EUROSON SCHOOL: Chest Ultrasound
Pereira Boo, L. Gallego Gomez , M.
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The miniprobe is used to visualize the lesion and to position the guide-sheath which after withdrawal of the miniprobe is used to position instruments for biopsy e. R-EBUS is the imaging method with the best detail resolution of the bronchial wall 59 which is of importance for early detection of bronchial carcinoma 60 , for differentiating tumor invasion from compression of large airways 61 , for assessment of the depth of local tumor infiltration 62 , 63 , and for guidance of endobronchial treatment photodynamic therapy in early-stage lung cancer R-EBUS may be helpful in the evaluation of unclear stenosis including carcinoma in situ which does not infiltrate lamina propria 66 , An important application of R-EBUS is biopsy-guidance in peripheral lung lesions 68 , in particular of bronchoscopically and fluoroscopically invisible solitary lung nodules However, the major advantage of R-EBUS-guided biopsy over CT-guided biopsy is its superior safety profile, in particular the significantly lower pneumothorax rate L-EBUS-scopes have been introduced in The examination techniques using radial and linear probes have been described in current textbooks The EBUS technique and the key anatomical landmarks are described in detail later in this review.
Conventional EUS via the transesophageal approach is a minimally invasive diagnostic and also therapeutically valuable technique. EUS also allows the guidance of biopsies to obtain tissue samples from mediastinal lymph nodes and other mediastinal masses but also from centrally located lung tumors and inflammatory diseases including sarcoidosis and tuberculosis.
Currently published data have shown that EUS is a valuable technique for the diagnosis of lung cancer and has improved lymph node staging For the evaluation of mediastinal lesions, EBUS and EUS are complimentary methods as various mediastinal and hilar nodal stations can be reached Figure 1 The added value of EUS to EBUS can be summarized by the complementary diagnostic reach of the lower mediastinum and aorto-pulmonary window in selected cases and the evaluation of the left adrenal gland and other infradiaphragmal metastatic sites [ Table 3 , data from: 5 , 16 , - ].
This specifically applies to nodal regions that can be reached by both techniques, the left paratracheal region station 4 L and the often affected subcarinal region station 7. The implementation of endosonographic techniques in lung cancer staging algorithms has also reduced the need for surgical staging options e. This knowledge has gained recognition in recent guidelines 1 , 2 , 5 , 13 , Both EUS and EBUS have also been successfully used for the assessment of mediastinal tumor spread of patients with extra-thoracic neoplastic diseases - and for the evaluation of mediastinal lymphadenopathy of unknown origin and especially for the diagnosis and differentiation of mediastinal granulomatous disease and malignant lymphoma , - The examination technique using longitudinal probes has been described in current textbooks 54 - For a practical approach we refer to the training chapter at the end of this review.
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The description of currently available equipment including echo-endoscopes and needles and their use has been summarized in detail Pneumological centers are widespread in the USA but less frequent in Europe, e. The financially and logistically interesting concept consists of a combined endobronchial and esophageal investigation using a single EBUS-echoendoscope where after an initial endobronchial assessment the EBUS scope is subsequently introduced in the esophagus.
An essential part of endosonography is carefully pathology handling. Cell block technique and preservation of small core particles for formalin fixation and paraffin embedding have improved the results - In addition genotyping of adenocarcinoma molecular staging, e. Complete genotyping of lung cancer was possible in a recent RCT in Rapid onsite cytopathological evaluation ROSE significantly improved the rate of complete genotyping and reduced the need for additional needle passes and repeat invasive procedures aiming at molecular diagnosis A recent guideline of the World Association for Bronchology and Interventional Pulmonology describes the acquisition and preparation of endosonographic samples for the diagnosis and molecular testing of suspected lung cancer One study including sheath-guided R-EBUS for the evaluation of peripheral lung nodules reported a 1.
The most serious adverse events 0. Serious adverse events were reported in 0.
Again, most adverse events were of infectious origin Safety issues have been also discussed elsewhere , , In addition to the head and neck regions cervical and supraclavicular nodes , mediastinal ultrasound is also able to detect and to guide sampling of pathological lymph nodes , and neoplasia in the supra-aortal, prevascular, pericardial, upper and lower located paratracheal region as well as in the aorto-pulmonary window.
TMUS is decisive in the supra-aortal, supraclavicular and head and neck regions indicating N3-respective M1-staging The White Hemithorax.
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Image Artifacts and Pitfalls. Interventional Chest Sonography. Stepwise Diagnostic Imaging Procedures in Pneumology. Back Matter Pages It is the method of choice to distinguish between solid and liquid lesions and allows the investigator to make an unequivocal diagnosis without exposing the patient to costly and stressful procedures. This book presents the state of the art in chest investigation by means of ultrasonography. A number of excellent illustrations and the compact text provide concise and easy-to-assimilate information about the diagnostic procedure.