Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy

doi:10.1016/j.jvir.2008.09.026

Journal of Vascular and Interventional Radiology

Volume 20, Issue 2, February 2009, Pages 235-239

https://doi.org/10.1016/j.jvir.2008.09.026 Get rights and content

Purpose

To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy.

Materials and Methods

From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation.

Results

The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation.

Conclusions

Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

Section snippets

Materials and Methods

This retrospective study was granted a waiver by the institutional review board. Data were handled in compliance with the Health Insurance Portability and Accountability Act. From January 2003 to January 2008, 132 patients (mean age, 66.4 years; age range, 23–89 years) underwent 139 procedures (Table 1). Five patients underwent implantations on two separate occasions for anatomically distinct tumors. Seventy-one patients were men and 61 were women. Of these 139 procedures, 44 were lung

Safety and Technical Success

The median number of fiducial markers implanted for each tumor was four (range, 3–7). There were no procedure-related deaths. Major complications occurred in seven of the 139 implantations (5%). Minor complications occurred in 24 patients (17.3%). Of the 139 implantations, 133 were technically successful; in six implantations (4.3%), the fiducial markers migrated and required additional procedures or alternate methods of implantation. The results are summarized in Table 2.

Lung Implantation

A total of 42 patients

Discussion

For more than half a century, principles of stereotaxy have been used in radiation therapy, predominantly for intracranial and spinal applications. Traditional sterotaxy requires rigid immobilization to establish spatial coordinates for precise guidance. This can be achieved for intracranial and spinal targets with rigid frames and skeletal fixation but is limited for extracranial sites. The limitations of applying conventional systems to extracranial targets include respiratory and

References (34)

D. Sacks et al.
Society of Interventional Radiology clinical practice guidelines
J Vasc Interv Radiol
(2003)
K. Ohara et al.
Irradiation synchronized with respiration gate
Int J Radiat Oncol Biol Phys
(1989)
C.S. Ross et al.
Analysis of movement of intrathoracic neoplasms using ultrafast computerized tomography
Int J Radiat Oncol Biol Phys
(1990)
E.A. Barnes et al.
Dosimetric evaluation of lung tumor immobilization using breath hold at deep inspiration
Int J Radiat Oncol Biol Phys
(2001)
J.W. Wong et al.
The use of active breathing control (ABC) to reduce margin for breathing motion
Int J Radiat Oncol Biol Phys
(1999)
D.E. Dosoretz et al.
Medically inoperable lung carcinoma: the role of radiation therapy
Semin Radiat Oncol
(1996)
P.H. Graham et al.
Radical radiotherapy for early nonsmall cell lung cancer
Int J Radiat Oncol Biol Phys
(1995)
M. Uematsu et al.
Computed tomography–guided frameless stereotactic radiotherapy for stage I non-small cell lung cancer: a 5-year experience
Int J Radiat Oncol Biol Phys
(2001)
R. Timmerman et al.
Extracranial stereotactic radioablation: results of a phase I study in medically inoperable stage I non-small cell lung cancer
Chest
(2003)
H. Hof et al.
Stereotactic single-dose radiotherapy of stage I non-small-cell lung cancer (NSCLC)
Int J Radiat Oncol Biol Phys
(2003)

Y. Nagata et al.

Clinical outcomes of 3D conformal hypofractionated single high-dose radiotherapy for one or two lung tumors using a stereotactic body frame

Int J Radiat Oncol Biol Phys

(2002)

A.C. Koong et al.

Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer

Int J Radiat Oncol Biol Phys

(2004)

A.C. Koong et al.

Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer

Int J Radiat Oncol Biol Phys

(2005)

J.F. Cardella et al.

Quality improvement guidelines for image-guided percutaneous biopsy in adults

J Vasc Interv Radiol

(2003)

S. Yousefi et al.

Complications of thoracic computed tomography-guided fiducial placement for the purpose of stereotactic body radiation therapy

Clin Lung Cancer

(2007)

L. Li et al.

CT-guided core needle biopsy in the diagnosis of pancreatic diseases with an automated biopsy gun

J Vasc Interv Radiol

(2008)

A.C. Pishvaian et al.

