Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging

Abstract

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Keywords

endoscopic ultrasound - endobronchial ultrasound - esophagus

Publication History

Article published online:
16 May 2022

• References

• 1 Hegde PV, Liberman M. Mediastinal staging: endosonographic ultrasound lymph node biopsy or mediastinoscopy. Thorac Surg Clin 2016; 26 (03) 243-249
• 2 Silvestri GA, Gonzalez AV, Jantz MA. et al. Methods for staging non-small cell 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): 211-250
• 3 Herth FJ, Annema JT, Eberhardt R. et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008; 26 (20) 3346-3350
• 4 Hegde P, Liberman M. eds. Minimally invasive endosonographic techniques: combined EBUS and EUS. In: FJF Herth Shah PL, Gompelmann D. eds. Interventional Pulmonology. Sheffield, United Kingdom: European Respiratory Society; 2017: 121-140
• 5 Hegde P, Goudie E, Liberman M. Endosonographic lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound: technique and technical tricks. Oper Tech Thorac Cardiovasc Surg 2018; 23 (03) 136-150
• 6 Toloza EM, Harpole L, Detterbeck F, McCrory DC. Invasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003; 123 (1, suppl): 157S-166S
• 7 Korevaar DA, Crombag LM, Cohen JF, Spijker R, Bossuyt PM, Annema JT. Added value of combined endobronchial and oesophageal endosonography for mediastinal nodal staging in lung cancer: a systematic review and meta-analysis. Lancet Respir Med 2016; 4 (12) 960-968
• 8 Vilmann P, Clementsen PF, Colella S. et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Endoscopy 2015; 47 (06) 545-559
• 9 Yasufuku K, Pierre A, Darling G. et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011; 142 (06) 1393-400.e1
• 10 Szlubowski A, Herth FJ, Soja J. et al. Endobronchial ultrasound-guided needle aspiration in non-small-cell lung cancer restaging verified by the transcervical bilateral extended mediastinal lymphadenectomy–a prospective study. Eur J Cardiothorac Surg 2010; 37 (05) 1180-1184
• 11 Crombag LMMJ, Szlubowski A, Stigt JA. et al. EUS-B-FNA vs conventional EUS-FNA for left adrenal gland analysis in lung cancer patients. Lung Cancer 2017; 108: 38-44
• 12 Uemura S, Yasuda I, Kato T. et al. Preoperative routine evaluation of bilateral adrenal glands by endoscopic ultrasound and fine-needle aspiration in patients with potentially resectable lung cancer. Endoscopy 2013; 45 (03) 195-201
• 13 Stather DR, Maceachern P, Chee A, Dumoulin E, Tremblay A. Trainee impact on advanced diagnostic bronchoscopy: an analysis of 607 consecutive procedures in an interventional pulmonary practice. Respirology 2013; 18 (01) 179-184
• 14 Hegde P, Liberman M. Echo-endoscopic lymph node staging in lung cancer: an endoscopic alternative. Expert Rev Anticancer Ther 2015; 15 (09) 1063-1073
• 15 Oliveira RL, Liberman M. Endosonographic mediastinal lymph node staging in non-small cell lung cancer: how I teach it. Ann Thorac Surg 2017; 104 (01) 18-21
• 16 Jenssen C, Annema JT, Clementsen P, Cui XW, Borst MM, Dietrich CF. Ultrasound techniques in the evaluation of the mediastinum, part 2: mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography. J Thorac Dis 2015; 7 (10) E439-E458
• 17 Liberman M, Duranceau A, Grunenwald E, Thiffault V, Khereba M, Ferraro P. Initial experience with a new technique of endoscopic and ultrasonographic access for biopsy of para-aortic (station 6) mediastinal lymph nodes without traversing the aorta. J Thorac Cardiovasc Surg 2012; 144 (04) 787-792 , discussion 792–793
