Endobronchial Ultrasound

KONKER XVI PDPI 2019

Dr Melvin Tay Chee Kiang
Consultant & Director of Interventional Pulmonology
Department of Respiratory & Critical Care Medicine, Singapore General Hospital
SingHealth Duke-NUS Centre
Adj Asst Professor, DukeNUS Medical School

1
 Scope
• Convex probe EBUS • Radial probe EBUS
– Indications – Should I use it?
– Lymph node anatomy – How do I do it well?
– Approach to evaluating – Other applications
suspected lung cancer
– Procedural
considerations

2
 Singapore General Hospital

3
 Endobronchial Ultrasound (EBUS)
2 types
• Convex probe EBUS (CP-EBUS)
• Radial probe EBUS (RP-EBUS)

4
 CP-EBUS
• EBUS bronchoscope provides real-time
ultrasound images of lymph nodes adjacent to
the major airways

5
 CP-EBUS
• Location of nodes determined by
– surface/radiologic landmarks
– ultrasound appearance of characteristic patterns of adjacent
vessels near lymph nodes

6
 CP-EBUS
• After aspiration, node material is extruded onto
– slides for cytology
– normal saline for cell block to allow histology,
immunohistochemistry, and genetic analysis

7
 Indications
1. Diagnosis and staging of lung cancer
2. Mediastinal lymphadenopathy of unclear
etiology
3. Sampling centrally located mass lesion

8
9
10
 Approach to suspected lung cancer
1. CT thorax (ideally PET*) Sensitivity Specificity
CT 55% 81%
2. Tissue Sampling PET 77% 86%
– Endoscopic over surgical
– *EBUS-TBNA/EUS-FNA vs Conventional Dx + Staging
• Reduces median time to treatment decision

11 Lancet Respir Med 2015;3: 282–89 Silvestri GA, et al. Chest. 2013;143(5 Suppl):e211S-250S.
 Radiographic categories of lung cancer

Mediastinal infiltration by tumor Normal mediastinal and PET -ve LN BUT

- Central tumor or
- Hilar (N1) LN involved

Peripheral tumor (CS 1A)

Enlarged or PET +ve mediastinal LN - Tumor < 3cm
- Mediastinal and hilar LN NOT involved

12 CHEST 2013; 143(5)(Suppl):e211S–e250S

 Invasive Testing of Radiographic Categories

Radiographic (CT) assessment

Mediastinal infiltration usually
by tumorsufficient Normal
Invasive mediastinal
staging (and PET-) LN BUT
of mediastinum
without invasive confirmation (Grade 2C) - Enlarged (or PET+) N1 LN
recommended over staging by imaging
- Central Tumor
(Grade 1C)

Invasive staging of mediastinum

Invasive preoperative evaluation of the
recommended over staging by imaging Peripheral tumor (CS 1A) and
mediastinal nodes is not required (Grade 2B)
(GradeEnlarged
1C) (or PET+) mediastinal LN Normal mediastinal LN (and PET-)

13 CHEST 2013; 143(5)(Suppl):e211S–e250S

 Procedural considerations
A. Does needle size matter?
B. How many passes at each site?
C.Is there a need for Rapid On-Site Evaluation
(ROSE)?

14 CHEST 2016; 149(3):816-835

 A. Does needle size (22 vs. 21G) matter?

• RCT
• N = 60 patients undergoing EBUS-TBNA for enlarged
hilar/mediastinal lymph nodes or a tumor adjacent to central airway
• Patients randomized to either 21 or 22G needle
• Result: No difference between needle gauges in diagnostic yield or
complications

15 J Bronchology Interv Pulmonol. 2011 Oct;18(4):306-10

 B. How many passes at each site?*

• 102 NSCLC patients

• EBUS-TBNA in 163 mediastinal LN stations
• Sample Inadequacy
the absence of was:
rapid on-site evaluation (ROSE) in patients suspected of having
lungfor
– 90.1% cancer
oneand undergoing EBUS-TBNA for diagnosis, we suggest that a minimum of
aspiration
3 separate needle passes be performed per sampling site (Ungraded)
– 100% for three aspirations
1 Chest. 2016;149(3):816-835.
2 3 4

Sensitivity 69.8 83.7 95.3 95.3

(31/43) (36/43) (41/43) (41/43)
Optimal number of aspirations = 3
AccuracyIf core
89.7+ 1st/2nd 94.4
aspiration,98.4
can stop at98.4
2
(113/126) (119/126) (124/126) (124/126)

