1. Bronchoscopy/ Endobronchial ultrasound
Chi Young Jung, MD, PhD
Associate professor
Division of Pulmonary & Critical Care Medicine
Daegu Catholic University Medical Center

2. Contents Bronchoscopy - diagnosis of primary tumor - staging
Endobronchial ultrasound (EBUS)
- EBUS-TBNA
- radial probe EBUS guided TBLB

3. Bronchoscopy

4. bronchoscopy

5. Types of bronchoscopy Flexible bronchoscopy Rigid bronchoscopy
virtual bronchoscopy

6. Anatomy of tracheobronchial tree

7. Flexible bronchoscopy
Traditional white light bronchoscopy
Endobronchial ultrasound (EBUS)
Navigation bronchoscopy (NB)
Ultrathin bronchoscopy
Confocal bronchoscopy
Fluorescence bronchoscopy

8. White light bronchoscopy

9. Endobronchial biopsy

10. Bronchial washings

11. Bronchial brushings

12. Transbronchial lung biopsy: TBLB

13. Transbronchial needle aspiration: TBNA

14. Staging Bronchoscopy is routinely performed pre-operatively
: assess for synchronous lesions
: delineate tumor margins
Blind bronchoscopic TBNA can access lymph nodes
: subcarinal (7), paratracheal (4), hilar (10)

15. Anatomy of tracheobronchial tree
2cm

16. Complication Bleeding Pneumothorax: TBLB
Mild transient hypotension related to sedation
Bronchospasm, hypoxemia
Infection
Epistaxis
Cardiac arrhythmia

17. Endobronchial ultrasound: EBUS

18. Endobronchial ultrasound (EBUS)

19. EBUS vs EUS
EBUS
EUS

20. Types of EBUS
Convex probe EBUS
Radial probe EBUS

21. EBUS-TBNA: Indications
Diagnosis & staging of lung cancer
Mediastinal lymphadenopathy of unclear etiology
Sampling parenchymal pulmonary nodules, endobronchial or peribronchial lesions
Sampling mediastinal masses

22. Schematic of EBUS-TBNA

23. EBUS-TBNA

24. EBUS-TBNA

25. EBUS-TBNA

26. Advantages Minimally-invasive, safe procedure Outpatient basis
Local anesthesia & conscious sedation
Access a wide range of mediastinal LN & hilar LN
Sample centrally located pulmonary lesions

27. Approaches to LNs in mediastinum

28. Bronchus and mediastinal structures

29. Diagnostic algorithm Lung mass with suspected NSCLC Imaging:
CT with contrast, PET-CT
Distant metastasis? No
Yes
Evidence of N1, N2,
or N3 by CT or PET
Biopsy most accessible lesion
Yes No
EBUS-TBNA or mediastinoscopy
Large tumor with
high pretest probability of nodal involvement
(T1b or larger)
Yes
Consider
EBUS-TBNA or mediastinoscopy

30. M/71 Cough

31. Chest CT scan

32. EBUS-TBNA
adenocarcinoma

33. EBUS-TBNA: meta-analysis
(11 studies, 1,299 patiens)
93%
100%
Eur J Cancer 2009;45:

34. EBUS-TBNA: meta-analysis
(10 studies, 817 patiens)
sensitivity
specificity
88%
100%
Thorax 2009;64:

35. EBUS-TBNA vs Mediastinoscopy
Lymph Node Size in mm: Mean ± SD (Range)
EBUS Yield
(%)
Mediastinoscopy Yield p
All lymph nodes
15 ± 2.6 (10–21)
109/120 (91)
94/120 (78)
0.007
Lymph node station
 2 all
16 ± 3.1 (10–21)
24/25 (96)
22/25 (88)
0.30
 2 right
18 ± 1.6 (14–20)
12/13 (92)
11/13 (85)
0.99
 2 left
14 ± 3.6 (10–21)
12/12 (100)
11/12 (92)
 4 all
15 ± 2.6 (10–19)
45/54 (83)
40/54 (74)
0.24
 4 right
29/34 (85)
24/34 (71)
0.14
 4 left
16/20 (80)  7
15 ± 2.4 (10–19)
40/41 (98)
32/41 (78)
Pathology
 Malignant
16 ± 2.7 (10–21)
64/74 (86)
49/74 (66)
0.004
 Benign
15 ± 2.5 (10–21)
45/46 (98)
(66 patients, 120 LNs)
J Thorac Oncol 2008;3:

36. EBUS-TBNA/EUS-FNA vs Mediastinoscopy79 94
Mediastinoscopy
EBUS-TBNA/EUS-FNA alone
Sensitivity
79%
85%
JAMA 2010;304:

37. EBUS-TBNA/EUS-FNA: meta-analysis
(8 studies, 821 patiens)
Sensitivity : 86%
Specificity : 100%

38. Combined EBUS-TBNA & EUS-FNA
Combined vs EBUS-TBNA
Combined vs EUS-FNA
Eur Respir J 2015;46:40-60.

39. Accuracy for staging of mediastium
Methods
Sensitivity
Specificity
PPV
NPV CT 55 81 58 83
PET 80 88 75 91
PET-CT 62 90 63
Mediastinoscopy
81(94*)
100
91(98*)
VATS 99 96
TBNA 78 77
EBUS-TBNA 89 86
EBUS-TBNA, real-time
EBUS-TBNA & EUS-FNA,
real-time
* Mediastinal lymphadenectomy & videomediastinoscopy
Chest 2013;143:e211s-50s.

40. Complication Hypoxemia, cough, agitation during the procedure
Atrial fibrillation
Bronchial edema/ hyperemia
Minute bleeding
Stridor
Pneumothorax
Hematoma
Asymptomatic pneumo-mediastinum
Infection: mediastinitis
Puncture of the bronchoscope

41. Radial probe EBUS

42. Transbronchial lung biopsy (TBLB)

43. in normal aereated lung
Within
Radial probe EBUS
Adjacent to
‘Snowstorm’ picture
in normal aereated lung

44. Radial probe EBUS

45. Radial probe EBUS

46. F/73 pneumonia

47. Chest CT scan

48. Radial probe EBUS guided
TBLB & cytology
Radial probe EBUS guided
adenocarcinoma

49. Summary
EBUS-TBNA have been shown to have a good diagnostic accuracy in the diagnosis and staging of lung cancer
EUBS-TBNA is technically feasible and safe procedure
Combination of EBUS-TNBA & EUS-FNA is preferred over either test alone
Radial probe EBUS-guided TBLB can be used for diagnosis of peripheral lung cancer