Transcript Endobronchial Ultrasound-Guided Transbronchial Needle

Endobronchial Ultrasound-Guided
Transbronchial Needle Aspiration
(EBUS-TBNA)
34th Congresso Brasileiro de Pneumologia e Tisiologia
Brasilia, Brazil, 2008
Henri Colt MD
University of California, Irvine
[email protected]
1
Objectives
Role of nodal staging in nonsmall cell
lung cancer
 Invasive and noninvasive modalities
 EBUS principles, technique and
instrumentation
 EBUS and CT, EBUS and PET, EBUS
and mediastinoscopy
 EBUS: new developments

2
Background
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
Non-small cell lung cancer (NSCLC) the leading
cause of death from malignant diseases
worldwide despite advances in surgical and
multimodality treatment.
Accurate staging of the disease is mandatory
not only to determine the prognosis but also to
decide the most suitable treatment plan.
The most significant treatment decision is
identifying patients who can benefit from
surgical resection.
3
Background


The presence of lymph node metastasis remains
one of the most adverse factors for prognosis in
NSCLC
The presence of mediastinal lymph node
involvement indicates the presence of stage IIIA
or IIIB, which suggests either inoperability
and/or the need for treatment by chemotherapy
and/or radiotherapy
4
Survival based on nodal invasion
5
Staging N factor
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Non-invasive staging (Imaging)
CT, MRI, PET, PET-CT, EBUS, EUS
Invasive staging (Sampling)
Surgical open biopsy (Med, VATS)
Needle Biopsy (TBNA, TTNA, EUS-FNA)
6
7
Staging N factor - Needle biopsy
Transthoracic Needle Aspiration
 Performed by interventional radiologists
 CT or fluoroscopic guidance
 High sensitivity in enlarged nodes 91%
 Low false negative rate 20-50%
 High incidence of pneumothorax 5-60%
Chest. 2003; 123: 157-66
 Implantation rare but possible
Radiol. Clin. North Am. 2000; 38: 525-34
Cardiovasc. Intervent. Radiol. 1991; 14: 17-23
Clin. Chest Med. 1993; 14: 99-110
Chest. 2001; 120: 1037-8
8
Chest. 2000; 118: 936-9
Staging N factor - Needle biopsy
EUS-FNA
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Only modality for #8, #9 LN
Limited to left paratracheal
Sensitivity 81-97%
Specificity 83-100%
Major drawback high false
Ann. negative
Surg. 2003; 238: rate
180-8
Chest. 1990; 98: 586-93
Endoscopy. 1994; 26: 784-7
Ann. Thorac. Surg. 1996; 61: 1441-5
Chest. 2000; 117: 339-45
Lung Cancer. 2003; 41: 259-67
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Am. J. Respir. Crit. Care Med. 2003; 168: 1293-7
TBNA – Different Methods
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Conventional TBNA
CT guided TBNA
Electromagnetic Navigation guided TBNA
Ultrasound guided TBNA
1) Radial Probe guided
2) Convex Probe guided (real time)
EBUS-TBNA
10
Conventional TBNA
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Sensitivity 14-91% (operator dependent)
Failure to place needle directly into LN
Depends on LN size and station
High false negative rate
Chest. 1983; 84: 571-6
Chest. 1989; 96: 1228-32
Am. Rev. Respir. Dis. 1986; 134: 146-8
Chest. 2003; 123: 157-66
Chest. 2005; 128: 869-75
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CT guided TBNA
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High yield 83-88%
Requires use of CT suite (costly)
Radiation exposure (both Pt and operator)
Confirmation of needle outside of LN
(42.1%)
Chest. 1998; 114: 36-9
Chest. 2000; 118: 1630-8
Chest. 2001; 119: 329-32
Radiology. 2000; 216: 764-7
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Navigational TBNA
V
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Navigational TBNA
Return on
investment ??
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EBUS-TBNA
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Fairly new diagnostic procedure (1999)
-2002: convex probe (real-time guidance)
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Originally developed for lymph node
staging
Other diagnostic uses
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Intrapulmonary tumors
Unknown hilar or mediastinal LAD
Mediastinal tumors
16
Medium
A
Ultrasound Transducer
B
1
C
2
2
D
2
3
4
4
4
5
Ultrasound Image
Tissue density
Acoustic impedence
Angle of probe with target tissue
17
Angle of
examination
and angle of
insertion will
be important
18
Endobronchial Ultrasound:
principles
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
piezoelectric
crystal
standard frequency
for EBUS is
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6.9 mm
20 MHz (radial)
7.5 MHz (convex)
19
The Processor
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Physics
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Definition: wave length
US > 20 KHz
Diagnostic 2-20 Mhz
Chest US: 3-5 MHz
EBUS:
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penetration
resolution
20 MHz
7.5 MHz
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Linear curvedEBUS-TBNA
transducer
Images obtained by
attaching a balloon
and inflating with
normal saline
Image is processed
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Lesions can be
measured
Images can be frozen
Doppler mode
22-gauge needle
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Internal sheath
22
EBUS-TBNA
23
Use of Doppler demonstrates blood
flow
24
Needle insertion
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Example EBUS-TBNA level R10 node
VIDEO
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EBUS-TBNA
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All mediastinal
lymph nodes
accessible except:

