PURPOSE:CyberKnife Frameless Image-Guided Radiosurgery with the SynchronyTM Motion Tracking Module is now available for the treatment of thoracic malignancies. Gold fiducial markers are required for the treatment planning and tracking of the tumor during each treatment. Fiducials for peripheral nodules have traditionally been placed under CT-guidance. We describe our center’s experience placing fiducials for peripheral lung tumors via flexible bronchoscopy.
METHODS:All patients referred for CyberKnife stereotactic radiosurgery at Georgetown University Hospital for treatment of thoracic malignancies were reviewed by a multidisciplinary thoracic oncology team. Patients with smaller peripheral tumors (<1.5 cm) had fiducials placed percutaneously via CT-guidance. Patients with larger peripheral tumors were selected for fiducial placement via flexible bronchoscopy. Data collected included patient demographics, number and location of fiducials placed, and complications associated with their placement.
RESULTS:Flexible bronchoscopy was used for peripheral insertion of 155 fiducials in 45 patients (average of 3.5 fiducials per target lesion) between July 2004 –April 2008. The majority of patients had non-small cell lung cancer. The most common reasons for choosing CyberKnife therapy included previous radiotherapy to the chest, severe COPD and prior lung resection. Three fiducials embolized during insertion via the pulmonary artery without adverse clinical consequence and 2 patients developed bronchospasm, 1 required mechanical ventilation for 48 hours, the other required an oral steroid taper. 11.0% of fiducials were expectorated prior to treatment. There was no incidence of pneumothorax nor significant bleeding.
CONCLUSION:Gold fiducials may be placed for CyberKnife stereotactic radiosurgery safely via flexible bronchoscopy to mark peripherally located lung tumors.
CLINICAL IMPLICATIONS:At our institution, flexible bronchoscopy is the preferred method for insertion of fiducials in mediastinal, hilar and larger peripheral tumors. CT-guidance is recommended for smaller peripheral nodules.
DISCLOSURE:Eric Anderson, Consultant fee, speaker bureau, advisory committee, etc. Honoraria for educational lectures from Accuray.; No Product/Research Disclosure Information