Implantation Of Fiducial Markers Research Articles

The Risk of Urosepsis in Patients Undergoing Fiducial Marker Placement for Image Guided Radiation Therapy (IGRT) of Prostate Cancer

To determine the risk of urosepsis after the placement of intraprostatic soft tissue fiducial markers used for IGRT for prostate cancer. Between June 2008 and December 2012, 3851 patients underwent fiducial-based kV (stereoscopic or CBCT) prostate IGRT for prostate cancer at our institution and serve as the population base for this study. Two gold soft-tissue markers (1 cm Visicoil) were implanted into the prostate by the Radiation Oncologist or Urologist using transrectal ultrasound via an 18 gauge pre-loaded needle in the right and left peripheral lobes of the prostate. All patients received prophylactic antibiotics prior to and after the procedure. Additional prep included temporary discontinuation of anticoagulants and typically a commercially available enema such as Fleets prior to the procedure to clear the rectal vault. Beginning in 2009, as part of our ongoing quality management processes, we instituted a standardized antibiotic prophylaxis regimen based on regional antibiogram which included double antibiotics, a mechanical double enema prep (night before and day of procedure instead of day of only), and a one hour delay between the procedure and any intramuscular injection of an antibiotic. Data was collected both on an on-going basis, as well as via a query of Radiation Oncology and Urology Electronic Medical Records (cross-referencing fiducial marker placement codes with subsequent sepsis hospitalization or treatment, with confirmation of generated data via hospital record review and/or direct patient and physician contact. A total of 7702 fiducials were inserted in 3851 patients for fiducial-based kV prostate IGRT. Of those, 31 patients developed urosepsis attributable to the placement of fiducial markers yielding a urosepsis rate of 0.8% per patient or 0.4% per marker placed. The number of cases of urosepsis fell over time with 65% (20/31), 22% (7/31), 6% (2/31), and 6% (2/31) of the cases occurring in 2008-2009, 2010, 2011, and 2012, respectively. Although the rate of urosepsis was only 0.8% overall, this rate significantly decreased by 2011 and remained low in 2012. Based on one of the largest cohorts of patients undergoing fiducial-based kV IGRT for prostate cancer, the risk of urosepsis due to implantation of soft-tissue fiducial markers for IGRT is extremely low. The routine use of double antibiotic prophylaxis, double enema (night before and day of procedure instead of day of only), and a one hour delay between the procedure and intramuscular injection of an antibiotic has decreased the incidence of urosepsis following fiducial marker placement. This decline in the sepsis rate is directly attributable to our institution's quality management measures which allowed for the standardization of the regimen prior to fiducial placement.

Complication Rates in Fiducial Marker Implantation for Prostate Radiation Therapy

Complication Rates in Fiducial Marker Implantation for Prostate Radiation Therapy

Free‐breathing conformal irradiation of pancreatic cancer

The purpose of this study was to assess treatment margins in free‐breathing irradiation of pancreatic cancer after bone alignment, and evaluate their impact on conformal radiotherapy. Fifteen patients with adenocarcinoma of the head of the pancreas underwent implantation of single fiducial marker. Intrafraction uncertainties were assessed on simulation four‐dimensional computed tomography (4D CT) by calculating maximal intrafraction fiducial excursion (MIFE). In the first ten patients, after bony alignment, the position of the fiducial was identified on weekly acquired megavolt cone‐beam CT (MV‐CBCT). The interfraction residual uncertainties were estimated by measuring the fiducial displacements with respect to the position in the first session. Patient mean (pM) and patient standard deviation (pSD) of fiducial displacement, mean (μM) and standard deviation (μSD) of pM, and root‐mean‐square of pSD (σres) were calculated. In the other five patients, MIFE was added to the residual component to obtain personalized margin. In these patients, conformal kidney sparing (CONKISS) irradiation was planned prescribing 54/45 Gy to PTV1/PTV2. The organ‐at‐risk limits were set according to current NCCN recommendation. No morbidity related to the fiducial marker implantation was recorded. In the first ten patients, along right–left, anterior–posterior, and inferior–superior directions, MIFE was variable (mean±std=0.24±0.13cm,0.31±0.14cm,0.83±0.35cm, respectively) and was at most 0.51, 0.53, and 1.56 cm, respectively. Along the same directions, μM were 0.09,−0.05,−0.05cm,μSD were 0.30, 0.17, 0.33 cm, and σres were 0.35, 0.26, and 0.30 cm, respectively. MIFE was not correlated with pM and pSD. In the five additional patients, it was possible to satisfy recommended dose limits, with the exception of slightly higher doses to small bowel. After bony alignment, the margins for target expansion can be obtained by adding personalized MIFE to the residual interfraction term. Using these margins, conformal free‐breathing irradiation is a reliable option for the treatment of pancreatic cancer.PACS number: 87.55.D‐

SU‐E‐T‐412: What Is the Benefit of Fiducial Marker Implantation for Pancreatic SBRT?

