EUS-guided fiducial placement for image-guided radiation therapy in GI malignancies by using a 22-gauge needle (with videos)

BackgroundImage-guided radiation therapy (IGRT) is dependent on the presence of fiducial markers for target localization and tracking. EUS-guided placement of fiducial markers with a 19-gauge needle has been reported. However, the size and stiffness of the 19-gauge needle may compromise the safety and ease of fiducial placement.ObjectiveThe aim of this study was to evaluate the safety and feasibility of EUS-guided placement of thin flexible gold coil fiducials by using a 22-gauge needle.DesignRetrospective study.SettingMemorial Sloan-Kettering Cancer Center, between December 2008 and November 2009.PatientsA total of 30 patients with GI malignancies of the mediastinum and upper abdomen who were to undergo IGRT.InterventionsEUS evaluation with a curvilinear-array echoendoscope was performed. The target lesion was identified, a 22-gauge needle preloaded with a gold coil fiducial was inserted into the lesion, and the fiducial was deployed under EUS guidance.Main Outcome MeasurementsTechnical success was defined as the ability to place fiducials in the desired location. Immediate and delayed complications were also noted.ResultsA total of 69 fiducials were placed in 12 different sites in the mediastinum and upper abdomen. Technical success was achieved in 29 out of 30 cases (97%). No intraprocedural complications were encountered. One patient developed a fever and abnormal liver function tests 12 hours after fiducial placement.LimitationsRetrospective design, small case series.ConclusionsEUS-guided placement of thin flexible gold coil fiducials by using a 22-gauge needle is both safe and feasible for upper GI malignancies.