A Guide to Endobronchial and Endoscopic Ultrasound (EBUS and EUS) for Thoracic Radiologists.

Transcription

1 A Guide to Endobronchial and Endoscopic Ultrasound (EBUS and EUS) for Thoracic Radiologists. AP Barker 1, S Karia 1, NR Carroll 1,2, RC Rintoul 2, J Herre 1, EM Godfrey 1, S Ramasundara 1, JL Babar 1 ; 1 Addenbrooke's hospital, Cambridge, United Kingdom. 2 Papworth hospital, Cambridge, United Kingdom. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

2 Relevant financial disclosures None for presenting authors Papworth Hospital EBUS course is supported by Olympus KeyMed Ltd A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

3 Overview Introduction to EBUS and EUS The IASLC lymph node map and lymph nodes stations that can be reached using EBUS/EUS EBUS/EUS and lung cancer staging Cases Malignancies other than lung cancer Non-neoplastic pathologies Summary References A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

4 Endobronchial Ultrasound (EBUS) and Endoscopic Ultrasound (EUS) EBUS and EUS are minimally invasive techniques that use ultrasound along with a bronchoscope (EBUS) or endoscope (EUS) to visualize the airway wall or oesophagus and structures adjacent to it. Balloon. Can be used to improve contact with the wall of the bronchus Ultrasound probe Ultrasound probe Endoscope Sampling needle Sheath Bronchoscope EBUS scope. This is a linear scope. Radial scopes can also be used but are outside the remit of this presentation. The EBUS scope is sometimes used in the oesophagus (EUS B). EUS scope. Linear scope. Larger bore than the EBUS probe. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

5 Technique Ideally patient should be able to lie prone. EBUS and EUS are usually performed under moderate sedation. Our centre uses an opioid and benzodiazepine to achieve this (Fentanyl and Midazolam). Deep sedation with continuous infusions of anaesthetic agents (Propofol) may also be used. Trans bronchial and oesophageal needle biopsies are obtained using 19-22G needles. Trans-bronchial needle aspirate (TBNA) with EBUS and fine needle aspirate (FNA) with EUS. At each biopsy site several needle passes are usually performed. Samples are sent for histopathological analysis. Some centres have a pathology service in the procedure room/suite (ROSE Rapid On- Site Evaluation). A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

6 Quality of images Images ideally saved to PACS, or printed out from the scope stack Videos saved to PACS demonstrate Probe Ultrasound characteristics of lesion Anatomical associations to the region being sampled Node Evidence of vascular involvement Useful to assist MDT discussion A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

7 Optimising sampling EBUS and EUS have excellent diagnostic sensitivity for most pathologies. Optimal number of samples per biopsy site appears to be 3 (1,2) Although samples are fine needle aspirates they produce multiple microcores and can be handled by the pathologists as histology samples Newer needles up to 19G can produce larger samples, although there are no good quality studies that prove this increases diagnostic yield. There is work demonstrating that EBUS-TBNA is safe and effective for diagnosis of lymphoma (3) In the era of molecular testing EBUS practitioners may also consider extra samples in patients with advanced disease for personalised medicine e.g. EGFR, PD-L1, ALK testing A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

8 Reaching the Nodal Stations the IASLC map RadioGraphics,. Published A Guide in: 6/14/2017 Ahmed to H. EBUS El-Sherief; and Charles EUS T. Lau; for Carol Thoracic C. Wu; Richard Radiologists. L. Drake; Gerald WCTI F. Abbott; 2017 Thomas W. Rice; RadioGraphics , 34, DOI: /rg by the Radiological Society of North America, Inc.

9 IASLC Nodal Stations: Station 2 2R 2L 2R: Thoracic inlet to Inferior margin of the brachiocephalic vein 2L : Thoracic inlet to superior border of the aortic arch. It is important to remember that 2R extends to the left lateral border of the trachea, not the midline. These stations can usually be reached using both EBUS and EUS. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

10 IASLC Nodal Stations: Station 4,5,6 4R 4L 6 5 4R 4R 6 4L- Extends inferiorly to the upper border of the left main pulmonary artery 4R - Inferior extent is the lower border azygos vein Station 4 nodes are a common drainage pathway for lung pathology. They can usually be sampled using both EBUS and EUS. Station 5 can often be sampled, but station 6 nodes are usually not amenable to TBNA as they are on the other side of the aorta. Often the vessel acts as an acoustic window so nodal morphology can be observed. There are case reports of trans-aortic sampling of these nodal stations (5), but this is not a common procedure! A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

