sbpt2008_d23endosc_henricolt01.ppt

8/9/2019 sbpt2008_d23endosc_HenriColt01.ppt

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&'(e#tives&'(e#tives)ole o! nodal staging in nonsmall)ole o! nodal staging in nonsmall#ell lung #an#er#ell lung #an#er

"nvasive and noninvasive modalities"nvasive and noninvasive modalities*BU+ rin#i les, te#hni-ue and*BU+ rin#i les, te#hni-ue andinstrumentationinstrumentation

*BU+ and CT, *BU+ and P*T, *BU+*BU+ and CT, *BU+ and P*T, *BU+and mediastinos#oand mediastinos#o*BU+. ne/ develo ments*BU+. ne/ develo ments


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Ba# groundBa# ground

1on small #ell lung #an#er 1+C C5 the leading1on small #ell lung #an#er 1+C C5 the leading#ause o! death !rom malignant diseases#ause o! death !rom malignant diseases/orld/ide des ite advan#es in surgi#al and/orld/ide des ite advan#es in surgi#al andmultimodalit treatment%multimodalit treatment% 6##urate staging o! the disease is mandator6##urate staging o! the disease is mandatornot onl to determine the rognosis 'ut also tonot onl to determine the rognosis 'ut also tode#ide the most suita'le treatment lan%de#ide the most suita'le treatment lan%

The most signi7#ant treatment de#ision is The most signi7#ant treatment de#ision isidenti! ing atients /ho #an 'ene7t !romidenti! ing atients /ho #an 'ene7t !romsurgi#al rese#tion%surgi#al rese#tion%


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The resen#e o! l m h node metastasis The resen#e o! l m h node metastasisremains one o! the most adverse !a#torsremains one o! the most adverse !a#tors

!or rognosis in 1+C C!or rognosis in 1+C C

The resen#e o! mediastinal l m h node The resen#e o! mediastinal l m h nodeinvolvement indi#ates the resen#e o!involvement indi#ates the resen#e o!stage """6 or """B, /hi#h suggests eitherstage """6 or """B, /hi#h suggests eitherino era'ilit and or the need !or treatmentino era'ilit and or the need !or treatment' #hemothera and or radiothera' #hemothera and or radiothera


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Survival based on nodal invasion


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+taging 1 !a#tor+taging 1 !a#tor

1on invasive staging "maging51on invasive staging "maging5CT, M)", P*T, P*T CT, *BU+, *U+CT, M)", P*T, P*T CT, *BU+, *U+

"nvasive staging +am ling5"nvasive staging +am ling5

+urgi#al o en 'io s Med, 96T+5+urgi#al o en 'io s Med, 96T+51eedle Bio s TB16, TT16, *U+1eedle Bio s TB16, TT16, *U+:165:165


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+taging 1 !a#tor 1eedle+taging 1 !a#tor 1eedle'io s'io s

Transthoracic Needle AspirationTransthoracic Needle AspirationPer!ormed ' interventional radiologistsPer!ormed ' interventional radiologists

CT or ;uoros#o i# guidan#eCT or ;uoros#o i# guidan#eHigh sensitivit in enlarged nodes High sensitivit in enlarged nodes o/ !alse negative rate 20 ?0>o/ !alse negative rate 20 ?0>High in#iden#e o! neumothora@ ? A0>High in#iden#e o! neumothora@ ? A0>"m lantation rare 'ut ossi'le"m lantation rare 'ut ossi'le

Chest. 2003; 123: 157-66Chest. 2003; 123: 157-66 Radiol. Clin. North Am. 2000; Radiol. Clin. North Am. 2000;38: 525-3438: 525-34Cardiovas . !ntervent. Radiol.Cardiovas . !ntervent. Radiol.

1""1; 14: 17-231""1; 14: 17-23Clin. Chest #ed. 1""3; 14: ""-Clin. Chest #ed. 1""3; 14: ""-


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+taging 1 !a#tor 1eedle+taging 1 !a#tor 1eedle

'io s'io sEUS-FNAEUS-FNA

&nl modalit !or 8, < 1&nl modalit !or 8, < 1

imited to le!t aratra#healimited to le!t aratra#heal+ensitivit 8= < >+ensitivit 8= < >+ e#i7#it 83 =00>+ e#i7#it 83 =00>

Ma(or dra/'a# high !alse negative rateMa(or dra/'a# high !alse negative rate Ann. $%r&. 2003; 238: 180-8 Ann. $%r&. 2003; 238: 180-8Chest. 1""0; "8: 586-"3Chest. 1""0; "8: 586-"3

'ndos o(). 1""4; 26: 784-7 'ndos o(). 1""4; 26: 784-7 Ann. *hora . $%r&. 1""6; 61: 1441-5 Ann. *hora . $%r&. 1""6; 61: 1441-5Chest. 2000; 117: 33"-45Chest. 2000; 117: 33"-45

+%n& Can er. 2003; 41: 25"-67 +%n& Can er. 2003; 41: 25"-67 Am. ,. Res(ir. Crit. Care #ed. 2003; Am. ,. Res(ir. Crit. Care #ed. 2003;


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TB16 DiEerent Methods TB16 DiEerent Methods

Conventional TB16Conventional TB16CT guided TB16CT guided TB16*le#tromagneti# 1avigation guided TB16*le#tromagneti# 1avigation guided TB16Ultrasound guided TB16Ultrasound guided TB16=5 )adial Pro'e guided=5 )adial Pro'e guided25 Conve@ Pro'e guided real time525 Conve@ Pro'e guided real time5*BU+ TB16*BU+ TB16


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Conventional TB16Conventional TB16

+ensitivit =4 o erator de endent5+ensitivit =4 o erator de endent5:ailure to la#e needle dire#tl into 1:ailure to la#e needle dire#tl into 1

De ends on 1 size and stationDe ends on 1 size and stationHigh !alse negative rateHigh !alse negative rate

Chest. 1"83; 84: 571-6Chest. 1"83; 84: 571-6Chest. 1"8"; "6: 1228-32Chest. 1"8"; "6: 1228-32

