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#7. EBUS-TBNA for right paratracheal node in a patient with COPD and lung
cancer ►Describe the 15
steps to performing EBUS-TBNA.
►Describe principles and use of endobronchial Doppler ultrasound
►Describe reported relation between PET negative lymph node size and malignancy.
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Case description (practical approach 7)
► 67 year old male with a 50 pack- year history of smoking developed cough and weight loss (15kg) for six months.
► Vital signs revealed a blood pressure of 160/80mmHg, heart rate 90/min, body temperature 37.2C and respiratory rate 18/min.
► Physical examination shows prolonged expiratory breath sounds and egophony in right upper lung field.
► He is a retired electrician and lives with his wife. He has no advance directives.
► He desires all available active treatment modalities if diagnosed with cancer.
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Case description (practical approach #7)
►WBC 8000 (neutrophil 81%, lymphocyte 2%)
►Hemoglobin 13 gm/dl, Platelets 310,000/mm3
►Arterial blood gas analysis pH 7.45, PaCO2 50 mmHg, PaO2 64 mmHg on 2L oxygen/min via nasal canula)
►Pulmonary function tests revealed FEV1- 1.6 L (49% predicted), DLCO- 50% predicted
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Case description (practical approach 7)
►CT Chest: 3 cm right upper lobe
mass. 1 cm right paratracheal
lymph node is PET negative.
►CT guided transthoracic needle aspiration of the right upper lobe mass positive for non-small cell lung cancer.
BI #. Practical Approach Title 5
The Practical Approach
Initial Evaluation Procedural Strategies
Techniques and Results
Long term Management
• 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
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Initial Evaluations
►Exam►Prolonged expiratory phase►ECOG performance status 1
►Comorbidities►Severe COPD, HTN, Tobacco abuse
►Support system►Wife and children all healthy and actively
involved with patients care.
►Patient preferences►Desires all available active treatment options.
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Procedural Strategies
►Indications: ►Minimally invasive staging of non-small cell
lung cancer with radiographically enlarged PET (-) node.
►Contraindications: ►None
►Expected Results: sensitivity and NPV of EBUS 93.8% and 96.9% respectively* for NSCLC with lymph nodes of 5–20 mm on chest CT
*Lee HS. Chest 2008; 134: 368–374.
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Procedural Strategies
►Risks-benefits: ►EBUS-TBNA has no serious complications
reported in the literature. ►Agitation, cough, and presence of blood at
puncture site have been reported infrequently.*
►Same day procedure.►Cost savings when compared to
mediastinoscopy.**►Increased risk in case general anesthesia
required.*Eur Respir J 2009; 33: 1156–1164
**Gastrointestinal Endoscopy 69, No. 2, Supp 1, 2009, S260
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Procedural Strategies
► Therapeutic alternatives:►Endoscopic ultrasound difficult to access level 4 node
compared with EBUS. In a head to head comparison* sensitivity and negative predictive value were 69% and 89% respectively) .
►Mediastinoscopy gold standard. 78% sensitivity**, but requires general anesthesia.
►VATS most invasive of alternatives. Only provides access to ipsilateral nodes. 75% sensitivity**. Benefits include definitive lobar resection at same time if frozen section negative.
