- •Foreword
- •Preface
- •Contents
- •About the Editors
- •Contributors
- •1: Tracheobronchial Anatomy
- •Trachea
- •Introduction
- •External Morphology
- •Internal Morphology
- •Mucous Layer
- •Blood Supply
- •Anatomo-Clinical Relationships
- •Bronchi
- •Main Bronchi
- •Bronchial Division
- •Left Main Bronchus (LMB)
- •Right Main Bronchus (RMB)
- •Blood Supply
- •References
- •2: Flexible Bronchoscopy
- •Introduction
- •History
- •Description
- •Indications and Contraindications
- •Absolute Contraindications
- •Procedure Preparation
- •Technique of FB Procedure
- •Complications of FB Procedure
- •Basic Diagnostic Procedures
- •Bronchoalveolar Lavage (BAL)
- •Transbronchial Lung Biopsy (TBLB)
- •Transbronchial Needle Aspiration (TBNA)
- •Bronchial Brushings
- •Advanced Diagnostic Bronchoscopy
- •EBUS-TBNA
- •Ultrathin Bronchoscopy
- •Transbronchial Lung Cryobiobsy (TBLC)
- •Therapeutic Procedures Via FB
- •LASER Bronchoscopy
- •Electrocautery
- •Argon Plasma Coagulation (APC)
- •Cryotherapy
- •Photodynamic Therapy
- •Airway Stent Placement
- •Endobronchial Valve Placement
- •Conclusion
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Procedure Description
- •Procedure Planning
- •Target Approximation
- •Sampling
- •Complications
- •Future Directions
- •Summary and Recommendations
- •References
- •4: Rigid Broncoscopy
- •Innovations
- •Ancillary Equipment
- •Rigid Bronchoscopy Applications
- •Laser Bronchoscopy
- •Tracheobronchial Prosthesis
- •Transbronchial Needle Aspiration (TBNA)
- •Rigid Bronchoscope in Other Treatments for Bronchial Obstruction
- •Mechanical Debridement
- •Pediatric Rigid Bronchoscopy
- •Tracheobronchial Dilatation
- •Foreign Bodies Removal
- •Other Indications
- •Complications
- •The Procedure
- •Some Conclusions
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Preprocedural Evaluation and Preparation
- •Physical Examination
- •Procedure-Related Indications
- •Application of the Technique
- •Topical Anesthesia
- •Anesthesia of the Nasal Mucosa and Nasopharynx
- •Anesthesia of the Mouth and Oropharynx
- •Superior Laryngeal Nerve Block
- •Recurrent Laryngeal Nerve Block (RLN)
- •Conscious Sedation
- •Monitored Anesthesia Care (MAC)
- •General Anesthesia
- •Monitoring the Depth of Anesthesia
- •Interventional Bronchoscopy Suites
- •Airway Devices
- •Laryngeal Mask Airway (LMA)
- •Endotracheal Tube (ETT)
- •Rigid Bronchoscope
- •Modes of Ventilation
- •Spontaneous Ventilation
- •Assisted Ventilation
- •Noninvasive Positive Pressure Ventilation (NIV)
- •Positive Pressure Controlled Mechanical Ventilation
- •Jet Ventilation
- •Electronic Mechanical Jet Ventilation
- •Postprocedure Care
- •Special Consideration
- •Anesthesia for Peripheral Diagnostic and Therapeutic Bronchoscopy
- •Anesthesia for Interventional Bronchoscopic Procedures During the COVID-19 Pandemic
- •Summary and Recommendations
- •Conclusion
- •References
- •Background
- •Curricular Structure and Delivery
- •What Is a Bronchoscopy Curriculum?