16 Chest. 2008 Aug;134(2):368-374

 * How many passes for molecular analysis?
• Retrospective review of 85
adenocarcinoma diagnosed by
EBUS-TBNA
In patients undergoing EBUS-TBNA for the diagnosis and/or
• Procedures done with
staging ROSEor known non-small cell lung cancer, we
of suspected
recommend that additional samples, beyond those needed to
• Tested for KRAS, EGFR
establish and be obtained for molecular analysis
the diagnosis,
ALK (Grade 1C)

• A median of 4 passes were

needed for adequate
molecular profiling of 95.3%

17 Ann Am Thorac Soc. 2013 Dec;10(6):636-43.

 C. Is there a need for ROSE?

• RCT in 108 patients: EBUS-TBNA +/- ROSE

– Sensitivity and accuracy for diagnosing lung cancer similar in both
groups
– Fewer punctures with ROSE (2.2 vs. 3.1; P < 0.001)
– Additional procedures other than the main target lesion were
performed in 11% of patients in ROSE group vs. 57% in non-ROSE
group (P < 0.001)

• ROSE was associated with a significantly lower need for additional

bronchoscopic procedures and puncture number.

18 Oki M, et al. Respiration. 2013;85(6):486-92.

 C. Is there a need for ROSE?

ROSE does not affect diagnostic yield or time

MAY reduce no. of aspirations/other procedures

MAY be beneficial in assessing adequacy of malignant cells for
molecular analysis

In patients undergoing EBUS-TBNA for diagnostic

evaluation, we recommend that tissue sampling can be
performed with or without rapid on-site evaluation
(Grade 1C).

19
 Technical aspects of EBUS-TBNA
Recommendation Grade
Moderate or deep sedation acceptable 2C
21- or 22-gauge needle acceptable 1C
Tissue sampling with or without ROSE 1C
US features can be used to predict malignant and benign diagnoses, Ungraded
but tissue samples should still be obtained to confirm a diagnosis
With or without suction Ungraded
In the absence of ROSE in patients suspected of having lung cancer, Ungraded
min. 3 needle passes per sampling site suggested
For NSCLC, obtain additional samples for molecular analysis 1C
Can be used in suspected sarcoidosis with hilar/mediastinal LN 1C
Can be used in suspected TB with hilar/mediastinal LN 1C
Suspected lymphoma, acceptable initial, minimally invasive Ungraded
diagnostic test

20 Chest. 2016 Mar;149(3):816-35.

 Radial EBUS (R-EBUS)

21
 1. Should I Use It?
A. What is the diagnostic yield?

B. What are cons compared to other

modalities?

22
 A. Diagnostic Yield
• Meta-analysis 57 studies,7872 lesions
• R-EBUS Diagnostic yield:
– 70.6% VB 67% vs. ENB 74% vs. TTNA 90%
– Increases with size >2 cm, malignancy, CT bronchus sign, probe in lesion
• Complication rates:
– 2.8% pneumothorax, bleeding, pneumonia
– 0.2% chest tube insertion (TTNA 25%)

23 Respirology. 2017 Apr;22(3):443-453.

 B. Cons of R-EBUS
• Time
– adds to procedure time BUT amount of time variable
– *1 min in Kurimoto study Kurimoto N. Chest 2004.126;959-965
• Training
– 50 to gain competence, then 5 to 10 procedures per year to maintain
competency (Radial) American College of Chest Physicians
– 40 procedures for trainees, then 25 procedures per year to maintain
competency (Radial/Convex) European Respiratory Society & American Thoracic Society
• Cost
– In Australia: CT-guided: AU$2,724 vs. EBUS–TBLB: AU$2,748

24
 2. How to do it well?
A. Patient selection
B. Knowledge – airway anatomy, US
C. Procedural planning

• Patient selection
• 2. Knowledge of airway anatomy
• 3. Planning of procedure
• 4. Adjuncts

25
 A. Patient selection

26 J Thorac Oncol. 2015 Mar;10(3):472-8.

 B. Good Knowledge of airway anatomy

27
 B. Good knowledge of ultrasound

NORMAL LUNG
Whitish snowstorm image
with comet tail artifacts

LUNG LESION
Hypoechoic

28
 US - Probe Within Lesion

Yield 83% Yield 64% Yield 1%

29 Chest 2007; 132; 603-8.

 C. Procedural Planning
• Guide sheath allows
repeated access into lesion
• Biopsy forceps, brush and
curette can be introduced
• Tamponades airway =
reduces bleeding
• Improves yield

30
 How Many Biopsies?

At least 5 biopsies

31 Chest 2007; 132:603–608

 3. Other RP-EBUS applications
Combination techniques

32
 Pleural Dye Marking

33 Respiration. 2018;95(5):354-361.
 Fiducial Markers for SBRT

34
 THANK YOU
melvin.tay.c.k@singhealth.com.sg

35