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Clinical Investigations: LUNG CANCER |

Real-time Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Mediastinal and Hilar Lymph Nodes* FREE TO VIEW

Kazuhiro Yasufuku, MD; Masako Chiyo, MD; Yasuo Sekine, MD; Prashant N. Chhajed, MD, FCCP; Kiyoshi Shibuya, MD; Toshihiko Iizasa, MD; Takehiko Fujisawa, MD
Author and Funding Information

From the Department of Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.

Correspondence to: Takehiko Fujisawa, MD, Professor and Chairman, Department of Thoracic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan; e-mail: fujisawat@faculty.chiba-u.jp



Chest. 2004;126(1):122-128. doi:10.1378/chest.126.1.122
Text Size: A A A
Published online

Study objectives: Although various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including conventional bronchoscopic transbronchial needle aspiration (TBNA), transesophageal ultrasonography-guided needle aspiration, and mediastinoscopy, there are limitations to these techniques, which include low yield, poor access, need for general anesthesia, or complications. To overcome these problems, we undertook the current study to evaluate the clinical utility of the newly developed ultrasound puncture bronchoscope to visualize and perform real-time TBNA of the mediastinal and hilar lymph nodes under direct endobronchial ultrasonography (EBUS) guidance.

Design: Prospective patient enrollment.

Setting: University teaching hospital.

Patients: From March 2002 to September 2003, 70 patients were included in the study.

Interventions: The new convex probe (CP) EBUS is integrated with a convex scanning probe on its tip with a separate working channel, thus permitting real-time EBUS-guided TBNA. The indications for CP-EBUS were the diagnosis of mediastinal and/or hilar lymphadenopathy for known or suspected malignancy. Lymph nodes and the surrounding vessels were first visualized with CP-EBUS using the Doppler mode. The dimensions of the lymph nodes were recorded, followed by real-time TBNA under direct EBUS guidance. Final diagnosis was based on cytology, surgical results, and/or clinical follow-up.

Results: All lymph nodes that were detected on the chest CT scan could be visualized using CP-EBUS. In 70 patients, CP-EBUS-guided TBNA was performed to obtain samples from mediastinal lymph nodes (58 nodes) and hilar lymph nodes (12 nodes). The sensitivity, specificity, and accuracy of CP-EBUS-guided TBNA in distinguishing benign from malignant lymph nodes were 95.7%, 100%, and 97.1%, respectively. The procedure was uneventful, and there were no complications.

Conclusions: Real-time CP-EBUS-guided TBNA of mediastinal and hilar lymph nodes is a novel approach that is safe and has a good diagnostic yield. This new ultrasound puncture bronchoscope has an excellent potential for assisting in safe and accurate diagnostic interventional bronchoscopy.

Figures in this Article

Various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including mediastinoscopy, CT-guided percutaneous needle aspiration, conventional bronchoscopic transbronchial needle aspiration (TBNA), CT-guided TBNA, and transesophageal ultrasonography (US)-guided needle aspiration.14 All of these techniques have some limitations, which include variation in yield, complications, poor access to some lymph nodes, need for general anesthesia, exposure to radiation, or the referral to a service that offers the specialized procedure.2,5Endobronchial ultrasonography (EBUS) using a radial probe through the working channel of the flexible bronchoscope has been used to identify mediastinal and hilar lymph nodes.6In addition, EBUS guidance has recently been reported7to improve the yield of TBNA. Direct transesophageal US-guided fine-needle aspiration of mediastinal lymph nodes has been reported8 to have a major impact on patient management. To our knowledge, there are no reports of direct real-time EBUS-guided TBNA of mediastinal and hilar lymph nodes under local anesthesia.

A new convex probe (CP) EBUS with the ability to perform real-time TBNA under direct US guidance was developed in collaboration with Olympus Corporation (Tokyo, Japan). We first performed preliminary studies on surgical specimens using this new ultrasound puncture bronchoscope on resected surgical lung specimens from patients with a primary or secondary lung malignancy.9 We undertook the current study to assess the clinical utility of the newly developed ultrasound puncture bronchoscope to visualize and perform real-time TBNA of the mediastinal and hilar lymph nodes under direct CP-EBUS guidance.

Patients

Between March 2002 and September 2003, 70 patients having mediastinal and/or hilar lymphadenopathy of > 1 cm and with known or suspected malignancy were included in the study. A chest radiograph and CT scan of the chest (plain and contrast- enhanced) were performed in all patients.

