EUS-guided Fiducial Marker Placement for Pancreatic Cancer

Abstract

Chemoradiation therapy (CRT) is increasingly being applied for localized pancreatic cancer (LPC) [1, 2]. In image-guided radiation therapy (IGRT), such as intensity-modulated radiation therapy (IMRT) and respiration synchronization, fiducial markers must be placed to maximize the efficacy of CRT and reduce its toxicity. Fiducial marker placement is also mandatory to reduce adverse events in high-dose radiation therapy techniques such as stereotactic body radiation therapy (SBRT) and heavy particle therapy. In the past, fiducial markers were placed percutaneously or intraoperatively under US or CT guidance. However, the markers can now be placed endoscopically by endoscopic ultrasound-guided fiducial marker placement (EUS-FP), using the safe and precise approach developed by Pishvaian in 2006 [3]. In this technique, the marker is loaded into the FNA needle by the back-loading method. A recent meta-analysis concluded that EUS-FP is feasible for GI malignancy and has a high technical success rate (98%), low adverse event (4%) and low fiducial migration rates (3%) [4].