J Liver Cancer.  2024 Sep;24(2):263-273. 10.17998/jlc.2024.06.03.

Assessment of real-time US-CT/MR-guided percutaneous gold fiducial marker implementation in malignant hepatic tumors for stereotactic body radiation therapy

• Hwang S
• Chun SJ
• Chie EK
• Lee JM

• KMID: 2559473
• DOI: http://doi.org/10.17998/jlc.2024.06.03

Abstract

Backgrounds/Aims
This study explored the initial institutional experience of using gold fiducial markers for stereotactic body radiotherapy (SBRT) in treating malignant hepatic tumors using real-time ultrasound-computed tomography (CT)/magnetic resonance (MR) imaging fusion-guided percutaneous placement.
Methods
From May 2021 to August 2023, 19 patients with 25 liver tumors that were invisible on pre-contrast CT received fiducial markers following these guidelines. Postprocedural scans were used to confirm their placement. We assessed technical and clinical success rates and monitored complications. The implantation of fiducial markers facilitating adequate treatment prior to SBRT, which was achieved in 96% of the cases (24 of 25 tumors), was considered technical success. Clinical success was the successful completion of SBRT without evidence of marker displacement and was achieved in 88% of cases (22 of 25 tumors). Complications included one major subcapsular hematoma and marker migration into the right atrium in two cases, which prevented SBRT.
Results
Among the treated tumors, 20 of 24 (83.3%) showed a complete response, three of 24 (12.5%) remained stable, and one of 24 (4.2%) progressed during an average 11.7-month follow-up (range, 2-32 months).
Conclusions
This study confirms that percutaneous gold fiducial marker placement using real-time CT/MR guidance is effective and safe for SBRT in hepatic tumors, but warns of marker migration risks, especially near the hepatic veins and in subcapsular locations. Using fewer markers than traditionally recommended-typically two per patient, the outcomes were still satisfactory, particularly given the increased risk of migration when markers were placed near major hepatic veins.

Keyword

Fiducial markers; Radiosurgery; Radiation oncology; Carcinoma, hepatocellular

Figure

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  Figure 1. Gold fiducial marker, 18-gauge syringe, and plunger from a Fiducial Marker Kit (Smart G. Medical, Incheon, Korea).

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  Figure 2. Achievement of technical success and clinical success in fiducial marker insertion for a 74-year-old man with hepatocellular carcinoma (HCC) and hepatitis B-related liver cirrhosis. (A) An arterial phase CT scan displays a 3.0-cm hyperenhancing HCC (arrow) in segment VIII of the liver. (B) A real-time US-MR fusion image illustrates the target tumor, and the fiducial marker insertion is demonstrated. (C) Complete response (arrow) was achieved with no local tumor progression observed in the 12-month follow-up CT. The background hepatic parenchyma exhibits heterogeneous attenuation due to changes post-radiation therapy. CT, computed tomography; US, ultrasound; MR, magnetic resonance.

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  Figure 3. Flow diagram of technical success and clinical success. SBRT, stereotactic body radiotherapy.

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  Figure 4. Fiducial marker migration with delayed hematoma formation. (A) A 66-year-old man with three hepatocellular carcinomas (HCCs) had three fiducial markers implanted into each tumor. Five days post-procedure, the patient experienced right flank pain and sought emergency medical care. (B) A CT scan showed that two of the fiducial markers were properly positioned. (C) However, one marker had migrated to the subcapsular region, accompanied by a delayed hematoma. (D) Transarterial embolization was performed to control the associated bleeding. Three fiducial markers are indicated with red arrows. After the embolization, there was no contrast leakage observed during contrast enhancement. CT, computed tomography.

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  Figure 5. Migration of a fiducial marker into the heart in an 80-year-old man. (A) Non-contrast enhanced axial CT scan before marker insertion showed no abnormal foreign material (arrow) in the right atrium. (B) The fiducial marker, which had migrated into the right atrium, was observed on the non-contrast phase of follow-up axial CT image (arrow), taken after marker placement and before the initiation of stereotactic body radiation therapy. (C) Contrast-enhanced coronal CT scan before marker insertion showed no abnormal foreign material (arrow) in the right atrium. (D) The fiducial marker, which had migrated into the right atrium, was observed on the portal phase of follow-up coronal CT image (arrow), taken after marker placement and before the initiation of stereotactic body radiation therapy. CT, computed tomography.

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  Figure 6. Achievement of complete response in fiducial marker insertion for a 72-year-old man with hepatocellular carcinoma (HCC) and hepatitis B-related liver cirrhosis. (A) An arterial phase CT scan displays two 1.1-cm hyperenhancing HCCs (arrows) in segments VII and VIII of the liver. (B) A complete response (arrows) was achieved with no local tumor progression observed in the 12-month follow-up CT scan. Fiducial markers inserted on the peripheral aspect of the tumor show metallic artifact. (C) A portal phase CT scan displays two HCCs (arrows) showing washout in segments VII and VIII of the liver. (D) A complete response (arrows) was achieved with no local tumor progression observed in the 12-month follow-up CT scan. Fiducial markers inserted on the peripheral aspect of the tumor show metallic artifact. CT, computed tomography.

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Reference

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