Endobronchial Ultrasound-Guided

Transbronchial Needle Aspiration

(EBUS-TBNA)
34th Congresso Brasileiro de Pneumologia e
Tisiologia
Brasilia, Brazil, 2008
Henri Colt MD
University of California, Irvine
hcolt@uci.edu

Objectives
Role of nodal staging in nonsmall
cell lung cancer
Invasive and noninvasive modalities
EBUS principles, technique and
instrumentation
EBUS and CT, EBUS and PET, EBUS
and mediastinoscopy
EBUS: new developments

Background

Non-small cell lung cancer (NSCLC) the leading

cause of death from malignant diseases
worldwide despite advances in surgical and
multimodality treatment.
Accurate staging of the disease is mandatory
not only to determine the prognosis but also to
decide the most suitable treatment plan.
The most significant treatment decision is
identifying patients who can benefit from
surgical resection.
3

Background

The presence of lymph node metastasis

remains one of the most adverse factors
for prognosis in NSCLC

The presence of mediastinal lymph node

involvement indicates the presence of
stage IIIA or IIIB, which suggests either
inoperability and/or the need for treatment
by chemotherapy and/or radiotherapy
4

Survival based on nodal invasion

Staging N factor

Non-invasive staging (Imaging)

CT, MRI, PET, PET-CT, EBUS, EUS

Invasive staging (Sampling)

Surgical open biopsy (Med, VATS)
Needle Biopsy (TBNA, TTNA, EUSFNA)
6

Staging N factor - Needle

biopsy
Transthoracic Needle Aspiration
Performed by interventional radiologists
CT or fluoroscopic guidance
High sensitivity in enlarged nodes 91%
Low false negative rate 20-50%
High incidence of pneumothorax 5-60%
Implantation rare but possible
Chest. 2003; 123: 157-66
Radiol. Clin. North Am. 2000;
38: 525-34
Cardiovasc. Intervent. Radiol.
1991; 14: 17-23
8
Clin. Chest Med. 1993; 14: 99-

Staging N factor - Needle

biopsy
EUS-FNA

Only modality for #8, #9 LN

Limited to left paratracheal
Sensitivity 81-97%
Specificity 83-100%
Major drawback high false negative rate

Ann. Surg. 2003; 238: 180-8

Chest. 1990; 98: 586-93
Endoscopy. 1994; 26: 784-7
Ann. Thorac. Surg. 1996; 61: 1441-5
Chest. 2000; 117: 339-45
Lung Cancer. 2003; 41: 259-67
9
Am. J. Respir. Crit. Care Med. 2003;

TBNA Different Methods

Conventional TBNA
CT guided TBNA
Electromagnetic Navigation guided TBNA
Ultrasound guided TBNA
1) Radial Probe guided
2) Convex Probe guided (real time)
EBUS-TBNA
10

Conventional TBNA

Sensitivity 14-91% (operator dependent)

Failure to place needle directly into LN
Depends on LN size and station
High false negative rate

Chest. 1983; 84: 571-6

Chest. 1989; 96: 1228-32
Am. Rev. Respir. Dis. 1986; 134: 1468
Chest. 2003; 123: 157-66

11

CT guided TBNA

High yield 83-88%

Requires use of CT suite (costly)
Radiation exposure (both Pt and operator)
Confirmation of needle outside of LN (42.1%)

Chest. 1998; 114: 36-9

Chest. 2000; 118: 1630-8
Chest. 2001; 119: 329-32
Radiology. 2000; 216: 764-7

12

13

Navigational
TBNA

14

Navigational TBNA

Return on
investmen
t ??