• 18 Szlubowski A, Zieliński M, Soja J. et al. A combined approach of endobronchial and endoscopic ultrasound-guided needle aspiration in the radiologically normal mediastinum in non-small-cell lung cancer staging–a prospective trial. Eur J Cardiothorac Surg 2010; 37 (05) 1175-1179
• 19 Dhooria S, Aggarwal AN, Gupta D, Behera D, Agarwal R. Utility and safety of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in mediastinal lymph node sampling: systematic review and meta-analysis. Respir Care 2015; 60 (07) 1040-1050
• 20 Ng J, Chan HP, Kee A, Khoo KL, See KC. Transitioning to combined EBUS EUS-B FNA for experienced EBUS bronchoscopist. Diagnostics (Basel) 2021; 11 (06) 1021
• 21 Hammoud ZT, Anderson RC, Meyers BF. et al. The current role of mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardiovasc Surg 1999; 118 (05) 894-899
• 22 Lemaire A, Nikolic I, Petersen T. et al. Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate. Ann Thorac Surg 2006; 82 (04) 1185-1189 , discussion 1189–1190
• 23 Szlubowski A, Soja J, Kocon P. et al. A comparison of the combined ultrasound of the mediastinum by use of a single ultrasound bronchoscope versus ultrasound bronchoscope plus ultrasound gastroscope in lung cancer staging: a prospective trial. Interact Cardiovasc Thorac Surg 2012; 15 (03) 442-446 , discussion 446
• 24 Annema JT, van Meerbeeck JP, Rintoul RC. et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010; 304 (20) 2245-2252
• 25 Liberman M, Sampalis J, Duranceau A, Thiffault V, Hadjeres R, Ferraro P. Endosonographic mediastinal lymph node staging of lung cancer. Chest 2014; 146 (02) 389-397
• 26 Nasir BS, Edwards M, Tiffault V. et al. Transesophageal pulmonary nodule biopsy using endoscopic ultrasonography. J Thorac Cardiovasc Surg 2014; 148 (03) 850-855 , discussion 855
• 27 Annema JT, Veseliç M, Rabe KF. EUS-guided FNA of centrally located lung tumours following a non-diagnostic bronchoscopy. Lung Cancer 2005; 48 (03) 357-361 , discussion 363–364
• 28 Rintoul RC, Glover MJ, Jackson C. et al. Cost effectiveness of endosonography versus surgical staging in potentially resectable lung cancer: a health economics analysis of the ASTER trial from a European perspective. Thorax 2014; 69 (07) 679-681
• 29 Guinde J, Roy P, Dutau H. et al. An international survey of mediastinal staging practices amongst interventional bronchoscopists. Respiration 2020; 99 (06) 508-515
• 30 Labarca G, Aravena C, Ortega F. et al. Minimally invasive methods for staging in lung cancer: systematic review and meta-analysis. Pulm Med 2016; 2016: 1024709
• 31 Oki M, Saka H, Ando M. et al. Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study. Chest 2015; 147 (05) 1259-1266
• 32 Meena N, Bartter T. Endosonography for mediastinal disease: esophageal ultrasound vs. endobronchial ultrasound. Endosc Int Open 2015; 3 (04) E302-E306
• 33 Pais FM, Shah RA, Vempilly JJ. et al. Transesophageal approach to lung, adrenal biopsy and fiducial placement using endoscopic ultrasonography (EUS): An interventional pulmonology experience. Initial experience of the UCSF-FRETOC (fresno tracheobronchial & oesophageal center) study group. Respir Med 2018; 141: 52-55
• 34 Martinez M, LeBlanc J, Al-Haddad M, Sherman S, DeWitt J. Role of endoscopic ultrasound fine-needle aspiration evaluating adrenal gland enlargement or mass. World J Nephrol 2014; 3 (03) 92-100
• 35 Micames CG, McCrory DC, Pavey DA, Jowell PS, Gress FG. Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: a systematic review and metaanalysis. Chest 2007; 131 (02) 539-548