► Informed consent: ►There were no barriers to learning identified. Patient has
good insight into his disease and realistic expectations.*JAMA. 2008;299(5):540-546
**Chest 2007;132;202-220
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Procedural Techniques and Results
►Anesthesia and peri-operative care Conscious sedation
Performed in clinic procedure room Most commonly used drugs are midazolam and
fentanyl Cost savings when compared to OR and extra
personnel required for general anesthesia May make procedure more difficult for
inexperienced operator May be more appropriate for targeted biopsy than
full staging of mediastinum* Has been used in combined staging TBNA, EBUS,
EUS procedures***Chest 2008;134;1350-1351
**JAMA. 2008;299(5):540-546
Procedural Techniques and Results►Anesthesia and peri-operative care
►General anesthesia with LMA Mostly performed in OR but may be done in clinic Total IV anesthesia with propofol is commonly used LMA mask size 4 or 5 required Allows easier biopsies of smaller nodes and
complete mediastinal staging; better for less experienced operators
►General anesthesia with ET tube Size 8.5 in women and 9.0 in men Allows for easier biopsies as above Indications may include difficult LMA placement,
obesity, and severe untreated GERD* Causes EBUS scope to lie centrally in trachea More difficult to visualize higher nodes 11
*JCVA, Vol 21, No 6 , 2007: pp 892-896
Procedural Techniques and Results► Instrumentation
EBUS scope provides direct real time US imaging with curved array ultrasound transducer incorporated in distal end of bronchoscope
As of 09/2009, types of Scopes and US processors
►Olympus- BF-UC160F-OL8 Hybrid scope 2.0 mm working channel; 6.9 mm O.D EU-C60 US processor 7.5 MHz with B-mode and color
power doppler►Olympus BF-UC180F Hybrid scope
2.2 mm working channel; 6.9 mm O.D. ALOKA prosound US processor 5, 7.5, 10, 12 MHz and B,
M, D-mode, flow and power flow modes May also be used with EU-C60 processor
►Pentax EB-1970UK Videoscope 2.0 mm working channel; 6.3 mm O.D. Hitachi HI Vision 5500 US processor 5MHz/7.5MHz/10MHz
with B-mode and color Doppler12
Aloka ProSound a5
Hitachi HI Vision 5500
EU-ME1
Procedural Techniques and Results
►Instrumentation Ultrasound processor
►Adjustable gain and depth Gain is the degree of brightness with which a given
signal intensity is displayed. Analogous to a volume control knob on a stereo.
Depth- allows optimal display of an area of interest on the screen.
►B mode and Doppler capabilities B-mode (brightness mode) uses an array of
transducers to scan a plane through the tissue to produce a two-dimensional image on the screen.
Doppler mode measures velocity of moving tissue. It detects blood flow in vessels and subsequently superimposes the display over the 2-D image.
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Image quality adjustment
►Gain adjustments The amplifier is often controlled by the operator
of the instrument, who sets the gain for various depths of the tissue
►Frequency adjustments Higher frequency has better resolutionbut less depth of penetration
GAIN CONTROL
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Penetration
►Penetration: refers to the distance between an imaged area and the transducer.
►The time delay between the energy going into the body and returning to the US probe determines the depth from which the signal arises ( longer times= greater depths) Depth=velocity X time/2
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Penetration and resolution
►Higher frequencies result in higher resolution.
►Higher frequencies (20 MHz) do not penetrate as deep as low frequencies (7.5 MHz).
penetration
frequency
Low frequencyhigh penetration
resolution
Large transducers transmit powerful beams and increase penetration depth
►Penetration depth is less for EBUS than for thoracic ultrasound.
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EBUS
PLEURAL
EFFUSION
Scanning methods
►For the convex probe, the scanning plane is parallel to the scope
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Convex
Transducer
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BF-UC160F-OL8 SpecificationsUltrasonicfunctions
Display mode B-modeColor Power Doppler mode
Scanning method Electrical curved linear array
Scanning direction Parallel to the insertion direction
Frequency 7.5MHz
Scanning range 50
Contacting method Balloon methodDirect contact method
http://www.olympusamerica.com/msg_section/download_brochures/b_bfuc160f_ol8.pdf
Bowling MR, South Med J. 2008 May 101(5) 534-8
Procedural Techniques and Results
► Instrumentation Needle
►Olympus NA-201SX-4022 or Medi-Globe SonoTip II 22 gauge echogenic needle with stylet Needle guide system locks to scope Lockable needle and sheath Precise needle projection up to 4 cm
► Anatomic dangers and other risks►Major blood vessels- azygous, PA, aorta, SVC and Left
atrium►Pneumothorax and pneumomediastinum►A case of bacterial pericardial effusion and nodal
infection have recently been reported as complications following EBUS with full needle extension***.