15

EBUS-TBNA

Fairly new diagnostic procedure (1999)

-2002: convex probe (real-time guidance)

Originally developed for lymph node

staging
Other diagnostic uses

Intrapulmonary tumors
Unknown hilar or mediastinal LAD
Mediastinal tumors
16

Medium
A

Ultrasound Transducer

2
4

2
4

D
2

Ultrasound Image
Tissue density
Acoustic
impedence

Angle of probe with

target tissue

17

Angle of
examinatio
n and angle
of insertion
will be
important

18

Endobronchial Ultrasound:
principles

piezoelectric
crystal
standard
frequency for
EBUS is

6.9 mm

20 MHz (radial)
7.5 MHz (convex)

19

The Processor

20

Physics

Definition: wave length

US > 20 KHz
Diagnostic 2-20 Mhz
Chest US: 3-5 MHz
EBUS:

penetration

resolution

20 MHz
7.5 MHz
21

EBUS-TBNA

Linear curved
transducer
Images obtained by
attaching a balloon and
inflating with normal
saline
Image is processed

Lesions can be measured

Images can be frozen
Doppler mode

22-gauge needle

Internal sheath

22

EBUS-TBNA

23

Use of Doppler demonstrates

blood flow

24

Needle
insertion

25

Example EBUS-TBNA level R10

node

VIDEO

26

EBUS-TBNA

All mediastinal
lymph nodes
accessible
except:

Subaortic

(5 and 6)

Paraesophageal

(8 and 9)

Gen Thorac Cardiovasc Surg (2008) 56: 268-276

27

Results of EBUS

METHODS: This was a retrospective

analysis of 152 consecutive patients who
underwent EBUS-TBNA with undiagnosed
intrathoracic adenopathy or cancer
staging as the primary indications.

The procedures occurred between January

2005 and June 2006 at a single academic
medical center. Of the 152 patients.
117 were included in the final statistical
analysis after excluding those with benign
disease diagnosed by
EBUS-TBNA. Rapid on-site cytopathologic
examination was used in all cases.

Vincent BD, Ann Thorac Surg. 2008

28

Real-time endobronchial ultrasoundguided transbronchial lymph node

aspiration.

RESULTS: Malignancy was identified in 113 patients, of

which 67 (59.3%) had non-small cell lung carcinoma, and
20 (17.7%) underwent surgical resection.

Four patients had benign diagnoses at surgical pathology. Only 1

surgical patient was found to have nodal metastasis at a lymph
node station previously biopsied by EBUS-TBNA (negative
predictive value, 97%).
Compared with radiologic staging, EBUS-TBNA down-staged
18 of 113 (15.9%) and up-staged 11 (9.7%). Sensitivity was
98.7%, with 100% specificity. No major complications were
associated with the procedure.

CONCLUSIONS: EBUS-TBNA is useful in accessing

mediastinal and hilar lymph nodes for the diagnosis and
staging of non-small cell lung cancer and other disorders
of the mediastinum. Thoracic surgeons and
pulmonologists are well positioned to use this tool in
everyday practice.

Vincent BD, Ann Thorac Surg. 2008

29

Minimally invasive endoscopic

staging of suspected lung cancer

Comparison of the diagnostic accuracy of 3

methods of minimally invasive endoscopic
staging (and their combinations):

traditional transbronchial needle aspiration

(TBNA)
endobronchial ultrasound-guided fine-needle
aspiration (EBUS-FNA)
transesophageal endoscopic ultrasound-guided
fine-needle aspiration (EUS-FNA)

Wallace MB, et al, JAMA. 2008

30

Minimally invasive endoscopic

staging of suspected lung cancer

138 patients:

42 (30%) had malignant lymph nodes.

EBUS-FNA: more sensitive than TBNA,
detecting 29 (69%) vs 15 (36%) malignant
lymph nodes (P = .003).
EUS plus EBUS: higher estimated sensitivity
(93% [39/42]; 95% confidence interval, 81%99%) and negative predictive value (97%
[96/99]; 95% confidence interval, 91%-99%)
compared with either method alone.

Wallace MB, et al, JAMA. 2008

31

Minimally invasive endoscopic

staging of suspected lung
cancer

EUS plus EBUS

higher

sensitivity and higher negative

predictive value for detecting lymph
nodes in any mediastinal location and for
patients without lymph node enlargement
on chest computed tomography

EBUS-FNA
higher

sensitivity than TBNA

Wallace MB, et al, JAMA. 2008

32

Conclusion

EUS plus EBUS

may

allow near-complete minimally

invasive mediastinal staging in patients
with suspected lung cancer
may be an alternative approach for
mediastinal staging in patients with
suspected lung cancer

33

1<2<3
Conventional TBNA
EBUS OR EUS guided
TBNA
EBUS AND EUS guided
TBNA
Multidisciplinary lung cancer
groups evaluates patients based on
disease process rather than on
medical/surgery specialty ???

