SESSION TITLE: Interventional Pulmonary Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: Fiducial marker (FM) guided stereotactic body radiotherapy (SBRT) is an attractive strategy for early stage lung cancer when surgery is not preferable, and in oligo-metastatic or recurrent neoplastic disease in the thorax. FM placement is usually done by CT-guided transthoracic needle placement, a procedure with a 40% or higher rate of pneumothorax. It is also an impractical approach for central nodal lesions. We present an alternative strategy with several examples of successful placement of FM via real-time ultrasound visualization using convex probe endobronchial ultrasound (CP-EBUS).
CASE PRESENTATION: 1. 76M with h/o treated oropharyngeal cancer with a hypermetabolic infrahilar lesion. 2. 84F with remote h/o treated squamous cell lung cancer with a hypermetabolic paratracheal lesion. 3. 68M with h/o treated NSCLC and SCLC with a hypermetabolic infrahilar lesion. 4. 57F h/o treated breast carcinoma with a hypermetabolic paratracheal lesion. In each case, the following steps were employed (Fig 1.): A. Lesion of interest located and sampled via CP-EBUS B. Rapid on-site evaluation (ROSE) cytology to confirm malignancy C. A FM coil is modified by straightening and then dividing it into shorter segments. D. These segments are backloaded into tip of EBUS needle, and the needle tip is sealed with sterile bone wax to prevent dislodgement. E. The lesion is then relocated, and punctured under real-time ultrasound guidance. The internal stylet is then advanced to the end of the needle, thereby pushing the FM into the lesion with placement confirmed by ultrasound.
DISCUSSION: The above outlined technique is easy to learn and perform, and adds little procedural time to the diagnostic and staging portion of the EBUS procedure. The FM placed by this method perform well and remain well positioned over time (Fig.2). The revolutionary impact of CP-EBUS in the diagnosis and staging of intrathoracic malignancies is well known. Its value continues to increase as new applications of CP-EBUS are elucidated. CP-EBUS is widely available; being taught in most pulmonary fellowship programs, and has an excellent safety profile. By using CP-EBUS for real time placement of FM for SBRT, we highlight a new application of CP-EBUS for select patients.
CONCLUSIONS: Use of CP-EBUS to place FM is a safe, efficient, and cost effective technique that can be easily learned by anyone proficient with CP-EBUS.
Reference #1: Kelsey, C.R., et al. Surg Oncol Clin N Am, 2013. 22(3): p. 463-81.
Reference #2: Kothary, N., et al. J Vasc Interv Radiol, 2009. 20(2): p. 235-9.
DISCLOSURE: The following authors have nothing to disclose: Benjamin Seides, Sara Greenhill, Kevin Kovitz, Neeraj Desai
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