11 IASLC Nodal Stations: Stations 7, 8, 10, 11 3A 10R 7 10L 8 11L 7- subcarinal nodes. Station 7 is very commonly sampled using either EBUS or EUS. Station 10 is hilar to the take off of the upper lobe bronchus, 11 is distal to the LUL bronchus. The hilar stations are usually only amenable to EBUS TBNA. Station 8 is paraoesophageal below the carina and is assessed with EUS. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

12 IASLC Nodal Stations: Stations 9 and L 9 - inferior pulmonary vein to the diaphragm. This station is assessed and sampled using EUS. Station 12 is subsegmental and is usually too far distal to sample with EBUS. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

13 Patient limitations for EBUS/EUS Although most patients are suitable, there are some limitations for EBUS/EUS: Patients with previous oesophageal surgery or pharyngeal pouch are higher risk for perforation with EUS. Poor lung function. On CT, it is important to comment on the degree of emphysema or fibrosis. Even with relatively poor lung function the patient may be amenable to EUS using the EBUS scope in the oesophagus, since this scope is narrower caliber than the EUS scope it is often better tolerated. However, in patients with very poor lung function it should be considered what further assessment is hoping to achieve. Other comorbidities which make sedation difficult e.g. alcohol excess, drug use. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

14 EBUS/EUS complications Mostly similar to those associated with standard bronchoscopy or endoscopy cough, hypoxaemia, postprocedure pyrexia Case reports of pneumothorax, airway injury, lung abscess, mediastinitis, haemopneumomediastinum, occasional mortality Generally complications are rare and large retrospective reviews show low complication rates of % (6, 7) A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

15 Staging literature In 2010 the ASTER randomised trial proved that EBUS was as effective as mediastinoscopy (8) and is reflected in the ACCP, NICE and ESTS guidelines, which recommend minimally invasive needle techniques are the tests of first choice to stage the mediastinum (9,10,1). Since then, prospective controlled trials are scarce, but in 2011 Yasufuku et al also demonstrated that EBUS-TBNA and mediastinoscopy achieve similar results for the mediastinal staging of lung cancer and suggested that EBUS-TBNA can replace mediastinoscopy in patients with potentially resectable non-small cell lung cancer (12). Another prospective study from Korea in 2015 showed the diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (NPV) of EBUS-TBNA on a perperson analysis were 88.0%, 100%, 92.9%, 100%, and 85.2%, respectively (13). In this study EBUS- TBNA was superior to mediastinoscopy in these terms. The ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer recommend that it is possible to visualize and sample lymph nodes with a short axis of >5 mm and the optimal number of aspirations per station is 3 (1) Evidence of efficacy of EBUS/EUS is demonstrated in meta-analyses from 2009 and 2013 (6, 11) involving 1299 and 1066 patients respectively. Both studies demonstrated a pooled sensitivity of >/= A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

16 Lung Cancer Common pathway: Routine staging CT performed +/- PET CT (especially in early stage lung cancer) +/- EBUS/EUS Staging the T Staging the N Staging the M (liver, adrenal, coeliac axis) A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

17 Staging the T Medial primary lesions can be directly sampled Heterogeneous mass EUS provided diagnostic material and staging information A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

18 Staging the N Guidelines state full staging necessary (1,6) Nodal morphology better assessed than on CT Case: A 32 yo woman presented with iliac DVT. Small nodes on CT showed increased uptake on PET, they were assessed with EBUS and EUS and proved to be metastatic lung cancer Iliac vein thrombus Lung primary Sampled nodes A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

19 Staging the M The left adrenal is a common site for lung cancer metastasis. The adrenal can usually be assessed with EUS or EUS-b (EBUS scope in the oesophagus) and sampled with FNA. Coeliac axis nodes and the liver can also be assessed for metastases with EUS. Sometimes the right adrenal can also be assessed, but this is more difficult due to its anatomical relation to the stomach. Left adrenal mass on staging CT. EUS-FNA confirmed this was a metastasis from a primary lung tumour. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

20 Malignancies other than lung cancer Nodes Case: confirmed with EUS biopsy A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

21 Metastases Case 1: Paraoesophageal and subcarinal nodal masses. EUS FNA demonstrated metastatic Malignant melanoma confirmed with EUS Case 2: Single enlarged 4R node with central low attenuation. EBUS-TBNA proved A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

22 Lymphoma Case: Large mediastinal/hilar mass. EUS demonstrated. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

23 Bulky mediastinal disease Case: EUS needle aspirate demonstrated A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

