PURPOSE: Robotic radiosurgery is available for treatment of thoracic malignancies. Standard fiducial placement for peripheral lung tumors has been performed by CT guidance. However, this is associated with a pneumothorax rate of 40%, pulmonary hemorrhage 16%, and hemoptysis 4%. We report our first 200 cases of successful placement of fiducials by flexible bronchoscopy with a lower incidence of complications.
METHODS: Retrospective review of the first 200 patients from 2004 to present who underwent thoracic fiducial insertion for both central and peripheral tumors by flexible bronchoscopy. Under fluoroscopic guidance, 3mm gold fiducials were placed using a 19/21 gauge TBNA needle. For select smaller peripheral tumors, electromagnetic navigation with superDimension was used to guide placement of gold fiducials or platinum VortX coils via a Renegade catheter.
RESULTS: Of the 200 patients in this study, 126 (67%) had underlying NSCLC while 62 (33%) had metastatic disease. 341 fiducials were placed for central tumors. 341 (100%) were seen on post operative CXR and planning CT. There were no migrations, pneumothoraces, or embolizations. Complications included COPD exacerbation in 1 patient and bleeding in 1 patient. 443 gold fiducials were placed for peripheral tumors, 134 by electromagnetic navigation. 436 (98%) were seen on post operative CXR. 391 (88%) were seen on planning CT. 15 platinum vortex coils were also placed, all seen on CT. Complications included COPD exacerbation in 5 patients and pneumothoraces in 3 patients. Fiducial embolization via the pulmonary artery occurred in 7 patients without consequence. 4 patients required additional fiducial placement by CT guidance.
CONCLUSIONS: Fiducial placement by flexible bronchoscopy is an accurate method for both central and peripheral tumor marking. It has a relatively low risk of complications compared to CT-guided placement.
CLINICAL IMPLICATIONS: Given the low risk of complications with fiducial placement, it is an accurate method for tumor marking in this patient population.
DISCLOSURE: Eric Anderson: Other: Honoraria from superDimension for educational lectures
Brian Collins: Consultant fee, speaker bureau, advisory committee, etc.: Consultant for Accuray
The following authors have nothing to disclose: Silpa Kilaru, Filip Banovac
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