胸骨后甲状腺活检使用支气管内超声引导下经支气管针吸

JoVE Journal
Medicine

Your institution must subscribe to JoVE's Medicine section to access this content.

Fill out the form below to receive a free trial or learn more about access:

 

Cite this Article

Copy Citation | Download Citations | Reprints and Permissions

Kumar, A., Mohan, A., Dhillon, S. S., Harris, K. Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration. J. Vis. Exp. (93), e51867, doi:10.3791/51867 (2014).

Please note that all translations are automatically generated.

Click here for the english version. For other languages click here.

Abstract

胸骨后甲状腺肿(STG),约占5.8%的纵隔病变1。有在由于缺乏对STG的一个统一的定义已发布的发生率有很大不同。活检通常需要区分恶性病变是良性的。与颈椎甲状腺,上覆胸骨排除STG超声引导下经皮细针穿刺。因此,外科纵隔镜是在大多数情况下进行的,从而导致显著过程相关的发病率和成本的医疗服务。支气管内超声引导下经支气管针吸活检(EBUS-TBNA)是一种常用的方法进行诊断的非小细胞肺癌(NSCLC)和分期。可以使用EBUS实时超声引导下进行微创活检为邻近于气道病变。其安全性和功效是公认的具有超过90%的灵敏度和特异性。执行EBUS作为能力与同一天排放的门诊手术具有明显的发病率和资金优势的手术。当执行EBUS医师获得程序的专门知识,他们试图分散其中的非淋巴结胸椎病状的诊断作用。我们在这里提出的EBUS-TBNA作用于胸骨后甲状腺病变的诊断,随着一步一步的协议的过程。

Introduction

胸骨后甲状腺肿(STG)是生长缓慢的肿瘤,最终导致症状的病例中70%-80%。按照文献综述,STG的2.5-22.6%之间可有恶变2。气管,食管,喉返神经和上腔静脉的压迫常常会导致像呼吸困难,喘鸣,咳嗽,吞咽困难,发音困难,声带麻痹,Horner氏综合征,上腔静脉综合征,脑水肿症状。也有报道显性甲亢偶然的情况下。一项回顾性研究由Shin 等人报道了甲状腺的大小和呼吸急促的存在,梅核气的感觉,和3甲亢症状之间存在正相关关系。这项研究,但没有发现甲状腺肿大尺寸和吞咽困难的存在,局部不适,改变声音,咯血,或甲状腺功能减退的症状之间的相互关系。无论胸骨后及颈部甲状腺肿进行类似恶性肿瘤的风险。 HoweveR,胸骨位置,使活检诊断和治疗STG非常具有挑战性的。大多数情况下,最终需要手术切除纵隔镜使用或胸骨。

支气管内超声(EBUS)最早是在1992年由Hurter和Hanrath 4所示 。多年来,EBUS-TBNA成为了选择用于诊断非小细胞肺癌和分期的方法。报告的敏感性,特异性和阳性预测值EBUS-TBNA对纵隔及肺门淋巴结肿大为94%,100%和100%分别有并发症发生率低使得它非常安全,有效,优于传统的滨海新区5。然而,常规和EBUS引导新区被发现有统计学上相似的结果为隆突淋巴结6。

两种类型的EBUS探针已经开发到目前为止 - 径​​向探头(RP-EBUS)和曲线形探针(CP-EBUS)。 RP-EBUS是第一个成为1999年商用它拥有水充气的气球提示里面薄薄的超声探头。探头转动一角度360°垂直于插入轴线的方向。膨胀的气球提供了一个圆形接触的探针,从而使其能够获取周围气道的360°视图。它是用于评价外周位于病变7,8的中央气道的气道浸润的评估,并获得活检。后病灶局限,径向探头必须取出引导鞘在支气管镜的工作通道让路活检工具。因此,一个实时超声引导的活检不能进行。三个不同的径向探测当前可用 - 20 MHz和30 MHz的微型探针,以及20 MHz的超微型探头。微型探针可以通过支气管镜在280毫米的工作通道插入,到达子断片的气道;更高的频率探头提供更好的图像清晰度olution 9。为1.4毫米的外径,所述的超微型探头适合的小支气管镜2毫米的工作通道,并到达多个外围病变。