Subaortic
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
(5 and 6)
Paraesophageal

(8 and 9)
Gen Thorac Cardiovasc Surg (2008) 56: 268-276
27
Results of EBUS
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METHODS: This was a retrospective
analysis of 152 consecutive patients who
underwent EBUS-TBNA with undiagnosed
intrathoracic adenopathy or cancer staging
as the primary indications.
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The procedures occurred between January
2005 and June 2006 at a single academic
medical center. Of the 152 patients.
117 were included in the final statistical
analysis after excluding those with benign
disease diagnosed by
EBUS-TBNA. Rapid on-site cytopathologic
examination was used in all cases.
Vincent BD, Ann Thorac Surg. 2008
28
Real-time endobronchial ultrasound-guided
transbronchial lymph node aspiration.
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RESULTS: Malignancy was identified in 113 patients, of
which 67 (59.3%) had non-small cell lung carcinoma, and
20 (17.7%) underwent surgical resection.
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Four patients had benign diagnoses at surgical pathology. Only 1
surgical patient was found to have nodal metastasis at a lymph
node station previously biopsied by EBUS-TBNA (negative
predictive value, 97%).
Compared with radiologic staging, EBUS-TBNA downstaged 18 of 113 (15.9%) and up-staged 11 (9.7%).
Sensitivity was 98.7%, with 100% specificity. No major
complications were associated with the procedure.
CONCLUSIONS: EBUS-TBNA is useful in accessing
mediastinal and hilar lymph nodes for the diagnosis and
staging of non-small cell lung cancer and other disorders
of the mediastinum. Thoracic surgeons and
pulmonologists are well positioned to use this tool in
everyday practice.
Vincent BD, Ann Thorac Surg. 2008
29
Minimally invasive endoscopic staging
of suspected lung cancer

Comparison of the diagnostic accuracy of
3 methods of minimally invasive
endoscopic staging (and their
combinations):
traditional transbronchial needle aspiration
(TBNA)
 endobronchial ultrasound-guided fine-needle
aspiration (EBUS-FNA)
 transesophageal endoscopic ultrasound30
guided
fine-needle
aspiration (EUS-FNA)
Wallace MB,
et al, JAMA.
2008
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Minimally invasive endoscopic staging
of suspected lung cancer
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138 patients:
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42 (30%) had malignant lymph nodes.
EBUS-FNA: more sensitive than TBNA,
detecting 29 (69%) vs 15 (36%) malignant
lymph nodes (P = .003).
EUS plus EBUS: higher estimated sensitivity
(93% [39/42]; 95% confidence interval, 81%99%) and negative predictive value (97%
[96/99]; 95% confidence interval, 91%-99%)
compared with either method alone.
Wallace MB, et al, JAMA. 2008
31
Minimally invasive endoscopic
staging of suspected lung cancer