- •Tradition, Teaching Styles, and Beliefs
- •Using Assessment Tools to Guide the Educational Process
- •The Ethics of Teaching
- •When Learners Teach: The Journey from Novice to Mastery and Back Again
- •The Future Is Now
- •References
- •Interventional Procedure
- •Assessment of Flow–Volume Curve
- •Dyspnea
- •Analysis of Pressure–Pressure Curve
- •Conclusions
- •References
- •Introduction
- •Adaptations of the IP Department
- •Environmental Control
- •Personal Protective Equipment
- •Procedure Performance
- •Bronchoscopy in Intubated Patients
- •Other Procedures in IP Unit
- •References
- •Introduction
- •Safety
- •Patient Safety
- •Provider Safety
- •Patient Selection and Screening
- •Lung Cancer Diagnosis and Staging
- •Inpatients
- •COVID-19 Clearance
- •COVID Clearance: A Role for Bronchoscopy
- •Long COVID: A Role for Bronchoscopy
- •Preparing for the Next Pandemic
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Clinical Presentation
- •Diagnosis
- •Treatment
- •History and Historical Perspectives
- •Indications and Contraindications
- •Benign and Malignant Tumors
- •Tumors with Uncertain Prognosis
- •Application of the Technique
- •Evidence Based Review
- •Summary and Recommendations
- •References
- •12: Cryotherapy and Cryospray
- •Introduction
- •Historical Perspective
- •Equipment
- •Cryoadhesion
- •Indications
- •Cryorecanalization
- •Cryoadhesion and Foreign Body Removal
- •Cryoadhesion and Mucus Plugs/Blood Clot Retrieval
- •Endobronchial Cryobiopsy
- •Transbronchial Cryobiopsy for Lung Cancer
- •Safety Concerns and Contraindications
- •Cryoablation
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Cryospray
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Advantages of Cryotherapy
- •Limitations
- •Future Research Directions
- •References
- •13: Brachytherapy
- •History and Historical Perspective
- •Indications and Contraindications
- •Application of the Technique
- •Evidence-Based Review
- •Adjuvant Treatment
- •Palliative Treatment
- •Complications
- •Summary and Recommendations
- •References
- •14: Photodynamic Therapy
- •Introduction
- •Photosensitizers
- •First-Generation Photosensitizers
- •M-Tetrahidroxofenil Cloro (mTHPC) (Foscan®)
- •PDT Reaction
- •Tumor Damage Process
- •Procedure
- •Indications
- •Curative PDT Indications
- •Palliative PDT Indications
- •Contraindications
- •Rationale for Use in Early-Stage Lung Cancer
- •Rationale
- •PDT in Combination with Other Techniques for Advanced-Stage Non-small Cell Lung Cancer
- •Commentary
- •Complementary Endoscopic Methods for PDT Applications
- •New Perspectives
- •Other PDT Applications
- •Conclusions
- •References
- •15: Benign Airways Stenosis
- •Etiology
- •Congenital Tracheal Stenosis
- •Iatrogenic
- •Infectious
- •Idiopathic Tracheal Stenosis
- •Distal Bronchial Stenosis
- •Diagnosis Methods
- •Patient History
- •Imaging Techniques
- •Bronchoscopy
- •Pulmonary Function Test
- •Treatment
- •Endoscopic Treatment
- •Dilatation
- •Laser Therapy
- •Stents
- •How to Proceed
- •Stent Placement
- •Placing a Montgomery T Tube
- •The Rule of Twos for Benign Tracheal Stenosis (Fig. 15.23)
- •Surgery
- •Summary and Recommendations
- •References
- •16: Endobronchial Prostheses
- •Introduction
- •Indications
- •Extrinsic Compression
- •Intraluminal Obstruction
- •Stump Fistulas
- •Esophago-respiratory Fistulas (ERF)
- •Expiratory Central Airway Collapse
- •Physiologic Rationale for Airway Stent Insertion
- •Stent Selection Criteria
- •Stent-Related Complications
- •Granulation Tissue
- •Stent Fracture
- •Migration
- •Contraindications
- •Follow-Up and Patient Education
- •References
- •Introduction
- •Overdiagnosis
- •False Positives
- •Radiation
- •Risk of Complications
- •Lung Cancer Screening Around the World
- •Incidental Lung Nodules
- •Management of Lung Nodules
- •References
- •Introduction
- •Minimally Invasive Procedures
- •Mediastinoscopy