Purpose: Localization of pancreatic tumors during Stereotactic Body Radiation Therapy (SBRT) is difficult due to the poor soft‐tissue contrast of abdominal cone‐beam CT (CBCT). The purpose of this study was to measure the increased accuracy of pancreas localization when radiopaque fiducial markers (RFM) are implanted into the tumor and peri‐pancreatic tissue to facilitate a reduction of margins and escalation of dose. Methods: 15 CBCT scans were acquired of patients implanted with RFM enrolled in a prospective study involving SBRT for pancreatic cancer, receiving 30 Gy in five fractions with PTV margins of 3–5 mm. In order to quantify the effect of RFM, matching sets of markerless CBCT images were created. An automated tracking algorithm was developed to identify the location of markers in each CBCT projection, and 2D Gaussian fitting was used to filter these markers from the images. The 3D dataset was re‐reconstructed using these filtered projections, yielding a CBCT image of the same patient geometry with no RFM. These markerless images were aligned to the reference CT images using the anterior vertebral surface/aorta and the pancreatic stent as a guide. Using the RFM images as a gold standard, the differences in position represent the error in localization due to the lack of RFM information. Results: The automated algorithm successfully yielded CBCT images without RFM, star artifacts due to markers, or artifacts due to the filtration process. When the vertebral bodies and aorta were used for localization, the average error (compared to RFM images) was 15.0±7.4 mm. When a pancreatic stent was used for localization, the average error was 3.9±2.1 mm. Conclusion: Implantation of RFM increases localization accuracy by 4–15 mm compared to conventional techniques. Marker implantation is necessary when using tight margins and/or increasing tumor dose, and can be used to increase the therapeutic ratio.

2:10 PM Abstract No. 211 - Transrectal ultrasound-guided prostate fiducial marker placement for prostate localization during external beam radiotherapy: a safe and reliable procedure

Purpose Fiducial markers may be used to localize the prostate during radiotherapy using portal film and/or cone-beam CT. The purpose of this study is to describe the technique, efficacy, and complications of transrectal ultrasound (TRUS)-guided prostate fiducial marker placement by interventional radiology. Materials and Methods With IRB approval, medical records of patients who underwent TRUS-guided prostate fiducial marker placement between 1/2011 and 8/2012 were reviewed. Three gold markers, Visicoil (IBA, Bartlett, TN) or AnchorMarker (Biocompatibles, Oxford, CT), were placed, 1 each in the right and left prostate base as well as right apex (1). Post-procedure frontal and lateral radiographs confirmed placement. An additional marker was placed if malposition was noted. Complications of fiducial placement and need for additional localization modality at radiotherapy were recorded. Results In total 111 men with mean age 69 years (range 52—90), mean PSA 11 (range 1—106), mean Gleason score 7 (range 6—9), and clinical stage T1c—T3b underwent marker placement. Prior TURP was noted in in 6 (5.4%), and cryotherapy in 1 (0.9%). Mean prostate volume was 31.5 mL (range 2—130). In 60 (54%), 1% lidocaine was injected into the neurovascular bundle; 51 (46%) received no lidocaine. Moderate sedation due to anxiety was used in 1 (0.9%) and general anesthesia due to anal canal stenosis was used in 1 (0.9%). Malposition of 1 marker was recognized at US in 4 (3.6%) and on radiograph in 2 (1.8%), necessitating additional fiducial placement. In all cases, the fiducials were still used during radiotherapy. Poor visualization of the fiducial markers required additional prostate localization in 3 patients (2.7%) using B-mode acquisition and targeting US. Post-procedure urinary tract infection requiring oral antibiotics occurred in 1 (0.9%). Urosepsis requiring admission and IV antibiotics occurred in 1 (0.9%). Conclusion TRUS-guided prostate fiducial marker placement is a safe and reliable technique that may be performed by the interventional radiologist for subsequent prostate localization during radiotherapy. Reference 1. Shinohara K, Roach M, 3rd. Technique for implantation of fiducial markers in the prostate. Urology. 2008 Feb;71:196–200.

