1. #8. Planning EBUS-TBNA of Left lower paratracheal lymph node (station 4L)
Describe the yield of EBUS-TBNA versus conventional TBNA at station 4L.
Describe how the coronal view of a computed tomography scan can be used to help plan the procedure.
Identify 4L and surrounding vascular structures using EBUS. 1
Bronchoscopy.org

2. Case description (practical approach # 8)
A 69 year-man with a 120 pack –year history of smoking presents with cough.
Computed tomography shows a 2.5 X 2 cm left upper lobe mass and a 1.5 cm left paratracheal lymph node.
Patient is referred for diagnosis and staging
Bronchoscopy.org 2

3. Case description (practical approach #8)
Axial CT view
Coronal CT view
1.5 cm left paratracheal lymph node
Bronchoscopy.org 3

4. The Practical Approach
Initial Evaluation
Procedural Strategies
Techniques and Results
Long term Management
Examination and, functional status
Significant comorbidities
Support system
Patient preferences and expectations
Indications, contraindications, and results
Team experience
Risk-benefits analysis and therapeutic alternatives
Informed Consent
Anesthesia and peri-operative care
Techniques and instrumentation
Anatomic dangers and other risks
Results and procedure-related complications
Outcome assessment
Follow-up tests and procedures
Referrals
Quality improvement 4
Bronchoscopy.org

5. Initial Evaluations Exam Comorbidities Support system
Decreased air entry bilaterally and prolonged exhalation
WHO functional status II
Comorbidities
COPD, Coronary artery disease
Support system
Lives with wife at home
Patient preferences
Desires diagnosis and considers all available active treatment options. 5
Bronchoscopy.org

6. Procedural Strategies
Indications
Invasive lymph node staging?
Invasive staging should be performed in patients with 1 or more risk factors for occult N2 disease* ** ***
The patient in this case has clinically evident N2 disease (1.5 cm left paratracheal node)
Bronchoscopic inspection can be performed at the time of EBUS-TBNA.
Diagnosis and staging can be performed during a single procedure.
*Ann Thorac Surg 2007;84:
**J Thorac Cardiovasc Surg 2006;131:
*** Eur J Cardiothorac Surg Jul;32(1):1-8 6
Bronchoscopy.org

7. Procedural Strategies
Indications
Obtain tissue diagnosis
Sample 4L (left paratracheal node) for staging purposes
Mediastinal lymph node involvement is found in 26% of newly diagnosed lung cancer patients*
The presence of lymph node metastasis remains one of the most adverse factors for prognosis in NSCLC
Mediastinal nodal involvement suggests stage IIIA or IIIB
inoperability and/or
need for treatment by chemotherapy and/or radiotherapy
* Spira A, Ettinger DS. Multidisciplinary management of lung cancer. N Engl J Med 2004; 350: 379–392.
Bronchoscopy.org 7

8. Procedural Strategies
Contraindications:
None
Expected Results:
The diagnostic rate of EBUS-TBNA for station 4L reportedly equal to conventional TBNA (72%vs. 71%)
Lymphocytes more often present on EBUS-TBNA specimens compared with conventional TBNA (82%vs. 71%)*
Experienced team and operator
Risks-benefits:
No serious complications reported in the literature.
Agitation, cough, and presence of blood at puncture site reported infrequently.**
Benefits: accurate, safe and same day procedure.
*Chest 2004; 125:322–325
**Eur Respir J 2009; 33: 1156–1164 8
Bronchoscopy.org

9. Procedural Strategies
Diagnostic alternatives:
CT-guided percutaneous needle aspiration of mass; high diagnostic rate (91%) but does not provide staging, and has increased risk for pneumothorax (5-60%)*
EUS-FNA( esophageal ultrasound reaches 4L node; Sensitivity 81-97% Specificity % **
Mediastinoscopy: considered gold standard.
Bronchoscopic airway inspection would still be required
VATS: most invasive of alternatives.
Only provides access to ipsilateral nodes. 75% sensitivity***.
Benefits include definitive lobar resection at same time if node negative.
*Chest. 2003; 123:
**Lung Cancer. 2003; 41:
***Chest 2007;132; 9

10. For station 4L, EBUS-TBNA and EUS-FNA have similar diagnostic rates
Am J Respir Crit Care Med Vol 171. pp , 2005
Bronchoscopy.org