EUS-guided fiducial placement for CyberKnife radiotherapy of mediastinal and abdominal malignancies

Gastrointest Endosc

(2006)

Cited by (154)

Simulation of a new respiratory phase sorting method for 4D-imaging using optical surface information towards precision radiotherapy
2023, Computers in Biology and Medicine
Respiratory signal detection is critical for 4-dimensional (4D) imaging. This study proposes and evaluates a novel phase sorting method using optical surface imaging (OSI), aiming to improve the precision of radiotherapy.
Based on 4D Extended Cardiac-Torso (XCAT) digital phantom, OSI in point cloud format was generated from the body segmentation, and image projections were simulated using the geometries of Varian 4D kV cone-beam-CT (CBCT). Respiratory signals were extracted respectively from the segmented diaphragm image (reference method) and OSI respectively, where Gaussian Mixture Model and Principal Component Analysis (PCA) were used for image registration and dimension reduction respectively. Breathing frequencies were compared using Fast-Fourier-Transform. Consistency of 4DCBCT images reconstructed using Maximum Likelihood Expectation Maximization algorithm was also evaluated quantitatively, where high consistency can be suggested by lower Root-Mean-Square-Error (RMSE), Structural-Similarity-Index (SSIM) value closer to 1, and larger Peak-Signal-To-Noise-Ratio (PSNR) respectively.
High consistency of breathing frequencies was observed between the diaphragm-based (0.232 Hz) and OSI-based (0.251 Hz) signals, with a slight discrepancy of 0.019Hz. Using end of expiration (EOE) and end of inspiration (EOI) phases as examples, the mean±1SD values of the 80 transverse, 100 coronal and 120 sagittal planes were 0.967, 0,972, 0.974 (SSIM); 1.657 ± 0.368, 1.464 ± 0.104, 1.479 ± 0.297 (RMSE); and 40.501 ± 1.737, 41.532 ± 1.464, 41.553 ± 1.910 (PSNR) for the EOE; and 0.969, 0.973, 0.973 (SSIM); 1.686 ± 0.278, 1.422 ± 0.089, 1.489 ± 0.238 (RMSE); and 40.535 ± 1.539, 41.605 ± 0.534, 41.401 ± 1.496 (PSNR) for EOI respectively.
This work proposed and evaluated a novel respiratory phase sorting approach for 4D imaging using optical surface signals, which can potentially be applied to precision radiotherapy. Its potential advantages were non-ionizing, non-invasive, non-contact, and more compatible with various anatomic regions and treatment/imaging systems.
Statistical evaluation of the effectiveness of dual amplitude-gated stereotactic body radiotherapy using fiducial markers and lung volume
2022, Physics and Imaging in Radiation Oncology
Citation Excerpt :
Fig. 1(a) shows the case of a patient in whom two of the three fiducial markers were dropped out, and the correlation between the fiducial markers was low at 0.27. There was a risk of subsequent dropout with treatment using fiducial markers alone [7]. Hence, in such cases, we believe that lung volume monitoring is an effective secondary method that could be used as a backup during treatment.
The low tracking accuracy of lung stereotactic body radiotherapy (SBRT) risks reduced treatment efficacy. We used four-dimensional computed tomography (4DCT) images to determine the correlation between changes in fiducial marker positions and lung volume for lung tumors, and we evaluated the effectiveness of the combined use of these images in lung SBRT.
Data of 30 patients who underwent fiducial marker placement were retrospectively analyzed. We calculated the motion amplitudes of the center of gravity coordinates of the lung tumor and fiducial markers in each phase and the ipsilateral, contralateral, and bilateral lung volumes using 4DCT. Moreover, we calculated the cross-correlation coefficient between the fiducial marker position and the lung volume changes waveform for the motion amplitude waveform of the lung tumor over three gating windows (all phases, ≤2 mm³, and ≤3 mm³).
Compared with the lung volume, approximately 30 % of the fiducial markers demonstrated a low correlation with the lung tumor. In the ≤2 mm³ and ≤3 mm³ gating windows, the cross-correlation coefficients between the lung tumor and the optimal marker (r > 0.9: 83 % and 86 %) were significantly different for all fiducial markers (r > 0.9: 39 %, 53 %) and the ipsilateral (r > 0.9: 35 % and 40 %), contralateral (r > 0.9: 44 % and 41 %), and bilateral (r > 0.9: 39 % and 45 %) lung volumes.
Some of the fiducial markers showed a low correlation with the lung tumor. This study indicated that the combined use of lung volume monitoring can improve tracking accuracy.
Four-Dimensional Computed Tomography-Based Correlation of Respiratory Motion of Lung Tumors With Implanted Fiducials and an External Surrogate
2022, Advances in Radiation Oncology
