demet karnak 1 , aydın Çiledağ 1 , koray ceyhan 2

ELECTROMAGNETIC NAVIGATION ELECTROMAGNETIC NAVIGATION DIAGNOSTIC BRONCHOSCOPY DIAGNOSTIC BRONCHOSCOPY

FOR PERIPHERAL LUNG LESIONS FOR PERIPHERAL LUNG LESIONS AND MEDIASTINAL LYMPH NODES *AND MEDIASTINAL LYMPH NODES *

Demet KarnakDemet Karnak 1 1, , Aydın ÇiledağAydın Çiledağ 1 1, Koray Ceyhan, Koray Ceyhan 2 2

Çetin AtasoyÇetin Atasoy 3 3, Serdar Akyar, Serdar Akyar 3 3, Oya Kayacan, Oya Kayacan 1 1

Ankara University School of Medicine, Departments of Ankara University School of Medicine, Departments of 11Chest Diseases, Chest Diseases, 22Pathology and Pathology and 33RadiodiagnosticRadiodiagnostic

* This study was supported by TUBITAK (project ## 107S156)

Lung cancerLung cancer

Lung cancer is leading cause of cancer Lung cancer is leading cause of cancer deathdeath

173.000/year in USA173.000/year in USA

150.000/year SPN in USA150.000/year SPN in USA

The incidence in Turkey: 11.5/100.000 The incidence in Turkey: 11.5/100.000

DIAGNOSISDIAGNOSIS

TraditionallyTraditionally

*Flexible bronchoscopy: Biopsy, washing, *Flexible bronchoscopy: Biopsy, washing,

brushing, TBNAbrushing, TBNA

*CT guided needle aspiration*CT guided needle aspiration

*VATS/Thoracotomy*VATS/Thoracotomy

Flexible bronchoscopyFlexible bronchoscopy

Less invasive procedureLess invasive procedure

Diagnostic yield depends on size and localizationDiagnostic yield depends on size and localization

In the absence of endobronchial disease, diagnostic

yield 20-80%

<2 cm lesions and proximal 1/3 of the chest 31%31%

<2 cm lesions and outher 1/3 of the chest 14%14%

DIAGNOSISDIAGNOSIS

*CT guided needle aspiration*CT guided needle aspiration

A high pneumothorax risk for central A high pneumothorax risk for central

lesions (13-38%)lesions (13-38%)

*VATS/Thoracotomy*VATS/Thoracotomy

(Invasive procedures, high morbitidy rate, (Invasive procedures, high morbitidy rate,

especiallly age >65 years)especiallly age >65 years)

MEDIASTINAL LYMPH NODESMEDIASTINAL LYMPH NODES

The diagnostic yield of TBNA with flexible The diagnostic yield of TBNA with flexible bronchoscopy bronchoscopy 15-89%15-89%

The diagnostic yield of TBNA in staging The diagnostic yield of TBNA in staging lung cancer lung cancer 50-60%50-60%

PET PET false positive results, especially in false positive results, especially in inflammatory lesionsinflammatory lesions

Mediastinoscopy/Mediastinotomy Mediastinoscopy/Mediastinotomy (invasive)(invasive)

New Guided Technique

The aim is minimal invasive procedure and low The aim is minimal invasive procedure and low

morbitdymorbitdy

**Electromagnetic Navigation Bronchoscopy Electromagnetic Navigation Bronchoscopy

(ENB)(ENB)

Electromagnetic Navigation Electromagnetic Navigation BronchoscopyBronchoscopy

Developed by adaptation of satellite based Developed by adaptation of satellite based

direction mapping of war technology to the direction mapping of war technology to the

medicinemedicine


“ROAD MAP” “LUNG MAP”


Anatomic registrationAnatomic registration

BronchoscopBronchoscop

Three-dimensional CT images

A steerable probe (LG)


