PLACEMENT OF FIDUCIAL MARKERS INTO A PULMONARY TUMOR VIA THE ESOPHAGUS USING EBUS

Abstract

SESSION TITLE: Procedures SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/10/2018 10:45 AM - 11:45 AM INTRODUCTION: While surgical resection for early stage non-small cell lung cancer continues to be the first-line therapy when available, alternative therapies such as stereotactic body radiation therapy (SBRT) should be considered in poor surgical candidates. Studies show SBRT to have non-inferior success rates in cure for early stage NSCLC. Fiducial markers can be placed in pulmonary nodules to assist with guiding SBRT. As bronchoscopy techniques have advanced, placing markers through the bronchoscopy is being used more frequently. Studies show fiducial markers can be placed during the same bronchoscopic procedure as tissue diagnosis and staging. Complication rates have been as low as 1.7%. We present the case of an Interventional Pulmonologist intentionally inserting the bronchoscope into the esophagus, locating a nodule in the RUL, obtaining tissue samples for diagnosis, and placing fiducial markers for SBRT. CASE PRESENTATION: A 71 year old female was found to have a 5mm nodule in the right upper lobe adjacent to the esophagus on a cardiac gated chest computed tomogram (CT) while undergoing evaluation of an enlarged aortic root. A one year follow up CT scan showed an increase in size to 16mm with features highly concerning for malignancy. This lesion was metabolically active on dual point time positive emission tomography (PET-CT) measured at 18.4 standardized uptake values (SUV). Convex probe endobronchial ultrasound (CP-EBUS) with biopsies was performed on the mediastinum lymph nodes in a staging fashion and all lymph nodes greater than 5mm were sampled by fine needle aspiration (FNA). This included stations 11L, 4L, 7, 11Ri. Rapid on-site evaluation (ROSE) showed adequate sampling and was negative for malignancy in all lymph node samples. The CP-EBUS scope was then removed from the trachea and re-inserted into the esophagus. Via the esophagus, the CP-EBUS probe located the right upper lobe nodule. A 22 Gauge EBUS needle was used for FNA of the nodule, which was positive on ROSE. Staging was consistent with Stage IA non-small cell lung cancer. With the CP-EBUS probe still in the esophagus, 2 gold fiducial markers were loaded into the EBUS needle distally (front-loaded). Under CP-EBUS guidance, each fiducial was placed inside the tumor along the periphery. Color Doppler was utilized to avoid vascular puncture or intravascular fiducial placement. No complications occurred. DISCUSSION: To our knowledge and review of the literature, this is the first case of fiducial markers being successfully placed in a lung cancer nodule through the esophagus via a CP-EBUS scope. This case highlights the capability of obtaining tissue, and placing fiducial markers, through a CP-EBUS by an experienced bronchoscopist. CONCLUSIONS: The success of this procedures offers the possibility of an alternative route and method for diagnosis of neoplastic disease, as well as placement of fiducial markers for SBRT. Reference #1: Harley DP, KrimskyWS, Sarkar S, Highfield D, Aygun C, Gurses B(2010) Fiducial marker placement using endobronchial ultrasoundand navigational bronchoscopy for stereotactic radiosurgery: an alternativestrategy. Ann Thorac Surg 89(2):368–373 discussion 73-4 Reference #2: Harris K, Gomez J, Dhillon SS, Alraiyes AH, Picone A. Convex probe endobronchial ultrasound placement of fiducial markers for central lung nodule (with video). Endoscopic Ultrasound. 2015;4(2):156-157. https://doi.org/10.4103/2303-9027.156757. Reference #3: Kular H, Mudambi L, Lazarus DR, Cornwell L, Zhu A, Casal RF. Safety and feasibility of prolonged bronchoscopy involving diagnosis of lung cancer, systematic nodal staging, and fiducial marker placement in a high-risk population. Journal of Thoracic Disease. 2016;8(6):1132-1138. https://doi.org/10.21037/jtd.2016.04.06. DISCLOSURES: no disclosure on file for Samir Makani; No relevant relationships by Michael Monson, source=Web Response