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The left inferior pulmonary vein cross the descending aorta. A prospective controlled trial of
endobronchial ultrasound guided transbronchial needle aspiration compared to mediastinoscopy for
mediastinal lymph node staging of lung cancer. Journal of Cardiovascular Development and Disease
(JCDD). It is determined by the width of the Ultrasound beam. Endoscopic ultrasound (EUS) was
developed in the 1980s for evaluation of gastrointestinal malignancies but was also used to sample
accessible lymph nodes in lung cancer. On anticlockwise rotation, the probe faces the posterior wall
of left main bronchus where the descending aorta, esophagus and vertebral column are seen ( Fig.
32, 33 ). A clockwise rotation shows station 7 lymph nodes ( Fig. 34). Station 10 L lymph nodes are
seen near the left main bronchus on anti-clockwise rotation ( Fig. 35). Figure 32. Imaging from the
left main bronchus-The left main pulmonary artery is seen in the anterior wall. Endobronchial
ultrasound is performed during bronchoscopy and permits sample collection for different thoracic
disease. On figure 1, there is an example of a male patient with lung cancer (adenocarcinoma) and a
chest tomography with a large lymph node at station 7. International Journal of Translational
Medicine (IJTM). The right superior pulmonary vein passes behind superior vena cava. Quick
diagnostic test done to examine the inner body Commonly ultrasound uses sound wave to depict soft
tissue Most commonly this procedure is non-invasive The Doppler ultrasound is to used to measure
blood flow and pressure by using high frequency sounds. Editors select a small number of articles
recently published in the journal that they believe will be particularly. The remaining main stem
intermediate bronchus, gives off, more distally, the middle lobe bronchus, which runs forward and
downward. EBUS and EUS (endoesophageal ultrasound) are these days routinely used and allow
for the visualization and sampling of mediastinal lymph nodes that lie adjacent to the trachea or
oesophagus respectively. At 5 M Hz ultrasound penetrates approximately 6 cm while at 10 M Hz the
penetration field of ultrasound is about 3 cm. Clinical utilization of endobronchial ultrasound
(EBUS) to stage lung cancer. Electrical Safety Testing All transducers are electrically safety tested to
ensure safe operation. Team: Janie Goldsworthy, Kristi Hinner, Nick Kortan, Crystal Marshek Client:
Dr. Elizabeth Burnside Advisor: John Webster. The lymph node 1 is seen lying close to the bronchus
below the upper rim of left pulmonary artery and belongs to station 10-L. Usefulness of preoperative
endobronchial ultrasound for airway invasion around the trachea: esophageal cancer and thyroid
cancer. A transbronchial needle forceps has also been evaluated and found a higher diagnostic yield
compared to a 21G needle. Especially in patients with (suspected) lung cancer adequate lymph node
staging is important to choose the most appropriate form of therapy for the patient. The left PA is
visualized behind the lateral wall of the left main bronchus up to the left lower paratracheal region;
continuing to pull back and orient the transducer laterally, the aortic arch is encountered (E). The
needle size and number of needle passes are both related factors that may determine the tissue yield
of the EBUS-TBNA biopsies. In our experience, larger bore EBUS needles may be helpful i to
secure adequate tissue in these cases. Toloza EM, Harpole L, Detterbeck F, McCrory DC Invasive
staging of non-small cell lung cancer: a review of the current evidence. Right: the radial probe
ultrasound image is 360 degrees to the long axis of the EBUS bronchoscope. The echoes that come
from deep within the body are more attenuated and need more amplification to make a smooth
image. The left pulmonary artery crosses the left principal bronchus and at the hilum, is superior to it,
whereas the right pulmonary artery crosses the intermediate bronchus, having given off a major
branch to the upper lobe before it enters the hilum. Of course EBUS TBNA samples are smaller than
samples obtained by mediastinoscopy, potentially resulting in more false negative samples.