Am. Rev. Res(ir. is. 1"86; 134: 146- Am. Rev. Res(ir. is. 1"86; 134: 146-

88Chest. 2003; 123: 157-66Chest. 2003; 123: 157-66


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CT guided TB16CT guided TB16

High ield 83 88>High ield 83 88>)e-uires use o! CT suite #ostl 5)e-uires use o! CT suite #ostl 5)adiation e@ osure 'oth Pt and o erator5)adiation e@ osure 'oth Pt and o erator5

Con7rmation o! needle outside o! 1 42%=>5Con7rmation o! needle outside o! 1 42%=>5

Chest. 1""8; 114: 36-"Chest. 1""8; 114: 36-"Chest. 2000; 118: 1630-8Chest. 2000; 118: 1630-8

Chest. 2001; 11": 32"-32Chest. 2001; 11": 32"-32 Radiolo&). 2000; 216: 764-7 Radiolo&). 2000; 216: 764-7


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1avigational1avigational TB16 TB16

V
http://lul.mpg/http://lul.mpg/


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Medium

A B C DUltrasound Transducer

Ultrasound Image

12 2 2 3

44

45

Acousticim edence

Tissue density

Angle of probe withtar et tissue


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Angle of

examination and angleof insertionwill be

important


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The Pro#essor The Pro#essor


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Ph si#sPh si#s

De7nition. /ave lengthDe7nition. /ave lengthU+ F 20 GHzU+ F 20 GHzDiagnosti# 2 20 MhzDiagnosti# 2 20 MhzChest U+. 3 ? MHzChest U+. 3 ? MHz

*BU+.*BU+.20 MHz20 MHz%? MHz%? MHz

!enetration

resolution


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*BU+ TB16*BU+ TB16inear #urvedinear #urvedtransdu#ertransdu#er"mages o'tained '"mages o'tained 'atta#hing a 'alloon andatta#hing a 'alloon andin;ating /ith normalin;ating /ith normal

salinesaline"mage is ro#essed"mage is ro#essedesions #an 'e measuredesions #an 'e measured"mages #an 'e !rozen"mages #an 'e !rozenDo ler modeDo ler mode

22 gauge needle22 gauge needle"nternal sheath"nternal sheath


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Use of Doppler demonstratesblood ow


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eedleinsertion


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*@am le *BU+ TB16 level )=0*@am le *BU+ TB16 level )=0nodenode

V!D"#
http://mosebusr10.mpg/http://mosebusr10.mpg/


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*BU+ TB16*BU+ TB16

All *ediastinalAll *ediastinally*ph nodesly*ph nodesaccessibleaccessiblee cept+e cept+

SubaorticSubaortic(' and ,)(' and ,)

araesopha.ealaraesopha.eal(/ and 0)(/ and 0)

"en T#orac Cardio$asc %urg &2''() 56* 26(+276


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)esults o! *BU+)esults o! *BU+

#ET$12S#ET$12S . This /as a retros e#tive. This /as a retros e#tiveanal sis o! =?2 #onse#utive atients /hoanal sis o! =?2 #onse#utive atients /hounder/ent *BU+ TB16 /ith undiagnosedunder/ent *BU+ TB16 /ith undiagnosedintrathora#i# adeno ath or #an#erintrathora#i# adeno ath or #an#er

staging as the rimar indi#ations%staging as the rimar indi#ations% The ro#edures o##urred 'et/een anuar The ro#edures o##urred 'et/een anuar200? and une 200A at a single a#ademi#200? and une 200A at a single a#ademi#medi#al #enter% &! the =?2 atients%medi#al #enter% &! the =?2 atients%== /ere in#luded in the 7nal statisti#al== /ere in#luded in the 7nal statisti#alanal sis a!ter e@#luding those /ith 'enignanal sis a!ter e@#luding those /ith 'enigndisease diagnosed 'disease diagnosed '*BU+ TB16% )a id on site*BU+ TB16% )a id on site # to athologi## to athologi#e@amination /as used in all #ases%e@amination /as used in all #ases%

in#ent BD, 6nn Thora# +urg% 2008


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3eal-ti*e endobronchial ultrasound-3eal-ti*e endobronchial ultrasound-.uided transbronchial ly*ph node.uided transbronchial ly*ph node

aspirationaspiration &&3ESU4TS3ESU4TS . Malignan# /as identi7ed in ==3 atients, o!. Malignan# /as identi7ed in ==3 atients, o!/hi#h A ?5 had non small #ell lung #ar#inoma, and/hi#h A ?5 had non small #ell lung #ar#inoma, and20 = % >5 under/ent surgi#al rese#tion%20 = % >5 under/ent surgi#al rese#tion%

:our atients had 'enign diagnoses at surgi#al atholog % &nl =:our atients had 'enign diagnoses at surgi#al atholog % &nl =surgi#al atient /as !ound to have nodal metastasis at a l m hsurgi#al atient /as !ound to have nodal metastasis at a l m hnode station reviousl 'io sied ' *BU+ TB16 negativenode station reviousl 'io sied ' *BU+ TB16 negativeredi#tive value, < >5%redi#tive value, < >5%5o*pared 6ith radiolo.ic sta.in.7 EBUS-TBNA do6n-sta.ed5o*pared 6ith radiolo.ic sta.in.7 EBUS-TBNA do6n-sta.ed8/ of 889 (8'&0:) and up-sta.ed 88 (0&%:)&8/ of 889 (8'&0:) and up-sta.ed 88 (0&%:)& +ensitivit /as+ensitivit /as, /ith =00> s e#i7#it% 1o ma(or #om li#ations /ere, /ith =00> s e#i7#it% 1o ma(or #om li#ations /ereasso#iated /ith the ro#edure%asso#iated /ith the ro#edure%