Written informed consent was obtained from all the patients included in the study. Conventional flexible bronchoscopy (model BF-240 bronchoscope; Olympus; Tokyo, Japan) was first performed in a standard fashion to examine the tracheobronchial tree, followed by CP-EBUS using the new ultrasound puncture bronchoscope (model XBF-UC260F-OL8; Olympus). Both bronchoscopy procedures were performed with the patient under local anesthesia and sedation (ie, midazolam) by the same operator.

CP-EBUS

The CP-EBUS was developed by integrating a convex transducer with a frequency of 7.5 MHz at the tip of a flexible bronchoscope, an ultrasound puncture bronchoscope, in collaboration with Olympus Optical Co., Tokyo, Japan (Fig 1 , top, A). This CP-EBUS is a linear curved-array transducer that scans parallel to the insertion direction of the bronchoscope. Images can be obtained by directly contacting the probe or by attaching a balloon to the tip and inflating it with saline solution (Fig 1, bottom, B). The ultrasound image is processed in a dedicated ultrasound scanner (model EU-C2000; Olympus) and is visualized along with the conventional bronchoscopy image on the same monitor. The ultrasound images can be frozen, and the size of lesions can be measured in two dimensions by the placement of cursors. This system also has a Doppler mode.

The outer diameter of the insertion tube of the flexible bronchoscope is 6.7 mm, and that of the tip is 6.9 mm. The angle of view is 90°, and the direction of view is 30° forward oblique. The inner diameter of the instrument channel is 2.0 mm. A dedicated 22-gauge needle was developed to perform transbronchial aspiration (Fig 1, bottom, B). The inner diameter of this needle is nearly equal to that of a conventional 21-gauge needle, which allows the sampling of histologic cores in some cases. The needle is also equipped with an internal sheath, which is withdrawn after passing the bronchial wall, avoiding contamination during TBNA. The exit of the needle is at 20° with respect to the outer covering of the insertion tube. The needle can be visualized through the optics and on the ultrasound image.

Procedure

Bronchoscopy procedures were performed orally. Following conventional flexible bronchoscopic examination of the tracheobronchial tree, CP-EBUS was performed to first identify the lymph nodes and the surrounding vessels. Lymph nodes were identified according to the International Staging System.10 Blood vessels were further confirmed using the Doppler mode. The dimensions of the lymph node seen on the CP-EBUS were recorded from frozen US images. A dedicated TBNA needle was inserted through the working channel of the bronchoscope, and the designated lymph node was punctured under direct EBUS guidance. The aspirated material was smeared onto glass slides. Smears were air-dried as well as fixed in 95% alcohol. Dried smears were evaluated by an on-site cytopathologist to confirm that the cell material obtained was of adequate quality. Adequate cell material was defined as a specific diagnosis or the presence of lymphocytes on the specimen. For each site, the median number of passes was two (range, one to five). If adequate tissue was not identified by on-site cytology after five passes, the procedure was terminated. Furthermore, Papanicolaou staining and light microscopy were carried out by an independent cytopathologist who was blinded to the details of the cases. Histologic specimens obtained in some cases were fixed in formalin before being sent to the pathology department. All patients underwent a chest radiograph after the procedure.

Statistical Analysis

The real-time CP-EBUS-guided TBNA diagnosis was confirmed by open thoracotomy, thoracoscopy, or clinical follow-up. A positive cytologic result of malignancy was accepted as evidence, and the patients were treated accordingly. The sensitivity, specificity, and accuracy were calculated using the standard definitions.

Seventy patients underwent CP-EBUS (52 men and 18 women; mean age, 64.3 years; SD, 10.4 years; range, 37 to 86 years). All lymph nodes that were detected on the chest CT scan could be visualized using CP-EBUS. Direct real-time CP-EBUS-guided TBNA was performed in all 70 patients to obtain samples from mediastinal lymph nodes (58 nodes) and hilar lymph nodes (12 nodes). The procedure was uneventful, and there were no complications.

Figures 2 and 3 show the CT scan appearance of the lymph nodes, the US-guided dimensions of the lymph nodes, the Doppler mode distinguishing vessels and lymph nodes, and the TBNA needle in the lymph node in patients with hilar and mediastinal lymphadenopathy, respectively. As shown in Table 1 , the material obtained from the targeted lymph nodes was adequate in 68 patients (96.0%) and inadequate in 2 patients. Malignancy was detected in 45 patients, and benign disease was detected in 25 patients by TBNA (Table 1).