EUS plus EBUS
 higher
sensitivity and higher negative
predictive value for detecting lymph nodes
in any mediastinal location and for patients
without lymph node enlargement on chest
computed tomography

EBUS-FNA
 higher
sensitivity than TBNA
Wallace MB, et al, JAMA. 2008
32
Conclusion
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EUS plus EBUS
 may
allow near-complete minimally invasive
mediastinal staging in patients with
suspected lung cancer
 may be an alternative approach for
mediastinal staging in patients with
suspected lung cancer
33
1<2<3
Conventional TBNA
EBUS OR EUS guided TBNA
EBUS AND EUS guided TBNA
Multidisciplinary lung cancer groups evaluates
patients based on disease process rather than
on medical/surgery specialty ???
34
Lung CA Staging: overview
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ACCP Invasive mediastinal staging
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2002: Revised 4 years later
Highlights
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Extensive mediastinal infiltration
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Discrete mediastinal lymph node enlargement
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Invasive staging not needed
Staging by CT or PET not sufficient
Invasive staging required
Normal sized lymph nodes -> mediastinoscopy
Clinical N1 (Stage II) or central tumor
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Mediastinoscopy
EBUS is an accepted alternative
Chest 2007; 132; 202-220
35
Lung CA Staging: overview

ACCP Invasive mediastinal staging

PET positive LAD in Stage I
Invasive staging is required
 EBUS alternative
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Overall
EBUS-TBNA is reasonable as long as
nondiagnostic results are followed by
Mediastinoscopy
 Mediastinoscopy is still the Gold Standard
 Still no study that directly compares
mediastinoscopy to EBUS-TBNA

Chest 2007; 132; 202-220
36
Comparisons: Different modalities
37
Endobronchial Ultrasound:
clinical applications

guidance of
mediastinal lymph
node biopsies
(J Bronchol 2006;13:84–91)
Herth FJ et al. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.
Chest 2003;123:604 –7.
38
Review of the literature: EBUS
and…
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Conventional TBNA
EUS and TBNA
Conventional mediastinoscopy
PET and CT
PET
Guiding bronchoscopic therapies
Lymph node size
Metastatic lung tumors
Normal mediastinum CT negative, and PET negative
CT, PET and surgical staging gold standard
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1. EBUS and TBNA
CHEST 2004; 125:322–325
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2. EBUS and EUS
Am J Respir Crit Care Med Vol 171. pp 1164–1167, 2005
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EBUS, TBNA, and EUS
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3. EBUS vs. mediastinoscopy
EBUS-TBNA
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502 patients
572 Lymph nodes
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Mediastinoscopy to confirm biopsy
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Nodes (2l, 2r, 3, 4r, 4l, 7, 10r, 10l, 11r, and 11l)
Mean diameter 1.6 (range.8-4.3)
535 resulted in diagnosis (94%)
Sensitivity 94%
Specificity 100%
PPV 100%
Recorded no complications
Herth et. al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling
43
mediastinal lymph nodes. Thorax 2006 61; 795-798
4. EBUS vs CT, TBNA, and PET
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Comparison of EBUS-TBNA, PET, and CT
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CT scan: lymph nodes positive if > 1cm
PET scan: lymph nodes positive if uptake >2.5
EBUS-TBNA: lymph nodes >5mm
Results
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280 patients evaluated
102 patients met criteria
Underwent CT and PET
EBUS-TBNA
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147 mediastinal and 53 hilar nodes
Surgical histology was then used for comparison
Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung
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Cancer. Chest 2006; 130:710-718
EBUS and Staging
Sensitivity
Specificity
Diagnositc
Accuracy
CT
76.9%
55.3%
60.8%
PET
80%
70.1%
72.5%
EBUS-TBNA
92.3%
100%
98%
Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung
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Cancer. Chest 2006; 130:710-718
Size of PET negative 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
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Probability for malignancy in lymph nodes measuring 1015 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%.
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Refrain from mediastinoscopy
If nodes > 16 mm and PET Negative, probability for
malignancy is 21%.
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Proceed with mediastinoscopy
46
5a. EBUS and PET positive nodes
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Performance of TBNA using linear EBUS
(real-time EBUS-TBNA) under local
anaesthesia and the value of PET for
prediction of pathological results were
assessed
Number of eluded surgical procedures was
evaluated
Bauwens O, et al, Lung Cancer 2008
47
EBUS and PET positive nodes in lung cancer
 106 Patients with suspected/proven lung
cancers and FDG-PET positive mediastinal
adenopathy
 Av. # of TBNA samples/patient: 4.9+/-1.1
 Prevalence of lymph node metastasis- 58%.
 Results of EBUS-TBNA staging of
mediastinal hot spots:

