transbronchial biopsy forceps used • Safe- one Pnuemothorax • Special equipment • Limited instruments • Small forceps and brushes fit EWC/GS • No needles attempted in studies

  32. Electromagnetic tracking system, consisting of a field generator, SCU, sensor interface unit, and sensor Hautmann, H. et al. Chest 2005;128:382-387

  33. Yield Gildea et al, AJRCC 2006, 174:982-989

  34. Pathology:Non-necrotizing Granulomas/Histiocytes

  35. Adenocarcinoma

  36. Procedure Yields

  37. Cleveland Clinic 4 yr Yield

  38. Therapeutic Indications 3 additional FDA approved techniques Pleural Dye Marking-Indigo carmine Fiducial Implantation-Implant not specified Brachytherapy Catheter placement

  39. Viewport Options Coronal CT Sagittal CT Static 3D Map Dynamic 3D Map Axial CT Tip View 3D CT Virtual Bronchoscopy Local View MIP Bronchoscope Video

  40. Veran Medical

  41. Vida/Broncus- LungPoint William E. Higgins et al. Computerized Medical Imaging and Graphics, Volume 32, Issue 8, December 2008, Page 732

  42. Tissue Sampling • Brush cytology • 2-3 passes • TBBX • 4-5 pieces of tissue • TBNA (does not require TBNA) • Peripheral * if possible* 22G • 2-4 passes • Central 19G or 22G • 4 passes/per station

  43. Brush, TBNA & TBBX • Brush and TBNA + for Adenocarcinoma • TBBX “no specific diagnosis”

  44. Performance Characteristics of Different Modalities for Diagnosis of Suspected Lung Cancer Schreiber G, et al., Chest. 2003;123:115S-128S

  45. ACCP Poster 2008Abdallah R. Incremental Yield with CB above biopsy:12% Incremental Yield with TBBX above biopsy:8% Incremental Yield with CB above biopsy:12% Incremental Yield with TBBX above biopsy:8% Incremental Yield with CB above biopsy:12% Incremental Yield with TBBX above biopsy:8% Incremental Yield with CB above biopsy:12% Incremental Yield with TBBX above biopsy:8%

  46. Suction Catheter versus ForcepsTBBX for Sampling of SPN Guided by ENB Eberhardt R et al, Respiration 2009 54 patients • Lesion <3cm • AFTRE mean 3.6 • REBUS used in all cases • Both suction catheter (SC) and TBBX • Olympus Cannula PR-2B-1 2.0 mm in diameter • Overall Yield 75%

  47. Eberhardt R, Respiration 2009 • Suction catheter was superior to TBBX • 36/40 (90%) SC vs. 22/40 TBX (55%) p = 0.035 • 45% only SC was positive • 10% only TBBX was positive • 45% Both • 30/55 (54%) seen found with EBUS • 28/30 (93%) Diagnostic • 60% + with TBBX/80% + with SC • 12/25 not found on EBUS had 48% yield • All 12 with SC • 4 with TBBX

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