Endoscopic Ultrasound-Guided Placement of Fiducials for the Treatment of Pancreatic Cancer

Abstract

Purpose: Alternative treatment options for locally unresectable pancreatic cancer are emerging. Radiosurgical therapy (Cyberknife, Accuray Inc, Sunnyvale, CA) is a new approach that allows for precise and flexible external beam radiation targeting of the tumor through an image-guided stereotactic radiosurgery system. Cyberknife treatment of pancreatic cancer requires placement of fiducial markers to enable computer tracking of the tumor during radiation delivery. This placement of the fiducial has traditionally required surgery. We present a novel technique of fiducial placement using endoscopic ultrasound.TableMethods: After informed consent, patients were given a dose of prophylactic intravenous antibiotic. Sedation was achieved in a routine fashion using intravenous midazolam and meperadine. A Pentax 5G-3630 UR radial echo endoscope was used to localize the pancreatic tumor. Next, using a Pentax 5G-3630 linear echoendoscope, one to three 5 mm gold fiducials were deployed into the center of the tumor using a Wilson Cook 19 gauge or 22 gauge EUS biopsy needle. The position of the fiducial (s) were documented by both sonography and fluoroscopy. The patients were recovered and discharged from our outpatient facility in the usual fashion. Post-implantation follow-up occurred at day # 10 during which time placement of the fiducial (s) was assessed by computed tomography. Results: Eleven patients underwent EUS-guided placement of sixteen fiducials. There were no intra-procedural complications with all patients being discharged from our ambulatory center. Upon follow-up, one patient had developed an infectious process which resolved with short-term oral antibiotics. Two patients experienced migration of their fiducials requiring repeat EUS-guided implantations without clinical consequences. All eleven patients went on to complete a 6 week course of radiosurgical therapy. Conclusions: We have shown that EUS placement of fiducials in pancreatic cancer for tumor localization can be accomplished safely and effectively. It may be an appealing alternative to conventional laparoscopic or surgical placement.