95% sensitivity, 97% accuracy, 91% negative
predictive value.
Bauwens O, et al, Lung Cancer 2008
48
Conclusion
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Surgical procedures
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eluded in 56% of the patients
Real-time EBUS-TBNA
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should be preferred over mediastinoscopy as
first step procedure in staging of PET
mediastinal hot spots in lung cancer patients
Bauwens O, et al, Lung Cancer 2008
49
5b. EBUS and PET positive
mediastinal lymph nodes
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diagnostic/staging yield of TBNA following
EBUS localization was assessed
number of avoided surgical procedures
was evaluated
33 patients referred for staging and/or
diagnosis of mediastinal FDG-PET positive
lesions
Plat G, et al, Eur Respir J. 2006
50
EBUS and PET positive mediastinal
lymph nodes
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TBNA sampling of lymph nodes
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Cytological or histological diagnoses
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performed after EBUS localisation
Av. number of TBNA samples/pt: 4.2+/-1.5.
obtained in 27 (82%) of the patients, of which
78% were obtained after previous EBUS
localization
In 25 (76%) of the 33 patients, surgical
staging procedures were suppressed.
Plat G, et al, Eur Respir J. 2006
51
Conclusion
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TBNA after EBUS localization

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should be considered as a primary method of
evaluation of lymph nodes positive by PET
scan
may replace the majority of surgical
mediastinal staging/diagnostic procedures.
Plat G, et al, Eur Respir J. 2006
52
6. EBUS guiding bronchoscopic
interventions
Bronchial wall invasion

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Tumor Invasion
 3-7 echo layers
EBUS: more sensitive than
CT for assessing bronchial
wall invasion
 105 patients
 EBUS: sensitivity of
89% and a specificity of
100%
 CT: sensitivity of 75%
and a specificity of 28%
Kurimoto N et al.
(CHEST 1999;
115:1500–1506)
Courtesy of N Kurimoto, Kawasaki, Japan
Herth F, Ernst A, Schulz M, Becker H. Endobronchial ultrasound reliably differentiates between airway
53
infiltration and compression by tumor. Chest 2003;123:458–62.
Bronchial wall invasion
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Selecting Therapy
EBUS to select patients with biopsy proven
squamous cell carcinoma (or CIS) for PDT
 9 of 18 lesions confirmed as local disease (not
extending through the cartilage) were treated
with PDT
 100% were considered to have complete
response on follow-up after a median of 32
months
 6 of the 9 lesions diagnosed as extracartilaginous with EBUS underwent surgical
54
Am
J Respir Crit Care Med 2002; 165:832–7.
resection
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EBUS and palliative bronchoscopic treatments
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N= 1,174 over a three year period
mechanical tumor debridement, stent
placement, Nd:YAG laser, APC,
brachytherapy, foreign body, ELC therapy
EBUS was found to guide or change
management in 43%
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selecting proper stent size
guiding tumor debridement
selecting patients for endoscopic therapy
versus surgical therapy
Eur Respir J 2002;20:118 –21.
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7. EBUS and Lymph Node Size
EBUS-TBNA for nodes < 1cm
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Patients then had surgical staging
119 lymph nodes
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Nodes (2r, 2l, 4r, 4l, 7, 10r, 10l, 11r, and 11l)
4-10 mm (mean 8.1mm)
Sensitivity 92.3%
Specificity 100%
Malignancy in 19pts by EBUS, but missed 2
Of note
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3 patients: N0 -> N3
13 patients: N2 -> N3
Herth et al. Endobronchial ultarasound-guided transbronchial needle aspirationof lymph nodes in the
radiologically normal mediastinum. Eur Respir J 2006; 28: 910-914
56
8. EBUS TBNA and lymph nodes: selection of
surgical candidates with metastatic lung tumors
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Patients with metastatic lung tumors with
radiologically defined mediastinal and/or hilar
lymph nodes on chest computed tomographic
scans
Retrospective.
Successful lymph node aspiration was evidenced
by the presence of malignant cells or normal
lymphocytes.
Cytologic and histologic analysis was used to
confirm metastasis in surgically resected
specimens unless metastasis was proven by
EBUS-TBNA.
Nakajima T, J Thorac Cardiovasc Surg. 2007 Dec
57
EBUS TBNA and lymph nodes: selection of surgical
candidates with metastatic lung tumors
 RESULTS: A total of 106 patients were referred
for metastasectomy
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EBUS-TBNA was performed in 60 lymph nodes (37
mediastinal and 23 hilar nodes) from 43 patients.
Cytologic and/or histologic samples were diagnostic in
41 (95.3%). EBUS-TBNA detected metastasis in 23.
The sensitivity, specificity, and diagnostic accuracy
rate of EBUS-TBNA for diagnosis of mediastinal and
hilar lymph node metastasis were 92.0%, 100%, and
95.3%,.
CONCLUSIONS: EBUS-TBNA highly sensitive
for the evaluation of mediastinal and hilar lymph
node metastasis in patients with metastatic lung
tumors.
Nakajima T, J Thorac Cardiovasc Surg. 2007 Dec
58
9a. EBUS CT negative normal
mediastinum


