Endoscopic Ultrasound (EUS)-Guided Fiducial Placement for Stereotactic Body Radiotherapy (SBRT): First Global Experience With a New 22-Gauge “Pre-loaded” EUS Fiducial Needle

Abstract

Fiducial guided SBRT has been approved for the treatment of various malignancies. Stereotactic radiosurgery system delivers radiation with high precision using real-time image guidance. Radiographic markers (gold fiducials) implanted in the tumor are used as reference points by the system to target the radiation beams. Fiducials have been placed intra-operatively, percutaneously or using a re-loadable EUS needle. We describe the first experience using a new 22-gauge “pre-loaded” EUS Fiducial needle (4 fiducials pre-loaded per needle).Figure 1Objective: To assess the feasibility, safety & efficacy of a new 22-gauge “pre-loaded” EUS fiducial needle in patients referred for image guided radiotherapy at two tertiary referral centers. Design: Patients were initially selected for SBRT based on clinical presentation and after multidisciplinary tumor board review. These patients were then referred for EUS guided fiducial placement at 2 tertiary referral centers. Ten consecutive, eligible patients underwent EUS guided fiducial placement using a new 22-gauge “pre-loaded” EUS fiducial needle between 4/2014-05/2015 (see Table 1 for details). All patients received intra-procedural antibiotics. Data was retrospectively reviewed per medical records. Results: Patient & procedure details are listed in Table 1. Mean patient age was 57 yrs; 70% were males. EUS-guided fiducial placement was successful in all 10 patients. All patients underwent successful SBRT. SBRT was defined “optimal” in 9/10 patients (per feedback from radiation oncology). Average fiducial placement time (time from first fiducial placed to last fiducial placed) was 7.2 min. There were no infections, complications or deaths related to the procedure. All procedures were performed on an outpatient basis and patients were discharged home after an uneventful procedure & recovery. Conclusion: EUS-guided fiducial placement using the new 22-gauge “pre-loaded” needle is safe, effective and very efficient. Successful deployment was achieved in all 9 patients; optimal SBRT was achieved in 9/10 patients. This series represents the first global experience with this new pre-loaded EUS fiducial needle. The pre-loaded nature of the needle simplifies the procedure, reduces overall procedure time and eliminates potential needle-stick exposure for ancillary staff. Further experience with this needle will clarify its role and impact in interventional EUS.