- •CT-Guided Transthoracic Biopsy
- •Fluoroscopy-Guided Transthoracic Biopsies
- •US-Guided Transthoracic Biopsy
- •Thoracentesis and Pleural Biopsy
- •Thoracentesis
- •Pleural Biopsy
- •Surgical or Medical Thoracoscopy
- •Image-Guided Pleural Biopsy
- •Closed Pleural Biopsy
- •Image-Guided Biopsies for Extrathoracic Metastases
- •Tissue Acquisition, Handling and Processing
- •Implications of Tissue Acquisition
- •Guideline Recommendations for Tissue Acquisition in Mediastinal Staging
- •Methods to Overcome Challenges in Tissue Acquisition and Genotyping
- •Rapid on-Site Evaluation (ROSE)
- •Sensitive Genotyping Assays
- •Liquid Biopsy
- •Summary, Recommendations and Highlights
- •References
- •History
- •Data Source and Methodology
- •Tumor Size
- •Involvement of the Main Bronchus
- •Atelectasis/Pneumonitis
- •Nodal Staging
- •Proposal for the Revision of Stage Groupings
- •Small Cell Lung Cancer (SCLC)
- •Discussion
- •Methodology
- •T Descriptors
- •N Descriptors
- •M Descriptors
- •Summary
- •References
- •Introduction
- •Historical Perspective
- •Fluoroscopy
- •Radial EBUS Mini Probe (rEBUS)
- •Ultrasound Bronchoscope (EBUS)
- •Virtual Bronchoscopy
- •Trans-Parenchymal Access
- •Cone Beam CT (CBCT)
- •Lung Vision
- •Sampling Instruments
- •Conclusions
- •References
- •History and Historical Perspective
- •Narrow Band Imaging (NBI)
- •Dual Red Imaging (DRI)
- •Endobronchial Ultrasound (EBUS)
- •Optical Coherence Tomography (OCT)
- •Indications and Contraindications
- •Confocal Laser Endomicroscopy and Endocytoscopy
- •Raman Spectrophotometry
- •Application of the Technique
- •Supplemental Technology for Diagnostic Bronchoscopy
- •Evidence-Based Review
- •Summary and Recommendations, Highlight of the Developments During the Last Three Years (2013 on)
- •References
- •Introduction
- •History and Historical Perspective
- •Endoscopic AF-OCT System
- •Preclinical Studies
- •Clinical Studies
- •Lung Cancer
- •Asthma
- •Airway and Lumen Calibration
- •Obstructive Sleep Apnea
- •Future Applications
- •Summary
- •References
- •23: Endobronchial Ultrasound
- •History and Historical Perspective
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •Convex Probe Ultrasound
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •CP-EBUS for Malignant Mediastinal or Hilar Adenopathy
- •CP-EBUS for the Staging of Non-small Cell Lung Cancer
- •CP-EBUS for Restaging NSCLC After Neoadjuvant Chemotherapy
- •Complications
- •Summary
- •References
- •Introduction
- •What Is Electromagnetic Navigation?
- •SuperDimension Navigation System (EMN-SD)
- •Computerized Tomography
- •Computer Interphase
- •The Edge Catheter: Extended Working Channel (EWC)
- •Procedural Steps
- •Planning
- •Detecting Anatomical Landmarks
- •Pathway Planning
- •Saving the Plan and Exiting
- •Registration
- •Real-Time Navigation
- •SPiN System Veran Medical Technologies (EMN-VM)
- •Procedure
- •Planning
- •Navigation
- •Biopsy
- •Complications
- •Limitations
- •Summary
- •References
- •Introduction
- •Image Acquisition
- •Hardware
- •Practical Considerations
- •Radiation Dose
- •Mobile CT Studies
- •Future Directions
- •Conclusion
- •References
- •26: Robotic Assisted Bronchoscopy
- •Historical Perspective
- •Evidence-Based Review
- •Diagnostic Yield
- •Monarch RAB
- •Ion Endoluminal Robotic System
- •Summary
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •General
- •Application of the Technique
- •Preoperative Care
- •Patient’s Position and Operative Field
- •Incision and Initial Dissection
- •Palpation
- •Biopsy
- •Control of Haemostasis and Closure
- •Postoperative Care
- •Complications
- •Technical Variants
- •Extended Cervical Mediastinoscopy
- •Mediastinoscopic Biopsy of Scalene Lymph Nodes
- •Inferior Mediastinoscopy
- •Mediastino-Thoracoscopy
- •Video-Assisted Mediastinoscopic Lymphadenectomy
- •Transcervical Extended Mediastinal Lymphadenectomy