11. Procedural Strategies
Risks-Benefits
Cost effectiveness- no formal evaluations have been published
In 2 separate decision-analytic models, both (EUS-FNA + EBUS-FNA) and (conventional TBNA + EBUS-FNA) were more cost-effective approaches than Mediastinoscopy for staging patients with NSCLC and abnormal mediastinal lymph nodes on non-invasive imaging* **
A strategy adding EUS-FNA to a conventional lung ca staging approach (mediastinoscopy thoracotomy) reduced costs by 40% per patient***
May actually increase health care costs if done in low volume centers by less experienced operators**** *****
Start up costs
Cost of equipment ~100K******and training
Physician reimbursement ~$280; facility reimbursement $257******
*Gastrointestinal Endoscopy 69, No. 2, Supp 1, 2009, S260
**J Bronchol 2008;15:17–20
***Thorax 2004;59;
****Lung Cancer 64 (2009) 127–128
*****J Bronchol 2008; 15:
****** Southern Medical Journal 2008;101,No5;534-38
Bronchoscopy.org

12. Procedural Strategies
Informed consent:
There were no barriers to learning identified. Patient has good insight into his disease and realistic expectations.
Drawing from Herth FJ et al. J Bronchol Volume 13, Number 2, April 2006
EBUS image from patient.
BI #. Practical Approach Title 12

13. Procedural techniques and results Anesthesia and perioperative care
Conscious (moderate) sedation
May be performed in bronchoscopy suite
Cost savings compared to general anesthesia.
Visualization and biopsy of smaller nodes technically more difficult than with general anesthesia.
General anesthesia with LMA (#4 or 4.5 )
Better visualization of higher nodes ( station 1 and 2) compared with ET tube
May not be appropriate in severe obesity or severe untreated GERD
General anesthesia with ET tube (#8.5 for female and #9 for male patients)
Usually performed in OR .
EBUS scope directed more centrally in airway which may make biopsies more difficult
J Cardiothorac Vasc Anesth 2007; 21:892–896 13
Bronchoscopy.org
Chest 2008;134;

14. Procedural Techniques and Results
Instrumentation
EBUS scope- direct real time US imaging with curved array ultrasound transducer incorporated in distal end of bronchoscope
Ultrasound processor
Adjustable gain and depth
B mode and Doppler capabilities
Needle
22 gauge acrogenic needle with stylet
Needle guide system locks to scope
Lockable needle and sheath
Precise needle projection up to 4 cm
Bronchoscopy.org 14

15. Procedural Techniques and Results
Anatomic dangers and other risks
Major blood vessels- Pulmonary Artery and Aortic arch
Risk of canulating major vessel may be reduced with real time B mode and Doppler mode imaging
“Minor” oozing of blood at puncture site was reported in 1 study there have been no reports of major bleeding*
Pneumothorax and pneumomediastinum**
Have been reported with blind TBNA but no reports in literature with EBUS guided FNA.
Chest 2004;126;
**Eur Respir J 2002; 19:356–373
Bronchoscopy.org 15

16. Procedural Techniques and Results
Aspirate cytology
Adequate/representative: in presence of frankly malignant cells, lymphocytes, lymphoid tissue, or clusters of anthracotic pigment-laden macrophages*
Inadequate/nonrepresentative : if there are no cellular components, scant lymphocytes (defined as <40 per HPF) blood only, or cartilage or bronchial epithelial cells only* **
A quantitative cut off value of at least 30% of cellularity composed of lymphocytes has been arbitrarily proposed by some experts***
Higher yield may be obtained by obtaining aspirates from the periphery of nodes****
*Am J Clin Pathol 2008;130:
**Chest 2008;134; ;
***Chest 2004;126;
****Techniques in GI Endoscopy, Vol 2, No 3, 2000: pp

17. Procedural Techniques and Results
Number of aspirates* if ROSE not utilized
Best yield with 3 aspirates per station (see table)
Two aspirations per LN station are acceptable when at least one tissue core specimen is obtained.
Sensitivity 91.7%, NPV 96.0%, and accuracy 97.2%
If operator believes targeting is inadequate or insufficient another aspirate should be performed 17
Bronchoscopy.org
* Chest 2008;134; ; 17

18. Maximum results after 3 aspirates
Rapid On Site Cytology may assure greater yield but potentially prolongs procedure time and costs.
Chest 2008;134;
Bronchoscopy.org 18

19. Procedural Techniques and Results
Results and procedure-related complications
EBUS-TBNA was performed under general anesthesia using a 9.0 endotracheal tube.
4L nodal cytology diagnostic for non small cell carcinoma (adenocarcinoma).
Bronchoscopic inspection : swelling and erythema distal left upper lobe bronchus. Washing positive for adenocarcinoma.
There were no complications.
Bronchoscopy.org 19

20. Long-term Management Plan
Outcome assessment
Patient was referred for multidisciplinary evaluation to include cardiothoracic surgery, oncology, and radiation oncology for potential trial enrollment for neoadjuvant treatment of stage IIIA adenocarcinoma of the lung.*
5 year survival for IIIA non-small cell lung ca is 23%.
Follow-up tests and procedures
Patient will follow up in 2 weeks to ensure involvement of above specialties.
Referrals
See above.
Quality improvement
Diagnosis and N2 metastasis identified by single procedure.
*Chest 2007;132;243S-265S
Bronchoscopy.org 20

