Virtual endobronchial ultrasound for transbronchial needle aspiration

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Virtual endobronchial ultrasound for transbronchial needle aspiration Masaaki Sato, MD, PhD, Fengshi Chen, MD, PhD, Akihiro Aoyama, MD, PhD, Tetsu Yamada, MD, Masaki Ikeda, MD, Toru Bando, MD, PhD, Hiroshi Date, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 146, Issue 5, Pages 1204-1212 (November 2013) DOI: 10.1016/j.jtcvs.2013.01.019 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Step-by-step instructions and characteristics of virtual EBUS using virtual bronchoscopy. A, Virtual EBUS standard uses conventional 3D virtual bronchoscopy constructed from thin-slice CT. B, Virtual EBUS advanced uses an advanced application that allows for displaying multilayers, including extracted 3D images of target lesions, associated vascular structures, and 3D virtual bronchoscopy. 3D, 3-Dimensional; CT, computed tomography; EBUS-TBNA, endobronchial ultrasound-guided transbronchial needle aspiration. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Preparation using virtual EBUS standard. A and B, Patient with a medical history of colon cancer shows a slightly enlarged left number 11 lymph node station (arrow in B) on enhanced CT scan. C, Number 11 station is weakly positive on PET (arrow). D, Series of 3D virtual bronchoscopy images (top) and linked CT images (bottom). The pyramid-shaped indicator in the CT image shows the direction of the view in virtual bronchoscopy. Note that in the far right images, virtual bronchoscopy penetrated the bronchial wall, simulating the TBNA procedure. This simulation step is the key in virtual EBUS standard to determine the spot and angle to be punctured in EBUS-TBNA. Bas, Basal segment; Lin, lingular segment; Sup, superior segment of lower lobe. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Preparation using virtual EBUS advanced. The same case as in Figure 2 was used as an example of virtual EBUS advanced. Outlining and extraction of target lymph node (A), associated left pulmonary artery (B), and left inferior pulmonary vein (C). The insets at the right lower corner indicate the 3D view of extracted images. D, Merged views of multiple layers with different bronchial wall transparencies. The layers include the target lymph node, pulmonary artery, and pulmonary vein in combination with 3D virtual bronchoscopy. PA, Pulmonary artery; PV, pulmonary vein. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A case of EBUS-TBNA planned for using virtual EBUS standard (case 2). A, CT scan shows an enlarged number 4L lymph node station, which is close to the pretracheal area. B, View of virtual bronchoscopy prepared for by virtual EBUS standard. Arrow indicates the spot to be punctured. C, Actual bronchoscopic view. The arrow indicates the spot that was actually punctured by TBNA. The verbal description was 1 ring cephalad to the carina, 10- to 11-o’clock angle from the carina. D, Ultrasound view of EBUS-TBNA. The needle is directly in the lymph node. Note that the location was hardly visible under ultrasound after inserting the needle into the EBUS scope. The puncture technique used in such a case is described in the text. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A case of EBUS-TBNA prepared for by virtual EBUS advanced (case 3). A, Patient with an abnormal nodule in the left lung shows enlarged numbers 4R and 10R lymph node stations. B, These lymph node stations were positive on PET/CT. C, View of virtual EBUS advanced at the number 4R station (top) with bronchial wall transparency (bottom). D, View of number 10R station (top) with bronchial wall transparency (bottom). BIM, Bronchus intermedius; RUL, right upper lobe; SVC, superior vena cava; AZ, azygos vein; PA, pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 A case of EBUS-TBNA planned for using virtual EBUS advanced (case 4). A, Intrapulmonary mass located close to the hilum was found on CT scan. The mass was positive on PET/CT (inset). B, View of virtual EBUS advanced, showing the relationship among the mass, right inferior pulmonary vein, and bronchi. C, View of actual bronchoscope. The arrow indicates the spot that was actually punctured by TBNA under ultrasound. D, Ultrasound view of EBUS-TBNA. The needle is directly in the target lesion. ML, Middle lobe; PV, pulmonary vein; T, mass; S, superior segment of lower lobe. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Illustration of technique to puncture a target at a high upper angle using virtual EBUS. A, Puncture of a target at a regular angle. EBUS-TBNA is easily conducted under ultrasound visualization with regular inflation of the EBUS balloon. B, Target located at a high upper angle. With regular inflation of the EBUS balloon, the target is hardly visible because of reduced flexibility of the EBUS scope after insertion of the needle in the scope. C, Hyperinflation of the EBUS balloon allows for visualization of the target at a high upper angle. However, real-time ultrasound visualization during TBNA is hindered by the inflated balloon, which is in the needle pathway. The puncture angle is also too small or almost tangent to the tracheobronchial wall. D, Technique to effectively puncture a target at a high upper angle using virtual EBUS. First, the tip of the needle is stuck at the spot predetermined by virtual EBUS (black arrow). Second, the EBUS balloon is then hyperinflated. Because the needle has already reached the tracheobronchial wall, the balloon no longer interferes with the needle. The angle of the needle against the tracheobronchial wall is still small or almost tangent. Third, once the target is visualized, the EBUS scope is progressed slightly (white arrow). A larger angle is now obtained for the bronchoscopist to conduct force to the needle to penetrate the tracheobronchial wall while ultrasound visualization of the target is maintained. Last, the target is punctured under real-time ultrasound visualization. The Journal of Thoracic and Cardiovascular Surgery 2013 146, 1204-1212DOI: (10.1016/j.jtcvs.2013.01.019) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions