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ENDOBRONCHIAL ULTRASOUND

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

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ENDOBRONCHIAL ULTRASOUND

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  1. ENDOBRONCHIAL ULTRASOUND Associate Professor Erdoğan Çetinkaya Yedikule Hospital of Chest Diseases and Thoracic Surgery

  2. 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

  3. Endobronchial Ultrasonound • Ultrasound imaging depends on the the capacity of tissues with different impedans according to variations in transmitting ,absorption, and reflecting the ultrasound waves

  4. Endobronchial Ultrasonound

  5. Endobronchial Ultrasound- EBUS-RP -2.8 mm inner diameter bronchoscope -2 mm diameter balloon-tipped catheter -Miniprobe 20 Mhz rotating360 degree -Axial scanning -Penetration depth4 cm

  6. Endobronchial Ultrasound- EBUS TBNA Scope -7,5-10 Mhz -linear scanning -Power Doppler -Real-time monitoring the needle

  7. Endobronchial Ultrasound (EBUS)Indications • 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

  8. Bronchial Wall-ECHOENDOSCOPY • Bronchial wall shows 5-7 ecographic layer

  9. Insitu carsinoma-EBUS Showing the depth of invasion in early stage cancer Pathological correlation > 95 % Kurimoto N. Chest 1999; 115:1500-1506 In carcinoma insitu , addition of EBUS in evaluation of airway defines the best patient group whom benefits from treatment

  10. EBUS- airway compression? infiltration ? EBUS is highly accurate diagnostic tool and superior to chest CT evaluating the question of airway involvement by central intrathoracic tumor n=105 EBUS CT Sensitivity 89%28% Specifity 100 %80% Accuracy 0,94 0,51 Herth F et al. Chest 2003; 123:458-462

  11. EBUS- airway compression? infiltration?

  12. Interventional Bronchoscopy-EBUS • 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

  13. EBUS-guided TBNA in mediastinal and hilar lymph nodes andin staging of lung cancer 1, 2R, 2L, 3, 4R, 4L, subcarinal mediastinal lymph nodes 10, 11 hilar lymph nodes EBUS TBNA scope EBUS-RP

  14. Conventional & EBUS-guided TBNA 100 50 EBUS-guided 50 conven. 40 diagnostic 36 diagnostic (80 %) (72 %) TBNA subcarinal ns Herth et al., Chest, 2004;125:322-325

  15. Conventional & EBUS-guided TBNA 100 50 EBUS-guided 50 conven. 42 diagnostic 29 diagnostic (74 %) (56 %) TBNA paratracheal p < 0,001 EBUS-guided TBNA compared with conventional method, decreased the number of needle puncture and increases the diagnostic value in paratracheal lymph nodes Herth et al., Chest, 2004;125:322-325

  16. EBUS-RP&EBUS-CP TBNA scope • 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

  17. Diagnostic value of EBUS-guided TBNA in mediastinal and hilar lymph nodes 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)

  18. Comparison of EBUS-TBNA, CT and PET in staging of lung cancer n:102 Sensitivity specifity PPV NPV Accuracy % % % % % CT 76.9 55.3 37 87.5 60.8 PET 80. 70.1 46.5 91.5 72.5 EBUS-TBNA 92.3 100 100 97.4 98.0 Yasufuku et al. Chest 2006;130:710-718

  19. CT >10 mm lymph node & PET (+) lymph node EBUS TBNA _ Mediastinoscopy 2R, 2L, 4R, 4L, Subcarinal, hilar CT>10 mm lymph node & PET (+) lymph node EUS-TBNA & VATS 5,8,9

  20. < 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) Pathological lymph nodes in CT (-/+) and mediastinal invasion in PET(-/+) All NSLC patients should be evaluated with EBUS-TBNA for preoperative staging. Felix H et al.Chest 2008;133:887-891

  21. EBUS-TBNA after neoadjuvant chemotherapy 83 patients treated with neoadjuvant chemotherapy due to N2 disease EBUS-TBNA to is a suitable method to evaluate mediastinal lymph nodes after neoadjuvant chemotheraphy. Herth et al., ATS 2006

  22. Role of EBUS-guided TBNA in staging of lung cancer

  23. First experience in EBUS-guided TBNA n:57 %97 adequate material 35 diagnostic 22 staging (%77) 15 (%68) sarcoidosis %84.6 EBUS-guided TBNA No need for further invasive staging methods diagnostic

  24. Endobronchial US- case

  25. Endobronchial US- case N. K, 40 y, F

  26. X100 PAP X400 PAP

  27. EBUS in peripheral lesions • Radial probe • 20 Mhz • With or without baloon

  28. EBUS & Fluoroscopy guided Transbronchial biopsy < 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

  29. 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

  30. 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

  31. 55 year old male patient. • Biopsy: Adenocarcinoma

  32. Multimodality approach to peripheral lung lesions EMN/EBUS Eberhardt R Am J Respir Crit Care Med 2007;176(1):36-41

  33. EMN and EBUS case

  34. ENDOBRONCHIAL ULTRASOUNDSummary • 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?

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