Further anticlockwise rotation may show the Left subclavian artery. Conflicts of Interest The authors
declare no conflict of interest. It is determined by the width of the Ultrasound beam. Lee et al were
able to show that 75 percent of EBUS TBNA contained core tissue allowing for molecular testing
including EGFR and ALK mutation analysis. EBUS TBNA was also found to be safe to perform in
patients taking clopidogrel although this was a small case series only. Herth FJ, Eberhardt R,
Krasnik M, Ernst A Endobronchial ultrasound-guided transbronchial needle aspiration of lymph
nodes in the radiologically and positron emission tomography-normal mediastinum in patients with
lung cancer. Lymph node station 4L lies between the aorta and the left main pulmonary artery. The
DNA yield of lymph node material obtained with the larger 19G needle (Olympus) or the Sonotip
Topgain (Medi-Globe) needle has not yet been reported but may very likely be higher. 6. PD-L1
Staining Immunohistochemical staining with anti-PD-L1 antibodies has become an integral part of
EBUS-TBNA pathology workup in lung cancer patients. Comparison of endobronchial ultrasound,
positron emission tomography, and CT for lymph node staging of lung cancer. Hospital Israelita
Albert Einstein Brazil Sao Paulo, SP, Brazil Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil.
B, Near-complete obstruction in the lower trachea and proximal mainstem bronchi because of
extrinsic compression and excessive dynamic airway collapse. Eur J Cancer. 2013;49(8):1860-7.
Review. - 5 5. Dong X, Qiu X, Liu Q, Jia J. Combined endobronchial and endoscopic ultrasound-
guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis.
Continuing to turn the bronchoscope laterally, the azygos vein is visualized (C). A small window
angle (50 to 75 degrees) in linear EBUS as compared with linear endoscopic US (130 to 180
degrees) makes visualization of the anatomic ultrasound landmarks difficult with EBUS. Routinely,
two punctures are performed for cytosmear and one is expelled into formalin for a cytospin and cell
block. In RP-EBUS the complications are pneumothorax and bleeding, ranging from 1 a 4% and 3 a
5%, respectively, in most series. 9 9. Ali MS, Trick W, Mba BI, Mohananey D, Sethi J, Musani AI.
Digital Analysis A quantitative interrogation of the transducer’s electrical and acoustic properties is
carried out on Probelogic’s Digital Analyser. Convex probe EBUS convex with Doppler mode allows
tumor measurement and visualization of the PA, SVC compression, and intratumoral vascularity. For
example, during mediastinal staging of lung cancer, it is mandatory to start from N3 station (from
contralateral or mediastinal hilum), followed by N2 (mediastinal or ipsilateral subcarinal lymph node)
and N1 nodes (ipsilateral hilum or lobar) at the end of exam. A total of 108 patients receiving EBUS-
TBNA for suspected lung cancer were randomized for the additional use of ROSE during their
EBUS procedure. European Journal of Investigation in Health, Psychology and Education (EJIHPE).
Infectious complications were found when puncturing cystic lesions and antibiotics are
recommended should a puncture be performed via EUS. The characteristic heterogenous pattern of a
tumor involved the lymph nodes is illustrated in Figure 1. 3. Biopsy Technique Thoughtful
procedural planning and the flexibility to adapt available biopsy techniques is needed to satisfy
increasing tissue demands for EBUS-TBNA. While doing imaging from the trachea certain cm
landmark of importance are upper border of arch of aorta (23cm), the lower end of trachea (25 cm),
lower border of arch of aorta (25 cm), the lower border of azygos vein (25 cm), the upper border of
left pulmonary artery (25 cm) and the upper border of left atrium (30 cm). The lymph node for
station 8 is seen at the level of left atrium. The left pulmonary artery is located above, rather than
directly in front of, the left bronchus. Time is of the essence for the management of lung cancer, and
there should be a close partnership between the pulmonary, surgical, and medical specialties
responsible for the management of lung cancer. For better orientation, it is useful to recognize key
anatomic landmarks and their relationship to the airways, apart from observing the position of the
probe while performing EBUS. The arch of aorta lies close to upper part of left main bronchus and
the left pulmonary artery ascends over its anterior surface just distal to the arch of the aorta. Figure
