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Laurence M.M.J Crombag



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    ES07 - Thoracic Ultrasonography: Diagnosis and Staging (ID 10)

    • Event: WCLC 2019
    • Type: Educational Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 2
    • Now Available
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      ES07.02 - Linear Endosonography (EBUS & EUS) (Now Available) (ID 3187)

      13:30 - 15:00  |  Presenting Author(s): Laurence M.M.J Crombag

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      ES07.03 - Radial Endosonography (Now Available) (ID 3188)

      13:30 - 15:00  |  Presenting Author(s): Laurence M.M.J Crombag

      • Abstract
      • Presentation
      • Slides

      Abstract

      Radial Endosonography

      Flexible bronchoscopy, with its attendant procedures, is a valuable tool for diagnosis and staging of patients with suspected lung cancer. The development of endobronchial ultrasound (EBUS) has extended the view of the bronchoscopist beyond the bronchial wall. Two types of EBUS exist. The curved linear (convex) probe EBUS and the radial probe EBUS. The convex ultrasound transducer is located at the tip of a flexible bronchoscope (linear scanning EBUS) and allows real-time sampling. This technique is mainly used for mediastinal nodal staging and assessment of centrally located lung tumours when lung cancer is known or suspected. The radial EBUS probe houses a rotating ultrasound transducer at the distal end which produces a high-resolution radial (360˚) ultrasound image of the airway wall and surrounding structures. This probe is inserted through the biopsy channel of a standard bronchoscope. In a lung cancer setting, this technique is used for evaluation of the depth of tumour invasion in the central airways enabling differentiation between early and invasive lung cancer and detection of peripheral pulmonary lesions (PPLs). Radial EBUS does not permit sampling in real-time such that sequential sampling with separate equipment is necessary. The current focus of this abstract is the role of radial EBUS for PPLs.

      With the increased use of chest CT-scans, the frequency of incidentally found PPLs has increased as well. Guidelines advise to evaluate and manage individuals with pulmonary nodules by estimating the probability of malignancy. The goal is to diagnose a malignancy promptly for timely treatment and to avoid invasive procedures and surgery in patients with benign lesions. Approaches to establish a tissue diagnosis include imaging-guided transthoracic and bronchoscopic sampling techniques.

      The sensitivity of traditional flexible bronchoscopy - with or without fluoroscopic guidance – for peripheral lesions in patients suspected of having lung cancer is suboptimal and is affected most by the size of the lesion (<2cm 34%; >2cm 63%).(1) For PPLs, the sensitivity of transthoracic needle aspiration (TTNA) is greater than that of bronchoscopy. In this setting, TTNA has an approximately 90% chance of providing confirmation of a diagnosis. However, CT-guided percutaneous TTNA has a considerable risk of pneumothorax.(1) This has led to the development of new modalities as radial EBUS, virtual bronchoscopy, electromagnetic navigation bronchoscopy and ultrathin bronchoscopes.

      In 2002, radial EBUS was first used to guide transbronchial lung biopsy (TBLB).(2) Numerous papers has been published since, reporting varying diagnostic performances of radial EBUS. Three systematic reviews and meta-analyses report a sensitivity of radial EBUS for diagnosis of peripheral lesions of 70% to 73%. Although there is considerable heterogeneity in lesion size, prevalence of malignancy, variable use of additional image guiding technology and reference standard in included studies.(3-5)

      The diagnostic yield of radial EBUS is significantly higher for lesion > 2 cm in size, malignant in nature and those associated with a bronchus sign on CT scan.(3-5) The diagnostic yield is also higher when the radial EBUS probe is in the center of the lesion opposed to being adjacent to it.(3) The diagnostic yield of radial EBUS does not exceed CT-guided percutaneous needle biopsy / aspiration. The major advantage of radial EBUS over a transthoracic approach is its safety profile (overall pneumothorax rate of just 1.0%)(4) and the ability to combine with staging procedures.

      In conclusion, to diagnose PPLs (not visible by bronchoscopy) radial EBUS is a safe and has a reasonably high diagnostic yield. Main limitations of the technique include operator dependence and the need for sequential sampling as radial EBUS does not allow real-time sampling.

      1. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e142S-e65S.

      2. Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. The European respiratory journal. 2002;20(4):972-

      3. Ali MS, Trick W, Mba BI, Mohananey D, Sethi J, Musani AI. Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology (Carlton, Vic). 2017;22(3):443-53.

      4. Steinfort DP, Khor YH, Manser RL, Irving LB. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. The European respiratory journal. 2011;37(4):902-10.

      5. Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-93.

      Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.

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