Planting the seeds of success: CT‐guided gold seed fiducial marker placement to guide robotic radiosurgery

Fiducial marker (FM)-guided stereotactic body radiation therapy (SBRT) allows for precise targeting and delivery of radiation to a tumor site. In this article, we briefly discuss SBRT, provide examples to describe CT-guided FM placement to guide SBRT, and discuss some of the associated risks and benefits. This article serves as a pictorial review for body imagers and interventional radiologists who perform CT-guided procedures and interpret diagnostic studies for oncology patients. CT-guided FMs were placed in patients who were appropriate candidates for SBRT. One week following placement, patients underwent diagnostic CT and/or MR examinations in order to include the FM data in the development of a treatment plan. From October 2007-November 2009, a total of 89 patients were implanted with FMs. Sites of implantation included lung, liver, bone, chest and abdominal wall, and peritoneum/retroperitoneum. Complications included pneumothorax and FM migration. Twenty-one patients (33%) with lung FM placement experienced at least a small pneumothorax and 6 patients (9%) required thoracostomy tubes. FM migration occurred in 5 patients (8%) with lung placement. SBRT provides a safer and more effective alternative to conventional radiotherapy, and CT-guided FM implantation of tumor sites increases the precision of SBRT. Technical improvements in FM placement can limit the complications associated with the procedure and further enable highly localized tumor therapy.

Patient-reported complications from fiducial marker implantation for prostate image-guided radiotherapy

To report on complications from transrectal ultrasound-guided insertion of fiducial markers for prostate image-guided radiotherapy. 234 patients who underwent transrectal fiducial marker insertion for prostate cancer image-guided radiotherapy were assessed retrospectively by questionnaire with regard to the duration and severity of eight symptoms experienced following the procedure. Pain during the implantation procedure was assessed according to the Wong-Baker faces pain scale. Of 234 patients, 32% had at least one new symptom after the procedure. The commonest new symptom following the procedure was urinary frequency affecting 16% of patients who had not been troubled by frequency beforehand. Haematuria, rectal bleeding, dysuria and haematospermia affected 9-13% of patients, mostly at Grade 1 or 2. Pain, obstruction, and fever and shivers affected 3-4% of patients. Grade 3 rectal bleeding, haematuria, fever and shivers, and urinary frequency affected 0.5-1.5% of patients. Only one patient had a Grade 4 complication (i.e. fever and shivers). Overall, 9% of patients had symptoms lasting more than 2 weeks. The commonest symptoms that lasted more than 2 weeks were frequency, dysuria, obstructive symptoms and rectal bleeding. Mean pain score during the procedure was 1.1 (range 0-5). Transrectal ultrasound-guided fiducial marker insertion for image-guided radiotherapy is well tolerated in the majority of prostate cancer patients. Most symptoms were Grade 1 or 2 in severity. Symptoms in the majority of patients last under 2 weeks. The most serious complication was sepsis in our study.

Safety and Efficacy of Ultrasound-Guided Fiducial Marker Implantation for CyberKnife Radiation Therapy

ObjectiveTo evaluate the safety and technical success rate of an ultrasound-guided fiducial marker implantation in preparation for CyberKnife radiation therapy.Materials and MethodsWe retrospectively reviewed 270 percutaneous ultrasound-guided fiducial marker implantations in 77 patients, which were performed from June 2008 through March 2011. Of 270 implantations, 104 were implanted in metastatic lymph nodes, 96 were in the liver, 39 were in the pancreas, and 31 were in the prostate. During and after the implantation, major and minor procedure-related complications were documented. We defined technical success as the implantation enabling adequate treatment planning and CT simulation.ResultsThe major and minor complication rates were 1% and 21%, respectively. One patient who had an implantation in the liver suffered severe abdominal pain, biloma, and pleural effusion, which were considered as major complication. Abdominal pain was the most common complication in 11 patients (14%). Among nine patients who had markers inserted in the prostate, one had transient hematuria for less than 24 hours, and the other experienced transient voiding difficulty. Of the 270 implantations, 261 were successful (97%). The reasons for unsuccessful implantations included migration of fiducial markers (five implantations, 2%) and failure to discriminate the fiducial markers (three implantations, 1%). Among the unsuccessful implantation cases, six patients required additional procedures (8%).ConclusionThe symptomatic complications following ultrasound-guided percutaneous implantation of fiducial markers are relatively low. However, careful consideration of the relatively higher rate of migration and discrimination failure is needed when performing ultrasound-guided percutaneous implantations of fiducial markers.

