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he gold standard for mediastinal lymph node staging ismediastinoscopy. Standard mediastinoscopy or video

ediastinoscopy provides access to levels 2R, 2L, 7, 4R, 4L,nd 10 lymph nodes. Standard mediastinoscopy helps con-rm the presence of malignant disease in clinically suspicious

ymph nodes and is reliable for diagnosing occult microscopicisease for the adequate staging of lung cancer. Endobronchialltrasound-guided transbronchial needle aspiration (EBUS-BNA) has provided an alternative to mediastinoscopy for theiopsy of mediastinal lymph nodes in select clinical situations asell as provided access to more peripheral nodes and nodules

hat mediastinoscopy cannot access.Mediastinoscopy is considered a very safe procedure with

reported operative mortality of 0.05 to 0.2% in a large seriesf patients with a complication rate of 0.56 to 1.07%.1,2 Re-orted complications include hemorrhage, vocal cord injury,racheal injury, and pneumothorax. A large series of EBUS-BNA have reported no mortality and almost no morbidityssociated with the procedure.3-5 Furthermore, preliminarytudies have reported sensitivity of EBUS-TBNA in identify-ng nodal metastases in the setting of lung cancer rangingrom 90 to 98%, depending on the population studied.4-7

nesthesiaeveral options are available for anesthesia during EBUS.onscious sedation with short-acting agents such as fentanyl

ashington University School of Medicine, Barnes-Jewish Hospital, SaintLouis, Missouri.

ddress reprint requests to Traves D. Crabtree, MD, Assistant Professor ofSurgery, Cardiothoracic Surgery, Washington University School of Med-icine, Barnes-Jewish Hospital, 660 South Euclid Avenue, Campus Box

s8234, Saint Louis, MO 63110. E-mail: crabtreet@wustl.edu

522-2942/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1053/j.optechstcvs.2009.04.001

nd midazolam may be utilized in an ambulatory setting toerform EBUS. Given the larger size of the EBUS videobron-hoscope, it is generally passed transorally rather than via thetandard transnasal approach. Predominant intravenous an-sthesia with propofol and fentanyl can also be utilized inoncert with a laryngeal mask airway device for adequateontrol of the airway. The tip of the scope can comfortably fithrough a no. 4 laryngeal mask. The procedure can also safelye performed under general anesthesia using a no. 8.5 or

arger endotracheal tube. The videobronchoscope can fithrough a no. 8 endotracheal tube as well but a larger tubellows for better ventilation. The laryngeal mask airway doesrovide the advantage of allowing for visualization of thentire paratracheal area. If using an endotracheal tube, theube may need to be withdrawn to a point near the vocalords to allow for ultrasound visualization of the high para-racheal lymph nodes. We typically prefer general anesthesiaiven the time required to perform multiple biopsies at mul-iple different nodal stations. Bronchoscopy is performedith a conventional flexible bronchoscope before EBUS to

dequately assess the airway for intrabronchial tumor, mu-osal abnormalities, and endotracheal tube positioning in theroximal trachea.During the procedure, a cytopathology technician is

resent in the operating room to help prepare the slides. Ann-site cytopathologist greatly facilitates the process by al-owing for immediate assessment of the adequacy of andiagnostic evaluation of the specimen. This is of critical im-ortance if EBUS-TBNA is to be utilized to make intraopera-ive decisions as is currently done with mediastinoscopy. Theresence of lymph tissue is often considered an adequate

pecimen.

99

100 T.D. Crabtree

Operative Technique

Figure 1 The linear array ultrasonic bronchoscope (Olympus XBF-UC 160F) with the biopsy sheath deployed. Theouter diameter of the EBUS scope is 6.7 mm and 6.9 mm at the tip. The optical system in this scope provides an80-degree field of view at a 35-degree forward oblique angle. The EBUS scope provides monocolor Doppler flowmapping for identification of blood vessels. (Color version of figure is available online at http://www.optechtcs.com.)

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Endobronchial ultrasound 101

igure 2 Mediastinal and hilar lymph nodes. (A) High-ighted nodes are typically accessible by standard cervicalideo mediastinoscopy. (B) Highlighted nodes are typi-ally accessible by EBUS-TBNA. a. � artery; Ao � aorta;A � pulmonary artery; pulm lig � pulmonary ligament;. � vein.