The procedure requires the patient to have

a spiral CT with thin cuts, usually about

1mm

The CT information is uploaded into the

navigating computer and a virtual

bronchoscopy image is created

AIMAIM

To evaluate diagnostic yield and safety of To evaluate diagnostic yield and safety of ENB for peripheral lung nodules-mass and ENB for peripheral lung nodules-mass and mediastinal lymph nodes (LN) when mediastinal lymph nodes (LN) when lesions were not good candidates for lesions were not good candidates for TTNA (central localization) and in the TTNA (central localization) and in the absence of endobronchial lesion absence of endobronchial lesion

21 patients21 patients

*5 patients had only peripheral lesion (PL)*5 patients had only peripheral lesion (PL)

*4 patients had PL+LN*4 patients had PL+LN

*12 patients had only LN*12 patients had only LN

On-site cytologic evaluationOn-site cytologic evaluation

9 peripheral lesions9 peripheral lesions

4 4 → Right upper lobe→ Right upper lobe

3 → Left upper lobe3 → Left upper lobe

1 → Lingula1 → Lingula

1 → Left lower lobe1 → Left lower lobe

The mean size: 25.88 The mean size: 25.88 ±± 12.24 mm 12.24 mm

31 lymph nodes31 lymph nodes

11 subcarinal11 subcarinal7 right hilar7 right hilar5 anterior carinal5 anterior carinal4 right paratracheal4 right paratracheal3 left hilar3 left hilar1 left paratracheal1 left paratracheal

The mean size:The mean size:18.16 18.16 ±± 6.01 mm 6.01 mm

The mean total procedure time The mean total procedure time

39.33 39.33 ±± 9.32 minute 9.32 minute

RESULTSRESULTS

The 8 of 9 peripheral lesions (88.9%)The 8 of 9 peripheral lesions (88.9%)

The 27 of 31 lymph nodes (87.1%)The 27 of 31 lymph nodes (87.1%)

were succesfully sampledwere succesfully sampled

RESULTSRESULTS

ENB was diagnostic in 18 of 21 patientsENB was diagnostic in 18 of 21 patients

The diagnostic yield: (85.7%)The diagnostic yield: (85.7%)

Pneumothorax in one patientPneumothorax in one patient

RESULTSRESULTS

5 nonsmall cell lung cancer5 nonsmall cell lung cancer

6 sarcoidosis6 sarcoidosis

3 tuberculous lymphadenitis3 tuberculous lymphadenitis

2 benign pulmonary nodule2 benign pulmonary nodule

2 reactive lymphadenitis2 reactive lymphadenitis

THE DIAGNOSTIC YIELD 18/21x100= 85.7%THE DIAGNOSTIC YIELD 18/21x100= 85.7%

DISCUSSIONDISCUSSION

89 patients (peripheral lesion)89 patients (peripheral lesion)

The diagnostic yield was 67%The diagnostic yield was 67%

Pneumothorax in two patientsPneumothorax in two patients

Eberhardt R, Anantham D, Herth FEberhardt R, Anantham D, Herth F. Et al. Chest 2007;131:1800-1805. Et al. Chest 2007;131:1800-1805

DISCUSSIONDISCUSSION60 patients (peripheral lesions or mediastinal 60 patients (peripheral lesions or mediastinal

lymph node)lymph node)

74% of peripheral lesions and 100% of lymph 74% of peripheral lesions and 100% of lymph

nodes were samplednodes were sampled

The diagnostic yield of EBN was 80.3%The diagnostic yield of EBN was 80.3%

Pneumothorax in two patientsPneumothorax in two patients

Gildea TR, Mazzone PJ, Karnak D, et al. Am Gildea TR, Mazzone PJ, Karnak D, et al. Am J Respir Crit Care Med 2006;174:982-989J Respir Crit Care Med 2006;174:982-989

CONCLUSIONCONCLUSION

ENB is a safe method for sampling ENB is a safe method for sampling

peripheral lung nodule-mass and peripheral lung nodule-mass and

mediastinal lymph nodes with high mediastinal lymph nodes with high

diagnostic yield diagnostic yield

demet karnak 1 , aydın Çiledağ 1 , koray ceyhan 2

Documents

patientsthe diagnostic

peripheral lung lesions

peripheral lesion pl

peripheral lung nodulesmass

staging lung cancer

ct guided needle aspiration

mediastinal lymph nodes

spiral ct