Endobronchial Ultrasound

(EBUS) Biopsy of Mediastinal

Lymph Nodes
Mediastinoscopy is the gold standard method for determining the presence of nodal
metastases in the mediastinum !enerally performed as an outpatient surgical procedure"
it is associated #ith a lo# rate of serious ad$erse e%ects (&'() and the procedure is
highly accurate" #ith false negati$e rates reported to be bet#een )( and *(
Endobronchial ultrasound (EBUS) guided +ne needle aspiration biopsy of mediastinal
nodes o%ers a less in$asi$e alternati$e for histologic sampling of the mediastinal nodes
,he procedure has been #idely adopted by pulmonologists and is poised to replace
mediastinoscopy in the future -or thoracic surgeons" the techni.ue can be easily learned
and it may be important to do so if our specialty is to maintain its traditional and
important role in the diagnosis and staging of thoracic malignancies
Figure 2: /n0ated balloon #ith needle and sheath ad$anced
,he EBUS bronchoscope (B-1U2')3-14L56 4lympus 7merica /nc" 2enter 8alley" 97) is
similar in dimensions to a standard adult +ber optic bronchoscope ,he ) mm diameter
scope has a cur$ilinear ultrasound (US) probe at its distal end #hich pro$ides a :3
degrees linear continuous B1mode ultrasound image" #ith color ;oppler capability to aid
identi+cation of $ascular structures (Figure 1) 9ro<imal to the US probe" and at =3
degrees to the long a<is of the bronchoscope" are a +ber optic lens and a biopsy channel"
through #hich a >>1! biopsy needle can be passed (N71>3'S?1@3>>6 4lympus 7merica
/nc" 2enter 8alley" 97) (Figure 2) 7 disposable late< balloon is placed o$er the US
probe" #hich is in0ated #ith sterile #ater to pro$ide a 0uid interface bet#een the probe
and the tracheal #all
4perati$e Steps
Scope Set1up
7 >3 cc syringe +lled #ith sterile #ater is attached to the balloon channel of the scope
using an arterial line #ith a stopcocA" and the channel +lled #ith #ater (Figure 1) 7
disposable late< balloon is then carefully placed o$er the ultrasound probe" using the
pro$ided applicator and then in0ated #ith saline 7ll air bubbles should be e$acuated
from the balloon prior to sealing it in place" #hich is easily done by applying pressure to
the distal circular lip of the balloon #ith the tip of a glo$ed +nger Silicone spray should
then be used to lubricate the scope
/maging 9rocedure
/n the United States EBUS is usually performed under general anesthesia #ith use of a
laryngeal masA air#ay and intra$enous anesthesia B'C (Figure 3) ,his permits
e$aluation of the upper paratracheal nodes #hich may not be accessible if an
endotracheal tube is used 7 standard +ber optic bronchoscope is +rst used to determine
anatomy" clear secretions and ensure absence of endobrochial disease that might maAe
EBUS super0uous ,he EBUS scope is then ad$anced into the trachea Dhen
manipulating the bronchoscope through the $ocal cords it is important to note that the
$isualiEed image is at =3 degrees to the long a<is of the bronchoscope ,he balloon is
then in0ated so that a small crescent of it may be seen at the bottom of the +ber optic
image (Figure 4) ,he image is inferior to that of a standard bronchoscope because of
the smaller diameter of the +ber optic system re.uired to accommodate the biopsy
channel and ultrasound ,he BUS1E?,C button on the ultrasound processor (EU12)36
4lympus 7merica /nc" 2enter 8alley" 97) toggles bet#een the +ber optic and ultrasound
$ie#s (Figure 5) Use of > monitors or a single monitor #ith picture1in1picture display is
useful
Figure 3: EBUS being performed under general intra$enous anesthesia #ith use of
laryngeal masA air#ay ,he 281'53 $ideo processor enables picture1in1picture
display" #hich allo#s easy correlation bet#een $isualiEed anatomy and the