34

Lung CA Staging: overview

ACCP Invasive mediastinal staging

2002: Revised 4 years later

Highlights

Extensive mediastinal infiltration

Discrete mediastinal lymph node enlargement

Invasive staging not needed

Staging by CT or PET not sufficient
Invasive staging required
Normal sized lymph nodes -> mediastinoscopy

Clinical N1 (Stage II) or central tumor

Mediastinoscopy
EBUS is an accepted alternative
Chest 2007; 132; 202-220

35

Lung CA Staging: overview

ACCP Invasive mediastinal staging

PET positive LAD in Stage I

Invasive staging is required
EBUS alternative

Overall
EBUS-TBNA is reasonable as long as
nondiagnostic results are followed by
Mediastinoscopy
Mediastinoscopy is still the Gold Standard
Still no study that directly compares
mediastinoscopy to EBUS-TBNA

Chest 2007; 132; 202-220

36

Comparisons: Different
modalities

37

Endobronchial Ultrasound:
clinical applications

guidance of
mediastinal
lymph node
biopsies

(J Bronchol 2006;13:8491)
Herth FJ et al. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.
Chest 2003;123:604 7.
38

Review of the literature: EBUS

and
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.

Conventional TBNA
EUS and TBNA
Conventional mediastinoscopy
PET and CT
PET
Guiding bronchoscopic therapies
Lymph node size
Metastatic lung tumors
Normal mediastinum CT negative, and PET
negative
CT, PET and surgical staging gold standard
39

1. EBUS and TBNA

CHEST 2004; 125:322325

40

2. EBUS and EUS

Am J Respir Crit Care Med Vol 171. pp 11641167, 2005

41

EBUS, TBNA, and EUS

42

3. EBUS vs.
mediastinoscopy
EBUS-TBNA

502 patients
572 Lymph nodes

Mediastinoscopy to confirm biopsy

Nodes (2l, 2r, 3, 4r, 4l, 7, 10r, 10l, 11r, and 11l)
Mean diameter 1.6 (range.8-4.3)
535 resulted in diagnosis (94%)
Sensitivity 94%
Specificity 100%
PPV 100%

Recorded no complications

Herth et. al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling
43
mediastinal lymph nodes. Thorax 2006 61; 795-798

4. EBUS vs CT, TBNA, and PET

Comparison of EBUS-TBNA, PET, and CT

CT scan: lymph nodes positive if > 1cm

PET scan: lymph nodes positive if uptake >2.5
EBUS-TBNA: lymph nodes >5mm

Results

280 patients evaluated

102 patients met criteria
Underwent CT and PET
EBUS-TBNA

147 mediastinal and 53 hilar nodes

Surgical histology was then used for comparison

Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung
44
Cancer. Chest 2006; 130:710-718

EBUS and Staging

CT
PET
EBUSTBNA

Sensitivity Specificity Diagnosit

c
Accuracy
76.9%
55.3%
60.8%
80%
70.1%
72.5%
92.3%
100%
98%

Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung
45
Cancer. Chest 2006; 130:710-718

Size of PET negative nodes impacts probability

of malignancy
Mediastinal lymph nodes and relation with metastatic
involvement: a Metanalysis
Langen et al, Eur J Cardiothorac Surg 2006;29:26-29

Probability for malignancy in lymph nodes

measuring 10-15 mm in the short axis is 29%,and
about 60% if nodes are larger.
If nodes 10-15 mm and PET Negative, probability
for malignancy is 5%.

Refrain from mediastinoscopy

If nodes > 16 mm and PET Negative, probability

for malignancy is 21%.

