EBUS Treatment Details - Dr. Nishtha Singh

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Endo-bronchial ultrasound (EBUS) Bronchoscopy-
from basics and beyond

• Dr Nishtha Singh
• Executive Director Pulmonary Consultant
• Asthma Bhawan, Jaipur

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Over 30 years proven performance
The EBUS Timeline
1992 Radial EBUS was introduced
Convex probe EBUS introduced 2003 First
publication with description Of EBUS-TBNA
principle
2008 EBUS First came in India
2013 International guidelines recommend
EBUS-TBNA as first testing method for lung
cancer
Rajasthan gets its First EBUS at Asthma
Bhawan 2016
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EBUS timeline
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Point

• Should Endobronchial Ultrasound Guide Every
  Transbronchial Needle Aspiration of Lymph Nodes?

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Can we drive our cars on the road with headlights
off at night?
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NO, We would not drive our cars at night without
using the headlights, even on a familiar road or
even after having studied images of that road
carefully.
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Sample by conventional TBNA
Sample by EBUS
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It is time to turn on the lights and be
confident that our chances of safe arrival at the
next destination is 90
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Point

• Should Endobronchial Ultrasound Guide Every
  Transbronchial Needle Aspiration of Lymph Nodes?

Yes
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Moving away from the era of Imagining
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• Who are the right candidates for EBUS?

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Case 1

• 50-year-old female presented with headache and
  chronic non-productive cough

• Transbronchial lung biopsy adenocarcinoma

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Case 2

• 68-year-old man presented with chronic cough

LUL mass 3.5 cm
Subcentimeter 4R node

• Transbronchial lung biopsy adenocarcinoma

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Case 3

• 45-year-old female with abnormal chest X-ray

• Transbronchial lung biopsy adenocarcinoma
• Negative MLN on PET-CT

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MLN staging?
Not required
Case 1
EBUS-TBNA
Case 2
Case 3
Not required
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Mediastinal staging
N1
N2
N3
T
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TNM classification

• 5-year survival

Rami-Porta R, et al. The IASLC lung cancer
staging project 8th edition of TNM
classification. J Thorac Oncol 2014.
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Staging and treatment
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EBUS Procedure
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EBUS Scope
Outer Diameter 6.9mm
Angulation- Up Down 120 70
Forward Oblique view 35
Working Length 600mm
Channel inner diameter 2.2mm
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Balloon ApplicationAir is enemy Water is Friend
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Ultrasound processor

• Adjustable Gain and Depth
• Gain is the degree of brightness with which given
  signal intensity is displayed. Analogous to a
  volume control knob on a stereo.
• Depth- allows optimal display of an area of
  interest on the screen.
• B mode and Doppler capabilities
• B-mode (brightness mode) uses an array of
  transducers to scan a place through the tissue to
  produce a two-dimensional image on the screen.
• Doppler mode measures the velocity of moving
  tissue. It detects blood flow in vessels and
  subsequently superimposes the display over the
  2-D image.

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Needle Gauge 19G/21G/22G
Compatible Channel 2mm
Aspiration port
Scale
Handle section
Insertion portion
Dimple shape for high echogenic reflection
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Preparation of EBUS- Patients
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Anaesthesia

• EBUS-TBNA is performed on an OPD basis under LA
  only or midazolam-induced conscious sedation.
• LA is achieved with 5ml nebulized 2 lidocaine
  solution in the pharynx.
• Oral route preferred.
• ECG, Pulse oximetry, and BP monitoring is
  required with/without the presence of an
  anesthesiologist.

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Anaesthesia and peri-operative care

• General Anaesthesia with LMA
• LMA mask size 4 or 5 required
• Total IV anesthesia with propofol is commonly
  used.
• General Anaethesia with ET tube
• Size 8.5 in women and 9.0 in men
• More difficult to visualize higher nodes
• Indications may include difficult LMA placement,
  obesity

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Subcarina (Station7) Definition based on IASLC
map

• Upper border
• the carina of the trachea
• Lower border
• The upper border of the lower lobe bronchus on
  the left
• The lower border of the bronchus intermedius on
  the right

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LN Characteristics-
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Anatomical landmarks during EBUS
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Insertion of EBUS

• Insertion
• Ballooning
• Searching Target
• Applying needle set
• Needle insertion
• Negative pressure

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• How to take biopsies
• When the target structure is identified, a biopsy
  can be taken.
• Insert the sheet in the operative channel of the
  endoscope and lock it
• Adjust the sheet with the tip a few millimeters
  outside the endoscope
• Move the needle with the stylet a few millimeters
  forward
• Retract the stylet 1 cm to make the needle sharp
• Hit the target
• Reinsert the stylet and then remove it
• Connect the suction to the needle and move it
  back and forth
• Stop moving needle and cease suction
• Retract the needle and make sure the needle is in
  the upper position
• Lock the needle and remove the equipment from the
  endoscope.