ultrasonic image
Figure 4:-iberoptic image of distal trachea #ith balloon partially in0ated
Figure 5: EBUS processor (EU12)36 4lympus 7merica /nc" Mel$ille" NF)
,he easiest place to start ultrasound imaging is generally the right main bronchus
and subcarinal areas 9ass the scope to the right side of the carina #ith the probe
facing anteriorly and apply to the anterior #all of the GMB ,his #ill bring into $ie#
the right main pulmonary artery 8ascular structures appear hypoechoic and
pulsatile" and are usually readily discernable #ithout using the color ;oppler /f
doubt persists 0o# #ithin can be con+rmed by s#itching to the ;oppler o$erlay
(BH29;6 Figures 5 and 6) ,urn the scope *3 degrees counter1clocA#ise ,his allo#s
$isualiEation of the subcarinal area from the right side By mo$ing the scope in and
out the le$el I subcarinal node can usually be identi+ed /f not" repeat this
procedure in the LMB turning the scope *3 degrees clocA#ise instead 4nce the
subcarinal nodes are $isualiEed it is relati$ely easy to identify other landmarAs" by
correlating anatomical location #ith the ultrasound image /t is useful to attempt to
map out all nodes that you #ish to biopsy +rst" before needle tract bleeding
confounds the +ber optic image ,he siEe of the node can be measured by freeEing
the US image B-reeEeC and using the BMeasureHSelectC button and cursor scroll ball
(Figures 5 and 7)
Figure 6a: Ultrasound image of G main pulmonary artery #ith (right) and #ithout
(left) color ;oppler
Figure 6b: Biopsy of right paratracheal node (arro#) #ith superior $ena ca$a
$isualiEed in its long a<is anteriorly
Figure 7: Measuring short a<is dimension of a subcarinal lymph node
Biopsy 9rocedure
,he biopsy needle consists of a >>1guage needle #ith inner stylet housed in a 0e<ible
sheath" both of #hich may mo$e independently of one another relati$e to the
bronchoscope ,he biopsy needle is passed through the biopsy channel and the housing
secured to the bronchoscope by a 0ange (Figure 8) ,here are t#o main techni.ues to
perform transbronchial puncture ,he .uicA Jab techni.ue is easiest and most useful for
the subcarinal nodes or nodes along the main stem bronchi #here the cartilage is
thinner (Figures 8 and 9) Dith the node $isualiEed by US" the sheath is ad$anced out
of the end of the scope until the top right corner of the ultrasound image becomes
slightly indented ,his indicates that the end of the sheath is in contact #ith the #all of
the bronchus and it is therefore safe to ad$ance the needle ,he guard for the needle is
then released and using a .uicA Jab the needle is plunged into the lymph node /f the
needle is more slo#ly ad$anced there is a tendency for it to push the #all of the
bronchus a#ay from the scope" thus losing contact #ith the balloon and resulting in
image loss 4nce the needle is $isualiEed #ithin the lymph node" the stylet is mo$ed in
an out a fe# times to dislodge any bronchial epithelium that may ha$e entered the
needle" and then #ithdra#n Suction is applied to the biopsy needle (typically negati$e
>3 cc of air using a 8ac1Loc syringe) and the needle passed in and out of the node
appro<imately '3 times under US $isualiEation Suction is then released and the entire
biopsy needle #ithdra#n Smears are prepared by ad$ancing the needle out of the
sheath" reinserting the stylet and applying a drop of the aspirate to frosted glass slides
7ir is used to 0ush remaining aspirate material either onto additional slides or into G9M/
medium for cell blocA analysis /deally = separate passes should be made into each
nodal station to ma<imiEe yield (Video 1)

Figure 8a: Biopsy needle (N71>3'S?1@3>>6 4lympus 7merica /nc" 2enter 8alley" 97)