Study to determine the accuracy of EBUSTBNA in sampling nodes <or=1 cm in
diameter.
Population

NSCLC patients with CT scans showing no
enlarged lymph nodes (no node >1 cm) in the
mediastinum.
Herth FJ, et al,Eur Respir J. 2006
59
EBUS-guided TBNA of lymph nodes in
the radiologically normal mediastinum

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Lymph nodes aspirated at locations 2r, 2l,
4r, 4l, 7, 10r, 10l, 11r and 11l
All patients underwent subsequent
surgical staging
Diagnoses based on aspiration results
were compared with surgical results
Herth FJ, et al, Eur Respir J. 2006
60
EBUS-guided TBNA of lymph nodes in
the radiologically normal mediastinum
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100 patients, 119 lymph nodes sampled
(range 5-10 mm)
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Malignancy detected in 19 pts, missed in two
Mean diameter of punctured lymph nodes8.1 mm.
Sensitivity of EBUS-TBNA for detecting
malignancy was 92.3%, specificity was 100%,
negative predictive value was 96.3%
No complications occurred.
Herth FJ, et al, Eur Respir J. 2006
61
Conclusion

EBUS-guided TBNA can accurately sample
even small mediastinal nodes, therefore
avoiding unnecessary surgical exploration
in one out of six patients who have no
computed tomography evidence of
mediastinal disease.
Herth FJ, et al, Eur Respir J. 2006
62
9b. EBUS and PET negative, normal
mediastinum



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Patients highly suspicious for NSCLC with CT scans
showing no enlarged lymph nodes (no node > 1 cm) and
a negative PET finding of the mediastinum underwent
EBUS-TBNA.
Identifiable lymph nodes at locations 2r, 2L, 4r, 4L, 7,
10r, 10L, 11r, and 11L were aspirated.
All patients underwent subsequent surgical staging.
Diagnoses based on aspiration results were compared
with those based on surgical results.
One hundred patients (mean age, 52.4 years; 59 men)
were included. After surgery, 97 patients (mean age,
52.9 years; 57 men) had NSCLC confirmed and were
included in the analysis.
Herth F et al. CHEST 2008; 133:887–891
63

In this group, 156 lymph nodes ranging 5 to 10 mm in
size were detected and sampled.