Although a positive cytologic diagnosis for malignancy was considered to be diagnostic, four patients with cytology-positive results in the hilar lymph nodes and four patients with cytology-positive results in the mediastinal lymph nodes underwent surgery for additional histologic diagnosis. Of the remaining 37 patients, 5 who received a final diagnosis of small cell lung cancer obtained by the procedure were referred for chemotherapy, and 9 with mediastinal lymphadenopathy during a follow-up of lung cancer after surgery underwent radiation therapy. Thoracotomy was avoided in 6 patients, and further invasive procedures for histologic sampling, including mediastinoscopy and thoracoscopy, were avoided in 17 patients. The clinical course of the 23 patients was rapid progression or death, and CP-EBUS-guided TBNA diagnoses were recorded as true-positive findings.

Of the 25 benign results, 21 were confirmed by histology (ie, surgery and thoracoscopy). One patient had a clinical follow-up since US findings revealed a cystic lesion (Fig 4 ), and three patients with a diagnosis of sarcoidosis were followed up as outpatients. The two patients with inadequate specimens proved to have malignancies, as determined by surgical biopsy. As a result of performing CP-EBUS, further invasive procedures were avoided in 19 patients. With two false-negative results and no false-positive results, the overall sensitivity, specificity, and diagnostic accuracy rate of direct CP-EBUS-guided TBNA in distinguishing benign from malignant lymph nodes were 95.7%, 100%, and 97.1%, respectively (Table 2 ).

When comparing the location of lymph nodes in the benign and malignant lesions, most of the benign lesions were in mediastinal lymph node 3. On the other hand, malignant lesions were distributed equally throughout the mediastinum and the hilum (Table 3 ). The lymph node stations of the two patients with false-negative diagnoses due to inadequate specimens were lymph node 2 and lymph node 11. Although the needle within the lymph node was confirmed by US in both patients, cytology revealed poor material, with only a few lymphocytes. Besides these two patients, there were no other difficulties in obtaining specimens. The site of the lymph node did not affect the procedure.

Most of the lymph nodes measured between 1 and 2 cm both in the benign and malignant lesions (Table 4 ). The size of the lymph nodes did not affect the TBNA procedure.

Present investigation methods in radiology such as CT and US have resulted in a decrease in the number of mediastinoscopies performed.11The limitations, complications, or morbidity associated with thoracoscopy,12 CT scan-guided percutaneous needle aspiration of mediastinal lymph nodes,5 and conventional TBNA2 have led some institutions to use transesophageal fine-needle aspiration to sample mediastinal lymph nodes. The need for direct EBUS-guided TBNA has been expressed previously.67,13 The results of this study demonstrate that direct real-time CP-EBUS-guided TBNA is a safe and accurate method of evaluating both mediastinal and hilar lymph nodes. CP-EBUS-guided TBNA had a sensitivity of 95.7% (45 of 47 patients), a specificity of 100%, and an accuracy of 97.1% (68 of 70 patients) in distinguishing benign from malignant mediastinal and/or hilar lymph nodes. To our knowledge, this is the first report that demonstrates the usefulness and safety of real-time EBUS-guided TBNA under local anesthesia in evaluating mediastinal and hilar lymphadenopathy.

In contrast to transesophageal US-guided needle aspiration, conventional TBNA is a fairly “blind” procedure, with guidance generally limited to a few endobronchial landmarks and mental reconstruction of a preprocedure chest CT scan.4 If successfully performed, TBNA may spare patients additional, more invasive procedures or surgery. The diagnostic yield of TBNA for the staging of lung cancer varies between 15% and 83%.2 As conventional TBNA requires accessing lymph nodes without direct visualization, the yield in less experienced hands can be suboptimal. TBNA guided by CT fluoroscopy has been reported4 to have a high diagnostic yield. However, CT scan guidance can be costly, and patients as well as the examiner are exposed to radiation. Although an initial report on EBUS-guided TBNA failed to demonstrate any benefit,13 the use of the balloon-tipped radial probe has been shown to improve the diagnostic yield of EBUS-guided TBNA.7 However, it is still not a real-time procedure with target visualization. Direct US-guided fine-needle aspiration of the mediastinal lymph nodes via the esophagus has been reported by many centers.1,14 The limitations of this technique are that the pretracheal and hilar lymph nodes cannot be visualized. Also, patients being managed by the bronchoscopist would need a referral in most institutions to perform the esophageal US-guided fine-needle aspiration of the mediastinal lymph nodes.