51N54US;1NS51N54US;1NS . *BU+ TB16 is use!ul in a##essing. *BU+ TB16 is use!ul in a##essingmediastinal and hilar l m h nodes !or the diagnosis andmediastinal and hilar l m h nodes !or the diagnosis andstaging o! non small #ell lung #an#er and other disordersstaging o! non small #ell lung #an#er and other disorderso! the mediastinum% Thora#i# surgeons ando! the mediastinum% Thora#i# surgeons andulmonologists are /ell ositioned to use this tool inulmonologists are /ell ositioned to use this tool inever da ra#ti#e%ever da ra#ti#e%

in#ent BD, 6nn Thora# +urg% 2008


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Minimall invasive endos#o i#Minimall invasive endos#o i#staging o! sus e#ted lung #an#erstaging o! sus e#ted lung #an#erCom arison o! the diagnosti# a##ura# o! 3Com arison o! the diagnosti# a##ura# o! 3methodsmethods o! minimall invasive endos#o i#o! minimall invasive endos#o i#staging and their #om'inations5.staging and their #om'inations5.

traditional trans'ron#hial needle as irationtraditional trans'ron#hial needle as irationTB165TB165endo'ron#hial ultrasound guided 7ne needleendo'ron#hial ultrasound guided 7ne needleas iration *BU+ :165as iration *BU+ :165transeso hageal endos#o i# ultrasound guidedtranseso hageal endos#o i# ultrasound guided7ne needle as iration *U+ :1657ne needle as iration *U+ :165

Ialla#e MB, et al, 6M6% 2008


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Minimall invasive endos#o i#Minimall invasive endos#o i#staging o! sus e#ted lung #an#erstaging o! sus e#ted lung #an#er=38 atients.=38 atients.

42 30>5 had malignant l m h nodes%42 30>5 had malignant l m h nodes%*BU+ :16. more sensitive than TB16,*BU+ :16. more sensitive than TB16,

dete#ting 2< A5 vs =? 3A>5 malignantdete#ting 2< A5 vs =? 3A>5 malignantl m h nodes P J %0035%l m h nodes P J %0035%*U+ lus *BU+. higher estimated sensitivit*U+ lus *BU+. higher estimated sensitivit K3< 42L #on7den#e interval, 8=> K3< 42L #on7den#e interval, 8=>

K #on7den#e interval,


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Minimall invasive endos#o i#Minimall invasive endos#o i#staging o! sus e#ted lungstaging o! sus e#ted lung

#an#er#an#er*U+ lus *BU+*U+ lus *BU+

higher sensitivit and higher negativehigher sensitivit and higher negative

redi#tive valueredi#tive value !or dete#ting l m h!or dete#ting l m hnodes in an mediastinal lo#ation and !ornodes in an mediastinal lo#ation and !oratients /ithout l m h node enlargementatients /ithout l m h node enlargementon #hest #om uted tomogra hon #hest #om uted tomogra h

*BU+ :16*BU+ :16higher sensitivit than TB16higher sensitivit than TB16

Ialla#e MB, et al, 6M6% 2008


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Con#lusionCon#lusion*U+ lus *BU+*U+ lus *BU+

ma allo/ near #om lete minimallma allo/ near #om lete minimallinvasive mediastinal staging in atientsinvasive mediastinal staging in atients/ith sus e#ted lung #an#er/ith sus e#ted lung #an#erma 'e an alternative a roa#h !orma 'e an alternative a roa#h !ormediastinal staging in atients /ithmediastinal staging in atients /ith

sus e#ted lung #an#ersus e#ted lung #an#er


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=N2N3=N2N3

$onventional T% A

"%U& #R "U& guidedT% A

"%U& A D "U& guidedT% A

'ultidisciplinary lung cancergroups evaluates patients based ondisease process rather than onmedical(surgery specialty ???


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ung C6 +taging. overvie/ung C6 +taging. overvie/6CCP "nvasive mediastinal staging6CCP "nvasive mediastinal staging

2002. )evised 4 ears later2002. )evised 4 ears later

HighlightsHighlights

*@tensive mediastinal in7ltration*@tensive mediastinal in7ltration"nvasive staging not needed"nvasive staging not needed

Dis#rete mediastinal l m h node enlargementDis#rete mediastinal l m h node enlargement+taging ' CT or P*T not suO#ient+taging ' CT or P*T not suO#ient"nvasive staging re-uired"nvasive staging re-uired1ormal sized l m h nodes F mediastinos#o1ormal sized l m h nodes F mediastinos#o

Clini#al 1= +tage ""5 or #entral tumorClini#al 1= +tage ""5 or #entral tumorMediastinos#oMediastinos#o*BU+ is an a##e ted alternative*BU+ is an a##e ted alternative

C#est 2''7, 132, 2'2+22'


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ung C6 +taging. overvie/ung C6 +taging. overvie/

6CCP "nvasive mediastinal staging6CCP "nvasive mediastinal stagingP*T ositive 6D in +tage "P*T ositive 6D in +tage "

"nvasive staging is re-uired"nvasive staging is re-uired*BU+ alternative*BU+ alternative

&verall&verall*BU+ TB16 is reasona'le as long as*BU+ TB16 is reasona'le as long asnondiagnosti# results are !ollo/ed 'nondiagnosti# results are !ollo/ed 'Mediastinos#oMediastinos#oMediastinos#o is still the old +tandardMediastinos#o is still the old +tandard+till no stud that dire#tl #om ares+till no stud that dire#tl #om aresmediastinos#o to *BU+ TB16mediastinos#o to *BU+ TB16

C#est 2''7, 132, 2'2+22'


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Com arisons. DiEerentCom arisons. DiEerent

modalitiesmodalities


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*ndo'ron#hial Ultrasound.*ndo'ron#hial Ultrasound.

#lini#al a li#ations#lini#al a li#ations.uidance of.uidance of*ediastinal*ediastinally*ph nodely*ph node

biopsiesbiopsies

-ert# / et al. Ultrasound+guided trans0ronc#ial needle as!iration* an e !erience in 242 !atients.C#est 2''3,123*6'4 7.