Proceed with mediastinoscopy

46

5a. EBUS and PET positive nodes

Performance of TBNA using linear

EBUS (real-time EBUS-TBNA) under
local anaesthesia and the value of PET
for prediction of pathological results
were assessed
Number of eluded surgical procedures
was evaluated

Bauwens O, et al, Lung Cancer 2008

47

EBUS and PET positive nodes in lung

cancer

106 Patients with suspected/proven lung

cancers and FDG-PET positive mediastinal
adenopathy
Av. # of TBNA samples/patient: 4.9+/-1.1
Prevalence of lymph node metastasis58%.
Results of EBUS-TBNA staging of
mediastinal hot spots:

95% sensitivity, 97% accuracy, 91% negative

predictive value.

Bauwens O, et al, Lung Cancer 2008

48

Conclusion

Surgical procedures

eluded in 56% of the patients

Real-time EBUS-TBNA

should be preferred over

mediastinoscopy as first step procedure
in staging of PET mediastinal hot spots
in lung cancer patients

Bauwens O, et al, Lung Cancer 2008

49

5b. EBUS and PET positive

mediastinal lymph nodes

diagnostic/staging yield of TBNA

following EBUS localization was
assessed
number of avoided surgical
procedures was evaluated
33 patients referred for staging
and/or diagnosis of mediastinal FDGPET positive lesions

Plat G, et al, Eur Respir J. 2006

50

EBUS and PET positive mediastinal

lymph nodes

TBNA sampling of lymph nodes

Cytological or histological diagnoses

performed after EBUS localisation

Av. number of TBNA samples/pt: 4.2+/-1.5.
obtained in 27 (82%) of the patients, of
which 78% were obtained after previous
EBUS localization

In 25 (76%) of the 33 patients, surgical

staging procedures were suppressed .

Plat G, et al, Eur Respir J. 2006

51

Conclusion

TBNA after EBUS localization

should be considered as a primary

method of evaluation of lymph nodes
positive by PET scan
may replace the majority of surgical
mediastinal staging/diagnostic
procedures.

Plat G, et al, Eur Respir J. 2006

52

6. EBUS guiding bronchoscopic

interventions
Bronchial wall invasion

Tumor Invasion
3-7 echo layers
EBUS: more sensitive
than CT for assessing
bronchial wall invasion
105 patients
EBUS: sensitivity of
89% and a specificity
of 100%
CT: sensitivity of 75%
and a specificity of
28%

Kurimoto N et al.
(CHEST 1999;
115:15001506)
Courtesy of N Kurimoto, Kawasaki, Japan

Herth F, Ernst A, Schulz M, Becker H. Endobronchial ultrasound reliably differentiates between airway
53
infiltration and compression by tumor. Chest 2003;123:45862.

Bronchial wall invasion

Selecting Therapy

EBUS to select patients with biopsy proven

squamous cell carcinoma (or CIS) for PDT
9 of 18 lesions confirmed as local disease (not
extending through the cartilage) were treated
with PDT
100% were considered to have complete
response on follow-up after a median of 32
months
6 of the 9 lesions diagnosed as extracartilaginous with EBUS underwent surgical
resection
The depth of tumor invasion was identical on
EBUS and histologic exam
Am J Respir Crit Care Med 2002; 165:8327.

54

EBUS and palliative bronchoscopic

treatments

N= 1,174 over a three year period

mechanical tumor debridement, stent
placement, Nd:YAG laser, APC,
brachytherapy, foreign body, ELC therapy
EBUS was found to guide or change
management in 43%

selecting proper stent size

guiding tumor debridement
selecting patients for endoscopic therapy
versus surgical therapy

Eur Respir J 2002;20:118 21.