Our purpose was to assess the suitability of airway-implanted internal fiducial markers and an external surrogate of respiratory motion for motion management during radiation therapy of lung tumors.
We analyzed 4-dimensional computed tomography scans acquired during radiation therapy simulation for 28 patients with lung tumors who had anchored fiducial markers bronchoscopically implanted inside small airways in or near the tumor in a prospective trial. We used a linear mixed model to build population-based correlative models of tumor and surrogate motion. The first 24 of the 28 patients were used to build correlative models, and 4 of the 28 consecutive patients were excluded and used as an internal validation cohort. Of the 24 patients from the model building cohort, all were used for the models based on the internal fiducial. The external surrogate was completely visualized in 11 patients from the model building cohort, so only those were used for the models based on the external surrogate. Furthermore, we determined the predicted residual error sum of squares for our correlative models, which may serve as benchmarks for future research.
The motion of the internal fiducials was significantly associated with the tumor motion in the anterior-posterior (P < .0001) and superior-inferior (SI) directions (P < .0001). We also observed a strong correlation of the external surrogate anterior-posterior motion to the tumor dominant SI motion (P < .0001). In the validation cohort, the internal fiducial SI motion was the only reliable predictor of lung tumor motion.
The internal fiducials appear to be more reliable predictors of lung tumor motion than the external surrogate. The suitability of such airway-implanted internal fiducial markers for advanced motion management techniques should be further investigated. Although the external surrogate seems to be less reliable, its wide availability and noninvasive application support its clinical utility, albeit the greater uncertainty will need to be compensated for.
On the interplay effect for moving targets treated with the CyberKnife static tracking system
2021, Physica Medica
To assess the interplay effect amplitude between different planned MU distributions and respiratory patterns in the CyberKnife system when treating moving targets with static tracking technique.
Small- and Large-Respiratory Motions (SRM and LRM) differing in amplitude and frequency were simulated in a semi-anthropomorphic dynamic thorax phantom. The interplay effect was evaluated for both respiration motions in terms of GTV coverage and conformity for three plans designed with an increasing range of MU per beam (small, medium and large). Each plan was delivered three times changing the initial beam-on phase to assess the inter-fraction variation. Dose distributions were measured using radiochromic films placed in the GTV axial and sagittal planes.
Generally, SRM plans gave higher GTV coverage and were less dependent on beam-on phases than LRM plans. For SRM (LRM) plans, the GTV coverage ranged from 95.2% to 99.7% (85.9% to 99.8%). Maximum GTV coverage was found for large MU plans in SRM and for small MU plans in LRM. Minimum GTV coverage was found for medium MU plans for both SRM and LRM. For SRM plans, dose conformity decreased with increasing MU range while the variation was reduced for LRM plans. Large MU plans reduced the inter-fraction variation for SRM and LRM.
We confirmed the interplay effect between target motion and beam irradiation time for CyberKnife static tracking. Plans with large MU per beam improved the GTV coverage for small motion amplitude and the inter-fraction dose variation for large motion amplitude.
Comparison of technical success and safety of transbronchial versus percutaneous CT-guided fiducial placement for SBRT of lung tumors
2021, Journal of Medical Imaging and Radiation Sciences
To evaluate the technical success and safety of transbronchial (bronchoscopic) fiducial placement compared to percutaneous CT-guided fiducial placement for stereotactic body radiotherapy (SBRT) of lung tumors.
This IRB-approved, HIPAA-compliant retrospective study was performed at a single tertiary institution. Consecutive patients undergoing lung fiducial placement for purposes of guiding SBRT (CyberKnife®, Accuray, Inc.) between September 2005 to January 2013 were included in the study. Fiducial seeds were placed percutaneously with CT guidance or transbronchially with bronchoscopic guidance. We compared procedure-related complications (pneumothorax, chest tube placement), technical success (defined as implantation enabling adequate treatment planning with CT simulation) and migration rate. The need for repeat procedures and their mode was noted. Statistical analysis was performed using Fisher exact and Chi square probability tests.