• 36 Tournoy KG, De Ryck F, Vanwalleghem LR. et al. Endoscopic ultrasound reduces surgical mediastinal staging in lung cancer: a randomized trial. Am J Respir Crit Care Med 2008; 177 (05) 531-535
• 37 Chrysikos S, Karampitsakos T, Zervas E. et al. Thoracic endosonography (EBUS/EUS-b) in the diagnosis of different intrathoracic diseases: a 4-year experience at a single-centre in Greece. Int J Clin Pract 2021; 75 (03) e13684
• 38 Hegde P, Molina JC, Thivierge-Southidara M. et al. Combined endosonographic mediastinal lymph node staging in positron emission tomography and computed tomography node-negative non-small-cell lung cancer in high-risk patients. Semin Thorac Cardiovasc Surg 2020; 32 (01) 162-168
• 39 von Bartheld MB, Versteegh MI, Braun J, Willems LN, Rabe KF, Annema JT. Transesophageal ultrasound-guided fine-needle aspiration for the mediastinal restaging of non-small cell lung cancer. J Thorac Oncol 2011; 6 (09) 1510-1515
• 40 Annema JT, Veseliç M, Versteegh MI, Willems LN, Rabe KF. Mediastinal restaging: EUS-FNA offers a new perspective. Lung Cancer 2003; 42 (03) 311-318
• 41 Erer OF, Erol S, Anar C, Aydoğdu Z, Özkan SA. Diagnostic yield of EBUS-TBNA for lymphoma and review of the literature. Endosc Ultrasound 2017; 6 (05) 317-322
• 42 Stacchini A, Carucci P, Pacchioni D. et al. Diagnosis of deep-seated lymphomas by endoscopic ultrasound-guided fine needle aspiration combined with flow cytometry. Cytopathology 2012; 23 (01) 50-56
• 43 von Bartheld MB, Dekkers OM, Szlubowski A. et al. Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial. JAMA 2013; 309 (23) 2457-2464
• 44 Trisolini R, Baughman RP, Spagnolo P, Culver DA. Endobronchial ultrasound-guided transbronchial needle aspiration in sarcoidosis: beyond the diagnostic yield. Respirology 2019; 24 (06) 531-542
• 45 Vilmann P, Puri R. The complete “medical” mediastinoscopy (EUS-FNA + EBUS-TBNA). Minerva Med 2007; 98 (04) 331-338
• 46 Mehta HJ, Jantz MA. Endobronchial ultrasound-guided intratumoral injection of cisplatin for the treatment of isolated mediastinal recurrence of lung cancer. J Vis Exp 2017; (120) 54855
• 47 Shah RA, Vempilly JJ, Noor Ul Husnain SM, Hegde P. Combined endosonography reduces time to diagnose pulmonary coccidioidomycosis. J Bronchology Interv Pulmonol 2018; 25 (02) 152-155
• 48 von Bartheld MB, van Breda A, Annema JT. Complication rate of endosonography (endobronchial and endoscopic ultrasound): a systematic review. Respiration 2014; 87 (04) 343-351
• 49 Grosu HB, Morice RC, Sarkiss M. et al. Safety of flexible bronchoscopy, rigid bronchoscopy, and endobronchial ultrasound-guided transbronchial needle aspiration in patients with malignant space-occupying brain lesions. Chest 2015; 147 (06) 1621-1628
• 50 Kazakov J, Hegde P, Tahiri M, Thiffault V, Ferraro P, Liberman M. Endobronchial and endoscopic ultrasound-guided transvascular biopsy of mediastinal, hilar, and lung lesions. Ann Thorac Surg 2017; 103 (03) 951-955
• 51 Molina JC, Chaudry F, Menezes V. et al. Transvascular endosonographic-guided needle biopsy of intrathoracic lesions. J Thorac Cardiovasc Surg 2020; 159 (05) 2057-2065
• 52 Konge L, Clementsen PF, Ringsted C, Minddal V, Larsen KR, Annema JT. Simulator training for endobronchial ultrasound: a randomised controlled trial. Eur Respir J 2015; 46 (04) 1140-1149
• 53 Ernst A, Silvestri GA, Johnstone D. American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest 2003; 123 (05) 1693-1717
• 54 Fernández-Villar A, Leiro-Fernández V, Botana-Rial M, Represas-Represas C, Núñez-Delgado M. The endobronchial ultrasound-guided transbronchial needle biopsy learning curve for mediastinal and hilar lymph node diagnosis. Chest 2012; 141 (01) 278-279