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1、Radial Endobronchial Ultrasound (Radial-EBUS)径向超声,Radial Endobronchial Ultrasoun,Radial-EBUS: For What?,Peripheral pulmonary lesions (PPLs) were defined as those that were surrounded by pulmonary parenchyma and not visible by bronchoscopy (no evidence of endobronchial lesion, extrinsic compression,
2、submucosaltumour, or narrowing, inammation or bleeding of the bronchus).,Radial-EBUS: For What?Peripher,PPLs are common problems in clinical practice. Clinical data and radiographic finding, such as chest radiography and computed tomography (CT) can provide some clues for diagnosis. However, in some
3、 circumstances, definite diagnosis is required before deciding on the appropriate treatment. Therefore, respiratory specimens are needed to identify the etiology of the lesions.,PPLs are common problems in cl,Flexible brochoscopy (FB) can reach into the airway up to the subsegmental bronchi; beyond
4、the visual range, the airway continually divides into many generations before the peripheral target is reached. Without guidance, FB cannot guarantee an accurate sampling at the exact location of the PPL.,Flexible brochoscopy (FB) can,Diagnostic yield for routine bronchoscopy for investigation of PP
5、L (i.e. lesions not endobronchially visible) may be 20%.The highest diagnostic yield for bronchoscopic evaluation of PPLs appears to be associated with use of Radial Endobronchial ultrasound (Radial-EBUS).,Diagnostic yield for routine b,Radial EBUS has a 20-MHz (12-30 MHz available) rotating transdu
6、cer that can be inserted together with or without a guide sheath (GS) through the working channel (2.0-2.8 mm) of a standard exible bronchoscope. Radial EBUS transducer probes come in different sizes with external diameters of 1.4-2.6 mm.,Radial EBUS has a 20-MHz (12-3,EBUS Central probes are utilis
7、ed with balloon sheaths in the proximal airways for either bronchial wall assessment or to guide TBNA of lymph nodes. EBUSperipheral probes without balloon sheaths are used to identify parenchymal lung lesions for biopsy.,EBUS Central probes are uti,EBUS was further combined with the guide- sheath (
8、GS) technique. Biopsy forceps covered with a GS can be moved to the lesions under EBUS guidance, after which biopsy and brushing specimens can be sequentially obtained by keeping the GS in the lesion.,EBUS was further combined with,1) to confirm the precise location of PPLs by EBUS imaging even when
9、 such lesions are not visible on X-ray uoroscopy; 2) to facilitate obtaining biopsy and brushing specimens repeatedly by leaving the GS in the PPLs; 3) to obtain biopsy specimens from PPLs that are accessible only through the use of a curette via the GS; 4) to decrease bleeding resulting from trappi
10、ng the GS in the bronchus; and 5) to assess the internal structure of PPLs. Points 2), 3) and 4) are additional values of the GS technique above Radial EBUS alone.,1) to confirm the precise loca,Radial EBUS: How to Use?,Radial EBUS is typically performed after standard bronchoscopic examination of t
11、he tracheobronchial tree, including the subsegmental bronchi.,Radial EBUS: How to Use?Radial,EBUS was performed using an endoscopic ultrasound system (EU-M30S; Olympus, Tokyo,Japan), equipped with a 20-MHz mechanical radial-type probe (XUM-S20-17R; Olympus), having an external diameter of 1.4 mm. FB
12、s with a working channel of 2.0 mm in diameter were used (BF-P-260F, BF-P-240, BF- P-200; Olympus).,EBUS was performed using an en,Endobronchial ultrasonography (EBUS)-guide-sheath (GS)-guided transbronchial biopsy (TBB). a) EBUS probe with GS is advanced to the PPL via FB. After confirmation by EBU
13、S imaging, b) the US probe is pulled out, and c) TBB and bronchial brushing are performed via the GS. When the lesion is not identified by EBUS imaging, d) a curette is inserted into the GS and the appropriate bronchus is selected. e) The curette is then pulled out and f) the EBUS probe is again ins
14、erted into the GS to perform EBUS imaging. After confirmation by EBUS imaging, g) TBB and bronchial brushing are performed.,Endobronchial ultrasonography,Pulmonary masses have a hypoechoic texture when compared with the surrounding tissue, and have sharply defined borders due to the strong reective
15、interface produced between the aerated lung and the lesions.,Pulmonary masses have a hypoec,Radial EBUS, snow storm pattern of normal EBUS image in lung periphery.,Radial EBUS, snow storm patte,Radial probe endobronchial ultrasound image indicating presence of peri- bronchial mass lesion. The positi