102 T.D. Crabtree

Figure 3 EBUS-TBNA of subcarinal(station 7) lymph nodes. (A) TheEBUS scope can be positioned in ei-ther the proximal right mainstembronchus (as depicted) or the proxi-mal left mainstem bronchus. (B) Thescope is positioned in the right main-stem bronchus with the balloon in-flated. Pulling the scope back allowsfor visualization of the contralateralmainstem bronchus at the level of thecarina. This provides a visual land-mark when examining the subcarinalspace. Ultrasound and Doppler identi-fication of the right and left pulmonaryartery also allows for orientation regard-ing the anterior portion of the respec-tive mainstem bronchus. EBUS � en-dobronchial ultrasound.

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Endobronchial ultrasound 103

igure 4 (A) Scope positioning for biopsy of a right paratrachealstation 4R) lymph node. (B) Lymph nodes are typically roundedith well-demarcated borders as depicted above. The needle isarbed to allow for ultrasound visualization. (C) Standard ultra-ound images can typically identify even small bronchial arteriesdjacent to lymph nodes. Color Doppler can also be performed toonfirm blood flow through these vessels. a. � artery; EBUS �ndobronchial ultrasound.

104 T.D. Crabtree

Figure 5 (A) Scope positioning for bi-opsy of a left paratracheal (station 4L)lymph node. (B) Biopsy of a 5- to6-mm station 4L lymph node posi-tioned between the aortic arch andthe left main pulmonary artery. Theneedle is deployed within the node.Marks adjacent to the image indicatecentimeters for calibration of nodalsize in planning the depth of needleinsertion. EBUS � endobronchial ul-trasound; PA � pulmonary artery.

Endobronchial ultrasound 105

Figure 6 N1 nodal stations can also be accessed by EBUS. Positioning of the scope in the bronchus intermedius allowsfor visualization of 11R lymph nodes most commonly identified at the junction of the right upper lobe and thebronchus intermedius. Visualization of the carina between the right upper lobe orifice and bronchus intermediusallows for proper orientation of the videobronchoscope for ultrasound identification of these lymph nodes. The EBUSvideobronchoscope can also be utilized to biopsy tumors adjacent to a segmental bronchus. It is often not necessary toinflate the balloon of the scope while performing ultrasound in the segmental bronchi. EBUS � endobronchial

ultrasound.

106 T.D. Crabtree

Figure 7 Transbronchial needle aspiration device attached to the working port of the EBUS videobronchoscope. Thesyringe attached is utilized to inflate the ultrasound balloon sheath with saline. A locking device at the base of theapparatus secures the device to the working port of the scope. (Color version of figure is available online at http://

www.optechtcs.com.)

Endobronchial ultrasound 107

Figure 8 (A) Once the node has been identified by ultrasound, the disposable needle aspiration device is secured to theworking port of the scope with the fastening device. It is important to hold the scope steady, maintaining nodalvisualization while the device is secured in place. This can be done by the bronchoscopist or by an assistant while thebronchoscopist steadies the scope. Once secured, the protective sheath must be deployed by loosening the screw andadvancing the shaft of the sheath. The 22-gauge needle remains within the sheath at this time. When deployed, thesheath must be well out of the working channel of the bronchoscope (B) and be clearly visible in the field of view of the

bronchoscope (C) to avoid needle injury to the inner channel of the scope. EBUS � endobronchial ultrasound.

108 T.D. Crabtree

Figure 9 Once the sheath is in posi-tion, the depth of needle insertion canbe set based on ultrasound assess-ment by adjusting the gray needleguard. (A) Demonstrates the needleguard set for a depth of 2 cm. This canbe set to a depth of up to 4 cm, al-though this is rarely necessary. Thesmall gray clip must be removed ifone desires a depth �2 cm. Once po-sitioned, the screw of the needleguard is secured and the needle isready to be engaged.

Once the needle guard is secured,the needle is advanced with the styletin place (B), deploying the needle outof the sheath (C). This requires asharp jab rather than a slow move-ment to allow for penetration throughthe bronchial wall. The videobron-choscope should be held steady tomaintain visualization of the nodeduring needle insertion.