CP-EBUS于2005年引入的是一个7.5兆赫凸探针生理盐水膨胀气囊,在支气管镜的前端内侧( 图1)。支气管镜管的外径为6.3毫米,且尖端的为6.9毫米。工作通道的内径为2.2毫米。范围看起来在一个35°向前倾斜角,用图的80°( 图2)的角度。凸探头本身产生一个50°的图像,并且扫描平行于插入轴线。超声图像可以通过使用前向屈曲,或通过附加膨胀球囊用生理盐水直接将探头在支气管壁而得到。水比超声波的空气更好的导体,并且提高了图像质量。沃什丘拉尔结构可以从使用​​彩色多普勒模式扫描组织区别开来。使用专用的22或21g的新区针与回声-凹形前端( 图3),其散发出来,在20°至支气管镜的长轴的角度进行活检。针具有40毫米的最大挤压行程,以用于停止它为20mm,以防止过度的突出部的安全机构。在针的内部导线最小化样品污染,而针穿过支气管壁。它也可用于清理针后,已通过支气管壁并进入靶疾患通过。的愿望“通过”的最佳数目据说是3-7令人满意的样品,但最高产量是从第一遍10,11。的图像中的专用超声处理器处理。这两种超声波和白光支气管镜图像在监视器上同时可见,允许EASY导航到疑似病变的部位。 CP-EBUS具有中度的镇静或全身麻醉进行实时新区直接超声引导的能力。该过程可以在门诊进行,消除了外科手术相关的发病率和需要住院手续。

为胸骨后甲状腺的诊断使用EBUS-滨海新区是新的,据报道,在只有少数病例报告12-18。根据目前的文献回顾,本文试图阐述的程序要求,并提出EBUS-TBNA的方式为胸骨后甲状腺活检。请注意,上面的设备的描述更具体奥林巴斯公司还有其他可商购的产品,以及,和较小的变化是存在的。

Subscription Required. Please recommend JoVE to your librarian.

Protocol

下面列出的协议遵循机构(美国纽约州立大学布法罗分校罗斯威尔帕克癌症研究所,NY)的指导方针。

1,前期准备工作

  1. 在中度镇静进行支气管内超声引导下经支气管针吸活检(EBUS-TBNA),监测麻醉护理(MAC),或深度镇静和全身麻醉。
    注:病人的调查显示良好的满意度与中度镇静19,但最近的数据显示,采用全身麻醉20高诊断率。
  2. 或者,执行该程序,而不在中度镇静的气道装置。使用喉罩(LMA;大小4)涉及深度镇静或全身麻醉过程。
    注:使用LMA的病变在气管较高。由于胸骨甲状腺高气管的位置,气管插管不应该在这些情况下使用的
  3. <利>在实验过程中,使用最低有效剂量的1%或2%利多卡因(的≤7毫克/公斤的累积最大剂量;最大血清浓度≤5毫克/升)用于局部麻醉气道通过支气管镜的工作通道21。

2.预过程监控支气管镜检查

  1. 通过口腔,或在LMA介绍常规的柔性支气管镜进入气道。执行每个子段的左和右气管支气管树的支气管明显异常的顺序检查和确保足够的呼吸道畅通。通过抽吸清洁任何分泌物或粘液的气道。完成时从气道中删除支气管镜。

