Transcription
Right. Thank you, Olympus, for inviting me today to present on convex probe slim EBUS. So, just to be clear, this is the BF UC 190F that we're talking about. This is a, um, scope with a 6.6 mm outer diameter, um, compared to the conventional EBUS scopes, which was .3 mm more. So this is not the potentially newer generation that you will be hearing more about, hopefully in the poster session, um, later today.
So, just a show of hands, who's been using this slim EBUS scope that's been commercially available for a number of years now? So, a quick show of hands, who's been using that? No, no one. Okay, so this is for you. So hopefully, I can show with some simple cases, um, how this scope can help, um, a little bit more compared to your conventional EBUS scope to get to lesions which would have been harder to reach with your standard EBUS.
So my name is Bandana Jibbin. I'm a chest physician based in the UK. Um, I'm the lead for EBUS and bronchoscopy in my unit. Um, just a little bit about North Tees. So this is based in the northeast of England. It's an area with really high, um, lung cancer incidence, um, significant socioeconomic deprivation, high smoking, um, rates, obesity, etc. So, perfectly located for getting lots of referrals in, and we provide a peripheral bronchoscopy, um, service for the northeast of England. We've been doing this for a number of years, and we were one of the first five centers to have set up EBUS, um, more than 15 years ago. So we continue to get a lot of referrals for convex probe EBUS from different hospitals, and when I look at the referral, I just think this is you, you're not requesting for specific expertise, but if you had the tool, perhaps the, uh, the, the local center could have reached the diagnosis.
So, um, just very quickly about the milestones in bronchoscopy now; there've been so many, but there is no doubt that EBUS-TBNA has been the key revolutionary development that's truly transformed what we can do for our patients in respiratory medicine, and the bulk of the work has been around diagnosis and staging of lung cancer, but even within this, we're going to be seeing so much change with increasing focus not just on N2 and N3 staging, but also N1 staging, especially as we move into an era for new adjuvant treatment. You have to select your patients for sublobar resection, potentially locally ablative therapy, so you really need the assurance: have you accurately staged your patient? So, not just N2, N3, but N1, and therefore the reach will be even more fundamental. And other than mediastinal staging, you've got so many uses of convex probe EBUS, which you would all know, including sampling of U-plural generally based masses next to the mediastinum and even endovascular lesions, which I personally don't tend to use for, but importantly, diagnosis of peripheral, of, um, peribronchial lung lesions, and indeed a systematic review that was published recently showed a really high sensitivity for the use of convex probe EBUS in intra-pulmonary lesions, but they've tended to be centrally located, and that's where most of the challenge, challenge relating to the convex probe EBUS is, because of the large outer diameter, the rigid distal tip, and of course, the difficulty in angulation and the viewing angle. All of these pose a lot of challenges for us to be able to reach far out. So we're pretty much restricted to the mediastinum.
So with that in mind, a few years ago, the slim EBUS, um, was designed with the view of reducing the outer diameter by .3 mm, but not sacrificing on the working channel, and you've got a shorter and narrower transducer. So you've got a smaller rigid tip as well. And importantly for me, I find the angulation that's improved from 120° to 160°. So when you're trying to sample the paratracheal lymph nodes, this comes in really, really handy. And this is just a picture with the VisShot needle being deployed. You can see that the angulation is relatively preserved and again really useful in, um, in sampling, especially when you're going for the subcentimeter paratracheal lymph nodes on the left-hand side.
One of the other benefits is the viewing angle. So that's been reduced to 20°, and that's partly because of the slightly retroflexed, um, position of the, u, slimmer EBUS scope, but for me, I think that really helps with the procedural learning curve as well, because it's closer to the bronchoscopes that we've been, um, used to using as well. And just a subtle difference is the, um, the sharper needle, uh, angle penetration. So that the idea is to make it easier to be able to puncture, especially avoiding around the bronchial, um, cartilages, and, um, a recent study by Fujino, well, it's not so recent anymore, but Fujino and Yasufuku et al had done a study comparing the standard EBUS scope with the slim EBUS scope in pig models and ex vivo human models, and it was interesting to note that the time taken to reach various lymph, lymph node stations was significantly reduced, um, with the slim EBUS compared to the standard EBUS, and this is key when the majority of centers are doing staging EBUS under conscious sedation.
So I thought it was quite useful just to show you a comparison of the endobronchial reach of the standard EBUS compared to the slim EBUS, just so you can see the subtle differences; subtle, but it can make a big difference in clinical practice. So we're going to start off with the standard convex probe EBUS. So we're now intubating and going into the left main, and we'll attempt to head towards the upper left upper division and really struggling to get any further and moving towards the lingula, maintaining a bit of an angulation so that the scope can slide into, and again some difficulty in getting further. So this is not to look at the lymph nodes, but purely to show you the endobronchial reach. We will then try and attempt to get into the left lower lobe, and we, the scope just gets essentially stuck at the orifice of the left lower lobe, and this is what we commonly see. So we can't really, often in practice, get any further beyond that. So we're now going to head towards the right-hand side. So heading towards the right-hand side and the right upper lobe. Again, you're stuck at the orifice. Um, perfectly fine for sampling the R10 and R11, but you can't really get, um, beyond that. Again, going for the middle lobe, a bit of a struggle to get beyond that. And we will now go towards the right lower lobe and a bit of a difficulty to reach that. Again, there can be a difference from patient to patient, but in this scenario, we just couldn't really quite reach.
