Surgical Endoscopy

, Volume 27, Issue 10, pp 3921–3926 | Cite as

Endoscopic ultrasound (EUS)-guided fiducial placement allows localization of small neuroendocrine tumors during parenchymal-sparing pancreatic surgery

  • Joanna K. Law
  • Vikesh K. Singh
  • Mouen A. Khashab
  • Ralph H. Hruban
  • Marcia Irene Canto
  • Eun Ji Shin
  • Payal Saxena
  • Matthew J. Weiss
  • Timothy M. Pawlik
  • Christopher L. Wolfgang
  • Anne Marie LennonEmail author
Dynamic Manuscript



Parenchymal-sparing pancreatic surgery is ideal for lesions such as small pancreatic neuroendocrine tumors (PanNET). However, precise localization of these small tumors at surgery can be difficult. The placement of fiducials under endoscopic ultrasound (EUS) guidance (EUS-F) has been used to direct stereotactic radiation therapy for pancreatic adenocarcinoma. This report describes two cases in which placement of fiducials was used to guide surgical resection. This study aimed to assess the feasibility, safety, and efficacy of using EUS-F for intraoperative localization of small PanNETs.


A retrospective study analyzed two consecutive patients with small PanNETs who underwent EUS-F followed by enucleation in a tertiary-care referral hospital. The following features were examined: technical success and complication rates of EUS-F, visibility of the fiducial at the time of surgery, and fiducial migration.


In the study, EUS-F was performed for two female patients with a 7-mm and a 9-mm PanNET respectively in the uncinate process and neck of the pancreas. In both patients, EUS-F was feasible with two Visicoil fiducials (Core Oncology, Santa Barbara, CA, USA) placed either within or adjacent to the tumors using a 22-gauge Cook Echotip needle. At surgery, the fiducials were clearly visible on intraoperative ultrasound, and both the tumor and the fiducials were successfully enucleated in both cases. No complications were associated with EUS-F, and no evidence of pancreatitis was shown either clinically or on surgical pathology. This investigation had the limitations of a small single-center study.


For patients undergoing enucleation, EUS-F is technically feasible and safe and aids intraoperative localization of small PanNETs.


Endoscopic ultrasound guidance Fiducial placement Parenchymal-sparing pancreatic surgery Small neuroendocrine tumor 



Pancreatic neuroendocrine tumor


Endoscopic ultrasound


Endoscopic ultrasound guided fiducial placement


Endoscopic ultrasound guided fine needle aspiration


EUS-guided tattooing



Joanna Law, Vikesh Singh, Mouen Khashab, Ralph Hruban, Marcia Irene Canto, Eun Ji Shin, Payal Saxena, Matthew Weiss, Timothy Pawlik, Christopher Wolfgang, and Anne Marie Lennon have no conflicts of interest of financial ties to disclose.

Supplementary material

Supplementary material 1 (MPG 11918 kb)


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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Joanna K. Law
    • 1
  • Vikesh K. Singh
    • 1
  • Mouen A. Khashab
    • 1
  • Ralph H. Hruban
    • 2
  • Marcia Irene Canto
    • 1
  • Eun Ji Shin
    • 1
  • Payal Saxena
    • 1
  • Matthew J. Weiss
    • 3
  • Timothy M. Pawlik
    • 3
  • Christopher L. Wolfgang
    • 3
  • Anne Marie Lennon
    • 1
    Email author
  1. 1.Division of GastroenterologyJohns Hopkins HospitalBaltimoreUSA
  2. 2.Department of Pathology, The Sol Goldman Pancreatic Cancer Research CenterJohns Hopkins HospitalBaltimoreUSA
  3. 3.Department of SurgeryJohns Hopkins HospitalBaltimoreUSA

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