PENTAX Medical & Hitachi

Endobronchial Ultrasound Mini Atlas

Case studies from clinical practice
 Index

Introduction5

EBUS in pulmonary practice 6–7

Discover new facets of vision  8–9

Case studies

Suspected lung cancer 10 – 11

Lung cancer staging 12 – 13

Hilar lymph node relapse 14 – 15

Small cell lung cancer 16 – 17

Mediastinal mass 18 – 19

Intrapulmonary tumor 20 – 21

EUS-B and the lower mediastinum 22 – 23

Sarcoidosis 24 – 25

Hodgkin’s lymphoma 26 – 27

2 3
 Introduction
Endobronchial ultrasound: new perspectives

Dear readers,

The key to a successful EBUS procedure is excellent visualization together with sufficient
tissue for diagnostic and staging purposes. Almost a decade after the first generation
EBUS endoscope was released, PENTAX Medical has accomplished several enhancements
to improve diagnostic outcomes. The second generation PENTAX Medical Ultrasound
Video Bronchoscope EB19-J10U has an enlarged working channel of 2.2mm, enabling
the use of large bore needles so that bigger tissue samples can be taken. Additionally,
the actual needle passage through the cartilage rings is facilitated by a steeper needle
angulation, allowing sub-centimeter and deeper lying lymph nodes to be sampled more
easily. The already superior ultrasound image quality has been further improved to include
frequencies of up to 13MHz, enabling high-resolution imaging in the near field. Optimal
orientation in the tracheobronchial tree is provided through superior optical image quality.
Without a doubt, the PENTAX Medical EB19-J10U EBUS endoscope will be an important
piece of equipment for your bronchoscopy practice.

In this mini atlas, several well-documented cases are presented that demonstrate the
capabilities of the new PENTAX Medical EBUS endoscope. Diagnostic cases include the
diagnosis and staging of lung cancer and the assessment of sarcoidosis and mediastinal
lymphoma. In addition, the use of the EBUS scope in the esophagus (EUS-B) is presented.

Dedicated and well-renowned endoscopic centers have contributed to this unique

selection of cases. Each case follows a similar format, starting with a CT and/or PET-CT
scan, followed by the EBUS and EBUS-TBNA procedure and cytopathological outcomes.

A big thank-you to all authors and people involved in the creation of this mini atlas of
cases. The following clinical cases show the enhanced capabilities you achieve when
using the EB19-J10U and support you in obtaining the best clinical outcomes for your
patients.

Kind regards,

Jouke T. Annema, MD PhD

Professor of Pulmonary Endoscopy
Amsterdam, The Netherlands

4 5
 EBUS in pulmonary practice

EBUS is regarded as the greatest innovation in pulmonary endoscopy, following

the invention of flexible bronchoscopy in the late 1960s. Numerous studies have
proven the value of EBUS as a diagnostic tool for various common pulmonary
diseases. Guidelines advocate EBUS as the initial tissue sampling technique of
choice – over mediastinoscopy – for lung cancer staging.1) Virtually all mediastinal
nodes – with the exception of the aorto pulmonary/aortic nodes – can be reached.
Additionally, the hilar nodal stations can be evaluated. In those patients with
suspected lung cancer without endobronchial abnormalities – but a centrally
located tumor adjacent to the major airways – EBUS-guided TBNA can safely
aspirate intrapulmonary tumors.

EBUS is increasingly used to stage the mediastinum for cases other than lung
tumors; for example mediastinal and hilar staging for esophageal cancer, breast,
or renal cancer.

EBUS is also the diagnostic technique with the highest rate in granuloma detection
in patients with sarcoidosis stage I/ II.2) Additionally, its safety profile is superior to
transbronchial lung biopsies.