&/ Bronc#ol 2''6,13*(4 1)


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)evie/ o! the literature. *BU+)evie/ o! the literature. *BU+

andQandQ=%=% Conventional TB16Conventional TB162%2% *U+ and TB16*U+ and TB163%3% Conventional mediastinos#oConventional mediastinos#o4%4% P*T and CTP*T and CT?%?% P*TP*TA%A% uiding 'ron#hos#o i# thera iesuiding 'ron#hos#o i# thera ies%% m h node sizem h node size8%8% Metastati# lung tumorsMetastati# lung tumors


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=% *BU+ and TB16=% *BU+ and TB16

C- %T 2''4, 125*322 325


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2% *BU+ and *U+2% *BU+ and *U+

Am / es!ir Crit Care Med ol 171. !! 1164 1167 2''5


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*BU+, TB16, and *U+*BU+, TB16, and *U+


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3% *BU+ vs%3% *BU+ vs%

mediastinos#omediastinos#o*BU+ TB16*BU+ TB16

?02 atients?02 atients

? 2 m h nodes? 2 m h nodes1odes 2l, 2r, 3, 4r, 4l, , =0r, =0l, ==r, and ==l51odes 2l, 2r, 3, 4r, 4l, , =0r, =0l, ==r, and ==l5Mean diameter =%A range%8 4%35Mean diameter =%A range%8 4%35?3? resulted in diagnosis 5?3? resulted in diagnosis 5

Mediastinos#o to #on7rm 'io sMediastinos#o to #on7rm 'io s+ensitivit +ensitivit + e#i7#it =00>+ e#i7#it =00>PP9 =00>PP9 =00>

)e#orded no #om li#ations)e#orded no #om li#ations

-ert# et. al. eal+time endo0ronc#ial ultrasound guided trans0ronc#ial needle as!iration or sam!lingmediastinal l8m!# nodes. T#ora 2''6 61, 7 5+7 (


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4% *BU+ vs CT, TB16, and P*T4% *BU+ vs CT, TB16, and P*T

Com arison o! *BU+TB16, P*T, and CTCom arison o! *BU+ TB16, P*T, and CTCT s#an. l m h nodes ositive i! F =#mCT s#an. l m h nodes ositive i! F =#mP*T s#an. l m h nodes ositive i! u ta e F2%?P*T s#an. l m h nodes ositive i! u ta e F2%?*BU+ TB16. l m h nodes F?mm*BU+ TB16. l m h nodes F?mm

)esults)esults280 atients evaluated280 atients evaluated=02 atients met #riteria=02 atients met #riteriaUnder/ent CT and P*TUnder/ent CT and P*T

*BU+ TB16*BU+ TB16=4 mediastinal and ?3 hilar nodes=4 mediastinal and ?3 hilar nodes+urgi#al histolog /as then used !or #om arison+urgi#al histolog /as then used !or #om arison

9asu u:u et al. Com!arison o ndo0ronc#ial Ultrasound ; T and CT or


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*BU+ and +taging*BU+ and +taging

+ensitivit+ensitivit + e#i7#it+ e#i7#it DiagnositDiagnosit

##6##ura#6##ura#

CTCT A%A% ??%3>??%3> A0%8>A0%8>P*TP*T 80>80> 0%=>0%=> 2%?>2%?>

*BU+*BU+ TB16 TB16

=00>=00>

9asu u:u et al. Com!arison o ndo0ronc#ial Ultrasound ; T and CT or


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?a%?a% *BU+ and P*T ositive nodes*BU+ and P*T ositive nodes

Per!orman#e o! TB16 using linearPer!orman#e o! TB16 using linear*BU+ real time *BU+ TB165 under*BU+ real time *BU+ TB165 underlo#al anaesthesia and the value o! P*Tlo#al anaesthesia and the value o! P*T!or redi#tion o! athologi#al results!or redi#tion o! athologi#al results/ere assessed/ere assessed

1um'er o! eluded surgi#al ro#edures1um'er o! eluded surgi#al ro#edures/as evaluated/as evaluated

Bau/ens &, et al, ung Can#er 2008

*BU+ and P*T ositive nodes in lung*BU+ and P*T ositive nodes in lung


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*BU+ and P*T ositive nodes in lung*BU+ and P*T ositive nodes in lung#an#er#an#er

=0A Patients /ith sus e#ted roven lung=0A Patients /ith sus e#ted roven lung#an#ers and :D P*T ositive mediastinal#an#ers and :D P*T ositive mediastinaladeno athadeno ath 6v% o! TB16 sam les atient. 4%%)esults o! *BU+ TB16 staging o!)esults o! *BU+ TB16 staging o!

mediastinal hot s ots.mediastinal hot s ots. sensitivit , < > a##ura# , negative sensitivit , < > a##ura# , negativeredi#tive value%redi#tive value%

au/ens &, et al, ung Can#er 2008


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Con#lusionCon#lusion

+urgi#al ro#edures+urgi#al ro#edureseluded in ?A> o! the atientseluded in ?A> o! the atients

)eal time *BU+ TB16)eal time *BU+ TB16should 'e re!erred overshould 'e re!erred overmediastinos#o as 7rst ste ro#eduremediastinos#o as 7rst ste ro#edure in staging o! P*T mediastinal hot s otsin staging o! P*T mediastinal hot s otsin lung #an#er atientsin lung #an#er atients

au/ens &, et al, ung Can#er 2008


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?'% *BU+ and P*T ositive?'% *BU+ and P*T ositivemediastinal l m h nodesmediastinal l m h nodes

diagnosti# staging ield o! TB16diagnosti# staging ield o! TB16!ollo/ing *BU+ lo#alization /as!ollo/ing *BU+ lo#alization /asassessedassessednum'er o! avoided surgi#alnum'er o! avoided surgi#alro#edures /as evaluatedro#edures /as evaluated33 atients re!erred !or staging33 atients re!erred !or stagingand or diagnosis o! mediastinal :Dand or diagnosis o! mediastinal :DP*T ositive lesionsP*T ositive lesions

lat , et al, *ur )es ir % 200A


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*BU+ and P*T ositive mediastinal*BU+ and P*T ositive mediastinall m h nodesl m h nodes

TB16 sam ling o! l m h nodes TB16 sam ling o! l m h nodeser!ormed a!ter *BU+ lo#alisationer!ormed a!ter *BU+ lo#alisation6v% num'er o! TB16 sam les t. 4%2R =%?%6v% num'er o! TB16 sam les t. 4%2R =%?%