The limiting factor in the incorporation of a linear probe onto the tip of the conventional bronchoscope has been its relatively smaller outer diameter, compared to GI endoscopes. We were able to overcome this limitation and develop the ultrasound puncture bronchoscope with the CP integrated at its tip and to have a separate working channel to perform TBNA under real-time direct EBUS guidance. The linear array CP allowed the visualization of the TBNA needle within the US plane. The vascular structures surrounding the lymph nodes to be sampled were confirmed using the Doppler mode. The diagnostic yield of TBNA of the mediastinal and hilar lymph nodes in our study was 97.1%. We believe that the evaluation of hilar and mediastinal lymphadenopathy relevant to pulmonary practice should be performed by the bronchoscopist. Our approach has the potential to save time and resources, and to avoid radiation when compared to techniques utilizing CT guidance.

Several limitations of our study should be noted. First of all, the direction of view of the scope is 30° forward oblique, making the manipulation difficult. From our experience, this new diagnostic modality requires at least 5 to 10 manipulations for an experienced bronchoscopist to be able to smoothly insert the scope and obtain clear images. In the present study, all the procedures were performed by a single experienced physician (K.Y.) who had been trained for EBUS procedures. Prior to EBUS-guided TBNA, the insertion of the scope and the visualization of the lymph nodes were repeated in preliminary studies. For these reasons, we were able to perform the procedure under local anesthesia without any complications. Second, the subaortic and paraesophageal lymph nodes were not accessible during CP-EBUS-guided TBNA. Since most of the mediastinal and hilar lymph nodes are present along the airway, they should be accessible using CP-EBUS. For lymph nodes that are not accessible with CP-EBUS, one may need to perform endoscopic-guided needle aspiration.8 Last, the problem of inadequate sampling should be noted. In our study, a single physician (K.Y.) who was experienced with the procedure performed all of the needle aspirations, resulting in success in all but two cases. Also, since the scope is suited only for a 22-gauge needle, the sample is usually suitable only for cytology. However, in one of four cases we were able to obtain histologic cores that were helpful, especially in the diagnosis of benign diseases. The development of a larger needle will probably solve these problems and increase the yield even further.

Complications following conventional TBNA include self-limited minor bleeding, pneumothorax, and pneumomediastinum.2 There were no major complications in our study. The minor oozing of blood at the site of puncture was observed in some patients following TBNA. None of the patients had significant bleeding, pneumothorax, or pneumomediastinum. It may sometimes be difficult to puncture the tracheal wall because of the thick cartilaginous rings. In this case, the puncture site needs to be changed by a few millimeters, keeping the designated lymph node in sight.

Since its invention in 1968, the flexible fiberoptic bronchoscope has undergone a great deal of development,15such as the development of the flexible video bronchoscope, the fluorescence bronchoscope,1617 the high-magnification bronchoscope,18and now the ultrasound puncture bronchoscope. With the evolution of technology, a reduction in the size of the CP-EBUS will potentially allow its use in the management of peripheral lesions. Compared to the 20-MHz radial probe, EBUS, which has an excellent resolution, is capable of imaging even the layers of the bronchial wall19 or lymph nodes that are not detectable on CT scan, but the 7.5-MHz CP was not suited for the evaluation of airway infiltration. We were not able to detect lymph nodes that due to their size cannot be detected by CT scan. Having the flexibility of using a variety of ultrasound frequencies ranging from 7.5 to 20 MHz would have the potential for its application in the evaluation of the airway wall and also would serve as a useful guide in performing therapeutic flexible bronchoscopy.

To conclude, real-time TBNA of the mediastinal and hilar lymph nodes under direct EBUS guidance using the new ultrasound puncture bronchoscope is a novel approach that is safe and has a good diagnostic yield. This new ultrasound puncture bronchoscope has an excellent potential in assisting safe and accurate diagnostic interventional bronchoscopy.