The EBUS endoscope is also intended for use in the esophagus. Mediastinal
evaluation with the EBUS endoscope (EUS-B) is increasingly used for several
reasons. An esophageal examination is generally tolerated better by patients
due to the absence of coughing in the examination; and easier tissue sampling
due to the lack of cartilage rings. Especially for the evaluation of lymph node
stations 4L and 7, EUS-B is an alternative for EBUS. An additional advantage is
the access to the lower mediastinum and the left adrenal gland. The addition of
EUS-B to EBUS improves the local regional staging of lung cancer and a recent
guideline recommends the consideration of EUS-B following EBUS.3)

1)
 ethods for staging non-small cell lung cancer: Diagnosis and management of lung cancer,
M
3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
Silvestri GA et al. Chest. 2013 May;143(5 Suppl):e211S-e250S
2)
Endosonography vs. conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA
randomized clinical trial.
von Bartheld MB et al. JAMA. 2013 Jun 19;309(23):2457-64
3)
Combined endobronchial and oesophageal endosonography for the diagnosis and staging of lung cancer.
European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European
Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS).
Vilmann P et al. Eur Respir J. 2015 Jul;46(1):40-60

6 7
 Discover new facets of vision:
The PENTAX Medical EB19-J10U
Ultrasound Video Bronchoscope

The PENTAX Medical Ultrasound Video Bronchoscope EB19-J10U is designed to improve

diagnostic outcomes. It features crystal clear ultrasound imaging to support diagnostic
accuracy, contributes to a smooth facilitation of the EBUS-TBNA, and is ergonomically
designed for ease of operation and high working comfort.

Equipment and approach for the EBUS mini atlas

Crystal clear imaging for precise visualization case collection
Offers state-of-the-art ultrasound image quality for clear visualization of the airway
wall, surrounding lymph nodes, and adjacent structures. It supports orientation and
navigation in the airways by the sharpened HD endoscopic view.
In combination with Hitachi Ultrasound systems (ARIETTA V70, HI VISION Preirus
and Noblus) and PENTAX Medical video processors (DEFINA EPK-3000 and
EPK-i5000), the ultrasound and endoscopic images taken with the EB19-J10U
offer crystal clear resolution for precise imaging of the airways. The equipment
was used to capture clinical ultrasound and endoscopic images shown in the
Reliable tissue acquisition
following cases. For further information about these products, please refer to
The combination of outstanding ultrasound imaging and an enlarged working
channel contribute to an accurate and easier real-time ultrasound-guided PENTAX Medical and Hitachi websites.
transbronchial needle aspiration (EBUS-TBNA) for the diagnosis and staging
of lung diseases through the use of a wide range of needles. The EBUS cases were collected in hospitals across Europe. All cases were
documented in the same structure: patient history and differential diagnosis,
EBUS findings, cytopathological diagnosis, and patient follow-up.

Unmatched ergonomic design for ease of operation Our special thanks goes to the editor of this EBUS mini atlas, Prof. Jouke T.
Optimal working comfort for users and high patient tolerance provided by the Annema of Academic Medical Centre, University of Amsterdam, The Netherlands.
small ultrasound transducer, the slim endoscope outer diameter, and the unique
ergonomics of the control body.

8 9
1
Suspected lung cancer Rocco Trisolini, MD, PhD
Pulmonologist
Pneumologia Interventistica
Policlinico S. Orsola
Bologna, Italy

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 76-year-old male, a former construction worker The EBUS confirmed the presence of an The EBUS-TBNA samples revealed a lymph node
and current smoker (40 pack-years) presented enlarged hilar lymph node 10L (short axis metastasis from an adenocarcinoma. Genotyping
with hemoptysis. The chest CT scan showed 14x12mm) with a round shape and sharp was performed but no mutations were found in
a mass in the left lower lobe and an enlarged borders with hypo-echoic texture. Real-time the genes EGRF, KRAS, ALK, and ROS1. In
lymph node station 10L. The PET-CT revealed Elastography showed a predominantly blue conclusion, this patient with a final diagnosis of
FGD uptake in the lung mass, LN 10L, and in pattern, indicating stiffness of the node pulmonary adenocarcinoma of the left lower lobe
multiple bone lesions. suggesting malignant involvement. An EBUS- (stage IV) was treated with cisplatin and
TBNA of the 10L lymph node was performed. pemetrexed chemotherapy.
Differential diagnosis:
• Pulmonary carcinoma (NSCLC, SCLC)
Image 5 – EBUS-TBNA aspirates showing
groups of adenocarcinoma cells (papanocolau
smear)

