Radial-EBUS-径向超声及其杂交技术(英文版)课件.pptx
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1、Radial Endobronchial Ultrasound (Radial-EBUS)径向超声径向超声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,submucosaltumour,or narrowing,infla
2、mmation or bleeding of the bronchus).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 circumstances,definite diagnosis is required before deciding on the app
3、ropriate treatment.Therefore,respiratory specimens are needed to identify the etiology of the lesions.Flexible brochoscopy(FB)can reach into the airway up to the subsegmental bronchi;beyond the visual range,the airway continually divides into many generations before the peripheral target is reached.
4、Without guidance,FB cannot guarantee an accurate sampling at the exact location of the PPL.Diagnostic yield for routine bronchoscopy for investigation of PPL(i.e.lesions not endobronchially visible)may be 20%.The highest diagnostic yield for bronchoscopic evaluation of PPLs appears to be associated
5、with use of Radial Endobronchial ultrasound (Radial-EBUS).Radial EBUS has a 20-MHz(12-30 MHz available)rotating transducer that can be inserted together with or without a guide sheath(GS)through the working channel(2.0-2.8 mm)of a standard flexible bronchoscope.Radial EBUS transducer probes come in
6、different sizes with external diameters of 1.4-2.6 mm.EBUS Central probes are utilised 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 bio
7、psy.EBUS was further combined with the guide-sheath(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.1)to confirm the precise location of PPLs by EBUS i
8、maging even when such lesions are not visible on X-ray fluoroscopy;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
9、 from trapping 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.Radial EBUS:How to Use?Radial EBUS is typically performed after standard bronchoscopic examination of the tracheobronchial tree,inc
10、luding the subsegmental bronchi.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.FBs with a working channel of 2.0 mm in diameter were used(BF-P-260F,BF
11、-P-240,BF-P-200;Olympus).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 EBUS imaging,b)the US probe is pulled out,and c)TBB and bronchial brushing are performed via the GS.When the lesion
12、 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 inserted into the GS to perform EBUS imaging.After confirmation by EBUS imaging,g)TBB and bronchial brushing are performed.Pu
13、lmonary masses have a hypoechoic texture when compared with the surrounding tissue,and have sharply defined borders due to the strong reflective interface produced between the aerated lung and the lesions.Radial EBUS,snow storm pattern of normal EBUS image in lung periphery.Radial probe endobronchia
14、l ultrasound image indicating presence of peri-bronchial mass lesion.The position 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).An 82-yr-
15、old male who underwent right upper lung lobectomy 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(a
16、rrows).c)Endobronchial ultrasonography 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.Typical
17、endobronchial 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.Radial EBUS,image of the peripheral pulmonary lesion.Radial EBUS image of the transducer probe withi
18、n a peripheral lung lesion that was proven to be adenocarcinoma on histology.Radial EBUS:The Sensitivity Results for sensitivity for detection of malignancy in individual studies ranged from 49%to 88%.The point sensitivity for pooled data was 0.73(95%CI 0.700.76).Pooled statistics demonstrated a dia
19、gnostic 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:Complication Rates Complication rates in studies varied from 0%to 7.4%.Experienced only minor self-limiting bleeding.No patients in any study experienced
20、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 pooled rate of intercostal catheter drainage of pneumothorax was 0.4%.No deaths were reported in any Radial EBUS studies.Radial EBUS:Advantages over
21、Alternative Techniques for PPLs1.Routine bronchoscopy Diagnostic yield for routine bronchoscopy for investigation of PPLs(i.e.lesions not endobronchially visible)may be 20%.2.FB under X-ray fluoroscopic guidance Nodules of 20 mm in diameter are difficult or impossible to visualise with fluoroscopic
22、guidance.Thus,for these nodules,an overall diagnostic sensitivity of 33%(range 576%)in a meta-analysis.Accuracy of diagnosing PPLs using FB under X-ray fluoroscopic guidance is reportedly 1471%.One factor that potentially limits the diagnostic accuracy of the standard bronchoscope is lesion size,as
23、lesions2 cm have very low yields ranging 1142%.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 navigat
24、ion is not widely 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.4.CT-guided percutaneous needle aspiration(CT-PNB
25、)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 using CT-PNB in most studies e
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