Non-migration of a Trackable Implanted Fiducial Marker in the Prostate from the Day of Implantation

It is common practice to wait 4 - 7 days after implantation of fiducial markers in the prostate before performing a CT scan for treatment planning to allow time for the implants to stabilize within the implanted tissue. It is not uncommon for implants to move several millimeters during the first few days. The purpose of this work is to assess the stability immediately following implantation of the crumpling coil design of a novel trackable implanted fiducial (Tracer, Navotek Medical Ltd., Israel).

Successful treatment of a T4 lung tumor with vertebral body invasion using fiducial markers in the thoracic spine for image-guided radiation therapy: A case report

IntroductionParavertebral and paraspinal tumors pose a significant challenge in radiation therapy because of the radiation sensitivity of the spinal cord and the need for maximum treatment accuracy. Implantation of fiducial markers into vertebral bodies has been described as a method of increasing the accuracy of radiation treatment for single-dose stereotactic radiosurgery for spinal and paraspinal primary tumors and metastases. However, utilization of this technique has not been described for conventionally fractionated radiation therapy. This report is the first of its kind in the literature and describes successful treatment of a T4 primary lung tumor with vertebral body invasion with conventionally fractionated, image-guided radiotherapy using fiducial markers implanted in the thoracic spine.Case presentationOur patient was a 47-year-old African-American man who presented to our hospital with a history of several months of increasing left arm pain, chest pain, dyspnea on exertion, occasional dry cough, and weight loss. He was found to have stage IIIA T4, N0, M0 lung cancer with vertebral body invasion. He had fiducial markers placed in the thoracic spine for image-guided radiation treatment set-up. The patient received 74 Gy radiation therapy with concurrent chemotherapy, and daily matching of the fiducial markers on the treatment machine allowed for treatment of the tumor while sparing the dose to the adjacent spinal cord. With one year of clinical follow-up, the patient has had regression of the tumor with only asymmetric soft-tissue thickening seen on a computed tomographic scan and grade 1 dyspnea on exertion as the only side effects of the treatment.ConclusionFiducial marker placement is a safe and effective technique for maximizing the accuracy and reproducibility for radiation treatment of lesions near the spinal cord. This technique may be used in conventionally fractionated radiation treatment regimens, such as those employed to treat a lung tumor with vertebral body invasion, to potentially improve clinical outcomes for patients.

UP-02.162 Fiducial Markers for Image Localization Guidance in Prostate Gland Radiotherapy

Increasing interest in dose escalation and conformal radiotherapy in treatment for prostate cancer is gathering momentum and great interest. The prostate gland movement during radiotherapy course highlighted the value and need for precise target localization in order to reduce treatment delivery errors and potential unwanted irradiation of surrounding tissues. We present our experience in implantation of Fiducial markers for image guidance in prostate radiotherapy.

Endoscopic ultrasonography‐guided ablation therapy

Endoscopic ultrasonography (EUS) imaging has undergone extensive technological advancement since its development in the 1980s, including improvement of echoendoscopes with larger channels and accessories.These advancements enable not only tissue procurement for diagnosis but also therapeutic interventions that hitherto would have required surgery, with its attendant risks. A wide array of interventional procedures are performed under EUS guidance, including celiac plexus neurolysis, drainage of pancreatic and pelvic fluid collections, drainage of obstructive pancreatic-biliary ducts, ablation of cyst neoplasms in the pancreas, and implantation of fiducial markers and radioactive seeds into gastrointestinal tumors. Various experimental procedures are also underway to evaluate the role of EUS in radiofrequency ablation, vascular therapy, and natural orifice transluminal endoscopic surgery. In this review, we examine the various EUS-guided ablation therapies currently undertaken in humans.

