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#8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L)

This article describes the yield of EBUS-TBNA compared to conventional TBNA at station 4L, and how the coronal view of a CT scan can be used to plan the procedure. It also identifies 4L and surrounding vascular structures using EBUS.

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#8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L)

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  1. #8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L) • Describe the yield of EBUS-TBNA versus conventional TBNA at station 4L. • Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. • Identify 4L and surrounding vascular structures using EBUS. 1 Bronchoscopy.org

  2. Case description(practical approach # 8) • A 69 year-man with a 120 pack –year history of smoking presents with cough. • Computed tomography shows a 2.5 X 2 cm left upper lobe mass and a 1.5 cm left paratracheal lymph node. • Patient is referred for diagnosis and staging Bronchoscopy.org 2

  3. Case description(practical approach #8) 1.5 cm left paratracheal lymph node 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 II • Comorbidities • COPD, Coronary artery disease • Support system • Lives with wife at home • Patient preferences • Desires diagnosis and considers all available active treatment options. Bronchoscopy.org 5

  6. Procedural Strategies *Ann Thorac Surg 2007;84:177-181 **J Thorac Cardiovasc Surg 2006;131:822-829 *** Eur J Cardiothorac Surg. 2007 Jul;32(1):1-8 • Indications • Invasive lymph node staging? • Invasive staging should be performed in patients with 1 or more risk factors for occult N2 disease* ** *** • The patient in this case has clinically evident N2 disease (1.5 cm left paratracheal node) • Bronchoscopic inspection can be performed at the time of EBUS-TBNA. • Diagnosis and staging can be performed during a single procedure. Bronchoscopy.org 6

  7. Procedural Strategies • Indications • Obtain tissue diagnosis • Sample 4L (left paratracheal node) for staging purposes • Mediastinal lymph node involvement is found in 26% of newly diagnosed lung cancer patients* • The presence of lymph node metastasis remains one of the most adverse factors for prognosis in NSCLC • Mediastinal nodal involvement suggests stage IIIA or IIIB • inoperability and/or • need for treatment by chemotherapy and/or radiotherapy • * Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med 2004; 350: 379–392. 7 Bronchoscopy.org

  8. Procedural Strategies *Chest 2004; 125:322–325 **Eur Respir J 2009; 33: 1156–1164 • Contraindications: • None • Expected Results: • The diagnostic rate of EBUS-TBNA for station 4L reportedly equal to conventional TBNA (72%vs. 71%) • Lymphocytes more often present on EBUS-TBNA specimens compared with conventional TBNA (82%vs. 71%)* • 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. Bronchoscopy.org 8

  9. Procedural Strategies *Chest. 2003; 123: 157-66 **Lung Cancer. 2003; 41: 259-67 ***Chest 2007;132;202-220 • Diagnostic alternatives: • CT-guided percutaneous needle aspiration of mass; high diagnostic rate (91%) but does not provide staging, and has increased risk for pneumothorax (5-60%)* • EUS-FNA( esophageal ultrasound reaches 4L node; 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. 9

  10. For station 4L, EBUS-TBNA and EUS-FNA have similar diagnostic rates Am J Respir Crit Care Med Vol 171. pp 1164-1167, 2005 Bronchoscopy.org

  11. Procedural Strategies Risks-Benefits Cost effectiveness- no formal evaluations have been published In 2 separate decision-analytic models, both (EUS-FNA + EBUS-FNA) and (conventional TBNA + EBUS-FNA) were more cost-effective approaches than Mediastinoscopy for staging patients with NSCLC and abnormal mediastinal lymph nodes on non-invasive imaging* ** A strategy adding EUS-FNA to a conventional lung ca staging approach (mediastinoscopy thoracotomy) reduced costs by 40% per patient*** May actually increase health care costs if done in low volume centers by less experienced operators**** ***** Start up costs Cost of equipment ~100K******and training Physician reimbursement ~$280; facility reimbursement $257****** *Gastrointestinal Endoscopy 69, No. 2, Supp 1, 2009, S260 **J Bronchol 2008;15:17–20 ***Thorax 2004;59;596-601 ****Lung Cancer 64 (2009) 127–128 *****J Bronchol 2008; 15:127-128 ****** Southern Medical Journal 2008;101,No5;534-38 Bronchoscopy.org

  12. Procedural Strategies Drawing from Herth FJ et al. J Bronchol Volume 13, Number 2, April 2006 EBUS image from patient. • Informed consent: • There were no barriers to learning identified. Patient has good insight into his disease and realistic expectations. BI #. Practical Approach Title 12

  13. 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 13 Bronchoscopy.org Chest 2008;134;1350-1351

  14. 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 14

  15. Procedural Techniques and Results Chest 2004;126;122-128 **Eur Respir J 2002; 19:356–373 • Anatomic dangers and other risks • Major blood vessels- Pulmonary Artery and Aortic arch • 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 blind TBNA but no reports in literature with EBUS guided FNA. Bronchoscopy.org 15