The stylet prevents contaminationof the needle with bronchial epithelialcells and cartilage during passage ofthe needle into the lymph node. El-derly patients with calcified trachealcartilage make passage of the needledifficult at times. Making slight ad-justments to the position of the bron-choscope while maintaining visual-ization of the lymph node to avoidpenetration of the tracheal ring maybe necessary. This is more pertinentwhen performing biopsies of the para-tracheal and pretracheal lymph nodes.

Endobronchial ultrasound 109

Figure 10 Once the needle has been deployed into the lymph node, the stylet is removed from the device and exchangedfor a vacuum lock syringe. With the needle visible in the node, the vacuum is applied to the needle via the stopcock.If blood is aspirated, the needle is withdrawn and the position of the scope is adjusted. The needle is then agitated 6 to10 times in the node with direct ultrasound visualization. Before retracting the needle from the lymph node, thevacuum is turned off. The needle is then retracted back into the sheath and the entire device is removed from the scopeto develop the slides for analysis. Multiple aspirations per node increases the diagnostic yield and accuracy of EBUS-

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ommentsn a prospective study of EBUS-TBNA for mediastinal stagingf lung cancer, the diagnostic accuracy rate was 96.3% inorrectly predicting lymph node stage in 105 patients.5 Inhis study, EBUS-TBNA prevented the need for mediastinos-opy in 29 patients, thoracotomy in 8 patients, and video-ssisted thoracoscopic surgery in 4 patients. A direct compar-son of EBUS-TBNA, computed tomography (CT), andositron emission tomography (PET) was performed in 102atients undergoing planned resection for lung cancer. Theensitivity of CT, PET, and EBUS-TBNA for the correct diag-osis of mediastinal and hilar lymph node staging was 76.9,0.0, and 92.3%, respectively. The diagnostic accuracy was0.8, 72.5, and 98%, respectively.8 The combined use ofBUS-TBNA and endoscopic ultrasound may improve theield compared with EBUS-TBNA alone by providing addi-ional access to level 8 and 9 station lymph nodes.6 Currently,ata are limited comparing mediastinoscopy and EBUS-BNA for mediastinal lymph node staging of lung cancer. 9 Ineneral, the higher sensitivities and accuracy reported in se-ies of patients undergoing EBUS-TBNA may be attributed togreater number of patients with suspicious lymph nodes byT or PET rather than identifying occult lymph node metas-

ases in patients with a negative PET and CT. To date, thereave been no reported major complications related to EBUS-BNA.Over the past 18 months, we have performed 200 EBUS-

BNA procedures at our center in patients with mediastinaldenopathy. In a cross-section of patients with mediastinaldenopathy undergoing EBUS-TBNA, 64.8% had a con-rmed diagnosis of malignancy, 7.6% had a diagnosis ofranulomatous disease, 19% had benign lymphoid tissue,hereas 6.7% of the biopsies were nondiagnostic. We havead no complications as a result of the EBUS procedure or thenesthesia.

It is likely that EBUS-TBNA may prevent the need forediastinoscopy in some patients with positive results byBUS. The greatest concern, however, is the clinical signifi-ance of a negative TBNA by EBUS when staging lung cancer.he presence of micrometastatic disease in normal-sized

ymph nodes may be more likely to be missed by FNA biopsyompared with mediastinoscopy. This issue should be con-idered when choosing to utilize EBUS instead of mediasti-oscopy for routine staging.EBUS can also be utilized for diagnosing other causes ofediastinal adenopathy. The presence of granulomas in nee-le biopsy specimens can assist in the diagnosis of granulo-atous disease. Separate biopsies should be performed si-ultaneously for culture. Utilization of EBUS for theiagnosis of suspected lymphoma requires multiple needleiopsies of the affected nodes to provide enough cellularissue for flow cytometric analysis. This reemphasizes themportance of having an on-site cytopathologist to assist withssessing the adequacy of the specimen.