7. The mediastinal surface of left lung is seen in this figure which shows relations of left bronchus.
Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics—A Technical
Review. J. Clin. Med. 2021, 10, 5646. Oezkan F, Eisenmann S, Darwiche K, Gassa A, Carbone DP,
Merritt RE, Kneuertz PJ. Simple apposition of the probe against the wall may be enough to establish
contact and use of balloon is not usually required with pentax scope. LAD, Lymphadenopathy; MV,
mechanical ventilation; TB, tuberculosis; TBNA, transbronchial needle aspiration. The air forms dirty
comet tail artifact which goes to the periphery of the screen in this picture. Figure 15. The left
subclavian artery is seen at a little distance away from the trachea with the mirror image artifact due
to sharp interface with the left lung (the left common carotid artery generally lies closer to trachea.
Right inferior pulmonary vein crosses the esophagus. 4.10. The pulmonary veins and the left atrium
The left atrium has two portions. It allows a 360 o surrounding view of the parenchyma. Varela-
Lema L, Fernandez-Villar A, Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-
transbronchial needle aspiration: a systematic review. Medford AR, Agrawal S, Free CM, Bennett JA
A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial
needle aspiration in a UK tertiary respiratory centre. So optimization of image is done by following
techniques. 1. Choose the correct frequency2. But it is an invasive and expensive procedure with
associated morbidity and mortality. The presence of cartilage during entry from trachea may be
difficult. The application of pulse Doppler confirms the arterial wave form. Figure 16. A 28 year old
lady is referred for evaluation of mediastinal lymphadenopathy. This paper will detail the indications
for EBUS as well as reviewing some of the training and financial issues before briefly discussing
future applications. In this context, in 2009 the International Association for the Study of Lung
Cancer (IASLC) 2 2. Most larger studies on this topic have been retrospective in nature. The patient
was referred to our center after unsuccessful attempts to get the diagnosis using bronchoscopic-
guided (including EBUS) and computed tomography-guided approaches at the referring institution.
It is superior to conventional transbronchial needle aspiration in lung cancer staging and diagnosis of
mediastinal lymphadenopathy. Endosonographers and radiologists all over the world do not yet have
a universal convention on the demonstration of images in linear EBUS so far as cranial and caudal is
concerned. Conflicts of Interest The authors declare no conflict of interest. Of course EBUS TBNA
samples are smaller than samples obtained by mediastinoscopy, potentially resulting in more false
negative samples. Endotracheal bronchogenic cysts are rare and most present in infancy with
respiratory failure. Prof Mordechai Kramer Rabin Medical Center Petach-Tikva Israel. High
frequency shortens the pulse length and gives a better axial resolution. The capital and running costs
need to be considered before setting up a service although it will reduce costs by avoiding
mediastinoscopies. Hospital Israelita Albert Einstein Brazil Sao Paulo, SP, Brazil Hospital Israelita
Albert Einstein, Sao Paulo, SP, Brazil. It is becoming increasingly important in the diagnosis and
staging of lung cancer as well as the diagnosis of benign diseases. JM VERGNON MD, Ph D Chief,
department of chest diseases And thoracic oncology University hospitals of St Etienne France
President of the GELF (French Speaking International group on thoracic endoscopy). To each his
own Most of the conventional bronchoscopist use two hands to maneoure the scope. Felix H et
al.Chest 2008;133:887-891 EBUS-TBNA after neoadjuvant chemotherapy 83 patients treated with
neoadjuvant chemotherapy due to N2 disease EBUS-TBNA to is a suitable method to evaluate
mediastinal lymph nodes after neoadjuvant chemotheraphy.