3.本地化兴趣的病变

  1. 引入凸探头,支气管内超声(CP-EBUS)支气管镜具有35°向前倾斜的角度来看。观察前气道壁和相邻的腔的得到控制而一小部分Ë推进支气管镜集中在气道。当通过声带传递,确保声门开放的只有前角可见。当气管,看到整个管腔与35°后倾屈需要。
  2. 当使用白光支气管镜观察显示屏幕。前进支气管镜到病灶的估计水平。始终,确保推进支气管镜,当管腔不完全可见。管腔的全视图表明CP-EBUS探针的尖端处于向后弯曲,并造成对后气道壁创伤刮削的风险。
  3. 到达所感兴趣的所需部位后,膨胀用约2ml生理盐水的气球。弯曲的CP-EBUS前进的尖端,使之与气道的接触。
  4. 打开使用专用超声处理器超声图。使用双屏幕显示(或分屏显示)看的这两个的内窥镜图管腔,以及相应的超声波图像一起在屏幕上。
  5. 确保EBUS支气管镜在屈曲位。动在小角度对CP-EBUS顺时针和逆时针方向在同一水平,以确定所述胸骨甲状腺。找出病灶。通过移动它向上和向下的,使得病变的最大直径被认为是调整CP-EBUS探针。
  6. 利用多普勒模式中,确定在相邻的血管结构,以确定病变的准确站22,并避免血管意外穿刺。
  7. 在损伤的程度,弯曲的EBUS支气管镜向前的顶端,以便其超声探针与所述气道接触,得到的病变的超声图。当需要时,弯曲的尖向后完全内窥镜观察。重复的机动飞行,并确定一个点两个气管环之间的滨海新区落针的。

4.获得支气管超声引导支气管穿刺活检

  1. 与CP-EBUS尖在中性(非弯曲)的位置,引入专用的22或21g的新区针入EBUS支气管镜的工作通道中。固定在针组件上使用的锁定机构的工作通道。
  2. 松开鞘调节旋钮和推进护套,使针尖可以勉强可视内窥镜图像上。现在固定鞘调节旋钮。
  3. 弯曲的CP-EBUS探头向前,使之与气道壁接触。上的超声图像,再次确认病灶的最长直径与针的突出路径对齐。确保针离开工作通道以20°的角度。
  4. 松开针调节旋钮,并通过气道壁穿刺进入实时超声引导下病变。随着病变内EBUS针,动摇内部钢丝清理出针尖。
  5. 除去内部STylet并附加20毫升真空产生注射器施加负压力。
  6. 移动针回的往复(“通”)的病灶内,用 - 20毫升负压通过一个特殊的真空产生注射器施加。总共有3-7遍,建议根据目前的文献10,11。
  7. 使遍足够数量后,负压旋钮处于关闭状态,并针被检索出的工作通道。
  8. 使用内部鞘压出组织学的核心。同时获得组织学核心以及细胞学抽吸通过该方法。另外,使用空气填充的6或12毫升注射器排出针的内容到幻灯片上,或在样品杯中。
  9. 确定使用的现场服务细胞学样品的adequateness。

5.手术后支气管镜检查监督

  1. 删除CP-EBUS支气管镜活检出来之后。重新引入传统支气管镜和执行监督支气管镜检查,以确认没有显著出血在滨海新区的网站。止血保证后,取出气管镜出来,总结的过程。

Subscription Required. Please recommend JoVE to your librarian.

Materials

Name Company Catalog Number Comments
7.5-MHz Convex Probe-EBUS bronchoscope
Dedicated 22 or 21 G TBNA needle
Ultrasound processor unit
On-site cytopathology (optional)
Moderate sedation drugs - benzodiazepines or fentanyl 
Deep sedation / General anesthesia drugs - propofol or remifentanil
Local anesthesia (for airways) - 1% or 2% lidocaine