*Chest 2004;126;122-128**Eur Respir J 2002; 19:356–373***Eur Respir J 2009; 33:935-938
Procedural Techniques and Results
►Results and procedure-related complications The 4R node was successfully sampled
with EBUS under general anesthesia and a 9.0 cuffed endotracheal tube.
There was representative tissue on cytology and it was negative for malignancy.
There were no complications.
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Long-term Management Plan
► Outcome assessment Patient underwent RUL lobectomy. Intraoperative
mediastinal staging confirmed negative nodes. At 1 month post operatively patient was back to
preoperative baseline functional status.► Follow-up tests and procedures
Clinical evaluation every 3-6 months for the first 2 years with surveillance imaging every 6 months (CXR or CT)*
► Referrals He was also referred to oncology for consideration of
adjuvant chemotherapy for I B disease.► Quality improvement
Early staging and definitive treatment of non-small cell lung ca
Expected 5 year survival for Stage Ib ~ 55%***Chest 2007 132:355S-367S
**Lung Cancer (2007) 55, 371-377
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Q 1: Describe the 15 steps to performing EBUS-TBNA
Procedure Technique
► Step 1 Advance needle through the working channel (neutral position)
► Step 2 Secure the needle housing by sliding the flange
Procedure Technique
► Step 3 Release the sheath screw
► Step 4 Advance and lock the sheath when it touches the wall
Procedure Technique
► Step 5 Release the needle screw
► Step 6 Advance the needle using the “jab” technique
Procedure Technique
► Step 7 Visualize needle entering target node
► Step 8 Move the stylet in and out a few times to dislodge bronchial wall debris.
Procedure Technique
► Step 9 Remove the stylet
► Step 10 Attach syringe
Procedure Technique
► Step 11 Apply suction
► Step 12 Pass the needle in and out of the node 15 times
Procedure Technique
► Step 13 Release suction by removing syringe
► Step 14 Retract the needle into the sheath
Procedure Technique
►Step 15 Unlock and remove the needle and sheath and prepare smears.
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Q 2: Describe principles and use of endobronchial Doppler
ultrasound
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Doppler ultrasound
►B-mode (brightness mode) uses an array of transducers to scan a plane through the tissue to produce a two-dimensional image on the screen.
►Doppler mode measures velocity of moving tissue. It detects blood flow in vessels and subsequently superimposes the display over the 2-D image.
Doppler ultrasound: Color Power Doppler
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Doppler Effect
►The frequency of the reflected ultrasound wave is changed when it strikes a moving object ( i.e blood in vessels)= Doppler effect
►Doppler frequency shift= ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ Ft transmitted frequency, Fr received
frequency, v speed of moving target, c speed of sound in soft tissue, θ angle between the direction of blood flow and direction of the transmitted sound phase
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Ascending aorta
4R
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The Doppler angle needs to be 60 degrees or slightly less to the long axis
of the vessel to obtain the correct velocity
ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ
cosine(60 degrees) = 0.5
Strong Doppler signal is obtained when the scanning plane forms a sharp angle with the blood vessel
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The Doppler angle needs to be 60 degrees or slightly less to the long axis
of the vessel to obtain the correct velocity
ΔF= Ft-Fr=2 X Ft X (v/c) X cos θ Very weak or no Doppler signal is obtained when the scanning plane is perpendicular to the blood vessel
cosine(90 degrees) = 0
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Q 3: Describe reported relation between PET negative lymph node size and malignancy.
The size of PET (-) nodes impacts probability of malignancy
Mediastinal lymph nodes and relation with metastatic involvement: a Metanalysis. Langen et al, Eur J Cardiothorac
Surg 2006;29:26-29
► Probability for malignancy in lymph nodes measuring 10-15 mm in the short axis is 29%,and about 60% if nodes are larger.
► If nodes 10-15 mm and PET Negative, probability for malignancy is 5%. Refrain from mediastinoscopy, proceed with
thoracotomy► If nodes > 16 mm and PET Negative,
probability for malignancy is 21%. Proceed with mediastinoscopy
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Thank you
BI Practical Approach #1 43
Prepared with the assistance of Steven Escobar MD and Septimiu Murgu MD
www.bronchoscopy.org