55

7. EBUS and Lymph Node

Size
EBUS-TBNA for nodes < 1cm

Patients then had surgical staging

119 lymph nodes

Nodes (2r, 2l, 4r, 4l, 7, 10r, 10l, 11r, and 11l)

4-10 mm (mean 8.1mm)

Sensitivity 92.3%
Specificity 100%
Malignancy in 19pts by EBUS, but missed 2

Of note

3 patients: N0 -> N3
13 patients: N2 -> N3

Herth et al. Endobronchial ultarasound-guided transbronchial needle aspirationof lymph nodes in the
radiologically normal mediastinum. Eur Respir J 2006; 28: 910-914

56

8. EBUS TBNA and lymph nodes: selection

of surgical candidates with metastatic lung
tumors

Patients with metastatic lung tumors with

radiologically defined mediastinal and/or
hilar lymph nodes on chest computed
tomographic scans
Retrospective.
Successful lymph node aspiration was
evidenced by the presence of malignant
cells or normal lymphocytes.
Cytologic and histologic analysis was used
to confirm metastasis in surgically
resected specimens unless metastasis was
proven by EBUS-TBNA.

Nakajima T, J Thorac Cardiovasc Surg.

2007 Dec

57

EBUS TBNA and lymph nodes: selection of

surgical candidates with metastatic lung
tumors

RESULTS: A total of 106 patients were referred

for metastasectomy

EBUS-TBNA was performed in 60 lymph nodes (37

mediastinal and 23 hilar nodes) from 43 patients.
Cytologic and/or histologic samples were diagnostic in
41 (95.3%). EBUS-TBNA detected metastasis in 23.
The sensitivity, specificity, and diagnostic accuracy
rate of EBUS-TBNA for diagnosis of mediastinal and
hilar lymph node metastasis were 92.0%, 100%, and
95.3%,.

CONCLUSIONS: EBUS-TBNA highly sensitive for

the evaluation of mediastinal and hilar lymph
node metastasis in patients with metastatic lung
tumors.

Nakajima T, J Thorac Cardiovasc Surg. 2007 Dec

58

9a. EBUS CT negative normal

mediastinum

Study to determine the accuracy of

EBUS-TBNA in sampling nodes <or=1
cm in diameter.
Population

NSCLC patients with CT scans showing

no enlarged lymph nodes (no node >1
cm) in the mediastinum.

Herth FJ, et al,Eur Respir J. 2006

59

EBUS-guided TBNA of lymph nodes

in the radiologically normal
mediastinum

Lymph nodes aspirated at locations

2r, 2l, 4r, 4l, 7, 10r, 10l, 11r and 11l
All patients underwent subsequent
surgical staging
Diagnoses based on aspiration
results were compared with surgical
results

Herth FJ, et al, Eur Respir J. 2006

60

EBUS-guided TBNA of lymph nodes

in the radiologically normal
mediastinum
100 patients, 119 lymph nodes sampled
(range 5-10 mm)

Malignancy detected in 19 pts, missed in

two
Mean diameter of punctured lymph nodes8.1 mm.
Sensitivity of EBUS-TBNA for detecting
malignancy was 92.3%, specificity was
100%, negative predictive value was 96.3%

No complications occurred.

Herth FJ, et al, Eur Respir J. 2006

61

Conclusion

EBUS-guided TBNA can accurately

sample even small mediastinal
nodes, therefore avoiding
unnecessary surgical exploration in
one out of six patients who have no
computed tomography evidence of
mediastinal disease.

Herth FJ, et al, Eur Respir J. 2006

62

9b. EBUS and PET negative,

normal mediastinum

Patients highly suspicious for NSCLC with CT scans

showing no enlarged lymph nodes (no node > 1
cm) and a negative PET finding of the mediastinum
underwent EBUS-TBNA.
Identifiable lymph nodes at locations 2r, 2L, 4r, 4L,
7, 10r, 10L, 11r, and 11L were aspirated.
All patients underwent subsequent surgical staging.
Diagnoses based on aspiration results were
compared with those based on surgical results.
One hundred patients (mean age, 52.4 years; 59
men) were included. After surgery, 97 patients
(mean age, 52.9 years; 57 men) had NSCLC
confirmed and were included in the analysis.

Herth F et al. CHEST 2008; 133:887891

63

In this group, 156 lymph nodes ranging 5 to 10 mm in size

were detected and sampled.

Malignancy was detected in nine patients but missed in one patient.

Mean diameter of the punctured lymph nodes was 7.9 mm.
The sensitivity of EBUS-TBNA for detecting malignancy was 89%,
specificity was 100%, and the negative predictive value was 98.9%.
No complications occurred.