C tologi#al or histologi#al diagnosesC tologi#al or histologi#al diagnoseso'tained in 2 82>5 o! the atients, o!o'tained in 2 82>5 o! the atients, o!/hi#h 8> /ere o'tained a!ter revious/hi#h 8> /ere o'tained a!ter revious*BU+ lo#alization*BU+ lo#alization

"n 2? A>5 o! the 33 atients, surgi#al"n 2? A>5 o! the 33 atients, surgi#alstaging ro#edures /ere su ressedstaging ro#edures /ere su ressed %%



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TB16 a!ter *BU+ lo#alization TB16 a!ter *BU+ lo#alizationshould 'e #onsidered as a rimarshould 'e #onsidered as a rimar

method o! evaluation o! l m h nodesmethod o! evaluation o! l m h nodesositive ' P*T s#anositive ' P*T s#anma re la#e the ma(orit o! surgi#alma re la#e the ma(orit o! surgi#almediastinal staging diagnosti#mediastinal staging diagnosti#ro#edures%ro#edures%



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A% *BU+ guiding 'ron#hos#o i#A% *BU+ guiding 'ron#hos#o i#interventionsinterventions

Bron#hial /all invasionBron#hial /all invasionTu*or ;n asionTu*or ;n asion

9-% echo layers9-% echo layersEBUS+ *ore sensiti eEBUS+ *ore sensiti e

than 5T for assessin.than 5T for assessin.bronchial 6all in asionbronchial 6all in asion8"' patients8"' patientsEBUS+ sensiti ity ofEBUS+ sensiti ity of/0: and a speci


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5454

Bron#hial /all invasionBron#hial /all invasion

Selectin. TherapySelectin. Therapy

EBUS to select patients 6ith biopsy pro enEBUS to select patients 6ith biopsy pro ens ua*ous cell carcino*a (or 5;S) for 2Ts ua*ous cell carcino*a (or 5;S) for 2T0 of 8/ lesions con


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5555

*BU+ and alliative 'ron#hos#o i#*BU+ and alliative 'ron#hos#o i#treatmentstreatments

N=N= 878%> o er a three year period878%> o er a three year period*echanical tu*or debride*ent7 stent*echanical tu*or debride*ent7 stentplace*ent7 Nd+?AG laser7 A 57place*ent7 Nd+?AG laser7 A 57brachytherapy7 forei.n body7 E45 therapybrachytherapy7 forei.n body7 E45 therapyEBUS 6as found to .uide or chan.eEBUS 6as found to .uide or chan.e*ana.e*ent in >9:*ana.e*ent in >9:

selectin. proper stent sizeselectin. proper stent size

.uidin. tu*or debride*ent.uidin. tu*or debride*entselectin. patients for endoscopic therapyselectin. patients for endoscopic therapyersus sur.ical therapyersus sur.ical therapy

ur es!ir / 2''2,2'*11( 21.


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5656

% *BU+ and m h 1ode% *BU+ and m h 1ode

+ize+ize*BU+ TB16 !or nodes*BU+ TB16 !or nodes NN =#m=#m1odes 2r, 2l, 4r, 4l, , =0r, =0l, ==r, and ==l51odes 2r, 2l, 4r, 4l, , =0r, =0l, ==r, and ==l5

Patients then had surgi#al stagingPatients then had surgi#al staging

==< l m h nodes==< l m h nodes4 =0 mm mean 8%=mm54 =0 mm mean 8%=mm5+ensitivit +ensitivit + e#i7#it =00>+ e#i7#it =00>Malignan# in =< ts ' *BU+, 'ut missed 2Malignan# in =< ts ' *BU+, 'ut missed 2

&! note&! note3 atients. 10 F 133 atients. 10 F 13=3 atients. 12 F 13=3 atients. 12 F 13

-ert# et al. ndo0ronc#ial ultarasound+guided trans0ronc#ial needle as!irationo l8m!# nodes in t#eradiologicall8 normal mediastinum. ur es!ir / 2''6, 2(* 1'+ 14


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5757

8% *BU+ TB16 and l m h nodes. sele#tion8% *BU+ TB16 and l m h nodes. sele#tiono! surgi#al #andidates /ith metastati# lungo! surgi#al #andidates /ith metastati# lung

tumorstumors

Patients /ith metastati# lung tumors /ithPatients /ith metastati# lung tumors /ithradiologi#all de7ned mediastinal and orradiologi#all de7ned mediastinal and orhilar l m h nodes on #hest #om utedhilar l m h nodes on #hest #om uted

tomogra hi# s#anstomogra hi# s#ans)etros e#tive%)etros e#tive%+u##ess!ul l m h node as iration /as+u##ess!ul l m h node as iration /aseviden#ed ' the resen#e o! malignanteviden#ed ' the resen#e o! malignant#ells or normal l m ho# tes%#ells or normal l m ho# tes%C tologi# and histologi# anal sis /as usedC tologi# and histologi# anal sis /as usedto #on7rm metastasis in surgi#allto #on7rm metastasis in surgi#allrese#ted s e#imens unless metastasis /asrese#ted s e#imens unless metastasis /asroven ' *BU+ TB16%roven ' *BU+ TB16%

a)a*ima T+ , Thorac $ardiovasc &urg-.//0 Dec

*BU+ TB16 and l m h nodes sele#tion o!*BU+ TB16 and l m h nodes sele#tion o!


