CyberKnife Frameless Image-Guided Radiosurgery with the Synchrony™ Motion Tracking Module is now available for the treatment of thoracic malignancies. CyberKnife offers an alternative for patients with lung cancer or thoracic metastatic disease who are inoperable, poor candidates for conventional radiotherapy because of compromised lung function or have received previous radiotherapy. Gold fiducial markers are required for the treatment planning and aiming of CyberKnife therapy. Fiducials have traditionally been placed under CT-guidance. We describe a novel use of the transbronchial needle aspiration needle (TBNA) for placing these fiducials and report our center’s experience compared to CT-guidance.
We conducted a retrospective review of patients referred for CyberKnife stereotactic radiosurgery at Georgetown University Hospital for treatment of thoracic malignancies. All patients underwent fiducial placement via CT-guidance or flexible bronchoscopy. Fiducials placed by bronchoscopy were loaded in the 19-gauge needle of a 19/21-gauge transbronchial needle. At the desired location, the 19-gauge needle was advanced into the tumor. The 21-gauge needle was extended and the fiducial deployed under fluoroscopic guidance. Data collected included patient demographics, number and location of fiducials placed, and complications associated with their placement.
Twenty-six patients underwent fiducial placement, 11 under CT-guidance and 15 via flexible bronchoscopy. The main diagnosis was non-small cell lung cancer (69%) and the main reason for choosing CyberKnife therapy was previous radiotherapy to the chest. In the CT group, there were 4 pneumothoraces (36%), 50% of them required chest tube drainage. One patient developed a small hemothorax. In the bronchoscopy group, there was no incidence of pneumothorax or significant bleeding. One fiducial embolized via the pulmonary artery without adverse clinical consequence and 1 patient developed bronchospasm requiring mechanical ventilation for 48 hours.
Flexible bronchoscopy using a TBNA needle for fiducial placement appears to be safe, especially for central tumors. More experience is needed to determine its applicability for peripheral tumors where CT-guidance is still favored.
Fiducial placement for CyberKnife stereotactic radiosurgery can be performed under CT-guidance or via flexible bronchoscopy.
Cristina Reichner, None.