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Case 1
- •Adrenal and Hepatic Metastases
- •Brain
- •Bone
- •Case 1 Continued
- •Biomarkers
- •Case 1 Concluded
- •Case 2
- •Chest X-Ray
- •Computerized Tomography
- •Positive Emission Tomography
- •Magnetic Resonance Imaging
- •Endobronchial Ultrasound with Transbronchial Needle Aspiration
- •Transthoracic Needle Aspiration
- •Transbronchial Needle Aspiration
- •Endoscopic Ultrasound with Needle Aspiration
- •Combined EUS-FNA and EBUS-TBNA
- •Case 2 Concluded
- •Case 3
- •Standard Cervical Mediastinoscopy
- •Extended Cervical Mediastinoscopy
- •Anterior Mediastinoscopy
- •Video-Assisted Thoracic Surgery
- •Case 3 Concluded
- •Case 4
- •Summary
- •References
- •29: Pleural Anatomy
- •Pleural Embryonic Development
- •Pleural Histology
- •Cytological Characteristics
- •Mesothelial Cells Functions
- •Pleural Space Defense Mechanism
- •Pleura Macroscopic Anatomy
- •Visceral Pleura (Pleura Visceralis or Pulmonalis)
- •Parietal Pleura (Pleura Parietalis)
- •Costal Parietal Pleura (Costalis)
- •Pleural Cavity (Cavitas Thoracis)
- •Pleural Apex or Superior Pleural Sinus [12–15]
- •Anterior Costal-Phrenic Sinus or Cardio-Phrenic Sinus
- •Posterior Costal-Phrenic Sinus
- •Cost-Diaphragmatic Sinus or Lateral Cost-Phrenic Sinus
- •Fissures18
- •Pleural Vascularization
- •Parietal Pleura Lymphatic Drainage
- •Visceral Pleura Lymphatic Drainage
- •Pleural Innervation
- •References
- •30: Chest Ultrasound
- •Introduction
- •The Technique
- •The Normal Thorax
- •Chest Wall Pathology
- •Pleural Pathology
- •Pleural Thickening
- •Pneumothorax
- •Pulmonary Pathology
- •Extrathoracic Lymph Nodes
- •COVID and Chest Ultrasound
- •Conclusions
- •References
- •Introduction
- •History of Chest Tubes
- •Overview of Chest Tubes
- •Contraindications for Chest Tube Placement
- •Chest Tube Procedural Technique
- •Special Considerations
- •Pneumothorax
- •Empyema
- •Hemothorax
- •Chest Tube Size Considerations
- •Pleural Drainage Systems
- •History of and Introduction to Indwelling Pleural Catheters
- •Indications and Contraindications for IPC Placement
- •Special Considerations
- •Non-expandable Lung
- •Chylothorax
- •Pleurodesis
- •Follow-Up and IPC Removal
- •IPC-Related Complications and Management
- •Competency and Training
- •Summary
- •References
- •32: Empyema Thoracis
- •Historical Perspectives
- •Incidence
- •Epidemiology
- •Pathogenesis
- •Clinical Presentation
- •Radiologic Evaluation
- •Biochemical Analysis
- •Microbiology
- •Non-operative Management
- •Prognostication
- •Surgical Management
- •Survivorship
- •Summary and Recommendations
- •References
- •Evaluation
- •Initial Intervention
- •Pleural Interventions for Recurrent Symptomatic MPE
- •Especial Circumstances
- •References
- •34: Medical Thoracoscopy
- •Introduction
- •Diagnostic Indications for Medical Thoracoscopy
- •Lung Cancer
- •Mesothelioma
- •Other Tumors
- •Tuberculosis
- •Therapeutic Indications
- •Pleurodesis of Pneumothorax
- •Thoracoscopic Drainage
- •Drug Delivery
- •Procedural Safety and Contraindications
- •Equipment
- •Procedure
- •Pre-procedural Preparations and Considerations
- •Procedural Technique [32]
- •Medical Thoracoscopy Versus VATS
- •Conclusion
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Endobronchial Valves
- •Airway Bypass Tracts
- •Coils
- •Other Methods of ELVR
- •Summary and Recommendations
- •References
- •36: Bronchial Thermoplasty
- •Introduction
- •Mechanism of Action
- •Trials
- •Long Term: Ten-Year Study
- •Patient Selection
- •Bronchial Thermoplasty Procedure
- •Equipment
- •Pre-procedure
- •Bronchoscopy
- •Post-procedure
- •Conclusion
- •References
- •Introduction
- •Bronchoalveolar Lavage (BAL)
- •Technical Aspects of BAL Procedure
- •ILD Cell Patterns and Diagnosis from BAL
- •Technical Advises for Conventional TLB and TLB-C in ILD
- •Future Directions
- •References
- •Introduction