Image 1 – FDG avid mass in the LLL and Image 2 – Enlarged LN 10L 14x12mm Image 3 – Elastography of LN 10L Image 4 – EBUS-TBNA of LN 10L using a 25G
an enlarged LN 10L demonstrating a predominantly blue pattern COOK needle

10 11
2
Lung cancer staging Erik (H.F.M.) van der Heijden, MD, PhD
Pulmonologist
Interventional Pulmonology & Thoracic Oncology
Dept. of Pulmonary Diseases
Radboud University Medical Centre Nijmegen
The Netherlands

Patient history & differential diagnosis • Pulmonary, lymfogenic, and distant metastasis Diagnosis & follow-up
from extra thoracic tumor (sarcoma)
A 60-year-old female, a never smoker, was • Infectious disease (tuberculosis, nocardia, fungi) The EBUS-TBNA samples of the 4R showed
referred with a cough and hemoptysis. A chest adenocarcinoma. Molecular analysis on EBUS
CT scan revealed an 8cm mass in the right upper EBUS findings cytology was performed with the following
lobe and a secondary mass in the middle lobe outcomes:
as well as enlarged nodes in the right hilum and The EBUS showed a normal appearance of left- • EGFR/ROS1/ALK/MET/ERB no abnormalities
paratracheal to the right (station 4R). A PET-CT sided lymph nodes. It delineated enlarged lymph • KRAS mutation c.34G>C (p.(Gly12Arg) 56%
revealed intense FDG uptake in the RUL mass nodes 2R, 4R, 7 and 10R. FineFlow imaging of mutant allelle
and lymph nodes, avid lymph nodes 2R, 4R LN 4R showed a well vascularized node. In conclusion, this patient with lung
and 7, as well as a single lesion in the pelvis. Elastography imaging showed a predominantly adenocarcinoma of the RLL, cT4N2M1c TTF-1 20x
blue pattern in the right side paratracheal nodes (bone metastasis pelvis), was treated
Image 5 – TTF1 positive compatible with
Differential diagnosis: (2R and 4R) suggesting malignant involvement. with cisplatin and pemetrexed.
adenocarcinoma; next generation sequencing
• Pulmonary carcinoma (NSCLC, SCLC) An EBUS-TBNA was performed. showed a KRAS mutation
• Lymphoma

HE 20x

Image 1 – PET-CT showing FDG avid mass Image 2 – Very well demarcated and Image 3 – Conventional image (right panel) Image 4 – Cell block of EBUS-TBNA aspirate
in the RUL and uptake in LN 4R vascularized LN 4R with an inhomogeneous and Elastography image (left panel) of LN 4R demonstrating clearly atypical cells with nuclei
echo texture demonstrating a mixed but predominantly of different form and gross chromatine with
blue pattern prominent nucleoli

12 13
3
Hilar lymph node relapse Rocco Trisolini, MD, PhD
Pulmonologist
Pneumologia Interventistica
Policlinico S. Orsola
Bologna, Italy

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 45-year-old, non-smoking Chinese male with The EBUS confirmed the presence of a hilar The EBUS-TBNA samples of LN 11R showed
prior left-sided pneumonectomy (pT4N1Mo, lymph node 11R (short axis 11mm) which was an adenocarcinoma with a lymphatic
adenocarcinoma) was admitted to the hospital. oval shaped with an inhomogeneous echo background. Genotyping didn’t reveal EGFR
A chest CT scan performed four months after texture and sharp borders. Elastography was or other mutations. This patient unfortunately
pneumonectomy showed a new lesion in the suggestive of malignant involvement showing a presented with recurrent adenocarcinoma and
right hilum. The patient was referred for an predominantly blue pattern. An EBUS-TBNA of started chemotherapy with cisplatin and
EBUS examination. the 11R lymph node was performed. pemetrexed.

