Korean J Radiol.  2012 Jun;13(3):307-313. 10.3348/kjr.2012.13.3.307.

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

• Kim JH
• Hong SS
• Kim JH
• Park HJ
• Chang YW
• Chang AR
• Kwon SB

• KMID: 1372850
• DOI: http://doi.org/10.3348/kjr.2012.13.3.307

Abstract

OBJECTIVE
To evaluate the safety and technical success rate of an ultrasound-guided fiducial marker implantation in preparation for CyberKnife radiation therapy.
MATERIALS AND METHODS
We 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.
RESULTS
The 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%).
CONCLUSION
The 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.

Keyword

Fiducial marker; Radiation oncology; Ultrasonography; interventional; Imaging-guided radiation therapy

MeSH Terms

Adult
Aged
Equipment Safety
Female
*Fiducial Markers/adverse effects
Humans
Male
Middle Aged
Radiosurgery/*methods
Retrospective Studies
Risk Factors
*Ultrasonography, Interventional

Figure

• 

  Fig. 1 Major complications. 61 year-old-man with hepatic metastasis from recurrent comon bile duct cancer underwent successful implantation of fiducial markers around tumor. After procedure, patient complained of fever, dyspnea and right flank pain. CT (A) shows well-located fiducial marker (arrowhead) around hepatic metastatic tumor and more upper level CT (B) shows ductal dilatation (arrow) of peripheral intrahepatic bile duct. Also, note pleural effusion and subcapsular hematoma around portion of liver dome (not seen).

• 

  Fig. 2 Fiducial migration. 59 year-old-man with HCC in liver had undergone implantation of 4 fiducial makers around tumor. Two weeks later, only 3 fiducial markers (arrowheads) were found around HCC on CyberKnife planning CT scan (A) and missing fiducial marker (arrow) was found in pelvic cavity on scanogram (B).

• 

  Fig. 3 Failure of fiducial discrimination. 55 year-old-man had metastatic lymph node from rectal cancer in right pelvic cavity. We implanted 4 fiducial markers within lesion by trans-rectal ultrasound-guidance. Two of markers (between number 1 and number 3, arrowheads) overlapped on CyberKnife planning radiograph (A), while two overlapped fiducial markers (arrowheads) are also seen on CyberKnife planning CT scan (B).

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