- •The Pediatric Airway
- •Advanced Diagnostic Procedures
- •Endobronchial Ultrasound
- •Virtual Navigational Bronchoscopy
- •Cryobiopsy
- •Therapeutic Procedures
- •Dilation Procedures
- •Thermal Techniques
- •Mechanical Debridement
- •Endobronchial Airway Stents
- •Metallic Stents
- •Silastic Stents
- •Novel Stents
- •Endobronchial Valves
- •Bronchial Thermoplasty
- •Discussion
- •References
- •Introduction
- •Etiology
- •Congenital ADF
- •Malignant ADF
- •Cancer Treatment-Related ADF
- •Benign ADF
- •Iatrogenic ADF
- •Diagnosis
- •Treatment Options
- •Endoscopic Techniques
- •Stents
- •Clinical Results
- •Stent Complications
- •Other Available Stents
- •Other Endoscopic Methods
- •References
- •Introduction
- •Anatomy and Physiology of Swallowing
- •Functional Physiology of Swallowing
- •Epidemiology and Risk Factors
- •Types of Foreign Bodies
- •Organic
- •Inorganic
- •Mineral
- •Miscellaneous
- •Clinical Presentation
- •Acute FB
- •Retained FB
- •Radiologic Findings
- •Bronchoscopy
- •Airway Management
- •Rigid Vs. Flexible Bronchoscopy
- •Retrieval Procedure
- •Instruments
- •Grasping Forceps
- •Baskets
- •Balloons
- •Suction Instruments
- •Ablative Therapies
- •Cryotherapy
- •Laser Therapy
- •Electrocautery and APC
- •Surgical Management
- •Complications
- •Bleeding and Hemoptysis
- •Distal Airway Impaction
- •Iron Pill Aspiration
- •Follow-Up and Sequelae
- •Conclusion
- •References
- •Vascular Origin of Hemoptysis
- •History and Historical Perspective
- •Diagnostic Bronchoscopy
- •Therapeutic Bronchoscopy
- •General Measures
- •Therapeutic Bronchoscopy
- •Evidence-Based Review
- •Summary
- •Recommendations
- •References
- •History
- •“The Glottiscope” (1807)
- •“The Esophagoscope” (1895)
- •The Rigid Bronchoscope (1897–)
- •The Flexible Bronchoscope (1968–)
- •Transbronchial Lung Biopsy (1972) (Fig. 42.7)
- •Laser Therapy (1981–)
- •Endobronchial Stents (1990–)
- •Electromagnetic Navigation (2003–)
- •Bronchial Thermoplasty (2006–)
- •Endobronchial Microwave Therapy (2004–)
- •American Association for Bronchology and Interventional Pulmonology (AABIP) and Journal of Bronchology and Interventional Pulmonology (JOBIP) (1992–)
- •References
- •Index
28 Lung Cancer Staging Methods: A Practical Approach |
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Table 28.2 Accuracy of staging tests in lung cancer patients: meta-analysis ACCP guidelines |
|
|||
|
|
|
|
|
Procedure |
Number of studies |
N |
Sensitivity |
Speci city |
Mediastinoscopy |
33 |
9267 |
78 |
100 |
|
|
|
|
|
EUS |
26 |
2443 |
88 |
100 |
|
|
|
|
|
EBUS |
31 |
2756 |
89 |
100 |
EBUS/EUS |
7 |
811 |
91 |
100 |
Endobronchial Ultrasound with Transbronchial Needle Aspiration
Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) utilizes real- time ultrasound to visualize the target lesion within the airway wall/mediastinum and to visualize the biopsy needle itself during biopsy [47]. Not only is EBUS-TBNA used to diagnose and stage advanced lung cancer, but can also provide enough material for molecular analysis for treatable driver mutations [48]. There are two types of EBUS, the radial probe EBUS (RP-EBUS) and the curvilinear probe EBUS (CP-EBUS). RP-EBUS is utilized by passing the probe through the working channel of a bronchoscope and advanced into the airway to obtain a 360-degree grey scale image of the airway and surrounding structures. Unfortunately, the RP-EBUS does not allow for ultrasound guidance biopsy in real time. In comparison, the CP-EBUS has a 35 degrees forward oblique view. The scope is passed directly into the airway and the probe balloon is infated with water to allow contact with the airway wall and conduction of ultrasound waves. This provides a higher resolution image with the ability to perform real-time ultrasound guided biopsies. Color fow and Doppler can also be utilized for identi cation of vascular and cystic structures [49].
