Systematic Endobronchial Ultrasound - The Six Landmarks Approach

Summary

Endobronchial ultrasound-guided sampling using transbronchial needle aspiration plays a key role in staging and diagnosing lung cancer. We propose a systematic stepwise approach dividing the procedure into six landmarks that should be taught to new operators.

Abstract

Lung cancer is the leading cause of cancer mortality globally. To ensure the correct diagnosis and staging in relation to treatment options, it is crucial to obtain valid biopsies from suspected tumors and mediastinal lymph nodes and accurate identification of the mediastinal lymph nodes regarding the Tumor-Node-Metastasis (TNM)-classification. Flexible bronchoscopy combined with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is essential in the workup and diagnosis of patients suspected of lung cancer. EBUS-TBNA from mediastinal lymph nodes is a technically difficult procedure and has been identified as one of the most important procedures that should be integrated into a simulation-based training program for invasive pulmonologists. More specific guidelines that govern training in EBUS-TBNA are needed to meet this demand. We hereby propose a systematic, stepwise approach with specific attention to six landmarks that support the endoscopist when navigating through the bronchial maze. The stepwise approach relying on the six landmarks is used in the EBUS-certified training program offered by the European Respiratory Society (ERS).

Introduction

Lung cancer is one of the most common cancers worldwide with 2.21 million cases in 2020, and the most frequent cause of cancer death with 1.80 million deaths in 2020¹. As with most cancers, fast and accurate diagnosis of lung cancer is crucial to be able to offer the best treatment, which in cases with a localized disease with no or little spreading to mediastinal lymph nodes can be surgical removal of the tumor. In order to be able to confirm or invalidate the suspicion of malignancy and to determine the Tumor-Node-Metastasis (TNM)-classification if lung cancer is confirmed², it is extremely important to have good and r....

Protocol

This study uses the EVIS Exera II endoscopy tower with a BF-UC180F EBUS endoscope (Figure 1) to demonstrate the scope and the Surgical Science Simulator (ENDO mentor suite) with the GI-Bronch Mentor software from Simbionix, Essential EBUS Case 6, when performing the EBUS procedure in the simulation-based setting. No patients are included in the study as the entire procedure is performed on the Surgical Science Simulator (ENDO mentor suite). Prior to the EBUS procedure, a complete bronchoscopy is performed using a regular bronchoscope to make sure the bronchial tree has been visualized systematically and to identify key anatomical position....

Results

The above-mentioned structured approach to an EBUS-TBNA procedure has been taught at CAMES since 2016 as part of the EBUS-certified training program offered by the European Respiratory Society (ERS)⁷. The 6 landmarks approach is based on a validated assessment tool for measuring competency in EBUS-guided transbronchial needle aspiration⁴. By performing EBUS-TBNA in a structured way, as shown above, no important lymph nodes will be missed, and the diagnostic accuracy will be.......

Discussion

We hereby propose a systematic approach to the EBUS-TBNA procedure by splitting the anatomy into six landmarks to help guide the endoscopist through the bronchial maze. Furthermore, we demonstrate how to perform needle aspiration in a systematic way possible to repeat every time to standardize the procedure.

Even though the simulation-based setting is a safe environment, the endoscopist should be aware of some critical steps in the procedure. Initially, it is important to know the oblique angl.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
EVIS Exera II endoscopy tower with a BF-UC180F EBUS endoscope	Olympus	https://medical.olympusamerica.com/products/bf-uc180f-ebus-bronchoscope
ENDO mentor suite	Surgical Science	https://simbionix.com/endo-mentor-suite/	Surgical Science Simulator
GI-Bronch Mentor software	Simbionix	https://simbionix.com/simulators/gi-mentor/