  16. 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* ** A quantitative cut off value of at least 30% of cellularity composed of lymphocytes has been arbitrarily proposed by some experts*** Higher yield may be obtained by obtaining aspirates from the periphery of nodes**** *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

  17. Procedural Techniques and Results • Number of aspirates* if ROSE not utilized • Best yield with 3 aspirates per station (see table) • Two aspirations per LN station are acceptable when at least one tissue core specimen is obtained. • Sensitivity 91.7%, NPV 96.0%, and accuracy 97.2% • If operator believes targeting is inadequate or insufficient another aspirate should be performed 17 Bronchoscopy.org * Chest 2008;134;368-374;

  18. Maximum results after 3 aspirates Rapid On Site Cytology may assure greater yield but potentially prolongs procedure time and costs. Chest 2008;134;368-374 Bronchoscopy.org

  19. Procedural Techniques and Results • Results and procedure-related complications • EBUS-TBNA was performed under general anesthesia using a 9.0 endotracheal tube. • 4L nodal cytology diagnostic for non small cell carcinoma (adenocarcinoma). • Bronchoscopic inspection : swelling and erythema distal left upper lobe bronchus. Washing positive for adenocarcinoma. • There were no complications. Bronchoscopy.org 19

  20. Long-term Management Plan • Outcome assessment • Patient was referred for multidisciplinary evaluation to include cardiothoracic surgery, oncology, and radiation oncology for potential trial enrollment for neoadjuvant treatment of stage IIIA adenocarcinoma of the lung.* • 5 year survival for IIIA non-small cell lung ca is 23%. • Follow-up tests and procedures • Patient will follow up in 2 weeks to ensure involvement of above specialties. • Referrals • See above. • Quality improvement • Diagnosis and N2 metastasis identified by single procedure. *Chest 2007;132;243S-265S Bronchoscopy.org 20

  21. Q 1: Describe the yield of EBUS-TBNA versus conventional TBNA at station 4L. Bronchoscopy.org

  22. EBUS-TBNA vs. Conventional TBNA Bronchoscopy International 22 CHEST 2004; 125:322–325

  23. The yield of EBUS-TBNA for diagnosing malignancy in station 4L is as high as 96% Bronchoscopy.org Herth F et al. Thorax 2006;61;795-798

  24. Q 2: Describe how the coronal view of a computed tomography scan can be used to help plan the procedure. Bronchoscopy.org

  25. Station 4L (left lower paratracheal)definition based on IASLC map Includes nodes to the left of the left lateral border of the trachea, medial to the ligamentum arteriosum. Upper border: upper margin of the aortic arch. Lower border: upper rim of the left main pulmonary artery. (J Thorac Oncol. 2009;4: 568–577) Both axial and coronal CT views are useful to define the borders of station 4L.

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

  27. 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 27

  28. AXIAL http://en.wikipedia.org/wiki/ CORONAL SAGITTAL 28 Bronchoscopy International

  29. Which CT view is most useful for planning EBUS-TBNA for station 4L? 12 9 Bronchoscopy from head of patient To visualize the left paratracheal node (4L), the operator turns the bronchoscope laterally to the 9-o’clock position and scans the area of lymph node station 4 L. Bronchoscopy.org

  30. The coronal CT view identifies the EBUS scanning plane cephalad Ao LN PA caudal Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006 The aortic arch is proximal and the left pulmonary artery is distal Bronchoscopy International 30

  31. Simultaneous coronal CT view and EBUS image at station 4L CORONAL The EBUS image at station 4L shows this pattern 4L Bronchoscopy.org

  32. 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 32

  33. While the coronal CT view is displayed as if the scope is vertical cephalad Ao LN PA 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 33

  34. Step by Step cephalad cephalad cephalad Aorta Aorta Aorta Lymph node Lymph node Lymph node Pulmonary Artery Pulmonary Artery Pulmonary Artery caudal 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 34

  35. The two images now correlate and show all structures in the same locations cephalad Aorta Lymph node LN Pulmonary Artery caudal PA Ao See how easy it is to identify the anatomic structures now ! This is a characteristic EBUS view of level 4 L Bronchoscopy International 35

  36. Q3: Identify 4L and surrounding vascular structures using EBUS. Bronchoscopy.org

  37. Characteristic image of lymph node station 4 L Bronchoscopy.org

  38. The lymph node is echogenic (circle) and vascular structures are anechoic (arrows) Bronchoscopy.org

  39. Because the green dot corresponds to the more cephalad, and therefore proximal aspect of the body)… PA Aorta Caudal/ distal Cephalad/ proximal The vascular structure at approximately 3 o’clock is the Aorta (proximal) while the vascular structure at 9 o’clock is the Pulmonary artery (distal) Bronchoscopy.org

  40. 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 40

  41. Prepared with the assistance SeptimiuMurgu M.D., University of California, Irvine www.bronchoscopy.org Bronchoscopy.org 41

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