16、on of the probe is indicated by the central black circle and the hyper- echoic line (arrows) demonstrates the solid tissueair interface between the peribronchial pulmonary mass lesion (P) and the surrounding lung (L).,Radial probe endobronchial ul,An 82-yr-old male who underwent right upper lung lob
17、ectomy for pulmonary adenocarcinoma and who had thyroid carcinoma 12 yrs previously was admitted to the study hospital with an abnormal chest shadow. a) Chest radiograph and b) computed tomography showed a pulmonary nodule of 8 mm in diameter in the left S3a (arrows). c) Endobronchial ultrasonograph
18、y showed a lowe-choic nodule surrounded by a strong reflected interface produced between the aerated lung and the lesion (arrowheads; scale bar=0.5 cm). Metastatic adenocarcinoma of the thyroid was diagnosed by EBUS-guide-sheath-guided transbronchial biopsy.,An 82-yr-old male who underwen,Typical en
19、dobronchial ultrasonographic image of a single solid pulmonary nodule, in this case a nodule of 14 mm in diameter in the left upper lobe of a 53- yr-old male with a suspected diagnosis of lung cancer.,Typical endobronchial ultraso,Radial EBUS, image of the peripheral pulmonary lesion.,Radial EBUS, i
20、mage of the per,Radial EBUS image of the transducer probe within a peripheral lung lesion that was proven to be adenocarcinoma on histology.,Radial EBUS image of the tran,Radial EBUS: The Sensitivity,Results for sensitivity for detection of malignancy in individual studies ranged from 49% to 88%. Th
21、e point sensitivity for pooled data was 0.73 (95% CI 0.700.76).Pooled statistics demonstrated a diagnostic yield of 56.3% (95% CI 51 61%) and 77.7% (95% CI 7382%) for lesions =20 mm (364 patients) and lesions 20 mm (367 patients), respectively.,Radial EBUS: The SensitivityRe,Radial EBUS: Complicatio
22、n Rates,Complication rates in studies varied from 0%to 7.4%.Experienced only minor self-limiting bleeding. No patients in any study experienced bleeding requiring intervention. Pneumothorax rate varied from 0% to 5.1%, with a pooled rate of pneumothorax across studies of 1.0% (11 out of 1,090). The
23、pooled rate of intercostal catheter drainage of pneumothorax was 0.4%.No deaths were reported in any Radial EBUS studies.,Radial EBUS: Complication Rate,Radial EBUS: Advantages over AlternativeTechniques for PPLs,Radial EBUS: Advantages over,1. Routine bronchoscopy,Diagnostic yield for routine bronc
24、hoscopy for investigation of PPLs (i.e. lesions not endobronchially visible) may be 20%.,1. Routine bronchoscopyDiagnos,2. FB under X-ray uoroscopic guidance,Nodules of 20 mm in diameter are difficult or impossible to visualise with fluoroscopic guidance. Thus, for these nodules, an overall diagnost
25、ic sensitivity of 33% (range 576%) in a meta- analysis.Accuracy of diagnosing PPLs using FB under X-ray uoroscopic guidance is reportedly 1471%. One factor that potentially limits the diagnostic accuracy of the standard bronchoscope is lesion size, as lesions2 cm have very low yields ranging 1142%.,
26、2. FB under X-ray uoroscopic,3. Electromagnetic navigation (EMN),An alternative to fluoroscopic guidance is electromagnetic navigation, which can guide the biopsy of peripheral lesions. The reported success in sampling lesions of 30 mm in diameter is 65%.However, electromagnetic navigation is not wi
27、dely available and requires thin-section computed tomography (CT) for planning and expensive disposables.EMN is an alternate guidance mechanism however it is very expensive and diagnostic accuracy is not significantly better than EBUS-TBLB.,3. Electromagnetic navigation,4. CT-guided percutaneous nee
28、dle aspiration (CT-PNB),CT-guided transthoracic needle aspiration may result in a diagnosis in 7496% of patients, again depending on lesion size, but is associated with reported pneumothorax rates that range 1544%.CT-guided needle biopsy and observed that sensitivity for detection of malignancy usin
29、g CT- PNB in most studies exceeds 90%; however, 20% of procedures were non-diagnostic, reflecting the lower yield of CT-PNB in benign conditions.,4. CT-guided percutaneous need,4. CT-guided percutaneous needle aspiration (CT-PNB),Although success rates CT-PNB might be very high, with 7697% diagnosti
30、c accuracy, these techniques have several problems. First, they have the potential to spread malignant cells from the tumour into the pleural cavity. For patients with poor pulmonary function, these techniques result in an increased risk of pneumothorax. Moreover, systemic arterial air embolism is a
31、 rare but severe complication.,4. CT-guided percutaneous need,4. CT-guided percutaneous needle aspiration (CT-PNB),In comparison, many studies describing CT- PNB report pneumothorax rates 25%, and as high as 69%, with many of these patients requiring admission or even intercostal catheter drainage.