Transperineal Implantation of Gold Fiducial Markers for Image-Guided Radiotherapy for Prostate Cancer

Transperineal Implantation of Gold Fiducial Markers for Image-Guided Radiotherapy for Prostate Cancer

Cardiac embolization of an implanted fiducial marker for hepatic stereotactic body radiotherapy: a case report

IntroductionIn liver stereotactic body radiotherapy, reduction of normal tissue irradiation requires daily image guidance. This is typically accomplished by imaging a surrogate to the tumor. The surrogate is often an implanted metal fiducial marker. There are few reports addressing the specific risks of hepatic fiducial marker implantation. These risks are assumed to be similar to percutaneous liver biopsies which are associated with a 1-4% complication rate - almost always pain or bleeding. To the best of our knowledge, we present the first case of such a fiducial marker migrating to the heart.Case presentationAn 81-year-old Caucasian man (5 years post-gastrectomy for a gastric adenocarcinoma) was referred post-second line palliative chemotherapy for radiotherapy of an isolated liver metastasis. It was decided to proceed with treatment and platinum fiducials were chosen for radiation targeting. Under local anesthesia, three Nester embolization coils (Cook Medical Inc., Bloomington, IN, USA) were implanted under computed tomography guidance. Before the placement of each coil, the location of the tip of the delivery needle was confirmed by computed tomography imaging. During the procedure, the third coil unexpectedly migrated through the hepatic vein to the inferior vena cava and lodged at the junction of the vena cava and the right atrium. The patient remained asymptomatic. He was immediately referred to angiography for extraction of the coil. Using fluoroscopic guidance, an EN Snare Retrieval System (Hatch Medical L.L.C., Snellville, GA, USA) was introduced through a jugular catheter; it successfully grasped the coil and the coil was removed. The patient was kept overnight for observation and no immediate or delayed complications were encountered due to the migration or retrieval of the coil. He subsequently went on to be treated using the remaining fiducials.ConclusionImplanted fiducial markers are increasingly used for stereotactic radiotherapy. There is sparse literature on the risks of such procedures. Although uncommon, the risk of migration does exist and therefore physicians (surgeons, oncologists and radiologists) and patients should be aware of this possibility.

How Soon after Fiducial Marker Implantation Should Patients Have Their Planning CT Scan Done for Prostate Cancer Radiotherapy?

How Soon after Fiducial Marker Implantation Should Patients Have Their Planning CT Scan Done for Prostate Cancer Radiotherapy?

1276: Safety and Efficacy of Ultrasound-guided Fiducial Marker Implantation for Cyberknife Radiation Therapy

1276: Safety and Efficacy of Ultrasound-guided Fiducial Marker Implantation for Cyberknife Radiation Therapy

Implantation of fiducial markers for image guidance in prostate radiotherapy: patient-reported toxicity

The purpose of this study was to evaluate patient-reported morbidity of implanted fiducial markers used for image guidance in prostate radiotherapy. Three fiducial markers were implanted under transrectal ultrasound guidance to 177 patients who were referred to our department for definitive radiotherapy between June 2005 and January 2008. No local anaesthesia was administered. Patients were asked to complete a questionnaire about the possible side effects of this invasive procedure. 135 patients completed the questionnaire at a median of 57 weeks after the procedure. Pain during the procedure was assessed with the Wong-Baker Faces Pain Rating Scale. Patients were also asked to compare the pain with the diagnostic biopsy. Although haematuria, rectal bleeding and fever were reported by 15%, 4% and 2% of the 135 patients, respectively, no major toxicity necessitating any intervention was observed. The mean pain score reported by the patients was 1.7 (range, 0-5). 87% of patients reported less (or comparable) pain than the diagnostic biopsy. In conclusion, implantation of fiducial markers for image guidance in prostate radiotherapy is a safe and well-tolerated procedure.

A Primer on Image-guided Radiation Therapy for the Interventional Radiologist

The use of image-guided radiation therapy in thoracic and abdominal tumors is increasing. Herein, the authors review the process of image-guided radiation therapy and describe techniques useful for optimal implantation of fiducial markers.

Percutaneous Implantation of Fiducial Markers for Imaging-Guided Radiation Therapy

The use of imaging-guided radiation therapy (IGRT) to treat thoracic and abdominal tumors is increasing. In this article, we review the process of IGRT and describe techniques to implant fiducial markers in the optimal geometry. Implantation of fiducial markers can be challenging. A better understanding of the physics of IGRT can help optimize fiducial marker placement for precise tumor targeting.

Abstract No. 132: Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-Guided Radiotherapy

Abstract No. 132: Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-Guided Radiotherapy