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154

4 Comparison ofEndobronchial Ultrasonography Images andResected Specimens

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biopsied tissue

including fibrosis

Fig. 4.15 Probable biopsy locations. The biopsy tissue on the top left

was probably sampled from close to the PA, indicated by the broken yellow line, and that on the top right, which contained an alveolar area,

Br2

Br1

Br2

biopsied tissue

including alveolar region

was probably sampled from a site further away from the PA. This is consistent with the fact that tissue was collected by angling the bronchoscope away from the PA during EBUS

probe

Fig. 4.16 Main comparison images. The relationships between the PA, the tumor, the mucus lake, and Br2 can be clearly seen, with Br1 with a

radial probe inserted at the center

Muc

Br2

Br1

Muc

4.3 Comparison

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155

bi group

a group

B3bii group

B3biby

B3bibx

23 4

bia

bib y

B3bib x

B3bibxx

bii

B3bib

B3bibxy

Bifurcation of

bibx

B3bibxx

accompanying

artery

Bifurcation of

bronchus in

the lesion

target point

Fig. 4.17 CT ndings. To map the branches of the involved bronchus

in the right upper lobe, the CT images are rotated 90° counterclockwise. Images (1–8) have been arranged in order so as to “scroll” caudally from the upper right lobe bronchus level. Starting from (3), which shows the opening of B

after B

biα that has branched craniad in (2) is B3biβ in (3), and we enter this. The airway we should enter runs caudad, slightly obliquely to the axial plane. In (3–4) we enter B

Fig. 4.18 Branching map (diagram of the bronchial branches). The

bronchi could be mapped as far as right B

bi, we rst enter B3bi. The remaining branch

biβ, but the branch remaining after the

biβxx (VII), a 7th-order bronchus. It was also anticipated that the left-right bifurcation of the pulmonary artery running on the cranial side would be visualized at this level

Case 2. Male in 80s. Chief Complaint: Right Lung Nodule

A “part-solid” lesion measuring 12 mm × 9 mm × 10 mm in the periphery of S3b in the right upper lobe was discovered in

immediate caudad bifurcation of the branch (B

biβx in (4–6), and we enter this. B3biβxy also branches ventrad in (4), and we proceed into the remaining branch, which is B can be seen that the pulmonary artery running on the cranial side of

biβxx bifurcates ventrad and dorsad at this point in (4). In (7) and (8),

biβy) seen in (5) is

biβxx in (6). It

the bronchus further bifurcates ventrad and dorsad within the tumor, with the dorsal branch seen to be heading toward the center of the tumor

a health checkup. As shown in Fig. 4.17, branch mapping from axial view high-resolution CT (HRCT) images showed the involvement of bronchi up to right B3biβxx, a 7th-order bronchus. It also suggested that a branch that was directed toward the patient’s dorsal side at the tumor margin was heading inside the tumor. Figure 4.18 shows the hand-drawn bronchoscopy images of the bronchus that was assumed to be involved to the lesion on the basis of analysis of these axial CT images. In this case, the bronchial branches were either up/down or left/right and were thus easy to draw, but in patients in whom they branch obliquely to the axial plane, they are less easy to map. In such cases, it is better to have the computer draw virtual bronchoscopy images. However, if airway extraction is difcult, generating MPR images to provide images orthogonal to the airway axis may give a better idea of the angle of branching. In cases such as this one, MPR image generation is essential when attempting to take account of airway branching within air-containing lesions. Looking at the MPR images in Fig.4.19, the position of the accompanying vessel is easier to see, but a closer look shows that the peripheral airway divides into three (superior, infe-

156

①

4 Comparison ofEndobronchial Ultrasonography Images andResected Specimens

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Fig. 4.19 MPR images

viewing the tumor from right

b. Images (1–3) approach the lesion from the proximal side, with the MPR images arranged to coincide with the images and orientation of the bronchoscopic observations. The pulmonary artery (red arrow) seen running on the cranial side of the involved bronchus in (1) divides into anterior and posterior branches (left and right in the MPR images) in (2), and inside the tumor (3) the bronchus is assumed to divide into three (superior, inferior, and anterior). Diagrams are shown on the right and the corresponding EBUS images on the left. A anterior, P posterior

②

③

rior, and anterior) in the area immediately after the vessel has bifurcated into anterior and posterior branches.

