Title: Impact of EUS-Guided Fiducial Markers in Management of Patients with Pancreatic Cancer (PANCAN) Undergoing Image Guided Radiation Therapy (IGRT)
Abstract: Background: During the course of radiotherapy (RT), both the patient's position and anatomy can vary from the original treatment planning setup, resulting in insufficient dose to the targeted tumor volume and an overdose to surrounding normal tissues. As soft tissue cannot be visualized easily on the IGRT machine, RT is currently delivered based on skeletal anatomy landmarks. Although EUS-guided placement of fiducials in pancreatic masses is technically feasible, its direct impact on patient management is unclear. Aim: Evaluate the impact of EUS-guided fiducial markers in management of patients with PANCAN undergoing RT. Methods: In this prospective study, 10 (6male, mean age 62 yrs [range, 40-86]) consecutive patients with PANCAN underwent EUS-guided fiducial placements over 3 months. Following computerized tomography (CT) simulation, a RT treatment plan was prepared for all patients to be delivered over 25 days. A kilovoltage (kv) image was obtained before each treatment session after positioning the patient on the linear accelerator. This image revealed fiducials within the tumor which was then fused with the original image generated during initial treatment planning; RT was then delivered. Daily shifts (organ movement) were recorded by comparing the fused images revealing fiducials with images fused based on skeletal anatomy (current standard of care). All patients had CT evaluation halfway through RT and at 5 weeks following RT to check for fiducial migration. Results: EUS-guided fiducial placement was technically successful in all 10 patients (location: 6 head of pancreas, 3 uncinate, 1 body) and no complications were encountered. Four patients underwent simultaneous CPN. A mean of 4 fiducials were placed per patient and the median procedural duration was 8 minutes (range, 6-10). The mean daily shifts (ranges and standard deviations) between images based on skeletal fusion and fiducial location was 0.27 cm (0-2 cm, 0.37), 0.39 cm (0-1 cm, 0.26) and 0.58 cm (0-1.4 cm, 0.37) in the lateral, vertical and longitudinal axes respectively. This suggests that an additional margin of 0.75 cm is required to account for soft tissue movement when fiducials are not used to guide treatment. The maximum acute toxicity recorded during RT was Grade I. Fiducial marker migration was not encountered in any patient. Conclusions: When available, EUS-guided fiducial placement should be strongly considered as it facilitates improved image-guidance for delivery of RT to patients with PANCAN. Also, the accurate delivery of RT to smaller fields helps reduce treatment-related toxicity and could potentially enable use of higher doses of RT over fewer fractions.
Publication Year: 2009
Publication Date: 2009-04-01
Language: en
Type: article
Indexed In: ['crossref']
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Cited By Count: 1
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