Abbreviations: CP = convex probe; EBUS = endobronchial ultrasonography; TBNA = transbronchial needle aspiration; US = ultrasonography

Figure Jump LinkFigure 1. Top, A: tip of the ultrasonic puncture bronchoscope (CP-EBUS; model XBF-UC260F) with the linear curved-array ultrasonic transducer. Bottom, B: the balloon attached to the tip of the bronchoscope is inflated with normal saline solution, and a dedicated TBNA needle is inserted through the working channel.Grahic Jump Location
Figure Jump LinkFigure 2. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) of the left lower lobe obtained in a 43-year-old patient with lung cancer. Top, A: CT scan demonstrates swelling of lymph node 11 (arrow). Middle, B: EBUS scan showing lymph node 11 (1.23 × 1.55 cm in diameter [markers are at 1-cm intervals]) and the pulmonary artery (PA) adjacent to the lymph node. Bottom, C: real-time CP-EBUS-guided TBNA was performed. A 22-gauge needle (needle) is seen within the lymph node. Cytologic results demonstrated mucoepidermoid carcinoma.Grahic Jump Location
Figure Jump LinkFigure 3. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) obtained in a 66-year-old patient with lung cancer of the right upper lobe. Top, A: CT scan shows pretracheal lymph node swelling (lymph node 3; arrow). Middle, B: EBUS scan shows lymph node 3, which is clearly distinguishable from the superior vena cava (SVC) by use of the Doppler mode. Bottom, C: real-time CP-EBUS-guided TBNA revealed adenocarcinoma. A 22-gauge needle (needle) is seen within the lymph node.Grahic Jump Location
Table Graphic Jump Location
Table 1. Cytologic Results of Real-Time EBUS-Guided TBNA in Mediastinal and Hilar Lymph Nodes
* 

Two of 20 patients had false-negative findings for malignancy.

Figure Jump LinkFigure 4. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) obtained in a 62-year-old patient in whom lung cancer had been resected 2 years earlier. Top, A: CT scan shows a low-density area in the pretracheal lesion (arrow). Middle, B: EBUS scan demonstrates a homogeneous low-density area (cyst) and the aorta (ao). Bottom, C: real-time CP-EBUS-guided TBNA confirmation of the aorta (ao) by the Doppler mode resulted in the aspiration of the cyst fluid.Grahic Jump Location
Table Graphic Jump Location
Table 2. Comparison of Real-time EBUS-Guided TBNA Results With Final Diagnosis in Mediastinal and Hilar Lymph Nodes
Table Graphic Jump Location
Table 3. Lymph Node Location of Real-time EBUS-Guided TBNA
* 

Includes one patient with false-negative findings within each group.

Table Graphic Jump Location
Table 4. Size of Lymph Nodes Punctured by Real-time EBUS-Guided TBNA
* 

Includes two patients with false-negative results.

The authors thank Kenichi Nishina and Yusuke Ichikawa (Olympus Optical Corporation) for technical assistance.

Fritscher-Ravens, A, Soehendra, N, Schirrow, L, et al (2000) Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer.Chest117,339-345. [CrossRef] [PubMed]
 
Bolliger, CT, Mathur, PN, Beamis, JF, et al ERS/ATS statement on interventional pulmonology: European Respiratory Society/ American Thoracic Society.Eur Respir J2002;19,356-373. [CrossRef] [PubMed]
 
Hammoud, ZT, Anderson, RC, Meyers, BF, et al The current role of mediastinoscopy in the evaluation of thoracic disease.J Thorac Cardiovasc Surg1999;118,894-899. [CrossRef] [PubMed]
 
Garpestad, E, Goldberg, S, Herth, F, et al CT fluoroscopy guidance for transbronchial needle aspiration: an experience in 35 patients.Chest2001;119,329-332. [CrossRef] [PubMed]
 
Zwischenberger, JB, Savage, C, Alpard, SK, et al Mediastinal transthoracic needle and core lymph node biopsy: should it replace mediastinoscopy?Chest2002;121,1165-1170. [CrossRef] [PubMed]
 
Okamoto, H, Watanabe, K, Nagatomo, A, et al Endobronchial ultrasonography for mediastinal and hilar lymph node metastases of lung cancer.Chest2002;121,1498-1506. [CrossRef] [PubMed]
 
Herth, FJ, Becker, HD, Ernst, A Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.Chest2003;123,604-607. [CrossRef] [PubMed]
 
Larsen, SS, Krasnik, M, Vilmann, P, et al Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management.Thorax2002;57,98-103. [CrossRef] [PubMed]
 
Yasufuku, K, Chhajed, PN, Sekine, Y, et al Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens.Oncol Rep2004;11,293-296. [PubMed]
 