secured to biopsy port of EBUS scope ,he sheath scre# is +rst released to allo# the
sheath to appro<imate the tracheobronchial #all Dhen the sheath is in contact #ith
the bronchial #all a slight distorting e%ect can be seen at the upper right corner of the
US image
Figure 8b: Dith the sheath appropriately ad$anced and secured by retightening the
scre#" the biopsy scre# is then released ,his #ill allo# the biopsy guard to slide out of
the #ay in preparation for needle ad$ancement
Figure 8c: 4nce the needle scre# has been released" the biopsy needle can usually
be easily ad$anced through the tracheobronchial #all and into the node using a
.uicA" slightly forceful Jab

7n alternati$e method of $isual needle placement is fre.uently necessary" particularly
for the paratracheal nodes #here the cartilaginous rings are thicAer /n this case an
appropriate intercartilaginous space is identi+ed relati$e to the location of the node of
interest" and the needle is placed in the interspace under direct +ber optic $isualiEation
/t is useful to ha$e the tip of the needle and sheath Just barely $isible at the bottom right
hand corner of the screen" and then ad$ance the scope for#ard" directing the tip of the
needle to the appropriate interspace ,he tip of the needle should puncture the mucosa
and #ith the needle no# +<ed in position" the scope can be slightly ad$anced ,his
causes the needle to assume a more perpendicular angle relati$e to the trachea and
allo#s the needle to a$oid the tracheal cartilages ,he needle is then passed across the
trachea and into the node" and aspiration proceeds (Figure 10, Video 2)
Mountain1;resler nodal stations accessible by EBUS include stations '">"="@"I"'3" and ''
and lymph nodes #ith short a<is dimensions of :mm or greater may usually be biopsied
#ithout diKculty Sensiti$ity and yield are ma<imiEed after = separate passes through
each node /t is important to ha$e real1time cytologic analysis and feedbacA in order to
con+rm that an ade.uate specimen containing lymphocytes has been achie$ed" #hich
pro$ides e$idence of nodal sampling (Figure 11)
Figure 9: Gight paratracheal node (@G) bet#een truncus anterior of G 97 (red
arro#) and aEygos $ein (blue arro#) Biopsy needle is ad$anced through the node
(#hite arro#)
Figure 10: 8isual placement of needle into intercartillaginous mucosa (left) #ith
slight ad$ancement of scope to increase angle of attacA as needle is ad$anced
(right) into a paratracheal node
Figure 11: EBUS aspirated cells from a s.uamous cell carcinoma metastatic to a
paratracheal lymph node Smaller cells are lymphocytes

9reference 2ard
EBUS bronchoscope (B-1U2')3-14L56 4lympus 7merica /nc" 2enter 8alley" 97)
EBUS ultrasound processor (EU12)36 4lympus 7merica /nc" 2enter 8alley" 97)
EBUS >> ! ,BN7 needle (N71>3'S?1@3>>6 4lympus 7merica /nc" 2enter 8alley"
97)
Standard +beroptic bronchoscope (for preliminary e$aluation and to suction
secretions better)
,#o monitors" one for the US $ie#" and one for the +beroptic image ,his #ill
pre$ent ha$ing to toggle bacA#ards and for#ards bet#een $ie#s 7lternati$ely" the
ne#er 4lympus $ideo processor (281'536 4lympus 7merica /nc" 2enter 8alley" 97)
allo#s picture1in1picture display" ob$iating the need for a second monitor
Balloon for the ultrasound probe
>3 cc syringe #ith tubing to apply suction to needle
Slide preparationL
Bo< of frosted glass slides (each separately marAed for $arious nodal stations" #ith
patient /;M) Usually you #ill maAe >1: slides per needle pass
Bo< of clear glass slides (for maAing smear)
Slide holders #ith +<ati$e (2arnoys soln) (' for each nodal station)
Slide holder for air dried slides (' is suKcient)
,ips N 9itfalls
Nodes in the subcarinal area are straightfor#ard to biopsy
