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Endoscopic and Endobronchial Ultrasonography According to the Proposed Lymph Node Map Definition in the Seventh Edition of the Tumor, Node, Metastasis.

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Presentation on theme: "Endoscopic and Endobronchial Ultrasonography According to the Proposed Lymph Node Map Definition in the Seventh Edition of the Tumor, Node, Metastasis."— Presentation transcript:

1 Endoscopic and Endobronchial Ultrasonography According to the Proposed Lymph Node Map Definition in the Seventh Edition of the Tumor, Node, Metastasis Classification for Lung Cancer  Kurt G. Tournoy, MD, PhD, Jouke T. Annema, MD, PhD, Mark Krasnik, MD, PhD, Felix J.F. Herth, MD, PhD, Jan P. van Meerbeeck, MD, PhD  Journal of Thoracic Oncology  Volume 4, Issue 12, Pages (December 2009) DOI: /JTO.0b013e3181c1274f Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

2 FIGURE 1 The different thoracic lymph node stations according to the newly proposed definition and the complementary reach to take biopsies with endoscopic curved-linear ultrasound with fine-needle aspiration (EUS-FNA) (A; green nodes) or endobronchial curved-linear ultrasound with transbronchial needle aspiration (EBUS-TBNA) (B; red nodes). Nodes that generally cannot be sampled with endoscopic ultrasound are dark gray. The dot lines indicate anatomic borders that are important for identification of the different lymph node stations by means of endoscopic ultrasound. Station 3a/p nodes are not indicated on this image. Stations 5 and 6 can often be seen during endoscopic ultrasound, whereas sampling is hazardous because of interposition of the great vessels. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

3 FIGURE 2 Computed tomography (CT) scan (left panel) and endoscopic curved-linear ultrasound (EUS) image (right panel) of lymph node (LN) station 2L. The inferior border of this lymph node is localized just cranial to the transverse plane through the superior margin of the aortic arch. On the computed tomography (CT) scan image, the lymph node is situated immediately adjacent to the trachea and ventrally to the esophagus. During endoscopic curved-linear ultrasound (EUS), the lymph node is found as a hypoechogenic sharp edged lesion just cranial to the transverse plane through the superior margin of the aortic arch. Note: the right side of the endoscopic ultrasound image (also for Figures 3–8) corresponds with the cranial (superior) side in the patient. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

4 FIGURE 3 Computed tomography (CT) scan and endobronchial curved-linear ultrasound (EBUS) image of lymph node stations 3A and 3P. Station 3P (upper panel) is located just behind the trachea (left panel) and reaches from the apex of the lung down to the main carina. 3P can be identified and sampled with endobronchial curved-linear ultrasound (EBUS) (right panel) or endoscopic curved-linear ultrasound (EUS). There are no ultrasound landmarks to identify the upper border of this lymph node station. Station 3A (lower panel) is on the right situated anterior to the superior vena cava (SVC) and on the left anterior to the left carotid artery. Although 3A can be seen with endobronchial curved-linear ultrasound (EBUS), sampling is impossible. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

5 FIGURE 4 Computed tomography (CT) scan and endoscopic curved-linear ultrasound (EUS) image of lymph node station 4L. Both the superior and inferior border of lymph node station 4L can be accurately identified by endoscopic ultrasound (right panel) being the transverse planes through the superior border of the aorta (Ao) and left pulmonary artery, respectively (LAP). The lateral border of this station being the ligamentum arteriosum is invisible both on computed tomography (CT) and during endoscopic ultrasound. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

6 FIGURE 5 Computed tomography (CT) scan, endobronchial curved-linear ultrasound (EBUS) image of lymph node station 4R, and the corresponding endobronchial view. The lower border of the azygos vein is an ultrasound landmark structure making the difference between 4R and 10R nodes. This vein is localized in the tracheobronchial corner on the right and is typically kidney shaped during identification with endobronchial curved-linear ultrasound (EBUS) (upper panel, right). The lymph nodes are then visualized just superior to and/or medially from the azygos vein as hypoechogenic sharp edged structures lying just posterior to the superior vena cava (SVC) or aorta. The puncture for endobronchial curved-linear ultrasound with transbronchial needle aspiration (EBUS-TBNA) is classically performed at or just above the tracheobronchial corner, leaving behind a small bloody puncture lesion (lower panel-left). Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

7 FIGURE 6 Computed tomography (CT) scan and endoscopic curved-linear ultrasound (EUS) images of lymph node stations 5 (left upper panel; white arrow) and 6 (left lower panel, white arrow). The inferior border of station 5 is the superior rim of the left pulmonary artery (right upper panel). The inferior border of the aortic arch is the frontier between stations 5 and 6. The superior border of station 6 (right lower panel) is the transverse plane through the superior border of the aortic arch. Although these stations and their borders can be identified by means of EUS and endobronchial curved-linear ultrasound (EBUS), sampling without transpassing the great vessels is often impossible. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

8 FIGURE 7 The subcarinal station shown on CT scan (left panel) can easily be visualized with both endoscopic curved-linear ultrasound (EUS) (right panel) but of course also with endobronchial curved-linear ultrasound (EBUS). During endoscopic curved-linear ultrasound (EUS), the subcarinal station identifies as a round, hypoechogenic sharply edged structure located in between the esophagus and the pulmonary artery. The upper rim of this artery corresponds in general with the main carina and is helpful during endoscopic curved-linear ultrasound (EUS). The main carina is visualized by means of endoscopy during endobronchial curved-linear ultrasound (EBUS). The inferior border is the roof of the lower lobe bronchus on the left and the bottom of the bronchus intermedius on the right. There are no unique ultrasound features that correspond to this definition although endoscopy during endobronchial curved-linear ultrasound (EBUS) is helpful. Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

9 FIGURE 8 Typical computed tomography (CT) images (left upper and lower panel) of node stations 8R and 8L. The ultrasound visualization of these stations was performed here with the endoscopic curved-linear ultrasound (EUS) scope (8R: right upper panel). There are no specific ultrasound landmarks to identify the borders of these lymph node stations although the inferior margin of both stations 8 and 9 is the diaphragm, which is readily identifiable with endoscopic curved-linear ultrasound with fine-needle aspiration (EUS-FNA) but not endobronchial curved-linear ultrasound with transbronchial needle aspiration (EBUS-TBNA). The esophagus is visualized by endobronchial curved-linear ultrasound (EBUS) as a longitudinal structure with a hyperechogenic band (right lower panel). Journal of Thoracic Oncology 2009 4, DOI: ( /JTO.0b013e3181c1274f) Copyright © 2009 International Association for the Study of Lung Cancer Terms and Conditions

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