Transcription
Good afternoon, everyone. Um, it's a great pleasure to be here in Milan, and it's nice to see some friendly faces and old friends, uh, around. Now, what I'd like to do, uh, for the next 10-15 minutes is really take you to where we were, uh, 20 years ago and then where we are today with the latest development of the EU ME3. Um, so basically, um, let me take you through there now. We can skip over that slide. Very unnecessary.
So, 20 years ago, radial ultrasound was really what we were doing. Uh, or maybe I should say 22 years ago. This was a vascular ultrasound. Uh, it was very complicated. You had all of these different, um, units to build together, and you had a balloon sheet which took you ages to try and get all the air bubbles out of. But you had some, um, fancy kind of images from it. And this is really where we started, in the sense that you had this, um, image of the ultrasound instead of just doing a blind transbronchial needle aspiration. But you can already see a flaw with this. The main flaw was that we could see the ultrasound image, but then there was no real-time imaging when you were actually sampling this lesion. So, it gave you great anatomical detail, but the precision wasn't there. And I, I can show you lots of little videos of amazing subsegmental anatomy. In fact, at one point, I was saying, "There's the pulmonary artery, there's the pulmonary vein. Maybe I shouldn't be putting needles in this kind of territory."
So, it was a great relief when we were looking at some of the data coming up with EBUS TBNA. And at about that time, Felix Her, Mark Kranik, and even myself were begging Olympus Japan to see how they could shrink the EUS scope and allow us to use it in the airway. And the very first prototypes we used, um, just gave us, um, imaging, no actual needle puncture, but very rapidly we transitioned, and we had the first publications in Thorax of 20 patients who had undergone EBUS TBNA, and that was a landmark moment because over the last 20 years this has probably been the most revolutionary intervention in the diagnosis and staging of lung cancer, but also it has reached other areas now where you're involved with, uh, sampling in conditions like sarcoidosis through to tuberculosis.
Now, this is the very first generation I used. You can see you had this little box-like device, and the ultrasound processor was very basic, but you did get imaging. You got lymph node structures, and you were able to, with high precision, get biopsies which gave you success rates of well over 90%. But you can see the whole system was very cumbersome. Um, but at the same time, we were getting very, very good data. One of the things that we saw with EBUS TBNA was not only was it giving you a diagnosis, but in the majority of people, it was giving you molecular information. You knew whether these patients had, um, adenocarcinoma, whether there was a mucinous adenocarcinoma, whether it was TTF-1 positive; you're getting immunohistochemistry data, and actually those same samples today are giving us, um, full genome sequencing. So you can see that this is an amazing tool that not only gives us diagnosis, staging, but now even a molecular signature of the tumor.
In 2008, we actually saw the generation, the launch of the EUME system, and this was a real step up in terms of the ultrasound imaging. The imaging characteristics went up by almost 10-fold. You got a lot more resolution of the borders, the kind of structure. You could see whether there was kind of necrosis within the node. You could see calcification. You could see the hilar vessels. You could use a Doppler mode in this, uh, system. So already we were seeing an upgrade in the quality of the imaging, and then with the EUME2 we all got introduced to elastography. Why is elastography important? Well, we spent the previous 10 years, uh, sampling with, um, the needle. But if you had a benign diagnosis, there was always this concern whether this was a sampling error or was this really a true negative? Was this a benign lesion that we can confidently say we don't need to do anything further with? So the advantage of elastography is that it really gives you that added information about the intrastructure of the lymph nodes. So you can see you get a different kind of color map, whether it's blue or whether it's green or whether it's red, and on that basis you can decide whether this has got benign features or malignant features, and then when you get your answer from your needle sampling and it comes back as negative, your negative predictive value dramatically improves from like 70% to about 90%, and follow-up over 12 months has proven that this is a very robust way of being able to diagnose benign lesions as well.
So, at that time, the ATA trial was published, which was a randomized controlled study between, um, EBUS TBNA, endobronchial ultrasound, and again this was a very important moment because now all the different societies, the American Thoracic Society, the European Respiratory Society, the European surgical societies, and basically all the guidelines became, um, came together to acknowledge that EBUS TBNA was the standard of care and should be the first step in the diagnosis and staging of lung cancer. For me, um, the needle developments was also quite dramatic, and you'll see in the, um, stand right behind me, four or five different types of needles. So you've got needles with, uh, whether they're 25 gauge, 22 gauge, 21 gauge, and now you opt, you have the option of getting slightly better histological samples with the 19 gauge. Again, there's data out there which shows, well, the diagnostic rate is already so high. What's the advantage of using a 19 gauge needle versus a 22 gauge needle? Clearly, again, benign disease where the where it becomes more important; you significantly increase your negative predictive value in these kind of circumstances by using a larger needle. So it's not all about just pure diagnosis, it's about being confident about your diagnosis.
