New and Improved: Our Experience with the 22G Cook Fiducial Needle System

Abstract

Traditionally fiducial markers have served as reference points and have been placed by Endoscopic ultrasound (EUS), intraoperatively, or percutaneously via ultrasound or CT. EUS guided placement has increased in popularity recently due to the ability of EUS to allow for close proximity to deeper abdominal structures not easily accessible via surgical or percutaneous routes. One limitation to the growth of this technique has been the need to individually back load and seal the fiducial using bone wax or recently described wet fill technique. The back loading procedure increases the time for the procedure, may increase risk to the operator if one is loading fiducials into dirty needles (when more than one fiducial is required), or increase cost if new FNA needles are used for each fiducial. The new 22G Cook Fiducial needle is preloaded with four gold fiducials, which solves many of the problems mentioned. Four patients underwent fiducial placement with the 22G Cook Fiducial Needle System. A 63 year old male with metastatic renal cell carcinoma to the stomach and proximal duodenum presented with melena. EGD showed a large ulcerated bleeding mass in the anterior wall of the stomach. Fiducials were placed to allow for selective embolization. A 52 year old male presented with progressive dysphagia and weight loss. EGD revealed a large partially obstructing lower esophageal mass. Pathology confirmed esophageal adenocarcinoma and he underwent fiducial placement to assist in intensity modulated neoadjuvant radiation therapy. A 68 year old male with rectal adenocarcinoma had a 10 mm mass in the left lobe of the liver. The patient was to undergo neo-adjuvant therapy followed by surgical resection of the primary tumor and wedge resection of the solitary liver lesion. Fiducial placement was requested prior to neoadjuvant therapy to mark the position of the mass for localization during the eventual wedge resection. A 57 year old male with abdominal pain had an EUS which showed an ill-defined mass in the pancreatic neck with background chronic pancreatitis. EUS FNA of the mass was positive for adenocarcinoma. Due to ill-defined nature of the mass, the presence of background chronic pancreatitis and for accurate surgical localization fiducial placement was requested. We have shown that this needle is easy and quick to use in a variety of settings with subsequent excellent visualization of the fiducial with no immediate or delayed complications.