Differential diagnosis:
• Recurrence of NSCLC (adenocarcinoma)
Image 5 – EBUS-TNA sample showing groups
• Reactive node post-pneumonectomy
of adenocarcinoma cells

Image 1 – Right hilar lesion (11R) and a Image 2 – EBUS showing two sharply Image 3 – Elastography image (right panel) Image 4 – EBUS-TBNA of LN 11R using a 22G
fluid-filled cavity after left-sided pneumonectomy demarcated, iso-echoic hilar lymph nodes (11R) of LN 11R demonstrating a predominantly COOK needle
blue pattern

14 15
4
Small cell lung cancer Erik (H.F.M.) van der Heijden, MD, PhD
Pulmonologist
Interventional Pulmonology & Thoracic Oncology
Dept. of Pulmonary Diseases
Radboud University Medical Centre Nijmegen
The Netherlands

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 72-year-old female, former smoker (45 pack- An enlarged hypo-echogenic LN 7 (18 mm) and Small cell lung cancer was found in the LN 7
years) with weight loss and impaired food an enlarged well-demarcated LN 11L (11mm) tissue acquired by EBUS-TBNA. Chemotherapy
passage was referred for analysis of a left upper were found during the EBUS examination. with cisplatinum and etoposide was given.
lobe mass as well as enlarged lymph nodes in Elastography of LN 7 clearly distinguished the
the left hilum (station 11L) and the subcarinal malignant area from the reactive tissue. EBUS-
region (station 7). The PET-CT showed a FDG TBNA was performed.
avid left upper lobe lesion and the two nodules
with compression of the esophagus.

Differential diagnosis:
Image 5 – EBUS-TBNA sample of LN 7
• Pulmonary carcinoma (NSCLC/SCLC)
showing malignant cells with molding and
• E
 sophageal carcinoma with regional a characteristic cytoplasm to nuclei ratio
metastases as seen in small cell lung cancer

Image 1 – CT scan of the chest showing Image 2 – PET-CT showing FDG uptake in Image 3 – LN station 11L showing an Image 4 – LN station 7 (subcarinal) oval shaped
enlarged lymph nodes 7 and 11L lymph nodes 7 and 11L isoechogenic texture with intense reflections with sharp borders and hypo-echoic texture
(right panel). Elastography (left panel) clearly
distinguishes the malignant (blue) area from
the reactive (red) tissue

16 17
5
Mediastinal mass Jouke T. Annema, MD, PhD
Pulmonologist
Dept. of Respiratory Medicine,
Academic Medical Centre,
University of Amsterdam
The Netherlands

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up
A B

A 61-year-old male, a former smoker (35 pack- During the bronchoscopy the right main bronchus The EBUS-TBNA samples showed a squamous
years), presented with thoracic pain. His chest CT was compressed without mucosal abnormalities. cell carcinoma with a necrotic background. In
scan showed a right hilar mass surrounding the An EBUS was performed and confirmed the conclusion, this patient had an extensive stage III
hilar vessel and compressing the intermediate presence of multiple enlarged LN stations 4R, squamous cell cancer of the right lower lobe. The
bronchus. A post-obstruction pneumonia was 10R, 7, and 2L. For diagnostic and staging treatment advice was chemotherapy consisting
found, in addition to multiple enlarged lymph purposes, an EBUS-TBNA was carried out. of a doublet including platinum.
nodes 11R, 10R, 7, 4R, 2R and 2L.

Differential diagnosis:
Image 5 –
• Pulmonary carcinoma (NSCLC/SCLC)
A Squamous cell carcinoma (Giemsa staining)
• Lymphoma B Typical bright blue cytoplasm in the Giemsa
staining

Image 1 – CT showing an enlarged mass in the Image 2 – Well-demarcated, inhomogeneous Image 3 – Optical image during EBUS-TBNA Image 4 – EBUS-TBNA of the right hilar lesion
right hilum compressing and invading the right lesions in the right hilum (station 10R) showing the blue sheath, the needle, and the
pulmonary artery and an enlarged subcarinal pressing the pulmonary artery ultrasound transducer at the bottom right
lymph node

