Transcript PA 7 - Bronchoscopy International

#7. EBUS-TBNA for right paratracheal node
in a patient with COPD and lung cancer
► Describe
the 15 steps
to performing EBUSTBNA.
► 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 37.2C 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
► CT
(practical approach 7)
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.
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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
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
BI #. Practical Approach Title
complications
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Initial Evaluations
► Exam
►Prolonged
expiratory phase
►ECOG performance status 1
► Comorbidities
►Severe
► Support
COPD, HTN, Tobacco abuse
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
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**Chest 2007;132;202-220
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
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Procedural Techniques and Results
► Anesthesia
►General




and peri-operative care
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
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*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, Dmode, 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 Bmode and color Doppler
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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 twodimensional 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.
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
GAIN CONTROL
 Higher frequency
has better resolution
but less depth of
penetration
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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
resolution
frequency
Low frequencyhigh penetration
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Large transducers transmit powerful beams
and increase penetration depth
► Penetration
depth is less for EBUS than for
thoracic ultrasound.
PLEURAL
EFFUSION
EBUS
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Scanning methods
►For
the convex
probe, the
scanning plane is
parallel to the
scope
Convex
Transducer
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BF-UC160F-OL8 Specifications
Ultrasonic
functions
Display mode
B-mode
Color Power Doppler
mode
Scanning method
Electrical curved linear
array
Scanning direction
Parallel to the insertion
direction
Frequency
7.5MHz
Scanning range
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Contacting method
Balloon method
Direct contact method
http://www.olympusamerica.com/msg_section/
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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.
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
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**Lung Cancer (2007) 55, 371-377
Q 1: Describe the 15 steps to
performing EBUS-TBNA
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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.
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.
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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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4R
Ascending
aorta
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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
cosine(90 degrees) = 0
Very weak or no Doppler signal is obtained
when the scanning plane is perpendicular to
the blood vessel
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Q 3: Describe reported relation
between PET negative lymph node
size and malignancy.
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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 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%.
 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
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Prepared with the assistance of
Steven Escobar MD and Septimiu Murgu MD
www.bronchoscopy.org
BI Practical Approach #1
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