In conclusion, EBUS-TBNA can be used to accurately

sample and stage patients with clinical stage 1 lung
cancer and no evidence of mediastinal involvement
on CT and PET.
Potentially operable patients with no signs of
mediastinal involvement may benefit from
presurgical staging with EBUS-TBNA.

64

Herth F et al. CHEST 2008; 133:887891

Herth F et al. CHEST 2008; 133:887891

65

10. Comparison of endobronchial ultrasound,

positron emission tomography, and CT for lymph
node staging of lung cancer

prospective comparison of methods used for

detection of mediastinal and hilar lymph node
metastasis in patients with lung cancer
considered for surgical resection.
direct real-time endobronchial ultrasound (EBUS)guided transbronchial needle aspiration (TBNA)
positron emission tomography (PET)
thoracic CT

Surgical

histology

used as the "gold standard" to confirm lymph node

metastasis unless patients were found inoperable for
N3 or extensive N2 disease proven by EBUS-TBNA.

Yasufuku K, et al, Chest 2006:130;710-718

66

Comparison of endobronchial
ultrasound, positron emission
tomography, and CT for lymph node
staging of lung cancer

One hundred two potentially operable patients

with proven (n = 96) or radiologically suspected
(n = 6) lung cancer were included in the study.
EBUS-TBNA proved malignancy in 37 lymph node
stations in 24 patients. (92.3% sensitivity)
CT identified 92 positive lymph nodes (80.0%
sensitivity)
PET identified 89 positive lymph nodes (4
supraclavicular, 63 mediastinal, 22 hilar).
(76.9% sensitivity)

Yasufuku K, et al, Chest 2006:130;710-718

67

New developments in EBUS

1. Miniforceps
2. Cost analysis
3. Restaging
4. Number of
aspirations

68

1. EBUS-guided miniforceps biopsy in

the biopsy of subcarinal masses in
patients with low likelihood of nonsmall cell lung cancer

Evaluation of the safety and efficacy

of obtaining specimens from
subcarinal masses using a 1.15-mm
miniforceps under EBUS guidance vs.
the diagnostic yield with TBNA alone.
75 patients

Herth FJ, et al, Ann Thorac Surg. 2008

69

EBUS-guided miniforceps biopsy in the

biopsy of subcarinal masses in patients
with low likelihood of NSCLC

EBUS-guided BNA of the lesion

performed using three methods:

First with a 22-gauge needle

Followed by a 19-gauge needle
Miniforceps was then passed through the
airway into the lesion under real-time EBUS
guidance

3 biopsy specimens were obtained

Herth FJ, et al, Ann Thorac Surg. 2008

70

Conclusion

Specific diagnosis made in:

36% of patients with the 22-gauge needle

49% with the 19-gauge needle
88% with the miniforceps

EBUS-guided miniforceps biopsy

Diagnostic yield is superior to TBNA alone

Procedure appears safe

Herth FJ, et al, Ann Thorac Surg. 2008

71

2. EBUS guided TBNA of

mediastinal lymph nodes for lung
cancer staging: a projected cost
analysis

EBUS-TBNA

a safe alternative to mediastinoscopy for

staging patients with lung cancer

Hypothesis

Patients found to have N2/N3 disease

would not require further investigation
with PET imaging and mediastinoscopy

Callister ME, et al, Thorax. 2008

72

EBUS guided TBNA of mediastinal

lymph nodes for lung cancer staging: a
projected cost analysis

Forty-seven patients underwent

mediastinoscopy as a staging procedure
for lung cancer at Leeds Teaching
Hospitals in 2006.
Twenty-eight patients were shown to have
malignant disease in N2 or N3 nodes, of
which 27 were deemed accessible to
EBUS-TBNA (all had mediastinal
lymphadenopathy on initial CT scan).

Callister ME, et al, Thorax. 2008

73

Conclusion

Mean EBUS-TBNA sensitivity for

malignancy in recently published
series was 92.3%
Projected that 25 patients would have
had mediastinal malignancy
demonstrated by EBUS-TBNA and
would therefore not have undergone
CT-PET and mediastinoscopy.