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5858

*BU+ TB16 and l m h nodes. sele#tion o!BU+ TB16 and l m h nodes. sele#tion o!surgi#al #andidates /ith metastati# lungsurgi#al #andidates /ith metastati# lung

tumorstumors3ESU4TS3ESU4TS . 6 total o! =0A atients /ere re!erred. 6 total o! =0A atients /ere re!erred!or metastase#tom!or metastase#tom

*BU+ TB16 /as er!ormed in A0 l m h nodes 3*BU+ TB16 /as er!ormed in A0 l m h nodes 3mediastinal and 23 hilar nodes5 !rom 43 atients%mediastinal and 23 hilar nodes5 !rom 43 atients%C tologi# and or histologi# sam les /ere diagnosti# inC tologi# and or histologi# sam les /ere diagnosti# in4=


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5959

+tud to determine the a##ura# o!+tud to determine the a##ura# o!*BU+ TB16 in sam ling nodes NorJ=*BU+ TB16 in sam ling nodes NorJ=

#m in diameter%#m in diameter%Po ulationPo ulation

1+C C atients /ith CT s#ans sho/ing1+C C atients /ith CT s#ans sho/ing

no enlarged l m h nodes no node F=no enlarged l m h nodes no node F=#m5 in the mediastinum%#m5 in the mediastinum%

erth : , et al,*ur )es ir % 200A


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6060

*BU+ guided TB16 o! l m h nodes*BU+ guided TB16 o! l m h nodesin the radiologi#all normalin the radiologi#all normal

mediastinummediastinumm h nodes as irated at lo#ationsm h nodes as irated at lo#ations

2r, 2l, 4r, 4l, , =0r, =0l, ==r and ==l2r, 2l, 4r, 4l, , =0r, =0l, ==r and ==l

6ll atients under/ent su'se-uent6ll atients under/ent su'se-uentsurgi#al stagingsurgi#al stagingDiagnoses 'ased on as irationDiagnoses 'ased on as iration

results /ere #om ared /ith surgi#alresults /ere #om ared /ith surgi#alresultsresults

Herth : , et al, *ur )es ir % 200A

*BU+ id d TB16 ! l h d*BU+ g id d TB16 ! l h d


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6161

*BU+ guided TB16 o! l m h nodes*BU+ guided TB16 o! l m h nodesin the radiologi#all normalin the radiologi#all normal

mediastinummediastinum=00 atients=00 atients , ==< l m h nodes sam led, ==< l m h nodes sam ledrange ? =0 mm5range ? =0 mm5

Malignan# dete#ted inMalignan# dete#ted in =< ts, missed in=< ts, missed in

t/ot/oMean diameter o! un#tured l m h nodesMean diameter o! un#tured l m h nodes8%= mm8%= mm %%+ensitivit o! *BU+ TB16 !or dete#ting+ensitivit o! *BU+ TB16 !or dete#tingmalignan# /as , s e#i7#it /asmalignan# /as , s e#i7#it /as=00>, negative redi#tive value /as =00>, negative redi#tive value /as

1o #om li#ations o##urred%1o #om li#ations o##urred%

erth : , et al, *ur )es ir % 200A


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6262


*BU+ guided TB16 #an a##uratel*BU+ guided TB16 #an a##uratelsam le even small mediastinalsam le even small mediastinal

nodes, there!ore avoidingnodes, there!ore avoidingunne#essar surgi#al e@ loration inunne#essar surgi#al e@ loration inone out o! si@ atients /ho have noone out o! si@ atients /ho have no

#om uted tomogra h eviden#e o!#om uted tomogra h eviden#e o!mediastinal disease%mediastinal disease%

erth : , et al, *ur )es ir % 200A


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6363


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6464

"n this grou , =?A l m h nodes ranging ? to =0 mm in size"n this grou , =?A l m h nodes ranging ? to =0 mm in size/ere dete#ted and sam led%/ere dete#ted and sam led%

Malignan# /as dete#ted in nine atients 'ut missed in oneMalignan# /as dete#ted in nine atients 'ut missed in one atient%atient%Mean diameter o! the un#tured l m h nodes /as %< mm%Mean diameter o! the un#tured l m h nodes /as %< mm%

The sensitivit o! *BU+ TB16 !or dete#ting malignan# /as 8, The sensitivit o! *BU+ TB16 !or dete#ting malignan# /as 8,s e#i7#it /as =00>, and the negative redi#tive value /as , and the negative redi#tive value /as


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6565-ert# et al. C- %T 2''(, 133*((7 ( 1

=0% Com arison o! endo'ron#hial ultrasound=0% Com arison o! endo'ron#hial ultrasound,


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6666

0% Com arison o! endo ron#hial ultrasound,0% Com arison o! endo ron#hial ultrasound,ositron emission tomogra h , and CT !or l m hositron emission tomogra h , and CT !or l m h

node staging o! lung #an#ernode staging o! lung #an#er

6 ros e#tive #om arison o! methods used !or6 ros e#tive #om arison o! methods used !ordete#tion o! mediastinal and hilar l m h nodedete#tion o! mediastinal and hilar l m h nodemetastasis in atients /ith lung #an#ermetastasis in atients /ith lung #an#er#onsidered !or surgi#al rese#tion%#onsidered !or surgi#al rese#tion%

dire#t real time endo'ron#hial ultrasound *BU+5dire#t real time endo'ron#hial ultrasound *BU+5guided trans'ron#hial needle as iration TB165guided trans'ron#hial needle as iration TB165ositron emission tomogra h P*T5ositron emission tomogra h P*T5thora#i# CTthora#i# CT

+urgi#al histolog+urgi#al histologused as the Sgold standardS to #on7rm l m h nodeused as the Sgold standardS to #on7rm l m h nodemetastasis unless atients /ere !ound ino era'le !ormetastasis unless atients /ere !ound ino era'le !or13 or e@tensive 12 disease roven ' *BU+ TB16%13 or e@tensive 12 disease roven ' *BU+ TB16%

9asu u:u > et al C#est 2''6*13',71'+71(

Com arison o! endo'ron#hialCom arison o! endo'ron#hial


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6767

Com arison o! endo'ron#hialCom arison o! endo ron#hialultrasound, ositron emissionultrasound, ositron emission

tomogra h , and CT !or l m h nodetomogra h , and CT !or l m h nodestaging o! lung #an#erstaging o! lung #an#er

&ne hundred t/o otentiall o era'le atients&ne hundred t/o otentiall o era'le atients/ith roven n J