The EBUS scope can access a wide range of mediastinal and hilar lymph nodes that include 2R, 2L, 3P, 4R, 4L, 7, 10R, 10L, 11R, 11L (Fig. 28.7). The overall median sensitivity of EBUS-TBNA is reported to be 89% in a systematic review of 2756 patients, with values ranging from 46% to 97%. The median NPV was 91% ( [12], Table 28.2). Most of the studies in the review included patients with bulky lymphadenopathy, mostly radiographic group B and some
A and C. However, two studies evaluated the performance of EBUS-TBNA in patients with a normal mediastinum by CT scan and PET-CT, respectively. The prevalence of mediastinal disease was lower in the negative PET-CT group, likely due to the higher sensitivity of PET-CT to detect disease. Despite this, the negative predictive value was comparable in both groups at around 96% [50, 51].
Navigational and Robotic
Bronchoscopy
Peripheral pulmonary lesions (PPL) frequently pose a dilemma for patients and physicians trying to establish the best strategy for workup. Historically, RP-EBUS and standard bronchoscopy with fuoroscopy have been used to try to biopsy these peripheral lesions. Tanner et al. in a RTC in 2018 compared thin bronchoscopy with radial EBUS (R-EBUS) with standard bronchoscopy and fuoroscopy (SB-F) and found a diagnostic yield of 49% for the R-EBUS arm and 37% for the SB-F arm. This was not statistically signi cant [52].Newer technologies such as virtual bronchoscopic navigation (VBN), electromagnetic navigational bronchoscopy (ENB) and robotic bronchoscopy (RB), facilitates PPL diagnosis by directing a bronchoscope to its intended target via visualized three-dimensional lung models [53].
Virtual bronchoscopy involves two phases, planning phase which uses a CT scan to construct a virtual bronchial tree and the actual bronchoscopy [53]. A prospective, multicenter trial randomized 199 patients to a procedure with or without VBN resulting in a diagnostic yield of 80% for VBN vs. 67% without VBN [54]. Recently, there have been controversies involving utility and yield of VBN. Bo et al. randomized
494 |
T. L. Ferguson et al. |
|
|
1R 1L
|
6 |
Ao |
5 mPA |
3p |
T |
3a |
|
vc |
|
|
|
|
E50 |
|
|
Fig. 28.7 Regional lymph node stations
Supraclavicular zone
1Low cervical, supraclavicular, and sternal notch nodes
SUPERIOR MEDIASTINAL NODES
Upper zone
2R Upper Paratracheal (right)
2L Upper Paratracheal (left)
3a Prevascular
3p Retrotracheal
4R Lower Paratracheal (right)
4L Lower Paratracheal (left)
AORTIC NODES
AP zone
5 Subaortic
6 Para-aortic (ascending aorta or phrenic)
INFERIOR MEDIASTINAL NODES
Subcarinal zone
7 Subcarinal
Lower zone
8 Paraesophageal (below carina)
9 Pulmonary ligament
N1 NODES
Hilar/Interlobar zone
10Hilar
11Interlobar
Peripheral zone
12Lobar
13Segmental
14Subsegmental
subjects to a standard bronchoscopy, RP-EBUS- guided bronchoscopy, or bronchoscopy combining both RP-EBUS and VBN. While both guided bronchoscopy groups were superior to standard bronchoscopy, there was again no difference in diagnostic yield between groups with and without VBN [55].