Mountain, CF, Dressler, CM Regional lymph node classification for lung cancer staging.Chest1997;111,1718-1723. [CrossRef] [PubMed]
 
Hujala, KT, Sipila, JI, Grenman, R Mediastinoscopy-its role and value today in the differential diagnosis of mediastinal pathology.Acta Oncol2001;40,79-82. [CrossRef] [PubMed]
 
Gossot, D, Toledo, L, Fritsch, S, et al Mediastinoscopy vs thoracoscopy for mediastinal biopsy: results of a prospective nonrandomized study.Chest1996;110,1328-1331. [CrossRef] [PubMed]
 
Shannon, JJ, Bude, RO, Orens, JB, et al Endobronchial ultrasound-guided needle aspiration of mediastinal adenopathy.Am J Respir Crit Care Med1996;153,1424-1430. [PubMed]
 
Hunerbein, M, Ghadimi, BM, Haensch, W, et al Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance.J Thorac Cardiovasc Surg1998;116,554-559. [CrossRef] [PubMed]
 
Ikeda, S, Yanai, N, Ishikawa, S Flexible bronchofiberscope.Keio J Med1968;17,1-16. [CrossRef] [PubMed]
 
Shibuya, K, Fujisawa, T, Hoshino, H, et al Fluorescence bronchoscopy in the detection of preinvasive bronchial lesions in patients with sputum cytology suspicious or positive for malignancy.Lung Cancer2001;32,19-25. [CrossRef] [PubMed]
 
Lam, S, MacAulay, C, Hung, J, et al Detection of dysplasia and carcinoma in situ with a lung imaging fluorescence endoscope device.J Thorac Cardiovasc Surg1993;105,1035-1040. [PubMed]
 
Shibuya, K, Hoshino, H, Chiyo, M, et al Subepithelial vascular patterns in bronchial dysplasias using a high magnification bronchovideoscope.Thorax2002;57,902-907. [CrossRef] [PubMed]
 
Baba, M, Sekine, Y, Suzuki, M, et al Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall.Lung Cancer2002;35,65-71. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. Top, A: tip of the ultrasonic puncture bronchoscope (CP-EBUS; model XBF-UC260F) with the linear curved-array ultrasonic transducer. Bottom, B: the balloon attached to the tip of the bronchoscope is inflated with normal saline solution, and a dedicated TBNA needle is inserted through the working channel.Grahic Jump Location
Figure Jump LinkFigure 2. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) of the left lower lobe obtained in a 43-year-old patient with lung cancer. Top, A: CT scan demonstrates swelling of lymph node 11 (arrow). Middle, B: EBUS scan showing lymph node 11 (1.23 × 1.55 cm in diameter [markers are at 1-cm intervals]) and the pulmonary artery (PA) adjacent to the lymph node. Bottom, C: real-time CP-EBUS-guided TBNA was performed. A 22-gauge needle (needle) is seen within the lymph node. Cytologic results demonstrated mucoepidermoid carcinoma.Grahic Jump Location
Figure Jump LinkFigure 3. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) obtained in a 66-year-old patient with lung cancer of the right upper lobe. Top, A: CT scan shows pretracheal lymph node swelling (lymph node 3; arrow). Middle, B: EBUS scan shows lymph node 3, which is clearly distinguishable from the superior vena cava (SVC) by use of the Doppler mode. Bottom, C: real-time CP-EBUS-guided TBNA revealed adenocarcinoma. A 22-gauge needle (needle) is seen within the lymph node.Grahic Jump Location
Figure Jump LinkFigure 4. Chest CT scan (top, A) and EBUS scans (middle, B, and bottom, C) obtained in a 62-year-old patient in whom lung cancer had been resected 2 years earlier. Top, A: CT scan shows a low-density area in the pretracheal lesion (arrow). Middle, B: EBUS scan demonstrates a homogeneous low-density area (cyst) and the aorta (ao). Bottom, C: real-time CP-EBUS-guided TBNA confirmation of the aorta (ao) by the Doppler mode resulted in the aspiration of the cyst fluid.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Cytologic Results of Real-Time EBUS-Guided TBNA in Mediastinal and Hilar Lymph Nodes
* 

Two of 20 patients had false-negative findings for malignancy.

