Transcript PA 11 - Bronchoscopy International

#11. Planning EBUS-TBNA of right lower
paratracheal lymph node (station 4R)
► Define
the borders of station
4R and justify this definition.
► Describe how sagittal view of a
computed tomography scan is
used to plan EBUS-TBNA at
station 4R.
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Case description
(practical approach # 11)
►A
77 year-man with a 50 pack –year
history of smoking presents with abnormal
CXR performed preoperatively for hernia
repair.
► Computed tomography shows a 1.5 X 1 cm
right upper lobe nodule and a 1.4 cm right
lower paratracheal lymph node.
► Patient is referred for tissue diagnosis
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Case description
Axial, coronal and sagittal
CT views from the patient
(practical approach #11)
Axial CT view
4R
Sagittal view
Coronal CT view
4R
4R
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The Practical Approach
Initial Evaluation
Procedural Strategies
• 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
Techniques and Results
• Anesthesia and peri-operative
care
• Techniques and
instrumentation
• Anatomic dangers and other
risks
• Results and procedure-related
complications
Long term Management
• Outcome assessment
• Follow-up tests and procedures
• Referrals
• Quality improvement
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Initial Evaluations
► Exam
►Decreased
air entry bilaterally and prolonged
exhalation
►Functional status ECOG 3
► Comorbidities
►COPD
( FEV1 23% predicted)
►Coronary artery disease
► Support
►Lives
► Patient
system
at home by himself
preferences
►Desires
diagnosis and considers all available active
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treatment options.
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Procedural Strategies
► 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 (1.4 cm right paratracheal node)
 Bronchoscopic inspection can be performed at
the time of EBUS-TBNA.
 Diagnosis and staging can be performed during
a single procedure.
*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
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Procedural Strategies
Indications
 Sample 4R (right paratracheal node) for diagnosis and
staging
► 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
► 4R nodal involvement in this patient suggests stage IIIA
 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.
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Procedural Strategies
►
►
Contraindications:
►None
Expected Results:
►The diagnostic rate of EBUS-TBNA for station 4R
is:
► 71-94
►
►
% * ***
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
 diagnosis and staging at the same time
*Chest 2004; 125:322–325
**Eur Respir J 2009; 33: 1156–1164
***Herth F et al. Thorax 2006;61;795-798
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For station 4R, EBUS-TBNA has slightly
better yield than conventional TBNA
Chest 2004; 125:322–325
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The yield of EBUS-TBNA for diagnosing
malignancy in station 4R is as high as 94%
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Herth F et al. Thorax 2006;61;795-798
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Procedural Strategies
► 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) may reach 4R node;
Sensitivity 81-97% Specificity 83-100% **
► Mediastinoscopy: considered gold standard.
 Bronchoscopic airway inspection would still be required
 More invasive
► VATS: most invasive of alternatives.
►Only provides access to ipsilateral nodes. 75%
sensitivity***.
►Benefits include definitive lobar resection at same time if
node negative.
*Chest. 2003; 123: 157-66
**Lung Cancer. 2003; 41: 259-6711
***Chest 2007;132;202-220
For station 4R, EBUS-TBNA is superior to
EUS-FNA
Am J Respir Crit Care Med Vol 171. pp 1164-1167, 2005
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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
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Procedural Strategies
► Informed
consent for EBUS-TBNA was obtained:
► There
were no barriers to learning identified. Patient has good
insight into his disease and realistic expectations.
Drawing modified from Herth F et al. J
Bronchol Volume 13, Number 2, 2006
BI #. Practical Approach Title
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Procedural techniques and results
Anesthesia 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
Chest 2008;134;1350-1351
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J Cardiothorac Vasc Anesth 2007; 21:892–896
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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
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Procedural Techniques and Results
► Anatomic
dangers and other risks
►Major blood vessels- pulmonary artery, azygos
vein, superior vena cava and ascending aorta
► 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 conventional TBNA but no
reports in literature with EBUS guided FNA.
Chest 2004;126;122-128
**Eur Respir J 2002; 19:356–373
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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%
* Chest 2008;134;368-374;
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Procedural Techniques and Results
► Results
and procedure-related complications
 EBUS-TBNA was performed under general anesthesia
using a 9.0 endotracheal tube.