DOWNLOAD MATERIALS LIST

References

  1. Creswell, L., Wells, S. Jr Mediastinal masses originating in the neck. Chest Surg Clin North Am. 2, 23-55 (1992).
  2. White, M. L., Doherty, G. M., Gauger, P. G. Evidence-based surgical management of substernal goiter. World Journal Of Surgery. 32, 1285-1300 (2008).
  3. Shin, J. J., et al. The surgical management of goiter Part I. Preoperative evaluation. The Laryngoscope. 121, 60-67 (2011).
  4. Hanrath, P. Endobronchial sonography: feasibility and preliminary results. Thorax. 47, 565-567 (1992).
  5. Herth, F. J., Eberhardt, R., Vilmann, P., Krasnik, M., Ernst, A. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 61, 795-798 (2006).
  6. Herth, F., Becker, H. D., Ernst, A. Conventional vs Endobronchial Ultrasound-Guided Transbronchial Needle AspirationA Randomized Trial. CHEST Journal. 125, 322-325 (2004).
  7. Kurimoto, N., et al. Assessment of usefulness of endobronchial ultrasonography in determination of depth of tracheobronchial tumor invasion. CHEST Journal. 115, 1500-1506 (1999).
  8. Baba, M., et al. Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall. Lung Cancer. 35, 65-71 (2002).
  9. Nakamura, Y., et al. A New Technique for Endobronchial Ultrasonography and Comparison of Two Ultrasonic ProbesAnalysis With a Plot Profile of the Image Analysis Software NIH Image. CHEST Journal. 126, 192-197 (2004).
  10. Chin, R. Jr, et al. Transbronchial needle aspiration in diagnosing and staging lung cancer: how many aspirates are needed. American journal of respiratory and critical care medicine. 377-381 (2002).
  11. Diacon, A. H., et al. Transbronchial needle aspirates: how many passes per target site. European Respiratory Journal. 29, 112-116 (2007).
  12. Rosário, F., Dd Costa, J., Dionísio, J., Mendonça, E., Sobrinho, L. Endobronchial ultrasound may reveal the presence of previously undiagnosed thyroid carcinoma. Thyroid : official journal of the American Thyroid Association. 16, 515-516 (2006).
  13. Jeebun, V., Natu, S., Harrison, R. Diagnosis of a posterior mediastinal goitre via endobronchial ultrasound-guided transbronchial needle aspiration. European Respiratory Journal. 34, 773-775 (2009).
  14. Chow, A., Oki, M., Saka, H., Moritani, S., Usami, N. Metastatic mediastinal lymph node from an unidentified primary papillary thyroid carcinoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration. Internal Medicine. 48, 1293-1296 (2009).
  15. Diaz, J., Chawla, M., Simoff, M. Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of metastatic thyroid cancer. Journal of bronchology. 16, 70-71 (2009).
  16. Chalhoub, M., Harris, K. The use of endobronchial ultrasonography with transbronchial needle aspiration to sample a solitary substernal thyroid nodule. CHEST Journal. 137, 1435-1436 (2010).
  17. Chalhoub, M., Harris, K. Endobronchial Ultrasonography with Transbronchial Needle Aspiration to Sample a Solitary Substernal Thyroid Nodule: A New Approach. Heart, Lung and Circulation. 21, 761-762 (2012).
  18. Roh, E., et al. A case of mediastinal ectopic thyroid presenting with a paratracheal mass. The Korean journal of internal medicine. 28, 361-364 (2013).
  19. Steinfort, D. P., Irving, L. B. Patient satisfaction during endobronchial ultrasound-guided transbronchial needle aspiration performed under conscious sedation. Respiratory care. 55, 702-706 (2010).
  20. Yarmus, L. B., et al. Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration. Annals of the American Thoracic Society. 10, 121-126 (2013).
  21. Wahidi, M. M., et al. AMerican college of chest physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. CHEST Journal. 140, 1342-1350 (2011).
  22. Mountain, C. F., Dresler, C. M. REgional lymph node classification for lung cancer staging. CHEST Journal. 111, 1718-1723 (1997).
  23. Haller, A. Disputationes Anatomica Selectae. Gottingen, Vandenhoeck. 96, 1749 Forthcoming.
  24. Rodríguez, J. M., Balsalobre, M. D., Tebar, F. J., Parrilla, P. The value of various definitions of intrathoracic goiter for predicting intra-operative and postoperative complications. Surgery. 147, 233-238 (2010).
  25. Torre, G., et al. Surgical management of substernal goiter: analysis of 237 patients. The American surgeon. 61, 826-831 (1995).
  26. Katlic, M. R., Wang, C. -a, Grillo, H. C. Substernal goiter. The Annals of thoracic surgery. 39, 391-399 (1985).
  27. Dahan, M., Gaillard, J., Eschapase, H. Surgical treatment of goiters with intrathoracic development. Thoracic surgery: frontiers and uncommon neoplasms. International trends in general thoracic surgery. St Louis. 5, Mosby. (1989).
