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Clinical Briefing: Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration For Diagnosis of Thoracic Adenopathy & Lung Cancer Staging

November/December 2008

Interventional pulmonologists at the Hospital of the University of Pennsylvania are using a new minimally invasive technology, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), to diagnose thoracic adenopathy and to stage lung cancer less invasively. EBUS-TBNA integrates ultrasonography, video-enhanced visualization and real-time echogenic needle aspiration into a single, flexible, bronchoscopy unit (Figure 1).

Using EBUS-TBNA, Penn interventional pulmonologists can observe and differentiate all mediastinal and hilar structures with the integrated ultrasound videobronchoscope. The unit’s dedicated 22-gauge needle can be seen with standard video visualization. More importantly, the needle is visualized under real-time ultrasound during the lymph node biopsy. This dedicated aspiration needle can be extended to roughly 4 cm and is capable of obtaining large core biopsies for cytologic and histopathologic analysis.

With this technology, Penn interventional pulmonologists can diagnose thoracic adenopathy and stage lung cancer with a minimally invasive approach using only conscious sedation in a same-day outpatient procedure. Clinical studies have shown that for lung cancer diagnosis and staging, the sensitivity and accuracy of EBUS-TBNA are nearly equivalent to the current gold standard, cervical mediastinoscopy. At Penn, this technology is actively being used to diagnose thoracic adenopathy and to stage cancers earlier and less invasively than previously possible.

Case Study
Mr. R., a 67-year-old man with an 80 pack-year history of tobacco abuse presented to his primary physician with cough. When his cough did not respond to antibiotics, his primary physician ordered a chest X-ray which demonstrated a right lung mass. The patient was referred to Penn Interventional Pulmonary Services for evaluation and diagnosis. A chest CT scan demonstrated a 4.2 x 3.4 cm right upper lobe lung mass with a 1.4 cm right hilar, a 1.1 cm right paratracheal, and 1.4 cm subcarinal lymph node (Figure 2). The Interventional Pulmonology Program then performed an EBUS-TBNA of the subcarinal and right paratracheal lymph nodes (Figure 3).

On-site cytologic analysis demonstrated lymphocytes without lung cancer in the subcarinal lymph node, but did demonstrate lung cancer in his right paratracheal lymph node. With the diagnosis of advanced regional lung cancer, the patient was not deemed a surgical candidate and was begun on concurrent definitive chemoradiotherapy. The patient has had a very good response to aggressive therapy.

Our Team of Faculty
Interventional Pulmonology Services at the Hospital of the University of Pennsylvania offers a broad array of diagnostic, therapeutic and palliative airway and pleural procedures. Treatments offered include flexible and rigid bronchoscopy with laser, electrocautery, and argon plasma tumor debulking modalities, endobronchial stenting, balloon brocho-plasty, early lung cancer detection via LIFE-Lung fluorescence bronchoscopy, endobronchial brachytherapy, photodynamic therapy, and indwelling tunneled catheters and pleuroscopy for pleural effusions.

The program is actively involved in many clinical trials evaluating various novel immunotherapeutic treatments for patients with lung cancer, mesothelioma, and metastatic pleural disease. In addition, the program participates in several clinical trials investigating novel bronchoscopic treatments for emphysema and asthma.

Daniel Sterman, MD
Associate Professor of Medicine
Director, Interventional Pulmonology and Thoracic Oncology

Andrew Haas, MD, PhD
Assistant Professor of Medicine
Medical Director, Interventional Pulmonology and Thoracic Oncology

Colin Gillespie, MD
Instructor of Medicine
Director of Education, Interventional Pulmonology and Thoracic Oncology

Anil Vachani, MD
Assistant Professor of Medicine
Director of Clinical Research,
Interventional Pulmonology and Thoracic Oncology

Locations
Patient appointments are available at:

Penn Lung Center
Hospital of the University of Pennsylvania
Interventional Pulmonology Services
3 Ravdin, Suite F
3400 Spruce Street
Philadelphia, PA 19104

To refer a patient and/or consult with a doctor, call 800-789-PENN (7366) or refer a patient online.

	Referring Physicians: To speak with a Penn physician or refer a patient, contact PennHealth through the secure online referral form or by calling 1-800-789-PENN (7366).