18 19
6
Intrapulmonary tumor Jouke T. Annema, MD, PhD
Pulmonologist
Dept. of Respiratory Medicine,
Academic Medical Centre,
University of Amsterdam
The Netherlands

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 69-year-old male, former smoker (30 pack- EBUS revealed an intrapulmonary left upper Tissue samples of EBUS-TBNA and EUS-B-FNA
years) was referred with severe lower back pain. lobe tumor visible next to the aorta without signs demonstrated adenocarcinoma.
CT scan of the chest and abdomen showed a of invasion (no T4). EBUS-TBNA of LN 4L was In conclusion, this patient with cT2-4N2M1
centrally located left upper lobe lesion (4.5cm), performed. EUS-B showed a visible tumor adenocarcinoma stage IV was treated by
and several large lymph node clusters (>5cm) adjacent to the esophagus with no invasion in cisplatin and pemetrexed.
in the mediastinum and a slightly enlarged LN the aorta. EUS-B-FNA of LN 4L (15mm) was
paratracheal to the left (station 4L) and a lesion performed.
in vertebra Th12.
Image 5 – Aspirate showing adenocarcinoma
Differential diagnosis: (giemsa staining) with typical light grey
• Pulmonary carcinoma (NSCLC/SCLC) cytoplasma and glandular formation of the
• M
 etastasis of extra thoracic tumor (sarcoma, cells
prostate, etc)

Image 1 – Mass in LUL, located adjacent to the Image 2 – Mass in the mediastinum adjacent Image 3 – Color Doppler signal (main panel) Image 4 – Well-demarcated LN 4L, hypoechoic
mediastinum with a close relation to the aortic to the ascending aortic arch; borderline sized depicts the aortic arch, LUL tumor showing texture with a single vessel, with the pulmonary
arch LN 4L no signs of tumor invasion; endoscopy image artery to the left
with airway mucosa and ultrasound head (left
upper panel)

20 21
7
EUS-B and the lower mediastinum Jouke T. Annema, MD, PhD
Pulmonologist
Dept. of Respiratory Medicine,
Academic Medical Centre,
University of Amsterdam
The Netherlands

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 58-year-old construction worker, current The EBUS imaging showed well-demarcated The EBUS-TBNA and EUS-B-FNA tissue
smoker (90 pack-years) presented to the hospital hypoechoic lymph nodes in stations 4R and samples showed squamous cell carcinoma
with a persistent cough. A perihilar mass in the 7 (both 15mm). Following a systematic EBUS with a lymphatic background. The treatment
right lower lobe (3.8x2.9cm) and enlarged lymph investigation and nodal sampling, the EBUS advice for this patient with squamous cell
nodes 11R, 7, and 2R were found in the chest CT endoscope was introduced in the esophagus carcinoma, RLL, cT3 N2 Mo was chemotherapy
scan. A PET-CT revealed FDG uptake in the right for an investigation of the lower mediastinal, consisting of a doublet including platinum.
lower lobe mass with signs of a post-obstruction subcarinal, and left-sided paratracheal nodes.
pneumonia. FDG-uptake was also present in An oval-shaped, well-demarcated lower
lymph nodes 11R, 10R, 7 and 4R. paraesophageal lymph node 8 was detected Image 5 – EUS-B of LN 8, para-esophageally
located in the lower mediastinum
by EUS-B.

Image 1 – PET-CT showing FDG uptake in Image 2 – CT scan showing mass suspected Image 3 – Multiple nodes in the subcarinal Image 4 – EUS-B of the liver with EBUS scope
mass RLL and lymph nodes 11R and 8 post-obstruction pneumonia and LN 8 space adjacent to the left atrium delineated by positioned in the distal esophagus
Color Doppler

22 23
8
Sarcoidosis Jouke T. Annema, MD, PhD
Pulmonologist
Dept. of Respiratory Medicine,
Academic Medical Centre,
University of Amsterdam
The Netherlands