24 Non-neoplastic Pathologies EBUS and EUS are often used to assist diagnosis in cases where there is uncertainty. The following slides demonstrate some cases where the differential was neoplastic, but the true diagnosis was not. These techniques are also useful to fully assess mediastinal abnormalities and examine their anatomical locations or associations more closely than is possible with CT. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

25 Infection Case: A 47 yo female with weight loss and cough. EBUS-TBNA proved her widespread mediastinal lymphadenopathy was due to A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

26 Sarcoid Low attenuation nodes in this case were proven to be sarcoid nodes With or without parenchymal disease, the differential for sarcoid can be difficult. EBUS and EUS provides a reliable way to biopsy these nodes as they allow multiple TBNA/FNA from each node and can give a good volume of representative tissue. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

27 Sarcoid-like reaction Case: Rectal tumour. Staging CT demonstrated widespread mediastinal lymphadenopathy. EUS FNA confirmed sarcoid-like reaction A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

28 Assessment of mediastinal mass Case: A 50 old female investigated for cough. Mediastinal mass on CT. MRI was equivocal as the abnormality contained a high concentration of proteinaceous fluid. EUS confirmed alleviating need for concern. No biopsy was performed as there is a risk of infection and no potential for malignant transformation A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

29 Ectopic parathyroid Case: A 46 yo male with hypercalcaemia. CT was performed to search for ectopic parathyroid. needle parathyroid EUS FNA confirmed the abnormality was rather than a node A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

30 Summary of Radiological evaluation If considering referral for EBUS/EUS: Size no minimum, but should be commented upon. Targets of 4 mm can be sampled by an experienced operator. Location IASLC nodal stations Attenuation low attenuation can indicate necrotic nodes Anatomical location and relation to other structures access to the CT imaging during the EBUS/EUS procedure essential for guidance. Helpful to review CT imaging at MDT to decide which targets to assess. A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

31 References and Suggested Reading 1. De Leyna P, Doomsb C, Kuzdzalc J, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. European Journal of Cardio- Thoracic Surgery 2014, Riviera MP et al. Establishing the diagnosis of lung cancer. Diagnosis and management of lung cancer, 3 rd edition: American College of Chest Physicians evidence-based clinical practice guidelines. Chest (2013) 3. Moonim MT, Breen R, Fields PA, Santis G. Diagnosis and subtyping of de novo and relapsed mediastinal lymphoma by endobronchial ultrasound needle aspiration. Am J Respir Crit Care Med Nov 15;188(10): Ahmed H. El-Sherief; Charles T. Lau; Carol C. Wu; Richard L. Drake; Gerald F. Abbott; Thomas W. Rice; RadioGraphics 2014, 34, Radiological Society of North America, Inc. 5. Von Barthled MB, Rabe KF, Annema JT; Transaortic EUS-guided FNA in the diagnosis of lung tumours and lymph nodes. Gastrointest Endosc (2): Gu P, Zhao YZ, Jiang LY et al. Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer May;45(8): Eapen GA, Shah AM, Lei X et al. Complications, consequences and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuiRE registry. American College of Chest Physicians Quality Improvement Registry, Education.. Chest Apr;143(4): Annema JT, van Meerbeeck JP, Rintoul RC et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA Nov 24;304(20): Silvestri GA, Gonzalez AV, Jantz MA et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest May;143(5 Suppl):e211S-50S. 10. The Diagnosis and Treatment of Lung Cancer (Update). National Collaborating Centre for Cancer (UK). Cardiff (UK): National Collaborating Centre for Cancer (UK); 2011 Apr. 11. Dong X, Qui X, Liu Q, Jia J. Endobronchial ultrasound-guided transbronchial needle aspiration in the mediastinal staging of non-small cell lung cancer: a meta-analysis. Ann Thorac Surg Oct;96(4): Yasufuku K, Pierre A, Darling G et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg Dec;142(6): Um SW, Kim HK, Jung SH et al. Endobronchial ultrasound versus mediastinoscopy for mediastinal nodal staging of non-small-cell lung cancer. J Thorac Oncol Feb;10(2): A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI

32 Presenting author Allanah Barker Specialty Registrar in Chest Radiology Cambridge University Hospitals NHS Foundation Trust Addenbrooke s Hospital Hills Road Cambridge, UK allanah.barker@addenbrookes.nhs.uk A Guide 6/14/2017 to EBUS and EUS for Thoracic Radiologists. WCTI