21. Q 1: Describe the yield of EBUS-TBNA versus conventional TBNA at station 4L.
Bronchoscopy.org

22. EBUS-TBNA vs. Conventional TBNA
Bronchoscopy International 22
CHEST 2004; 125:322–325 22 22

23. The yield of EBUS-TBNA for diagnosing malignancy in station 4L is as high as 96%
Bronchoscopy.org
Herth F et al. Thorax 2006;61;

24. Q 2: Describe how the coronal view of a computed tomography scan can be used to help plan the procedure.
Bronchoscopy.org

25. Station 4L (left lower paratracheal) definition based on IASLC map
Includes nodes to the left of the left lateral border of the trachea, medial to the ligamentum arteriosum.
Upper border: upper margin of the aortic arch.
Lower border: upper rim of the left main pulmonary artery.
(J Thorac Oncol. 2009;4: 568–577)
Both axial and coronal CT views are useful to define
the borders of station 4L. 25

26. Bronchoscopy International
CT views
Bronchoscopy International 26 26

27. Bronchoscopy International
CT views: coronal
A coronal (aka frontal) plane is perpendicular to the ground, which (in humans) separates the anterior from the posterior, the front from the back, the ventral from the dorsal
Bronchoscopy International 27 27

28. Bronchoscopy International
AXIAL
CORONAL
SAGITTAL
Definitions and images for the three views 28
Bronchoscopy International 28

29. Which CT view is most useful for planning EBUS-TBNA for station 4L?9 12
Bronchoscopy from head of patient
To visualize the left paratracheal node (4L), the operator turns the bronchoscope laterally to the 9-o’clock position and scans the area of lymph node station 4 L.
Bronchoscopy.org

30. The coronal CT view identifies the EBUS scanning plane
cephalad
caudal Ao PA LN
Drawing modified from Herth F et al. J Bronchol Volume 13, Number 2, 2006
The aortic arch is proximal and the left pulmonary artery is distal
Bronchoscopy International 30 30 30

31. Simultaneous coronal CT view and EBUS image at station 4L
The EBUS image at station 4L shows this pattern 4L
Bronchoscopy.org

32. Bronchoscopy International
To understand the use of coronal CT view one must understand the reference points on the EBUS image
caudal
cephalad
The EBUS image is projected on the monitor as if the scope is horizontal
The green dot on the monitor represents the point where the needle exits the scope and corresponds to the superior (cephalad) aspect of the body
This dot is by default towards the 1’o’clock position of the screen
Bronchoscopy International 32 32 32

33. While the coronal CT view is displayed as if the scope is vertical
cephalad
caudal Ao PA LN
Several adjustments can be made to the coronal CT image in order to bring the
scope to a horizontal position, the green dot cephalad (towards the 1 o’clock position on the screen) to match the EBUS image…
Bronchoscopy International 33 33 33

34. Bronchoscopy International
caudal
cephalad
Aorta
Pulmonary
Artery
Lymph
node
Step by Step
caudal
cephalad
Aorta
Pulmonary
Artery
Lymph
node
caudal
cephalad
Aorta
Pulmonary
Artery
Lymph
node
1. Print out a single frame of the CT image
2. Rotate the CT image clockwise
in order to horizontalize the scope and bring
the green dot cephalad towards the
1 o’clock position.
Bronchoscopy International 34 34 34

35. The two images now correlate and show all structures in the same locations
caudal
cephalad
Aorta
Pulmonary
Artery
Lymph
node LN PA Ao
See how easy it is to identify the anatomic structures now !
This is a characteristic EBUS view of level 4 L
Bronchoscopy International 35 35 35

36. Q3: Identify 4L and surrounding vascular structures using EBUS.
Bronchoscopy.org

37. Characteristic image of lymph node station 4 L
Bronchoscopy.org

38. The lymph node is echogenic (circle) and vascular structures are anechoic (arrows)
Bronchoscopy.org

39. Because the green dot corresponds to the more cephalad, and therefore proximal aspect of the body)…PA
Aorta
Caudal/
distal
Cephalad/
proximal
The vascular structure at approximately 3 o’clock is the Aorta (proximal)
while the vascular structure at 9 o’clock is the Pulmonary artery (distal)
Bronchoscopy.org

40. All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as:
Bronchoscopy International: Practical Approach, an Electronic On-Line Multimedia Slide Presentation. Published 2009 (Please add “Date Accessed”).
Thank you 40
Bronchoscopy.org

41. Prepared with the assistance Septimiu Murgu M. D
Prepared with the assistance Septimiu Murgu M.D., University of California, Irvine
Bronchoscopy.org 41