Figure 4.20 shows the progress of the bronchoscope from the opening of right upper lobe B3 to the target involved bronchus. The photograph at the left-hand end of the bottom row shows a frontal view of B3biβ from the tip of the bronchoscope, and at this point it should have been possible to show the next bifurcation into B3biβx and B3biβy, but, unfortunately, this was too dark to see, possibly because of insufcient light or poor resolution. As many other operators will also have experienced, the operator advanced into B3biβ anyway to take a good look and see if it was possible to identify the directions of the openings of the next bifurcation (B3biβx and B3biβy). As shown in Fig.4.20, the limits imposed by the size of the bronchoscope tip (4mm in diameter) meant that the bronchoscope could be inserted as far as B3biβx, from which B3biβxx and B3biβxy would be visible. A thin- section CT image identied an air-density lesion with ground-glass opacity visible in almost all lesions. It was considered to become difcult to detect such a pneumatic tumor by EBUS after saline injection, so that saline injection was not performed. The probe was inserted into B3biβxx, and the focus was switched to the EBUS images. As shown in Fig.4.21, the accompanying vessel was visualized as anticipated, and by advancing little by little, the location of its bifurcation was established. At this point, the tip of the bronchoscope was exed so that the probe tip was pointing dorsally (obliquely right and down on the EBUS images). The patient’s cranial side and the 12 o’clock direction on bronchoscopy images coincided with the 1 o’clock direction on the EBUS images. The adjacent area on the EBUS images was biopsied, and

adenocarcinoma was diagnosed (Fig.4.22). A retrospective look at the right-hand EBUS image in Fig. 4.21 showed that, with the exception of the area considered to represent the solid part at 1 o’clock to the probe, punctate bright hyperechoic spots had intensied overall, and they were considered to be a visualization of the pneumatic area within the lesion. The probe had thus reached the point within the tumor that was the objective on CT.

Figure 4.23 shows the procedure for inserting a surgical probe into the involved airway following Liebow’s bronchial probe technique and then following its track with a knife. This technique usually entails inserting two probes, working out where the surface is and deciding on the course of the knife accordingly [1], but in this case, a single probe was used because the intention was to make a craniocaudal incision in B3bi. This technique exposed the involved bronchus along its entire length, as shown in Fig. 4.24. Magnication of this image, as shown in Fig.4.25, showed the interior of the bronchus despite the fact that even a 4-mm-thin bronchoscope could not be inserted, and it showed the details of the bronchus that entered the tumor directly. The pulmonary artery running along the cranial side of the bronchus was also cleanly cut out. In Fig.4.26, the involved bronchus has been laid out by folding each side outward and compared with MPR images in the airway long axis plane. The cut surfaces of the tumor corresponding to the MPR images in the airway short-axis plane have also been laid out. Now take another look at the bronchoscopy ndings in Fig. 4.20. All branches identied in the bronchoscopy images can be matched with those in the specimen. The small hole of right B3biβxy, which was visible on CT branching anteriorly and the orice of which was identi-

4.3 Comparison

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B3b

157

B3b

bii

B3bi

bii

biα

B3biβ B3biβx B3biβxx

biα

biβ

Fig. 4.20 Bronchoscopic ndings. Findings from the opening of B3 in

the right upper lobe to the most peripheral bronchus in which a thin bronchoscope with a tip 4mm in diameter could be inserted. The name of the branch just past the tip of the bronchoscope at that point is indicated at the top of each photograph, and a yellow dot marks the vicinity of the rst spur to aim for in the next branch to be entered. The bron-

Fig. 4.21 EBUS images. By

angling the probe dorsally (obliquely right and down on the EBUS images) and advancing and withdrawing it, the bifurcation of the accompanying pulmonary artery and the lesion could be visualized. The left-hand EBUS image corresponds to the level of the MPR image in Fig.4.19-(2). PA pulmonary artery

AnglethescopetipdorsallyafterthebifurcationofthePA

accompanyingPA

biβx

biβy

B3a

biβxy

biβ

biβxx

chial order on which the operator is focused in terms of where to aim for next is indicated within the name of the bronchus in yellow letters. Of the branches that the bronchoscope could enter from B

case, B

biβxy appears as a slit-shaped opening, as indicated by the red

biβx in this

broken line and arrow because of the limitations imposed by the direction of the bronchoscope tip

Tumor

158

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Fig. 4.22 Biopsy tissue.