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Malignancy was detected in nine patients but missed in one
patient.
Mean diameter of the punctured lymph nodes was 7.9 mm.
The sensitivity of EBUS-TBNA for detecting malignancy was
89%, specificity was 100%, and the negative predictive value
was 98.9%. No complications occurred.
In conclusion, EBUS-TBNA can be used to
accurately sample and stage patients with clinical
stage 1 lung cancer and no evidence of
mediastinal involvement on CT and PET.
Potentially operable patients with no signs of
mediastinal involvement may benefit from
presurgical staging with EBUS-TBNA.
64
Herth F et al. CHEST 2008; 133:887–891
Herth F et al. CHEST 2008; 133:887–891
65
10. Comparison of endobronchial ultrasound, positron
emission tomography, and CT for lymph node staging of
lung cancer

A prospective comparison of methods used for
detection of mediastinal and hilar lymph node
metastasis in patients with lung cancer considered
for surgical resection.




direct real-time endobronchial ultrasound (EBUS)guided transbronchial needle aspiration (TBNA)
positron emission tomography (PET)
thoracic CT
Surgical histology

used as the "gold standard" to confirm lymph node
metastasis unless patients were found inoperable for
N3 or extensive N2 disease proven by EBUS-TBNA.
Yasufuku K, et al, Chest 2006:130;710-718
66
Comparison of endobronchial ultrasound,
positron emission tomography, and CT for
lymph node staging of lung cancer




One hundred two potentially operable patients with
proven (n = 96) or radiologically suspected (n = 6)
lung cancer were included in the study.
EBUS-TBNA proved malignancy in 37 lymph node
stations in 24 patients. (92.3% sensitivity)
CT identified 92 positive lymph nodes (80.0%
sensitivity)
PET identified 89 positive lymph nodes (4
supraclavicular, 63 mediastinal, 22 hilar). (76.9%
sensitivity)
Yasufuku K, et al, Chest 2006:130;710-718
67
New developments in EBUS
1. Miniforceps
2. Cost analysis
3. Restaging
4. Number of aspirations
68
1. EBUS-guided miniforceps biopsy in the
biopsy of subcarinal masses in patients with
low likelihood of non-small cell lung cancer


Evaluation of the safety and efficacy of
obtaining specimens from subcarinal
masses using a 1.15-mm miniforceps
under EBUS guidance vs. the diagnostic
yield with TBNA alone.
75 patients
Herth FJ, et al, Ann Thorac Surg. 2008
69
EBUS-guided miniforceps biopsy in the
biopsy of subcarinal masses in patients with
low likelihood of NSCLC

EBUS-guided BNA of the lesion performed
using three methods:




First with a 22-gauge needle
Followed by a 19-gauge needle
Miniforceps was then passed through the
airway into the lesion under real-time EBUS
guidance
3 biopsy specimens were obtained
Herth FJ, et al, Ann Thorac Surg. 2008
70
Conclusion

Specific diagnosis made in:




36% of patients with the 22-gauge needle
49% with the 19-gauge needle
88% with the miniforceps
EBUS-guided miniforceps biopsy


Diagnostic yield is superior to TBNA alone
Procedure appears safe
Herth FJ, et al, Ann Thorac Surg. 2008
71
2. EBUS guided TBNA of mediastinal
lymph nodes for lung cancer staging: a
projected cost analysis

EBUS-TBNA


a safe alternative to mediastinoscopy for
staging patients with lung cancer
Hypothesis

Patients found to have N2/N3 disease would
not require further investigation with PET
imaging and mediastinoscopy
Callister ME, et al, Thorax. 2008
72
EBUS guided TBNA of mediastinal lymph
nodes for lung cancer staging: a projected
cost analysis


Forty-seven patients underwent
mediastinoscopy as a staging procedure
for lung cancer at Leeds Teaching
Hospitals in 2006.
Twenty-eight patients were shown to have
malignant disease in N2 or N3 nodes, of
which 27 were deemed accessible to
EBUS-TBNA (all had mediastinal
lymphadenopathy on initial CT scan).
Callister ME, et al, Thorax. 2008
73
Conclusion