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6868

1e/ develo ments in *BU+1e/ develo ments in *BU+

1- 'iniforceps

.- $ost analysis2- Restaging

3- umber ofaspirations

=% *BU+ guided mini!or#e s 'io s in=% *BU+ guided mini!or#e s 'io s in


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6969

ggthe 'io s o! su'#arinal masses inthe 'io s o! su'#arinal masses inatients /ith lo/ li elihood o! nonatients /ith lo/ li elihood o! non

small #ell lung #an#ersmall #ell lung #an#er

*valuation o! the sa!et and eO#a#*valuation o! the sa!et and eO#a#

o! o'taining s e#imens !romo! o'taining s e#imens !romsu'#arinal masses using a =%=? mmsu'#arinal masses using a =%=? mmmini!or#e s under *BU+ guidan#e vs%mini!or#e s under *BU+ guidan#e vs%the diagnosti# ield /ith TB16 alone%the diagnosti# ield /ith TB16 alone%? atients? atients

Herth : , et al, 6nn Thora# +urg% 2008

*BU+ g id d i i! # 'i i th*BU+ guided mini!or#e s 'io s in the


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7070

*BU+ guided mini!or#e s 'io s in the*BU+ guided mini!or#e s 'io s in the'io s o! su'#arinal masses in atients'io s o! su'#arinal masses in atients

/ith lo/ li elihood o! 1+C C/ith lo/ li elihood o! 1+C C

*BU+ guided B16 o! the lesion*BU+ guided B16 o! the lesioner!ormed using three methods.er!ormed using three methods.

:irst /ith a 22 gauge needle:irst /ith a 22 gauge needle:ollo/ed ' a =< gauge needle:ollo/ed ' a =< gauge needleMini!or#e s /as then assed through theMini!or#e s /as then assed through the

air/a into the lesion under real time *BU+air/a into the lesion under real time *BU+guidan#eguidan#e

3 'io s s e#imens /ere o'tained3 'io s s e#imens /ere o'tained

erth : , et al, 6nn Thora# +urg% 2008


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7171


+ e#i7# diagnosis made in.+ e#i7# diagnosis made in.3A> o! atients /ith the 22 gauge needle3A> o! atients /ith the 22 gauge needle

4 /ith the =< gauge needle4 /ith the =< gauge needle88> /ith the mini!or#e s88> /ith the mini!or#e s

*BU+ guided mini!or#e s 'io s*BU+ guided mini!or#e s 'io s

Diagnosti# ield is su erior to TB16 aloneDiagnosti# ield is su erior to TB16 alonePro#edure a ears sa!ePro#edure a ears sa!e

erth : , et al, 6nn Thora# +urg% 2008


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*BU+ guided TB16 o! mediastinal*BU+ guided TB16 o! mediastinal


73/88

7373

*BU+ guided TB16 o! mediastinal*BU+ guided TB16 o! mediastinall m h nodes !or lung #an#er staging. al m h nodes !or lung #an#er staging. a

ro(e#ted #ost anal sisro(e#ted #ost anal sis:ort seven atients under/ent:ort seven atients under/entmediastinos#o as a staging ro#eduremediastinos#o as a staging ro#edure!or lung #an#er at eeds Tea#hing!or lung #an#er at eeds Tea#hingHos itals in 200A%Hos itals in 200A%

T/ent eight atients /ere sho/n to have T/ent eight atients /ere sho/n to havemalignant disease in 12 or 13 nodes, o!malignant disease in 12 or 13 nodes, o!

/hi#h 2 /ere deemed a##essi'le to/hi#h 2 /ere deemed a##essi'le to*BU+ TB16 all had mediastinal*BU+ TB16 all had mediastinall m hadeno ath on initial CT s#an5%l m hadeno ath on initial CT s#an5%

allister M*, et al, Thora@% 2008


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7474


Mean *BU+ TB16 sensitivit !orMean *BU+ TB16 sensitivit !ormalignan# in re#entl u'lishedmalignan# in re#entl u'lished

series /as series /as Pro(e#ted that 2? atients /ould havePro(e#ted that 2? atients /ould havehad mediastinal malignan#had mediastinal malignan#

demonstrated ' *BU+ TB16 anddemonstrated ' *BU+ TB16 and/ould there!ore not have undergone/ould there!ore not have undergoneCT P*T and mediastinos#o %CT P*T and mediastinos#o %

Callister M*, et al, Thora@% 2008


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7575

But !or ma multidis#i linarBut !or ma multidis#i linarteams, P*T /ould 'e o!tenteams, P*T /ould 'e o!ten

/arranted an /a 'e#ause o!/arranted an /a 'e#ause o!no/n =0 =4 er#ent in#iden#eno/n =0 =4 er#ent in#iden#eo! unsus e#ted e@trathora#i#o! unsus e#ted e@trathora#i#

metastasesmetastases


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7676

3% *BU+ /ith TB16 !or restaging3% *BU+ /ith TB16 !or restagingthe mediastinum in lung #an#erthe mediastinum in lung #an#er

"nvestigated the sensitivit and"nvestigated the sensitivit anda##ura# o! endo'ron#hial ultrasounda##ura# o! endo'ron#hial ultrasoundguided trans'ron#hial needleguided trans'ron#hial needleas iration *BU+ TB165 !or restagingas iration *BU+ TB165 !or restagingthe mediastinum a!ter indu#tionthe mediastinum a!ter indu#tion

#hemothera in atients /ith non#hemothera in atients /ith nonsmall #ell lung #an#er 1+C C5%small #ell lung #an#er 1+C C5%

erth : , et al, Clin &n#ol% 2008

*BU+ /ith TB16 !or restaging the*BU+ /ith TB16 !or restaging the


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7777

BU+ /ith TB16 !or restaging theBU+ /ith TB16 !or restaging themediastinum in lung #an#ermediastinum in lung #an#er

=24 atients /ith tissue roven stage """6=24 atients /ith tissue roven stage """612 disease /ho /ere treated /ith indu#tion12 disease /ho /ere treated /ith indu#tion#hemothera and /ho had undergone#hemothera and /ho had undergone

mediastinal restaging ' *BU+ TB16mediastinal restaging ' *BU+ TB16Patients su'se-uentl under/entPatients su'se-uentl under/entthora#otom /ith attem ted #urativethora#otom /ith attem ted #urativerese#tion and a l m h node disse#tionrese#tion and a l m h node disse#tionregardless o! *BU+ TB16 7ndings%regardless o! *BU+ TB16 7ndings%