Electromagnetic navigational bronchoscopy involves generation of an electromagnetic eld around the patient in which devices equipped with small transponders can be tracked [53]. One
RTC looked at three arms, either RP-EBUS, ENB, or a combination of the two. The diagnostic yields were 88% for the combined procedure, 69% for RP-EBUS alone, and 59% for ENB alone [56]. Similar to VBN, there have been conficting data regarding yield of ENB. The results from the AQuIRE registry showed a much lower diagnostic yield of 38.5% with ENB alone and 47.1% with EBN combined with RP-EBUS [57].
Robotic bronchoscopy shows the ability to hold the endoscope in a locked curved position,
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28 Lung Cancer Staging Methods: A Practical Approach |
495 |
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favoring the placement of biopsy tools within the target without straightening during sampling [58]. A recent prospective, multicenter study involving 54 patients from Chen and colleagues showed a diagnostic yield of 74% [59]. Ideally, a prospective, randomized trial or a robust comparison of diagnostic yield will need to be performed before robotic bronchoscopy can become mainstream in diagnosis and staging of lung cancer.
Transthoracic Needle Aspiration
Transthoracic needle aspiration has been utilized by clinicians for decades to biopsy lung lesions and rarely stage the mediastinum. Advances in histopathology and imaging, speci cally the switch between fuoroscopy to CT, have increased the accuracy and ef cacy of TTNA [60]. The procedure involves marking the patient’s skin with radio-opaque markers and then undergoing a short spiral CT for planning of needle trajectory. Once the site and trajectory are selected, the needle passes percutaneously under image guidance to aspirate or biopsy (TTNB) tissue [61]. The pooled sensitivity for TTNA is reported to be 90% in a meta-analysis of 19 studies with a trend toward a lower sensitivity involving lesions <2 cm [62]. Given the proximity of lymph nodes to major thoracic vessels and to heart, TTNA is mostly limited to the superior mediastinal lymph nodes. The most common complication of TTNA is iatrogenic pneumothorax. The incidence of pneumothorax averages approximately 15% and 6.6% requiring chest tube placement for evacuation [63]. These factors limit the use of TTNA in staging the mediastinum and clinicians may have to rely on other biopsy modalities to obtain tissue.
Transbronchial Needle Aspiration
Transbronchial needle aspiration (TBNA) has been utilized for decades to biopsy the mediastinum, but this was initially done through a rigid bronchoscope. The rst use of TBNA through a fexible bronchoscope was introduced in 1983,
but it wasn’t until a year later that Wang and colleagues described the procedure in detail [64]. The procedure involves passing the needle catheter, which comes in different sizes, through the working channel of the bronchoscope and then directed to the target lesion. The needle is then passed through the bronchial wall and material is aspirated for tissue sampling. It can be performed as an unguided procedure during bronchoscopy or under image-guidance using a bronchoscope with endobronchial ultrasound or electromagnetic navigational capability. It is used most commonly to assess subcarinal lymph nodes and less frequently with paratracheal lymph nodes due to dif culty with directing the bronchoscope and the needle toward these lymph nodes. The overall median sensitivity was 78% (range 14%–100%) and the negative predictive value was 77% in a systematic review evaluating 2408 patients [12]. The patients included in the studies mainly had N2/N3 disease. As such, these results can be reliably applied to patients with bulky mediastinal disease; however, the high false negative rates make TBNA less useful for staging the mediastinum in patients with normal sized lymph nodes. A negative TBNA therefore cannot effectively rule out mediastinal nodal involvement and additional staging procedures should be performed. In a comparative study directly evaluating the accuracy of TBNA against the endobronchial ultrasound ne needle aspiration (EBUS-FNA) and endoscopic ultrasound ne needle aspiration (EUS-FNA), TBNA was less sensitive when individually compared to EBUS-FNA and EUS-FNA in identifying mediastinal involvement (36% vs. 69%). Ultrasound guided techniques, such as EBUS-TBNA and EUS-FNA, have largely replaced TBNA and this is due to TBNA having a lower sensitivity than ultrasound guided biopsy techniques [65].
Endoscopic Ultrasound with Needle Aspiration
Endoscopic ultrasound with ne needle aspiration for cytologic diagnosis of pancreatic cancer was rst performed by Peter Vilmann in 1991