Mean EBUS-TBNA sensitivity for
malignancy in recently published series
was 92.3%
Projected that 25 patients would have had
mediastinal malignancy demonstrated by
EBUS-TBNA and would therefore not have
undergone CT-PET and mediastinoscopy.
Callister ME, et al, Thorax. 2008
74
But for may multidisciplinary teams,
PET would be often warranted
anyway because of known 10-14
percent incidence of unsuspected
extrathoracic metastases
75
3. EBUS with TBNA for restaging the
mediastinum in lung cancer

Investigated the sensitivity and accuracy
of endobronchial ultrasound-guided
transbronchial needle aspiration (EBUSTBNA) for restaging the mediastinum after
induction chemotherapy in patients with
non-small-cell lung cancer (NSCLC).
Herth FJ, et al, J Clin Oncol. 2008
76
EBUS with TBNA for restaging the
mediastinum in lung cancer


124 patients with tissue-proven stage
IIIA-N2 disease who were treated with
induction chemotherapy and who had
undergone mediastinal restaging by EBUSTBNA
Patients subsequently underwent
thoracotomy with attempted curative
resection and a lymph node dissection
regardless of EBUS-TBNA findings.
Herth FJ, et al, J Clin Oncol. 2008
77
EBUS with TBNA for restaging the
mediastinum in lung cancer

Persistent nodal metastases




detected by using EBUS-TBNA in 89 patients
(72%).
no metastases assessed by EBUS-TBNA in 35
patients
28 out of 35 were found to have residual
stage IIIA-N2 disease at thoracotomy
91% of false negative results

due to nodal sampling error rather than
detection error.
Herth FJ, et al, J Clin Oncol. 2008
78
EBUS with TBNA for restaging the
mediastinum in lung cancer





Sensitivity-76%
Specificity-100%
Positive predictive value-100%
Negative predictive value-20%
Diagnostic accuracy of EBUS-TBNA for
mediastinal restaging after induction
chemotherapy-77%
Herth FJ, et al, J Clin Oncol. 2008
79
Conclusion


EBUS-TBNA was found to be a sensitive,
specific, accurate, and minimally invasive
test for mediastinal restaging of patients
with NSCLC.
Because of the low negative predictive
value, tumor-negative findings should be
confirmed by surgical staging before
thoracotomy.
Herth FJ, et al, J Clin Oncol. 2008
80
But let’s look at the numbers:

124 patients


89 had cancer on restaging EBUS
35 did not

Of these, 28 had cancer on restaging open surgery
117/124 patients still had cancer at restaging
81
4. EBUS TBNA and the
number of aspirates
82
Background

The number of aspirations needed in
conventional TBNA

the maximum diagnostic yield was obtained in
five to seven needle passes
Chin R Jr, McCain TW, Lucia MA, et al. Transbronchial needle
aspiration in diagnosing and staging lung cancer: how many
aspirates are needed? Am J Respir Crit Care Med 2002;
166:377–381
Diacon AH, Schuurmans MM, Theron J, et al. Transbronchial
needle aspirates: how many passes per target site? Eur Respir
J 2007; 29:112–116
83
Background

There are greater limitations in the size
and location of accessible LNs that can be
aspirated using TBNA vs EBUS-TBNA. In a
metaanalysis

the pooled sensitivity of conventional TBNA in
the mediastinal staging of NSCLC was
reported to be 39 to 78%.
Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for
mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax 2005;
60:949 –955
84
Objectives and Methods

Objective: The goal of this study was to

Methods: EBUS-TBNA was performed in
determine the optimal number of aspirations per
lymph node (LN) station during endobronchial
ultrasound (EBUS)-guided transbronchial needle
aspiration (TBNA) for maximum diagnostic yield
in mediastinal staging of non-small cell lung
cancer (NSCLC) in the absence of rapid on-site
cytopathologic examination.
potentially operable NSCLC patients with
mediastinal LNs accessible by EBUS-TBNA (5 to
20 mm). Every target LN station was punctured
four times.
Chest 2008;134;368-374
85
86
Chest 2008;134;368-374
Maximum results after 3 aspirates
Rapid On Site Cytology is
standard of care to assure greater
yield and better patient care
Chest 2008;134;368-374
87
Thank you
88