And then the slim EBUS scope, which a lot of you are using, um, is the third generation of scope that's out there. A lot of you might be using it just to stage the mediastinum, but actually I can guarantee you that a lot of nodules in the mid-third of the lung are accessible with this slim scope, particularly if the nodule is anterior and in the lower lobe. Try and use your EBUS scope rather than a standard conventional or a CT-guided biopsy. Also, you can see the flexibility of that scope is a lot greater. So you are going to be able to go more anterior and get a better diagnostic, uh, yield. And the beauty of this is that again it's real-time imaging. You can see your needle in the nodule, and you can really get good samples from this technique.
So basically, what we've seen is EBUS TBNA is a very consistent performer. It's also a very simple technique. You don't need to be Felix Her to get 90% results. Basically, it takes most bronchoscopies to the Felix Her level. He was number one for a few weeks, but he's been deposed. There's someone else now is number one, and it's not me. Uh, now the real pleasure I have is probably I was lucky enough to be the first clinical user of the EU ME3 platform. This absolutely is a mind-blowing detail in ultraography. The detail you get is just the same or if not better than the large footprint systems that we all use. You can look at the distal detail is in incredible detail because if you use the the previous systems what you see is you got high-quality data up here, but everything up here becomes less focused. But with this new, um, EUME3 you're getting high resolution throughout the depth of the imaging. The the B-mode is also very much more clear. You can see that you get very fine detail, and you don't need a high-resolution radial probe for this mode as well.
And then this is my favorite trick. Uh, the tissue harmonic echo is the what I would recommend everyone to use. If you've got that functionality, you actually have that functionality in EUME2, but it's even better in EUME3. And it really improves the image, reduces all the kind of, um, artifacts and gives you almost like a three-dimensional feel for the image and depth. And I would strongly recommend just put your system on default for tissue harmonic echo and just use that. You don't need to then fiddle around with contrast or anything, uh, throughout your procedure. You can just concentrate on the procedure. The actual keyboard and everything is very easy to use. And again, I would invite you to go and have a look over my shoulder into the workshop up there. You can see the EM3. You can see the layout. You can even see the imaging quality.
And then elastography is made even more simpler. For those of you who've used the old version of elastography, you'll know that you have to push hard on the tissue, create about a 6 kilopascal of strain, and then you get a more reliable image. But with the new, uh, eyelastography, it's a lot more robust, a lot more simpler, and you get an image very quickly. U and furthermore, you can get histogram analysis of this image. And so you can sort of pick one area of interest and you can find out what that tissue characteristics. You can then even use this to target your needle biopsy. So if there's, let's say, a slightly differential area where you think that there's a focus of cancer, then you can literally more selectively sample that area. And then the Doppler mode you can see is absolutely phenomenal. Now, all of you guys who are fans of, uh, EBUS cryobiopsy, I would recommend this mode because if you can't see the inner hilar vessels, then I'm afraid there's going to be a lot of problems. So if you're going to use, uh, EBUS cryobiopsy, make sure you invest in a, um, 3.
And so really, I'd like you just to establish the heritage of EBUS. Olympus was the first company to develop EBUS TBNA. It is still the leading edge in terms of future developments of EBUS TBNA. And you can see that this was the initial 10-year history of the work that was done. And we went through improvements not only on the platform, we've gone through improvements in the actual scope. We've gone through improvements in the tools like the needles. And at the moment, what you're going to be experiencing for those who want to go and try it is the fourth generation ultrasound processor.
So, on that note, I'd like to stop there. Now, as I said, you have actually got the processor for you to try out in the booth behind me, but also the L lung team learning is a platform that's available for everyone. There's a lot of interactive questions and answers on this platform. So, be, um, happy for you guys to really start using it, and the QR code for it is up there. So what we'd like to make this is a very inclusive learning environment, and u I'd be happy to take any burning questions that you might have. [Applause]