Table Graphic Jump Location
Table 2. Comparison of Real-time EBUS-Guided TBNA Results With Final Diagnosis in Mediastinal and Hilar Lymph Nodes
Table Graphic Jump Location
Table 3. Lymph Node Location of Real-time EBUS-Guided TBNA
* 

Includes one patient with false-negative findings within each group.

Table Graphic Jump Location
Table 4. Size of Lymph Nodes Punctured by Real-time EBUS-Guided TBNA
* 

Includes two patients with false-negative results.

References

Fritscher-Ravens, A, Soehendra, N, Schirrow, L, et al (2000) Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer.Chest117,339-345. [CrossRef] [PubMed]
 
Bolliger, CT, Mathur, PN, Beamis, JF, et al ERS/ATS statement on interventional pulmonology: European Respiratory Society/ American Thoracic Society.Eur Respir J2002;19,356-373. [CrossRef] [PubMed]
 
Hammoud, ZT, Anderson, RC, Meyers, BF, et al The current role of mediastinoscopy in the evaluation of thoracic disease.J Thorac Cardiovasc Surg1999;118,894-899. [CrossRef] [PubMed]
 
Garpestad, E, Goldberg, S, Herth, F, et al CT fluoroscopy guidance for transbronchial needle aspiration: an experience in 35 patients.Chest2001;119,329-332. [CrossRef] [PubMed]
 
Zwischenberger, JB, Savage, C, Alpard, SK, et al Mediastinal transthoracic needle and core lymph node biopsy: should it replace mediastinoscopy?Chest2002;121,1165-1170. [CrossRef] [PubMed]
 
Okamoto, H, Watanabe, K, Nagatomo, A, et al Endobronchial ultrasonography for mediastinal and hilar lymph node metastases of lung cancer.Chest2002;121,1498-1506. [CrossRef] [PubMed]
 
Herth, FJ, Becker, HD, Ernst, A Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients.Chest2003;123,604-607. [CrossRef] [PubMed]
 
Larsen, SS, Krasnik, M, Vilmann, P, et al Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management.Thorax2002;57,98-103. [CrossRef] [PubMed]
 
Yasufuku, K, Chhajed, PN, Sekine, Y, et al Endobronchial ultrasound using a new convex probe: a preliminary study on surgically resected specimens.Oncol Rep2004;11,293-296. [PubMed]
 
Mountain, CF, Dressler, CM Regional lymph node classification for lung cancer staging.Chest1997;111,1718-1723. [CrossRef] [PubMed]
 
Hujala, KT, Sipila, JI, Grenman, R Mediastinoscopy-its role and value today in the differential diagnosis of mediastinal pathology.Acta Oncol2001;40,79-82. [CrossRef] [PubMed]
 
Gossot, D, Toledo, L, Fritsch, S, et al Mediastinoscopy vs thoracoscopy for mediastinal biopsy: results of a prospective nonrandomized study.Chest1996;110,1328-1331. [CrossRef] [PubMed]
 
Shannon, JJ, Bude, RO, Orens, JB, et al Endobronchial ultrasound-guided needle aspiration of mediastinal adenopathy.Am J Respir Crit Care Med1996;153,1424-1430. [PubMed]
 
Hunerbein, M, Ghadimi, BM, Haensch, W, et al Transesophageal biopsy of mediastinal and pulmonary tumors by means of endoscopic ultrasound guidance.J Thorac Cardiovasc Surg1998;116,554-559. [CrossRef] [PubMed]
 
Ikeda, S, Yanai, N, Ishikawa, S Flexible bronchofiberscope.Keio J Med1968;17,1-16. [CrossRef] [PubMed]
 
Shibuya, K, Fujisawa, T, Hoshino, H, et al Fluorescence bronchoscopy in the detection of preinvasive bronchial lesions in patients with sputum cytology suspicious or positive for malignancy.Lung Cancer2001;32,19-25. [CrossRef] [PubMed]
 
Lam, S, MacAulay, C, Hung, J, et al Detection of dysplasia and carcinoma in situ with a lung imaging fluorescence endoscope device.J Thorac Cardiovasc Surg1993;105,1035-1040. [PubMed]
 
Shibuya, K, Hoshino, H, Chiyo, M, et al Subepithelial vascular patterns in bronchial dysplasias using a high magnification bronchovideoscope.Thorax2002;57,902-907. [CrossRef] [PubMed]
 
Baba, M, Sekine, Y, Suzuki, M, et al Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall.Lung Cancer2002;35,65-71. [CrossRef] [PubMed]
 
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