 4R nodal cytology diagnostic for non small cell
carcinoma (adenocarcinoma).
 Bronchoscopic inspection: normal airways
 Transient laryngospasm post-extubation was relieved by
positive pressure mask ventilation.
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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
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Q 1: Define the borders of station
4R and justify this definition.
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Bronchoscopy.org
Station 4R (right lower paratracheal)
based on IASLC map
► 4R
station includes:
right paratracheal
nodes, and
pretracheal nodes
extending to the left
lateral border of
trachea
Left lateral
border
(J Thorac Oncol. 2009;4: 568–577)
Station 4R (right lower paratracheal)
based on IASLC map
► Upper
border:
intersection of
caudal margin of
innominate vein
with the trachea.
► Lower
border:
lower border of
azygos vein.
(J Thorac Oncol. 2009;4: 568–577)
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Station 4R (right lower paratracheal)
based on IASLC map
►
►
Concise and anatomically
distinct descriptions are
provided in the IASLC
map for the upper and
lower borders of lymph
node stations
The pleural reflection (red
arrows) no longer serves
as the border between
nodal stations 4 and 10 as
in Mountain- Dressler map
Mountain-Dressler map
(J Thorac Oncol. 2009;4: 568–577)
Advantages of IASLC map
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Station 4R (right lower paratracheal)
based on IASLC map
►
►
Because lymphatic drainage in
the superior mediastinum
predominantly occurs to the
right paratracheal area and
extends past the midline of
the trachea…
the boundary between the
right- and left-sided stations 2
and 4 lymph nodes has been
reset to the left lateral wall of
the trachea.
IASLC Map
4R
This is why station 4R is redefined
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(J Thorac Oncol. 2009;4: 568–577)
Lymphatic drainage in the superior mediastinum
predominantly occurs to the right and extends past
the midline of the trachea
Inferior mediastinal
lymphatic drainage
Bronchoscopy.org
M. Riquet / Cancer/Radiothérapie 11 (2007) 4–10
Superior mediastinal
lymphatic drainage
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Furthermore....
► The
left paratracheal
nodes are localized
around the left
laryngeal recurrent
nerve and lie behind
the nerve.
► Therefore, the border
should be moved to the
left tracheal margin.
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Bronchoscopy.org
Zielinski M and Rami-Porta R. Journal of Thoracic Oncology 2; January 2007: 3-6
The oncologic and surgical midline
for station 4 (and 2) is now the left
lateral border of trachea
Left lateral border
of the trachea
Station 4R
(J Thorac Oncol. 2009;4: 568–577)
Bronchoscopy.org
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Q 2: Describe how the sagittal view
of a computed tomography scan can
be used to help plan EBUS-TBNA at
station 4R.
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CT views
http://en.wikipedia.org/wiki
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CT views: sagittal
►A
sagittal (known
as median) plane is
perpendicular to the
ground, which
separates left from
right. The
midsagittal plane is
the specific sagittal
plane that is exactly
in the middle of the
body.
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Bronchoscopy International
http://en.wikipedia.org/wiki
Which CT view is most useful for
planning EBUS-TBNA for station 4R?
EBUS scanning plane
12
9
L
1
3
R
R
L
Drawing modified from Herth F et al. J
Bronchol Volume 13, Number 2, 2006
Bronchoscopy from head of patient
The scope is positioned just proximal to the main carina. Turn it to the 3o’clock position, and check lymph node station 4 R for lymph nodes;
very often, 4R is more anterior …so gradually rotate the scope
counterclockwise towards 12 o’clock position during the inspection.
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When 4R has a pretracheal component, the sagittal
view is useful;
The aorta is seen in this particular scanning plane
4R station includes right paratracheal
nodes, and pretracheal nodes extending to
the left lateral border of trachea
Ascending
aorta
Lymph
node
Thus, when the scanning plane (dashed red line) is
oriented anteriorly (12 o’clock position), the lymph
node and ascending aorta will be visualized
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Therefore, the sagittal 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 ascending aorta is anterior to the node
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Simultaneous sagittal CT view
and EBUS image at station 4R
cephalad
Ao
Node
Aorta
LN
PA
caudal
cephalad
The EBUS image at station 4R shows this pattern
when the scanning plane is anterior towards the
ascending aorta ( Doppler mode on).