Callister ME, et al, Thorax. 2008

74

But for may multidisciplinary

teams, PET would be often
warranted anyway because of
known 10-14 percent incidence
of unsuspected extrathoracic
metastases
75

3. EBUS with TBNA for restaging

the mediastinum in lung cancer

Investigated the sensitivity and

accuracy of endobronchial ultrasoundguided transbronchial needle
aspiration (EBUS-TBNA) for restaging
the mediastinum after induction
chemotherapy in patients with nonsmall-cell lung cancer (NSCLC).

Herth FJ, et al, J Clin Oncol. 2008

76

EBUS with TBNA for restaging the

mediastinum in lung cancer

124 patients with tissue-proven stage IIIAN2 disease who were treated with induction
chemotherapy and who had undergone
mediastinal restaging by EBUS-TBNA
Patients subsequently underwent
thoracotomy with attempted curative
resection and a lymph node dissection
regardless of EBUS-TBNA findings.

Herth FJ, et al, J Clin Oncol. 2008

77

EBUS with TBNA for restaging the

mediastinum in lung cancer

Persistent nodal metastases

detected by using EBUS-TBNA in 89 patients

(72%).
no metastases assessed by EBUS-TBNA in
35 patients
28 out of 35 were found to have residual
stage IIIA-N2 disease at thoracotomy

91% of false negative results

due to nodal sampling error rather than

detection error.

Herth FJ, et al, J Clin Oncol. 2008

78

EBUS with TBNA for restaging the

mediastinum in lung cancer

Sensitivity-76%
Specificity-100%
Positive predictive value-100%
Negative predictive value-20%
Diagnostic accuracy of EBUS-TBNA for
mediastinal restaging after induction
chemotherapy-77%

Herth FJ, et al, J Clin Oncol. 2008

79

Conclusion

EBUS-TBNA was found to be a

sensitive, specific, accurate, and
minimally invasive test for mediastinal
restaging of patients with NSCLC.
Because of the low negative predictive
value, tumor-negative findings should
be confirmed by surgical staging
before thoracotomy.

Herth FJ, et al, J Clin Oncol. 2008

80

But lets look at the numbers:

124 patients

89 had cancer on restaging EBUS

35 did not

Of these, 28 had cancer on restaging open

surgery

117/124 patients still had cancer

at restaging
81

4. EBUS TBNA and the

number of aspirates

82

Background

The number of aspirations needed in

conventional TBNA

the maximum diagnostic yield was obtained

in five to seven needle passes

Chin R Jr, McCain TW, Lucia MA, et al. Transbronchial needle

aspiration in diagnosing and staging lung cancer: how many
aspirates are needed? Am J Respir Crit Care Med 2002;
166:377381
Diacon AH, Schuurmans MM, Theron J, et al. Transbronchial
needle aspirates: how many passes per target site? Eur
Respir J 2007; 29:112116
83

Background

There are greater limitations in the

size and location of accessible LNs
that can be aspirated using TBNA vs
EBUS-TBNA. In a metaanalysis

the pooled sensitivity of conventional

TBNA in the mediastinal staging of
NSCLC was reported to be 39 to 78%.

Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration
for mediastinal staging of non-small cell lung cancer: a meta-analysis. Thorax
2005;
60:949 955

84

Objectives and Methods

Objective: The goal of this study was to

determine the optimal number of aspirations per
lymph node (LN) station during endobronchial
ultrasound (EBUS)-guided transbronchial needle
aspiration (TBNA) for maximum diagnostic yield
in mediastinal staging of non-small cell lung
cancer (NSCLC) in the absence of rapid on-site
cytopathologic examination.

Methods: EBUS-TBNA was performed in

potentially operable NSCLC patients with
mediastinal LNs accessible by EBUS-TBNA (5 to
20 mm). Every target LN station was punctured
four times.
Chest 2008;134;368-374

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Chest 2008;134;368-374

Maximum results after 3

aspirates

Rapid On Site Cytology is

standard of care to assure
greater yield and better

Chest 2008;134;368-374
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Thank you

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