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up

A 24-year-old male, a non-smoker of African Multiple enlarged, well-demarcated, isoechoic The EBUS-TBNA specimen revealed multiple
origins, presented with symptoms of an uveitis, mediastinal and hilar lymph nodes at locations granulomas with lymphatic background, with no
fatigue, and non-productive cough. A chest 4L, 5, 6, 7, 11L and 11R were found during sign of necrosis. In conclusion, this patient with
X-ray revealed bilateral hilar and mediastinal EBUS. The EUS-B showed clustered, well- sarcoidosis stage 1 needs to undergo regular
lymphadenopathy which were confirmed by demarcated, isoechogenic lymph nodes 4L, intervals for clinical and radiological follow-up.
a chest CT scan that showed no parenchymal 5, 6, 7 and 8. EBUS-guided TBNA of lymph This uveitis was treated with topical steroids.
involvement. node stations 4R and 11L was performed.

Differential diagnosis:
Image 5 – Clustered groups of giant cells with
• Sarcoidosis stage 1
atypical-shaped nuclei, typical of granuloma,
• Lymphoma on a lymphatic background, without necrosis,
• Tuberculosis compatible with the diagnosis sarcoidosis
(Giemsa coloring)

Image 1 – Chest X-Ray showing bilateral hilar Image 2 – CT scan of the chest with enlarged Image 3 – Clustering of isoechoic, Image 4 – View of an enlarged LN station 6,
and mediastinal lymphadenopathy lymph nodes 7 and 11L well-demarcated lymph nodes around located adjacent to the aortic arch (with Color
the pulmonary artery (station 11L) Doppler)

24 25
9
Hodgkin’s lymphoma Marcus Kennedy, MD MB BCh BAO FRCPI FCCP
Pulmonologist
Consultant Respiratory and General Physician
Cork University Hospital
Ireland

Patient history & differential diagnosis EBUS findings Diagnosis & follow-up
A B C

A 23-year-old female student presented with The EBUS investigation identified diffuse EBUS-TBNA samples showed Reed-Sternberg
chest pain. Previous medical history revealed mediastinal and hilar nodal enlargement of lymph cells. In conclusion, this patient with recurrence
a stage 2A sclerosing Hodgkin’s lymphoma, nodes stations 11R, 7, 4R and 4L. EBUS-TBNA of sclerosing Hodgkin’s lymphoma was referred
for which she received six cycles of ABVD samples were obtained from station 7 (20mm). to the hematologist for chemotherapy treatment.
chemotherapy. The CT and PET-CT were
suggestive of lymphoma relapse with extensive
Image 5 –
osseous, nodal, and pulmonary involvement.
AR  apid Giemsa stain of EBUS-TBNA sample
showing many Reed-Sternberg cells with a
Differential diagnosis: background of lymphoid cells, histiocytes,
• Recurrence of Hodgkin’s lymphoma and eosinophils
B H &E stain of cell block made from the
needle rinse of EBUS-TBNA showing many
large Reed-Sternberg cells and scattered
eosinophils
C C D30 stain showing many positive
Reed-Sternberg cells

Image 1 – Chest CT Thorax demonstrating Image 2 – Integrated PET-CT with FDG Image 3 – LN 11R inhomogenuous texture Image 4 – Multiple, clustered subcarinal
an enlarged subcarinal node avid nodes on location 7 and 11R and with underlying lung and pleura nodes with an inhomogenous echo texture
and irregular borders

26 27
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professionals. Before usage and for detailed product specifications, please refer to the instructions
for use. In the interest of technical process, specifications may change without notice.

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The legal manufacturer of the PENTAX EBUS EB19-J10U is Hoya Corporation, Tokyo, Japan.
LCM/02/07/16/320091/02

This bronchoscope is distributed by PENTAX and Hitachi in their assigned geographical areas.
The manufacturer of ARIETTA V70, HI VISION Preirus and Noblus is Hitachi Ltd., Tokyo, Japan.
These ultrasound systems are exclusively distributed by Hitachi Medical Systems Europe
Holding AG, Zug, Switzerland and their subsidiaries.
Specifications and physical appearance may be changed without prior notice.