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To understand the use of sagittal CT view one must
understand the reference points on the EBUS image
caudal
caudal
cephalad
1. The EBUS image is projected on the monitor as if the scope is horizontal
2. 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
3. This dot is by default towards the 1’o’clock position of the screen
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The sagittal CT view is displayed as if the scope is
vertical
cephalad
cephalad
Ao
LN
PA
LN
Ao
PA
Several adjustments can be made to the coronal CT image in order to bring the
scope to a horizontal position and the green dot cephalad (towards the 1 o’clock position on
the screen) to match the EBUS image…
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Step by step
cephalad
cephalad
Ao
LN
LN
PA
1
LN
Ao
PA
2
1. Print out a single frame of the CT image.
2. Flip the image is over like a page. The CT image is now adjusted
so that the cephalad part is to the right, similar to the EBUS screen.
3. Next, the image will be rotated clockwise in order to horizontalize
the scope and bring the green dot cephalad towards the 1 o’clock position.
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cephalad
LN
Step by step
LN
Ao
PA
LN
LN
3
Now, the scope is horizontalized.
The green dot is towards the 1o’clock position
and the cephalad section of the image is towards the
right side, as it is displayed by default on the EBUS screen
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3
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The two images now correlate and show
all structures in the same locations
Node
Ascending
Aorta
LN
Ascending
Aorta
Characteristic image at 4R when the scanning plane is sagittal
towards the aorta
Bronchoscopy International
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When 4R has a pretracheal component, the sagittal view
is useful; the
Superior Vena Cava is seen in this scanning plane
4R includes right paratracheal nodes, and
pretracheal nodes extending to the left
lateral border of trachea
Superior Vena
Cava
Lymph
node
Thus, when the scanning plane (dashed red line) is
oriented anteriorly and to the right (endoscopically at
1-2 o’clock), the lymph node and superior vena cava
will be visualized.
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The sagittal CT view identifies the
EBUS scanning plane
cephalad
LN
SVC
PA
Drawing modified from Herth F et al. J
Bronchol Volume 13, Number 2, 2006
caudal
The SVC is anterior to the node
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Simultaneous sagittal CT view
and EBUS image at station 4R
cephalad
LN
SVC
PA
caudal
cephalad
caudal
The EBUS image at station 4R shows this pattern
when the scanning plane is anterior towards the
SVC ( Doppler mode off)
Bronchoscopy.org
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To understand the use of sagittal CT view one must
understand the reference points on the EBUS image
caudal
cephalad
1. The EBUS image is projected on the monitor as if the scope is horizontal
2. 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
3. This dot is by default towards the 1’o’clock position of the screen
Bronchoscopy International
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The sagittal CT view is displayed as if the scope is
vertical
cephalad
cephalad
LN
SVC
SVC
PA
LN
PA
caudal
caudal
Several adjustments can be made to the coronal CT image in order to bring the
scope to a horizontal position and the green dot cephalad (towards the 1 o’clock position on
the screen) to match the EBUS image…
Bronchoscopy International
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cephalad
cephalad
LN
LN
SVC
SVC
PA
caudal
LN
PA
1
2
caudal
1. Print out a single frame of the CT image
2. The CT image has to be adjusted so that the cephalad part
is to the right, as it is projected on the EBUS screen. Therefore, the
image is flipped over like a page
3. Then it is rotated clockwise in order to horizontalize the scope and
bring the green dot cephalad towards
the 1 o’clock position.
Bronchoscopy.org
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cephalad
LN
LN
SVC
PA
3
caudal
Now, the scope is horizontalized,
the green dot is towards the 1o’clock position
and the cephalad section of the image is towards
the right side, as it is displayed by
Bronchoscopy.org
default on the EBUS screen
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The two images now correlate and show
all structures in the same locations
LN
SVC
Characteristic image at 4R when the scanning plane is sagittal
towards the superior vena cava
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2009 (Please add “Date Accessed”).
Thank you
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Prepared with the assistance of Septimiu Murgu M.D.,
University of California, Irvine
www.bronchoscopy.org
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