  28. Hsu, B., Reeve, T. S., Guinea, A. I., Robinson, B., Delbridge, L. Recurrent substernal nodular goiter: incidence and management. Surgery. 120, 1072-1075 (1996).
  29. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Discussion. The American surgeon. 68, 245-252 (2002).
  30. Risk factors for malignancy in multinodular goitres. European Journal of Surgical Oncology (EJSO). 30, 58-62 (2004).
  31. Chauhan, A., Serpell, J. W. Thyroidectomy is safe and effective for retrosternal goitre). ANZ journal of surgery. 76, 238-242 (2006).
  32. Cooper, D. S., et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid : official journal of the American Thyroid Association. 19, 1167-1214 (2009).
  33. Gharib, H., et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Journal of endocrinological investigation. 33, 1-50 (2010).
  34. Bomeli, S. R., LeBeau, S. O., Ferris, R. L. Evaluation of a thyroid nodule. Otolaryngologic clinics of North America. 43, 229 (2010).
  35. Sarkiss, M., et al. Anesthesia technique for endobronchial ultrasound-guided fine needle aspiration of mediastinal lymph node. Journal of cardiothoracic and vascular anesthesia. 21, 892-896 (2007).
  36. Sarkiss, M. Anesthesia for bronchoscopy and interventional pulmonology: from moderate sedation to jet ventilation. Current Opinion in Pulmonary Medicine. 17, 274-278 (2011).
  37. Lee, H. J., et al. Pilot randomized study comparing two techniques of airway anaesthesia during curvilinear probe endobronchial ultrasound bronchoscopy (CP‐EBUS). Respirology. 16, 102-106 (2011).
  38. Kennedy, M. P., et al. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Thyroid NodulesEndobronchial Ultrasound of the Thyroid NodulePushing the Boundary Too Far. CHEST Journal. 142, 1690-1691 (2012).
  39. Tanner, N. T., Pastis, N. J., Silvestri, G. A. Training for Linear Endobronchial Ultrasound Among US Pulmonary/Critical Care FellowshipsTraining for Linear Endobronchial UltrasoundA Survey of Fellowship Directors. CHEST Journal. 143, 423-428 (2013).
  40. Folch, E., Majid, A. Point: Are >50 supervised procedures required to develop competency in performing endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging? yes. CHEST Journal. 143, 888-891 (2013).
  41. Kinsey, C. M., Channick, C. L. Counterpoint: Are >50 supervised procedures required to develop competency in performing endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging? no. CHEST Journal. 143, 891-893 (2013).
  42. Samad, A., et al. Endobronchial ultrasound‐guided transbronchial needle aspiration diagnosis of mediastinal lymph node metastasis of mucinous adenocarcinoma: Arborizing Stromal Meshwork Fragments as a Diagnostic Clue. Diagnostic Cytopathology. (2012).
  43. Tochigi, T., et al. Initial diagnosis of mediastinal lymph node metastases from prostate cancer by endobronchial ultrasound-guided transbronchial needle aspiration. Journal of bronchology. 16, 59-60 (2009).
  44. Wakamatsu, T., et al. Usefulness of preoperative endobronchial ultrasound for airway invasion around the trachea: esophageal cancer and thyroid cancer. Respiration. 73, 651-657 (2006).
  45. Soja, J., et al. The use of endobronchial ultrasonography in assessment of bronchial wall remodeling in patients with asthma. CHEST Journal. 136, 797-804 (2009).
  46. Yang, H., et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of non-lymph node thoracic lesions. Annals of thoracic medicine. 8, 14 (2013).
  47. Silvestri, G., Silvestri, M., Silvestri, G. A. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proceedings of the American Thoracic Society. 6, (2), Official Journal of the American Thoracic Society. 180-186 (2009).
  48. Nakajima, T., et al. Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in patients with lung cancer. Annals of thoracic surgery. (2013).
  49. Nakajima, T., Yasufuku, K. How I do it—optimal methodology for multidirectional analysis of endobronchial ultrasound-guided transbronchial needle aspiration samples. Journal of Thoracic Oncology. 6, 203-206 (2011).
  50. Bulman, W., Saqi, A., Powell, C. A. Acquisition and processing of endobronchial ultrasound-guided transbronchial needle aspiration specimens in the era of targeted lung cancer chemotherapy. American journal of respiratory and critical care medicine. 185, 606 (2012).

Comments

0 Comments


    Post a Question / Comment / Request

    You must be signed in to post a comment. Please sign in or create an account.

    Usage Statistics