Adenocarcinoma is diagnosed

4 Comparison ofEndobronchial Ultrasonography Images andResected Specimens

B3bi

B3bii

B3a

Fig. 4.23 The left-hand image shows the bronchial stump opened up

to look at the involved bronchus. The right-hand image shows the probe exiting the visceral pleural surface. A longitudinal incision was made in

right B

bi to enable the direct examination of deeper areas. The probe

ed on bronchoscopy as a slit-shaped depression, can be seen. The collapsed accompanying vessel has also been exposed to view. The point at which this accompanying vessel bifurcates left and right is shown as a pale green arrow (the arrow in Fig. 4.26). The branching beyond right B3biβxx, which could not be observed bronchoscopically, is now clear. Even the details of more peripheral branchings that were impossible to observe by bronchoscopy could be

was gently inserted from B the tumor. As shown in the right-hand image, in this case the probe easily reached the pleural side

biβ and used to feel its way gently toward

identied by comparison with MPR images. Observation of the exposed accompanying vessel also identied the point of bifurcation on EBUS images. In the bottom right photograph of Fig.4.26, showing the short-axis plane of the specimen, the bronchus inside the tumor could be seen to divide into three, with the bottom right branch entering the interior of the tumor and the other two branches running along its margin.

4.3 Comparison

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159

Fig. 4.24 Longitudinal section of the involved bronchus. With the aim

of revealing the pulmonary artery running on the cranial side of the

Fig. 4.25 Enlargement of the

cut surface. The association between the involved bronchus and the tumor is clear. Although the accompanying blood vessel had collapsed, it could be seen on the cranial side of the bronchus. As was clear on the CT images, this vessel bifurcates into left and right branches as it approaches the tumor. This is shown in Fig.4.26

involved bronchus, a knife was drawn along the probe in a single sweep to produce a craniocaudal cut surface, and a clean cross section was obtained. The airway directly involved in the tumor is clearly visible

Interlobe surface between

upper lobe and middle

Scope tip

tumorhead-side direction

Because the involved bronchus determines the position at

which the lesion is reached, I started out by saying “From the

diagnostic viewpoint, the only degree of freedom is in the choices of whether to take the sample in the proximal side or distal side of the involved bronchus on the longitudinal axis and, at best, of whether the angle of approach should be from above or below the bronchus and to its right or left.” However, it should also be known that there may be the fur-

ther possibility of selecting a branch within the tumor, as in Case 2. This requires a readiness to use EBUS to identify accompanying vessels and understand the internal structure of the lesion. Every institution has its own rules for handling

histopathological specimens. It is important to consult closely with pathology department staff and pathologists to obtain the maximum possible information from the excised specimen.

160

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4 Comparison ofEndobronchial Ultrasonography Images andResected Specimens

antero-posterior view medio-lateral view

Bifurcation

point of

accompanying

bxx

bxy

Section like a double doors

Fig. 4.26 Comparison chart. The top left image is an anteroposterior

view of the MPR of the involved bronchus, and the top right image is an MPR image of the lesion in the plane orthogonal to the involved bronchus, corresponding to a mediolateral view. The bottom left image is the exposed cut surface of the specimen showing the entire length of the involved bronchus, which has been cut and folded out to show all the branches. This coincides with the anteroposterior view. The area within the blue inset coincides with the counterpart of the main exposed cut surface of the involved bronchus. The pulmonary artery running on the cranial side of the bronchus bifurcates into two branches at the point shown by the pale green arrow. Points of approximate correspondence between the MPR anteroposterior view at the top left and the exposed longitudinal cut surface of the specimen at the bottom left are indicated

by yellow double-headed arrow and red double-headed arrow from comparison of the MPR image and the longitudinal cut surface of the specimen. An incision was also made in an orange dotted line to obtain a section orthogonal to the involved bronchus in order to obtain more information. The bottom right image shows this cut surface. It corresponds exactly to the MPR image at the top right. The bronchus divided into three near the tumor is clearly visible, and the correspondence between the branches is indicated with numbers. The accompanying pulmonary artery that bifurcated on the patient’s dorsal side (on the right-hand side of the images) is indicated by “PA.” The probe seems to have entered the 2i branch heading toward the center of the tumor. Returning to the image at the bottom left, matching the bronchus inside the tumor strongly suggests that it was the 2i branch that entered the tumor