Herth : , et al, Clin &n#ol% 2008

*BU+ /ith TB16 !or restaging the*BU+ /ith TB16 !or restaging the


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7878

BU+ /ith TB16 !or restaging theBU /ith TB16 !or restaging themediastinum in lung #an#ermediastinum in lung #an#er

Persistent nodal metastasesPersistent nodal metastasesdete#ted ' using *BU+ TB16 in 8< atientsdete#ted ' using *BU+ TB16 in 8< atients2>5%2>5%

no metastases assessed ' *BU+ TB16 inno metastases assessed ' *BU+ TB16 in3? atients3? atients28 out o! 3? /ere !ound to have residual28 out o! 3? /ere !ound to have residualstage """6 12 disease at thora#otomstage """6 12 disease at thora#otom

o! !alse negative results o! !alse negative resultsdue to nodal sam ling error rather thandue to nodal sam ling error rather thandete#tion error%dete#tion error%



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7979

*BU+ /ith TB16 !or restaging the*BU+ /ith TB16 !or restaging themediastinum in lung #an#ermediastinum in lung #an#er

+ensitivit A>+ensitivit A>+ e#i7#it =00>+ e#i7#it =00>Positive redi#tive value =00>Positive redi#tive value =00>1egative redi#tive value 20>1egative redi#tive value 20>Diagnosti# a##ura# o! *BU+ TB16 !orDiagnosti# a##ura# o! *BU+ TB16 !ormediastinal restaging a!ter indu#tionmediastinal restaging a!ter indu#tion#hemothera >#hemothera >



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8080


*BU+ TB16 /as !ound to 'e a*BU+ TB16 /as !ound to 'e asensitive, s e#i7#, a##urate, andsensitive, s e#i7#, a##urate, and

minimall invasive test !or mediastinalminimall invasive test !or mediastinalrestaging o! atients /ith 1+C C%restaging o! atients /ith 1+C C%Be#ause o! the lo/ negative redi#tiveBe#ause o! the lo/ negative redi#tivevalue, tumor negative 7ndings shouldvalue, tumor negative 7ndings should'e #on7rmed ' surgi#al staging'e #on7rmed ' surgi#al staging'e!ore thora#otom %'e!ore thora#otom %


l l hB l l h '


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8181

But let s loo at the num'ers.But let s loo at the num'ers.

=24 atients=24 atients8< had #an#er on restaging *BU+8< had #an#er on restaging *BU+

3? did not3? did not&! these, 28 had #an#er on restaging o en&! these, 28 had #an#er on restaging o ensurgersurger

117/124 patients still had cancerat restaging


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8282

4% *BU+ TB16 and the4% *BU+ TB16 and the

num'er o! as iratesnum'er o! as irates


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8383

The num'er o! as irations needed in The num'er o! as irations needed in#onventional TB16#onventional TB16

the ma@imum diagnosti# ield /as o'tainedthe ma@imum diagnosti# ield /as o'tainedin 7vein 7ve to seven needle assesto seven needle assesChin ) r, M#Cain TI, u#ia M6, et al% Trans'ron#hialChin ) r, M#Cain TI, u#ia M6, et al% Trans'ron#hial needleneedle

as iration in diagnosing and staging lung #an#er. ho/ manas iration in diagnosing and staging lung #an#er. ho/ manas irates are needed 6m )es ir Crit Care Med 2002as irates are needed 6m )es ir Crit Care Med 2002

=AA.3 38==AA.3 38=Dia#on 6H, +#huurmans MM, Theron , et al% Trans'ron#hialDia#on 6H, +#huurmans MM, Theron , et al% Trans'ron#hial

needle as irates. ho/ man asses er target site *urneedle as irates. ho/ man asses er target site *ur)es ir 200 2


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8484

There are greater limitations in the There are greater limitations in thesize and lo#ation o! a##essi'le 1ssize and lo#ation o! a##essi'le 1s

that #an 'e as irated using TB16 vsthat #an 'e as irated using TB16 vs*BU+ TB16% "n a metaanal sis*BU+ TB16% "n a metaanal sisthethe ooled sensitivit o! #onventionalooled sensitivit o! #onventional

TB16 TB16 in the mediastinal staging o!in the mediastinal staging o!1+C C /as re orted to 'e1+C C /as re orted to 'e 90 to %/:&90 to %/:&


Holt *, Gus#hner I , ould MG% 6##ura# o! trans'ron#hial needle as iration!or mediastinal staging o! non small #ell lung #an#er. a meta anal sis% Thora@200?A0.


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8585

ObjectiveObjective :: The goal o! this stud /as to The goal o! this stud /as todeterminedetermine the o timal num'er o! as irations erthe o timal num'er o! as irations erl m h node 15 stationl m h node 15 station during endo'ron#hialduring endo'ron#hialultrasound *BU+5 guided trans'ron#hial needleultrasound *BU+5 guided trans'ron#hial needleas iration TB165 !or ma@imum diagnosti# ieldas iration TB165 !or ma@imum diagnosti# ieldin mediastinal staging o! non small #ell lungin mediastinal staging o! non small #ell lung#an#er 1+C C5 in the a'sen#e o! ra id on site#an#er 1+C C5 in the a'sen#e o! ra id on site# to athologi# e@amination%# to athologi# e@amination%

MethodsMethods :: *BU+ TB16 /as er!ormed in*BU+ TB16 /as er!ormed inotentiall o era'le 1+C C atients /ithotentiall o era'le 1+C C atients /ithmediastinal 1s a##essi'le ' *BU+ TB16 ? tomediastinal 1s a##essi'le ' *BU+ TB16 ? to20 mm5%20 mm5% *ver target 1 station /as un#tured*ver target 1 station /as un#tured!our times!our times %%

&'(e#tives and Methods&'(e#tives and Methods

Chest 2008 =34 3A8 3 4


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8686Chest 2008 =34 3A8 3 4

M @i l ! 3M @i lt !t 3


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8787

Ma@imum results a!ter 3Ma@imum results a!ter 3as iratesas irates

Chest 2008 =34 3A8 3 4

Rapid On Site Cytology isstandard of care to assuregreater yield and better


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Than ou Than ou

sbpt2008_d23endosc_henricolt01.ppt

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