Other clinical situations favor the utilization of EBUS-BNA. When used in conjunction with mediastinoscopy,BUS-TBNA can be useful in the staging and restaging ofatients undergoing induction therapy for lung cancer.BUS-TBNA may be utilized as the initial procedure followed

y mediastinoscopy after induction therapy or vice versa. We

ave also used EBUS-TBNA in the setting of superior venaava syndrome where mediastinoscopy can be hazardous orn patients who have undergone extensive neck dissectionsor head and neck tumors, limiting neck mobility and acces-ibility necessary for mediastinoscopy. In addition to theforementioned benefits of linear EBUS-TBNA, radial EBUS-BNA has also been shown to improve the diagnostic yield ofiopsy of parenchymal nodules compared with standardronchoscopy with fluoroscopy.10 Radial endobronchial ul-rasound is an ultrasound probe surrounded by a saline-filledalloon that fits through the working channel of a regular sizeronchoscope. This allows for ultrasound localization of tu-ors that cannot be visualized intrabronchially with stan-ard video bronchoscopy. The ultrasound allows for local-

zation of these tumors to a specific bronchus for subsequentiopsy. The biopsy is not performed in real-time with ultra-ound as the radial probe only allows for localization. It musthen be removed for standard biopsy techniques, unlike theinear EBUS scope.

Regarding coding and billing for EBUS-TBNA, the currentrocedural terminology (CPT) code for bronchoscopy withBNA is 31629. The national average physician fee for thisode is $191.96 in a physician facility and $643.67 in aonphysician facility. The physician fee for TBNA for eachdditional nodal station (CPT 31633) is $63.61 in a physi-ian facility and $86.46 in a nonphysician facility. Addition-lly, the physician fee for EBUS (CPT 31620) is $67.79 in ahysician facility and $273.08 in a nonphysician facility.11 Asn example, a standard bronchoscopy with EBUS biopsy ofhree nodal stations would be billed as bronchoscopy withiopsy ($195.69 for first nodal station), EBUS ($68.19), andor each additional separate nodal station biopsy ($65.23 �) for a total of $394.34. Standard bronchoscopy combinedith EBUS-TBNA of one nodal station generally requires ap-roximately 10 to 20 minutes to perform with an additionalto 10 minutes/nodal station.

onclusionsBUS-TBNA is an emerging technology that is a useful ad-

unct in the evaluation of patients with or without lung can-er with mediastinal adenopathy. The reported accuracy toate in select patients is favorable, although the role of EBUS

n routine staging of lung cancer remains undetermined. Me-iastinoscopy remains the gold standard for staging of lungancer when performed with very low morbidity in experi-nced hands. It is essential that thoracic surgeons play a rolen the application of EBUS for the biopsy of mediastinalymph nodes to maintain the same standard for lymph nodeiopsy that mediastinoscopy has afforded.

eferences1. Hammoud ZT, Anderson RC, Meyers BF, et al: The current role of

mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardio-vasc Surg 118:894-899, 1999

2. Lemaire A, Nikolic I, Petersen T, et al: Nine-year single center experi-ence with cervical mediastinoscopy: Complications and false negativerate. Ann Thorac Surg 82:1185-1189, 2006

3. Sarkiss M, Kennedy M, Riedel B, et al: Anesthesia technique for endo-bronchial ultrasound-guided fine needle aspiration of mediastinallymph node. J Cardiothorac Vasc Anesth 21:892-896, 2007

4. Vincent BD, El-Bayoumi E, Hoffman B, et al: Real-time endobronchial

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ultrasound-guided transbronchial lymph node aspiration. Ann ThoracSurg 85:224-230, 2008

5. Yasufuku K, Chiyo M, Koh E, et al: Endobronchial ultrasound guidedtransbronchial needle aspiration for staging of lung cancer. Lung Can-cer 50:347-354, 2005

6. Wallace MB, Pascual JM, Raimondo M, et al: Minimally invasive endo-scopic staging of suspected lung cancer. JAMA 299:540-546, 2008

7. Lee HS, Lee GK, Lee H, et al: Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of non-small cell lung cancer: How many aspirations per target lymph node

station? Chest 134:368-374, 2008 1

8. Yasufuku K, Nakajima T, Motoori K, et al: Comparison of endobron-chial ultrasound, positron emission tomography, and CT for lymphnode staging of lung cancer. Chest 130:710-718, 2006

9. Ernst A, Anantham D, Eberhardt R, et al: Diagnosis of mediastinaladenopathy-real-time endobronchial ultrasound guided needle aspira-tion versus mediastinoscopy. J Thorac Oncol 3:577-582, 2008

0. Chao TY, Chien MT, Lie CH, et al: Endobronchial ultrasound-guidedtransbronchial needle aspiration increases the diagnostic yield of pe-ripheral pulmonary lesions: A randomized trial. Chest 2008 Sep 23(Epub ahead of print)

1. www.encoderpro.com. Accessed August 1, 2008