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EBUS-TBNA is a boon for mediastinal diagnosis

• Access lymph node stations 1,2,4,7,10,11,12
• Minimal invasive SAFE technique
• Real time procedure
• Doppler mode helps differentiate LN from vessel
• Used for diagnosis and staging

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EBUS
Duration 11 months
No of EBUS 82
No of Lymph node stations sampled 136
No of masses sampled 6
Mean Age(yr) 52.2 (16-85)
MaleFemale 5626
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Experience in our Institute Asthma Bhawan
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Diagnosis of the 82 patients
Malignancy 38(46.3)
Squamous 17
Small cell 10
Adenocarcinoma 7
Non-small cell 4
Inconclusive 17(20.7)
1 to 10 cases 4
ILD 3
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Our experience so far!
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Our experience so far!
Learning Curve
We took consecutive patients of Mediastinal
Adenopathy
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Diagnosis changed
Number of patients Diagnosis before EBUS Diagnosis after EBUS
6 TB Malignancy
4 Sarcoidosis TB
5 TB Sarcoidosis
2 TB/Sarcoidosis Hodgkins Lymphoma
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Case 1- 27 yr female with fever intermittent
since 1 yr
PUO?
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• CT was suggestive of mediastinal lymphadenopathy

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• Bronchoscopy done before was normal.
• The diagnosis of treating physician was of
  Tuberculosis or Sarcoidosis. And he started
  patient on ATT.
• After 1 month, patient came to us.

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• EBUS was done.
• Results????

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EBUS-TBNA s/o Reed sternberg like cells
Cytology showed Hodgkins lymphoma.
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Is there a role of EBUS-TBNA in Lymphoma?
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Is there a role of EBUS-TBNA in Lymphoma?

• Current guidelines though do not recommend use of
  EBUS-TBNA1
• HOWEVER recent evidence suggest sensitivity
  38-91 and specificity 1002,3
• Core biopsy can be obtained through 21G needle
  and specimen can be examined for HPE and IHC
• 1. British Thoracic Society guideline for
  advanced diagnostic and therapeutic flexible
  bronchoscopy in adults. Thorax 201166(Suppl
  3)iii1-21.  
• 2. Kheir F. Endosc ultrasound 2016543-8
• 3. Ko et al. Diagn Cytopathol 2013411023-30.

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Core biopsy
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Our experience with Lymphoma
No. of Patients
No of Patients 4
MF 22
Mean age 52.5
Lymph node station 7 4R 3 3
Diagnosis before TB/Sarcoidosis
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Case2- Unexplained cough?

• A 66 year old male presented with cough for 6
  months.
• He was taking anti tubercular treatment for last
  2 months.
• CT chest showed mediastinal adenopathy at 7 and
  4R lymph nodes.

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• Bronchoscopy was normal.

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• EBUS- TBNA was done.
• Proved to be Squamous cell Carcinoma.

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Case3- Can EBUS change treatment plan?

• 65 year old male with c/o
• Difficulty in breathing and cough since 6 months
• He received radiotherapy for squamous cell
  carcinoma mouth in 2008

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• Bronchial biopsy NSCC
• EBUS-TBNA (7) metastatic carcinoma
• EBUS-TBNA (4R) metastatic carcinoma

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IASLC 7th edition (2010)
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UNRESECTABLE
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Case 4-52 year old male with c/o cough and
dyspnoea since 2 months
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EBUS TBNA s/o non-necrotizing granulomatous
lymphadenitis
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Role of EBUS-TBNA in Sarcoidosis?
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Case5- Are we giving the right Treatment? No
Response with ATT?

• 15 year old male with c/o
• ?appetite, loss of weight since 3 months
• Past h/o
• ATT since 6months since Sep2015 Mar2016

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EBUS-TBNA s/o caseating granulomatous
lymphadenitis
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Case6- Normal reports?

• 50 y old male presented with
• Cough 6m
• Decreased appetite and weight loss 6m
• Sputum AFB- negative
• Mantoux test - negative

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4L
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EBUS-TBNA

• Cytopathology Benign lymphoid hyperplasia
• GeneXpert MTB detected with NO RIFAMPICIN
  resistance

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Role of EBUS-TBNA in tuberculosis?
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Tuberculosis

• What should the sample be sent for?

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Tuberculosis

• What should the sample be sent for?
• Cytopathology
• AFB smear
• GeneXpert MTB / Rif resistance
• TB-PCR
• Mycobacterial culture sensitivity

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Complications of EBUS

• Safe in 98 cases

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Complications of EBUS
Prophylactic antibiotics in patients with pus
aspirated on FNA

• Fever
• Cough
• Mediastinal abscess
• Mediastinal emphysema
• Pericarditis
• Sepsis
• Needle breakage
• Lung abscess
• Empyaema
• Bleeding, hypotension, death
• Complications due to anaesthesia

Reported in literature
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Procedure
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• EBUS TBNA Game changer in diagnosis treatment
  of mediastinal lymphadenopathy

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Thank you