32、Pulmonary haemorrhage is less frequent, but still complicates 110% of CT-PNB.,4. CT-guided percutaneous need,5. Radial EBUS: Initial procedure,With additional use of a GS, localization of the lesion has consistently translated to better diagnostic yields ranging from 73 to 92 percent.EBUS-TBLB has i
33、mproved diagnostic yield of bronchoscopic investigation of PPLs to a level more comparable to CT-PNB, with improvement in sensitivity most apparent for smaller lesions.,5. Radial EBUS: Initial proced,5. Radial EBUS: Initial procedure,The major advantage of EBUS-TBLB over CT- PNB is its safety profil
34、e. A meta-analysis demonstrated an overall pneumothorax rate of just 1.0%, and an overall intercostal drain insertion rate of 0.4%.,5. Radial EBUS: Initial proced,Radial EBUS: Prospect,With excellent specificity and sensitivity markedly higher than for routine bronchoscopy, although a little lower t
35、han for CT-PNB, an extremely favourable safety profile of EBUS-TBLB, supporting initial investigation of patients with PPLs using EBUS-TBLB.,Radial EBUS: ProspectWith exce,EBUS has the potential to become part of standard bronchoscopy because of negligible complications, improved diagnostic yield an
36、d short learning curve.,EBUS has the potential to beco,Radial EBUS: Influencing Factors of Sensitivity,Lesion size?-Most important, variation in size of PPLs.Lobe?-YAMADA et al. noted a higher yield for PPLs positioned in the right middle lobe and lingular lobe, EBERHARDT et al. noted higher yield i
37、n the right middle and right lower lobes and KURIMOTO et al. noted a significantly lower yield for the apicoposterior left upper lobe segment.,Radial EBUS: Influencing Facto,Malignant?-Higher sensitivity for detection of malignant compared to benign lesions.Probe within lesion?-Unsurprisingly, ident
38、ification of PPL position by the EBUS probe was associated with higher diagnostic.,Malignant?-Higher sensitivit,Central or peripheral lesion?-Proximity of PPL to the pulmonary hilum was reported to be associated with increased diagnostic, a lower sensitivity in pleurally based or sub- pleural lesion
39、s.Number of samples?-Noted an improved yield to a plateau of five biopsies.,Central or peripheral lesion?-,Radial EBUS: Images PPLs,Radial EBUS: Images PPLs,Radial endobronchial ultrasound images for ground-glass opacity pulmonary lesions,Radial endobronchial ultrasoun,Since the introduction of low-
40、dose helical computed tomography (CT) scanning for lung cancer screening, the frequency of detecting pulmonary ground-glass opacity (GGO) has been about 20%. GGOs commonly represent a variety of diseases such as interstitial pneumonia, pulmonary lymphoproliferative disease, organising pneumonia, and
41、 pre- invasive, minimally invasive or moderately/poorly differentiated carcinoma.,Since the introduction of low-,Radial EBUS images,The R-EBUS images of GGOs were named blizzard or mixed blizzard.,Radial EBUS imagesThe R-EBUS i,Blizzard sign,The blizzard sign was defined as a subtle, but noticeable
42、increase in the intensity and radius of the whitish acoustic shadow while scanning from normal lung tissue to the ground-glass area. This change in the ultrasound signal is similar to a whiteout and has a relatively larger radius from the centre of the probe compared with the R-EBUS snowstorm appear
43、ance generated while scanning the area of normal alveolar tissue. On meticulous inspection, the details that constitute the acoustic signal are relatively thick and crude compared with the details that constitute the refined snowstorm appearance of normal lung tissue.,Blizzard signThe blizzard sign,
44、Mixed blizzard sign,In the mixed blizzard sign the internal echo of the lesions demonstrated diffuse heterogeneity with several hyperechoic dots, linear arcs and vessels that were distributed irregularly or combined with the blizzard sign.,Mixed blizzard signIn the mixe,Blizzard sign- mechanisms,Bli
45、zzard sign on the R-EBUS image was consistently observed in lesions with more GGO component. The mechanism behind this change is diffraction phenomenon. Pure and GGO-dominant lesions demonstrate this pattern on R-EBUS (blizzard) and this could be explained by the large amount of residual air in the
46、intact alveoli (without stromal invasion).,Blizzard sign- mechanismsBliz,Mixed blizzard sign- mechanisms,The mixed blizzard sign on the R-EBUS image was not found in any pure GGO lesion, but was consistently observed in lesions with a larger proportion of solid component. All blizzard lesions were o
47、n the spectrum of adenocarcinoma in situ to well- differentiated adenocarcinoma, while the majority of mixed blizzard lesions were well-differentiated invasive lepidic-predominant and moderately to poorly differentiated adenocarcinoma. This signal, mixed blizzard, may represent tumour invasion beyon
48、d the alveolar spaces, which usually happens when a GGO lesion develops a solid component.,Mixed blizzard sign- mechanis,Mixed blizzard sign- mechanisms,The ultrasound image can be easily recognized because it appears hypoechoic compared with the snowstorm appearance of normal lung and can be explai
49、ned by the difference in the medium through which the ultrasound wave was propagated (i.e., air-filled alveolar space versus alveolar space with less or no air). The GGO component that usually surrounds the periphery of a part-solid lesion corresponds to the area that generates a blizzard signal in
50、the R-EBUS image.,Mixed blizzard sign- mechanis,a) Normal lung. b) A subtle, but noticeable increase in the intensity and radius of the whitish acoustic shadow (blizzard sign). c) Mixed blizzard sign, a diffusely heterogenous acoustic shadow (with some hyperechoic dots, linear arcs and vessels) that