References

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161

1+2

Fig. 4.27 Additional explanation of Case 1. As in the central CT

image, if the bronchus running laterally at the branching level of the subsegments of the upper division sub-lobe is B

V2b

assumed

line

1+2

c, the intersegmental

4.3.1.1 Memo

Additional explanation of Case 1

Some people may take issue with the naming of the subsegmental bronchi in the CT images of Fig.4.7. It departs from the positional relationships within the lung that are assumed on the basis of the names of the segments and subsegments in the upper division of the left upper lobe. That is, given the nomenclature

S3: Anterior segment of the upper lobe S3a: Lateral subsegment of the anterior upper lobe S3b: Medial subsegment of the anterior upper lobe S3c: Superior subsegment of the anterior upper lobe

the directions of the bronchi are:

1+2

vein V

c between S3a and S intersubsegmental vein V nial side

1+2

c appears on the caudal side, and the

b between S

1+2

b and S

1+2

assumed

line

1+2

c appears on the cra-

between the lobes, with a branching pattern independent of A3b +A3c, which branch from the mediastinal surface (23%, [5] 10% [6, 7]), but the former nomenclature mentioned above in Fig. 4.27 could be reasonable from CT image. However, when the branches are named according to bronchoscopy ndings, they are named in order from the center. In this case, as shown in Fig. 4.8, the left upper division clearly contains the two subsegmental bronchi of the same size, and it is thus impossible to name the rst branch of B3

1+2

as B

c. In surgery, however, the boundary vein between segments is an important landmark for (sub)segmentectomy. This is a case in which it is impossible to achieve consistency between subsegments as dened by veins and as dened by bronchi. In this case, I have followed the bronchoscopy branching nomenclature.

B3a: Runs laterad almost horizontally along the ventral side

from the hilar region B3b: Runs ventrad B3c: Runs ventrad/craniad, through an area corresponding to

right S2b

It can thus be easily understood that the bronchus involved in the lesion is B3a and that the branches that lead off centrally to it are B

1+2

c (Fig.4.27). Of the branches that extend anteriorly and immediately bifurcate up/down, the branch running upward is B3c, and that running somewhat downward is B3b. In this case, from this nomenclature, the vein running between B3a and B the boundary vein named V2c by Yamashita [5] (Arai etal.’s

1+2

[6] V

d). The pulmonary artery that accompanies B according to this nomenclature is also more easily understood as A

1+2

c. The pulmonary artery accompanying B3a

shown in Fig.4.7 could be regarded as A3a coming out from

1+2

c is most easily understood as

References

1. Litzky LA, Gal A. Lung specimen handling and practical considerations. In: Hasleton P, Flieder DB, editors. Spencer’s pathology of the lung. 6th ed. Cambridge: Cambridge University Press; 2013. p.45–65.

2. Kobashi Y: Histopathological examination. In: Izumi T, Sakatani M, Ngai S, etal., editors. Clinical practice of diffuse lung disease. 3rd ed. Kyoto: Kinpodo; 2003. p.44–7. (in Japanese)

General Rule for Clinical and Pathological Record of Lung Cancer.

3. 7th ed, in Japanese by The Japan Lung Cancer Society. Tokyo: Kanehara Publishing; 2010. (in Japanese)

4. Kurimoto N. How to perform endobronchial ultrasonography. In: Kurimoto N, Fielding DIK, Musani A, editors. Endobronchial ultrasonography. Wiley; 2011. p.26–35.

5. Yamashita H.Roentgenologic anatomy of the lung. Tokyo: IgakuShoin, Ltd.; 1978.

6. Arai T, Shiozawa M. Pulmonary resections: anatomy and surgical

1+2

technique. Tokyo: Asakura Publishing; 1983. (in Japanese)

7. Nomori H, Okada M.Systematic pulmonary segmentectomy learned by illustrations– Atlas of segmentectomy. Tokyo: Bunkodo; 2011. p.155. (in Japanese)

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