EBUS Plymouth experience. Cyrus Daneshvar Consultant Respiratory Medicine

Transcription

1 EBUS Plymouth experience Cyrus Daneshvar Consultant Respiratory Medicine

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5 Introduction Plymouth historically referred to Exeter Introduced in October 2014 Anticipated 50 procedures in the first year based on previous referral rates Rapid on-site evaluation (ROSE) considered to be unnecessary

6 Training Spent training period in Oxford with initial experience following introduction of EBUS by David Breen. Followed David Breen to Galway University Hospitals for a one year interventional fellowship

7 Centre experiences Slide processing was variable ROSE rarely used with exception of high suspicion of small cell lung cancer (<4%) Quicker to perform systematic sampling and place samples straight into formalin Baseline diagnostic yield - >90% - based on 3 passes per nodal station

8 Early experience Oxford: Approximately 2 per week initially By end of training 4-5 per week Galway: Initially 3 per week Currently 4-5 per week

9 Plymouth Similar size centres Anticipated similar expansion First year 150 procedures Second year on target for 200 procedures

10 Process

11 T-CT -EBUS Step 1 - selection T-CT EBUS T-CT eek EBUS Are there lymph nodes? CT criteria are unreliable PET-CT avidity is unreliable Is there anything else that would upstage? Is it appropriate?

12 1 in 5 nodes <10 mm 25% positive diagnosis 7% non-representative 3% borderline

13 180 patiets PET-CT PPV 47% NPV 86% 91 PET-CT 89 No PET-CT 14% of FDG negative nodes were malignant 52% of FDG avid nodes were benign 61 PET-CT pre-ebus 14 PET-CT <1 week afterebus 16 PET-CT >1 week afterebus 106 nodes 24 nodes 37 nodes

14 Neck ultrasound: Lung cancer by radiological staging Number of patients Neck Lymph nodes present Abnormal lymph nodes Stage I-IIIA 8 6 (75%) 1 (13%) IIIB-IV (94%) 8 (50%) N stage (0%) 0 (0%) (67%) 1 (17%) (86%) 2 (29%) (100%) 6 (75%)

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16 Step 2 Consent Step 3 Typically minor effects effects Serious side effects Derived from the Acquire Registry and large Japanese registry WHO safety checklist

17 Step 4 Sedation Local anaesthetic mouth Midazolam Fentanyl Spray as go

18 Procedure Plymouth Galway Male n(%) 136 (53%) Age (years) 68 [58-75] 59 Light sedation 99% Midazolam (mg) 3 [2-4] 6 [4-7] Fentanyl (mcg) 50 [50-75] Oxygen via nasal cannula 4 [2-5] l/min Comfort score (0-10; 10 bad) Doctor 3 [1-6] Nurse 4 [1-6] Patient 3 [1-5]

19 Examination Initially inspect airways within the limitations of the EBUS optic Systematic examination of the mediastinum using ultrasound Describe nodal sites Short axis Shape Echogenic properties Vascularity

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28 Coils White Black Clots

29 Next... We pray Sometimes we panic Sometimes we check to see if our specialist pathologist is on annual leave Occasionally we use a core needle

30 Total number of procedures 256 Total number of nodes sampled 504 Size 13 [10-20] mm Representative sample 456 (90%) Borderline sample 14 (2.7%) Non-representative 34 (6.7%) Positive 236 Negative 208 Suspicious 4 Non-diagnostic 8 Lung cancers 151 Metastatic disease 32

31 Sampling sites in 146 patients Sampling sites in 256 patients 1 32 (1.2%) (1%) Station 3 3 (1.2%) Primary 6 (2.3%) ot (53%) (48%) (21%) (9%) 212 (1%) (5%) (25%) (36%) (49%) (68%) 3267 (22%) (26%)

32 SCLC NSCLC Metastasis Sarcoid TB Lymphoma

33 NSCLC Molecular testing 46 patients 76 nodes 9 (12% <10mm) Mixed NSCLC/SCLC NOS Adeno squam Adeno also sent for ALK-FISH 1 fell off plate 5 negative 1 positive 0/0 3/3 2/2 32/33 97% EGFR extraction (7%)

34 ROSE Diagnosis Number Nodes ROSE Reduction in procedure time SCLC Yes 156 minutes NSCLC squamous Maybe NSCLC adeno Maybe Sarcoid Maybe Metastastic disease Maybe Time saving = procedurally is minimal?

35 Current ROSE 3 studies that are adequate for meta-analysis: 2- retrospective 1- RCT but limited numbers 1650 passes 1100 passes Conclusions: 4950 minutes 3300 minutes Reduced number of passes Time of procedure equivalent Sensitivity and diagnostic accuracy equivalent Time saved 27 hours (21 minutes per week) Pathology tim at procedure 234 hours (3 hours per week)

36 Sampling Storm Bronchial biopsy Other samples EBUS nodal samples Total bronch bx assoc sampling

37 Total number of bronchoscopy samples 800 Total Total

38 Endobronchial disease Lung cancer diagnosis Nodal disease by CT endobronchial component No endobronchial component

39 CT guided biopsy (Galway data) Number of referral Cancer n (%) 54 (17%) 90 (19%) Patients with peripheral lesions and mediastinal lymphadenopathy PN+mediastinal lymphadenopathy undergoing CT guided biopsy* Total number of CT guided thoracic procedures** (100%) 28 (37%) 49 (15.5%) 49 (10.1%) * p <0.001; ** p= 0.02

40 Conclusions Introduction to Plymouth successful so far Services need to expect growth in the first few years Avoids more invasive procedures Shortens 2WW diagnostic pathway ROSE is probably a luxury

41 Thank you And to all the secretaries, nursing staff, colleagues, laboratory staff and technicians for the essential collective effort it takes to run the service.

42 How Sampling Apply lidocaine Insert needle 13 step procedure Pass into node under direct vision Apply suction or no suction Move back and forth 8-12 times, adjusting angles Turn suction off and remove needle Content placed into labeled pot of formalin Repeat 4 times per node +/- 1 sample for microbiology

43 Sampling sites in 146 patients GUH 1 2 (1%) ot 78 (53%) 13 (9%) 2 (1%) 52 (36%) 72 (49%) 32 (22%)