Two hundred and forty-four patients with lung tumors and 272 fiducial seed placements were included in the study. Two hundred and twenty-one of the 272 (81.2%) fiducial markers were placed percutaneously and 51/272 (18.8%) were placed transbronchially. Pneumothorax was seen in 73/221 (33%) of percutaneously-placed fiducials and in 4/51 (7.8%) of transbronchial placements (p<0.001). No significant difference was seen in the rate of chest tube placement between the two groups: 20/221 (9%) of percutaneously placed fiducials and 2/51 (3.9%) of transbronchially placed fiducials (p=0.39). Fifteen of the 51 (29%) of fiducial placements with transbronchial approach were unsuccessful, as discovered at radiotherapy planning session, and required a repeat procedure. Nine of the 15 (60%) of repeat procedures were performed percutaneously, 5/15 (33%) were placed during repeat bronchoscopy, and 1/15 (7%) was placed at transesophageal endoscopic ultrasound. No repeat fiducial placements were required for patients who had the fiducials placed percutaneously (p<0.001), with a technical success rate of 100%.
Transbronchial fiducial marker placement has a significantly higher rate of failed seed placements requiring repeat procedures in comparison to percutaneous placement. Complication rate of pneumothorax requiring chest drain placement is similar between the two approaches.
Évaluer la réussite technique et la sécurité de la pose de repères transbronchiques (bronchoscopiques) par rapport à la pose de repères percutanés guidés par tomodensitométrie pour la radiothérapie stéréotaxique (SBRT) de tumeurs pulmonaires.
Cette étude rétrospective, approuvée par le comité d'éthique de la recherche et conforme à la loi HIPAA, a été réalisée dans un seul établissement tertiaire. L'étude a porté sur des patients consécutifs ayant subi une implantation de points de repères dans les poumons pour guider la SBRT (CyberKnife®, Accuray, Inc.) entre septembre 2005 et janvier 2013. Les repères fiduciaires ont été placés par voie percutanée avec guidage par tomodensitométrie ou par voie transbronchique avec guidage bronchoscopique. Nous avons comparé les complications liées à la procédure (pneumothorax, pose d'un drain thoracique), le succès technique (défini comme une implantation permettant une planification adéquate du traitement avec une simulation par tomodensitométrie) et le taux de migration. La nécessité de procédures répétées et leur mode ont été notés. L'analyse statistique a été réalisée à l'aide des tests de probabilité Fisher exact et Chi carré.
244 patients atteints de tumeurs pulmonaires et 272 placements de repères fiduciaires ont été inclus dans l'étude. 221/272 (81,2 %) marqueurs fiduciaires ont été placés par voie percutanée et 51/272 (18,8 %) ont été placés par voie transbronchique. Un pneumothorax a été observé dans 73/221 (33%) des repères placés par voie percutanée et dans 4/51 (7,8 %) des placements par voie transbronchique (p<0,001). Aucune différence significative n'a été observée dans le taux de mise en place d'un drain thoracique entre les deux groupes: 20/221 (9 %) des repères placés par voie percutanée et 2/51 (3,9 %) des repères placés par voie transbronchique (p=0,39). 15/51 (29 %) des placements de repères par voie transbronchique ont échoué, comme cela a été constaté lors de la séance de planification de la radiothérapie, et ont nécessité une nouvelle procédure. 9/15 (60 %) des procédures répétées ont été réalisées par voie percutanée, 5/15 (33 %) ont été placés lors d'une nouvelle bronchoscopie et 1/15 (7 %) a été placé lors d'une échographie endoscopique transœsophagienne. Aucun nouveau placement de repère n'a été nécessaire pour les patients chez qui les repères ont été placés par voie percutanée (p<0,001), avec un taux de réussite technique de 100 %.
La pose de marqueurs fiduciaires par voie transbronchique présente un taux d’échec du positionnement des repères significativement plus élevé nécessitant des procédures répétées, par rapport à la pose percutanée. Le taux de complication de pneumothorax nécessitant la pose d'un drain thoracique est similaire entre les deux approche.
Quantification of intra-fraction motion in breast radiotherapy using cine EPID images
2024, Journal of Radiotherapy in Practice

View all citing articles on Scopus

: None of the authors have identified a conflict of interest.

View full text

Clinical studySafety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Safety and Technical Success

Lung Implantation

Discussion

J Vasc Interv Radiol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Semin Radiat Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Chest

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

J Vasc Interv Radiol

Clin Lung Cancer

J Vasc Interv Radiol

Gastrointest Endosc

Clinical study
Safety and Efficacy of Percutaneous Fiducial Marker Implantation for Image-guided Radiation Therapy