So, we're now going to swap over to the slim EBUS scope. So starting on the right-hand side this time. So again heading towards the, um, the right upper lobe, and with further flexion, you can see that my reach is now, I can see the segments quite clearly, um, probably not as far as I would have really wanted it, um, but, um, pretty good still, and further attempt at getting into the middle lobe. So we, the scope can't really get any further into that, and we're now going to head towards the right lower lobe, and then hopefully you will see the RB8 and then heading towards the RB9 and 10. Now moving towards the left upper lobe, the left main bronchus. So now the left upper lobe, and again in this patient, the reach wasn't as good as in the cases that I'm going to hopefully show you. But the difference that you're going to see is the reach with the left lower lobe. So hopefully you can see that we can visualize the segments a lot clearly, um, and then hopefully you can, uh, wedge your scope nicely, and then hopefully be able to sample any of the peribronchial lesions with more ease compared to the standard EBUS scope.
So just about three cases to show, um, the reach of the slim EBUS, case, uh, scope. So the first patient is a 64-year-old, um, never smoker who's previously had a nephrectomy for clear cell renal cell cancer. And you can see on the CT scan, which I'm going to show you, um, that they had a right lower lobe FDG-negative, um, lymph node that was adjacent to the RB9 with no other disease that was, uh, present, um, on the CT scan. So hopefully the video will play. So just focusing on this area there. So you can see distally the, um, abnormal lymph node coming into view. And this patient had undergone standard EBUS in the referring center with inability to be able to reach the target lesions. So the patient was therefore referred in to us. So we proceeded with slim EBUS. Um, there was no requirement for any staging in this scenario. So the EBUS scope will try and lodge into the right lower lobe adjacent to the RB9. And hopefully we can then demonstrate with the use of the, um, the convex probe EBUS. You can see a rounded, um, node coming into view with distinct margins and highly heterogeneous, clearly abnormal, and subsequently then sampling was undertaken, and a diagnosis was made of metastatic renal cell, um, carcinoma. So the needle will be coming round shortly. Um, there you go.
The next patient is a 73-year-old who, um, again got referred in from a different, um, trust, um, found to have a 9 mm left hilar nodule which was positive on the PET scan with a small isolated left hilar node that was weakly avid on the PET-CT, but on CT there was some, just about 1 cm sized R4 and station 7. So the referring center had attempted to stage the patient and was proven to be N2 and N3 negative, but they were unable to reach the N1 node, and perhaps on the CT you can see as to why: you can see that the, um, the hilar node is actually quite distal and opposite the takeoff of the, um, apicoposterior segment of the left upper lobe, and this is the tiny left hilar, um, nodule that the patient also has. So we do need to do repeat, um, staging, but we decided in this scenario to start off with, um, selective, um, staging in this case. So to target the L12 lymph node first with, um, rapid onsite pathology. So hopefully you can see the reach of the scope with this, and you can see the beautiful, um, views of the, um, left upper lobe there. And further manipulation of the scope can get, can get us much, much further and close to the apical posterior segment of the left upper lobe. And with further flexion there, and hopefully you can see the lymph node coming into view. That allowed us then to do some targeted sampling. And in this patient, the rapid pathologist was a little bit uncertain. Um, they thought there were some atypical cells. So for that reason, then we felt we had to then proceed with the navigational bronchoscopy. So just a quick, um, show. So we performed virtual bronchoscopic navigation with a, with the just the use of a planner, memorized our path, and then we used the ultra-thin bronchoscope, and we knew exactly which subsegment to take, um, and subsequently then deployed the radial probe, which you will see in a second, and then you will hopefully see the radial image, um, coming into view. Yeah. And you can see an eccentric, um, lesion that, um, that's appeared there, following which we've been able to do some targeted sampling using fluoroscopy. So this confirmed to be adenocarcinoma, and the final pathology was also adenocarcinoma in the, um, l, um, the in the hilar lymph node.
So just to finish off the third case, we've got again an 82-year-old patient who's an ex-smoker, persistent cough, and a left lower lobe, suspicious nodule, and hopefully you can appreciate on the CT scan is noted to be fairly distal there, and again not reachable with a standard EBUS scope. So in this patient, again, we just used a slim EBUS and really with, with a lot of ease managed to get into it and, uh, provided the, um, the diagnosis as well of adenocarcinoma.
So simple take-home messages. So we know that the landscape for the use of convex probe EBUS in mediastinal and higher staging is changing and rapidly evolving, and there'll be an increasing need for us to be sampling peribronchial lesions, and there are current challenges with the current convex probe, um, EBUS scopes that we're using, and the BF UC 190F potentially provides some additional, um, technical benefits for us to be able to get better, uh, visibility and endobronchial maneuver our scope, so we can hopefully select out some cases that may benefit from this. But really what's needed is for Olympus to come out with a further miniaturized, um, convex probe EBUS, which I'm really looking forward to. Thank you. Any questions? [Music]