9aratracheal nodes" particularly those at the left tracheobronchial angle may
sometimes present a challenge" particularly if they are small 4n the left side it is
almost al#ays best to $isually place the needle in the intercartillaginous space"
allo#ing the needle to hooA the mucosa" and then ad$ance the bronchoscope slightly
to allo# the needle to pass at more of a right angle to the #all of the trachea
4ther#ise the needle #ill tend to pass at =3 degrees to the tracheal #all and it
in$ariably hits cartilage instead
E<treme care must be taAen #hen ad$ancing and retracting the needle /t is
important that the tip of the sheath be outside the scope #hen the needle is
ad$anced to a$oid deploying the needle inside the scope #hich #ill cause damage to
it Similarly" if the needle is not completely retracted into the sheath before
#ithdra#ing the needle from the scope" the e<posed tip of the needle can damage the
inside of the scope
-or biopsy of more distal nodes (le$els '3 or '') it is often better to do so #ith the
balloon de0ated so that the scope can be passed more distally
7lthough not designed for use in the esophagus" the B-1U2')3-14L5 scope can be
passed into the esophagus to access nodes in the periesophageal" perigastric and
e$en celiac a<is areas
Gesults
,#o recent reports ha$e e<amined the utility of EBUS in staging of the mediastinum in
patients #ith NS2L2 FasufuAu" et al" performed EBUS1-N7 on '3> patients #ith
potentially operable NS2L2 2, identi+ed *> suspicious (positi$e) mediastinal nodes
and 9E, identi+ed 5* B>C EBUS1-N7 diagnosed mediastinal nodal metastases in only =I
nodes ,he sensiti$ity" speci+city and accuracy of EBUS1-N7 #as *>(" '33( and *5("
compared to I)(" ::( and )'( for 2," and 53(" I3( and I=( for 9E, ,he false
negati$e rate #as 5( /n a separate study" Oerth" et al" performed EBUS1-N7 on :3>
patients #ith 2, enlarged mediastinal nodes and reported sensiti$ity" speci+city and
accuracy rates of *@(" '33( and *@( respecti$ely B=C /n this study =I nodes did not
yield a positi$e diagnosis after EBUS1-N7" and =: of these #ere found at surgery to ha$e
malignancy" resulting in a N98 of only ''( Neither study reported any serious
complications follo#ing the procedure
4nly one study has directly compared the accuracy of EBUS1-N7 to mediastinoscopy for
the mediastinal staging of lung cancer 7nnema" et al" performed EBUS1-N7 and
mediastinoscopy on >' patients #ith NS2L2" ') of #hich had normal siEed (&'cm short
a<is dimension) nodes B@C Si< patients had N> or N= nodal metastases" ho#e$er only >
#ere detected by EBUS (@ #ere detected by mediastinoscopy) ,he false negati$e rate of
EBUS1-N7 #as ))(" and ==( for mediastinoscopy Because of the lo# pre$alence of
N>HN= metastases in this study" and the o$erall small number of patients included" it is
diKcult to dra# conclusions form it
4ur surgical group has currently performed o$er :3 EBUS procedures #ithout
complication and training in EBUS is no# part of our resident curriculum Dhether EBUS1
-N7 is as accurate as mediastinoscopy for staging of the mediastinum remains to be
determined and is currently the obJect of an ongoing prospecti$e study at ,he Uni$ersity
of ,e<as M; 7nderson 2ancer 2enter Oo#e$er" gi$en the fact that EBUS a$oids an
operation" is easily practiced in an outpatient setting #ith less morbidity and discomfort
compared to mediastinoscopy" it seems liAely that it #ill become the predominant
method for histologic sampling of mediastinal nodes in the future 9ulmonologists
throughout the country ha$e already embraced EBUS Dith our detailed Ano#ledge of
mediastinal anatomy and technical pro+ciency" it is a simple and natural techni.ue for
thoracic surgeons to master