Implanting Two Fiducials into the Liver with Single Needle Insertion Under CT Guidance for CyberKnife® SBRT

Conference paper
Part of the Lecture Notes in Electrical Engineering book series (LNEE, volume 269)

Abstract

Purpose We implanted four to six fiducial markers before treating liver tumors with CyberKnife® to allow image-guided positioning before treatment and real-time tracking during treatment. In the conventional implanting technique, a needle insertion is required to place each fiducial, i.e., patients would receive four to six needle punctures. To improve efficiency and reduce the time required for the procedure, not to mention the pain and risks of fiducial implantation, we invented a technique whereby two fiducials are implanted with each needle insertion. Methods and Materials Liver tumors constitute the most common disease treated at our radiotherapy center. From August 2011 to July 2012, 429 patients with liver tumors underwent fiducial implantation with the technique of one-needle insertion placing two fiducials at a time. Ages varied 19–74 years old. In total, 1252 fiducials were implanted with this technique. For the new technique, an initial CT image of the tumor was used to determine the implanting depth and angle of the first fiducial marker. The first fiducial was placed using an 18-gauge needle, and the needle stylet and set remain stationary for 3–5 min, after which it was slowly pulled 3–5 cm out, and then the second fiducial was released. Another image of the fiducials was acquired to assess the distance between the fiducials, their angle with respect to each other, and their compliance with the requirements of fiducial placement before continuing the procedure. Results Among the 1252 fiducials implanted with the technique, 18 (1.44 %) had a distance smaller than 20 mm between each other, 24 (1.92 %) were collinear at 45° vantage point, 17 (1.04 %) migrated to other organs, and the success rate was 95.28 %. With this technique, 626 punctures were required whereas 1252 punctures would have been needed with the conventional technique. Besides, implanting with a 35°–5° angle makes fiducials collinear in the 45° direction. For some patients, for whom the two-fiducial insertion technique required a puncture deeper than 5 cm, the fiducials were inserted one by one. Conclusion Dual fiducial insertion doubles the implanting efficiency and halves the number of punctures so that the costs and risks are both reduced. The distance between fiducials being smaller than 20 mm and collinear fiducials at the 45° angle direction are the most common complications affecting success rate.

Keywords

CT guidance Fiducial implantation CyberKnife SBRT 

References

  1. 1.
    Kuo JS, Yu C, Petrovich Z, Apuzzo ML (2003) The CyberKnife stereotactic radiosurgery system: description, installation, and an initial evaluation of use and functionality. Neurosurgery 53:1235–1239CrossRefGoogle Scholar
  2. 2.
    Chan SD, Main W, Martin DP, Gibbs IC, Heilbrun MP (2003) An analysis of the accuracy of the CyberKnife:a robotic frameless stereotactic radiosurgical system. Neurosurgery 52:140–146Google Scholar
  3. 3.
    Wunderink W, Mendez Romero A, de Kruijf W et al (2008) Reduction of respiratory liver tumor motion by abdominal compression in stereotactic body frame, analyzed by tracking fiducial markers implanted in liver. Int J Radiat Oncol Biol Phys 71:907–915 Google Scholar
  4. 4.
    Kim JH, Hong SS, Kim JH et al (2012) Safety and efficacy of ultrasound-guide fiducial marker implantation for CyberKnife radiation therapy. Korean J Radiol 13(3):307–313Google Scholar
  5. 5.
    Anantham D, Feller-Kopman D, Shanmugham LN et al (2007) Electromagnetic navigation bronchoscopy-guided fiducial placement for robotic stereotactic radiosurgery of lung tumors. Chest 132(3):930–935Google Scholar
  6. 6.
    Mallarajapatna GJ, Susheela SP, Kallur KG et al (2011) Image guided internal fiducial placement for stereotactic radiosurgery (CyberKnife). Indian J Radiol Imag 21:3–5CrossRefGoogle Scholar
  7. 7.
    Kothary N, Dieterich S, Louie JD et al (2009) Percutaneous implantation of fiducial markers for imaging-guided radiation therapy. AJR 192:1090–1095Google Scholar
  8. 8.
    Berbeco RI, Nishioka S, Shirato H et al (2005) Residual motion of lung tumors in gate radiotherapy with external respiratory surrogates. Phys Med Biol 50:3655–3667CrossRefGoogle Scholar
  9. 9.
    Ryu SI, Chang SD, Kim DH et al (2001) Image-guide hypo-fractionated stereotactic radiosurgery to spinal lesions. Neurosurgery 49:838–846Google Scholar
  10. 10.
    Kothary N, Heit JJ, Louie JD et al (2009) Safety and efficacy of percutaneous fiducial marker implantation for image-guide radiation. J Vasc Interv Radiol 20(2):235–239Google Scholar
  11. 11.
    Dieterich Sonja et al (2011) Quality assurance for robotic radiosurgery: report of the AAPM task group 135. Med Phys 38(6):2924–2926Google Scholar
  12. 12.
    Quinn AM (2002) CyberKnife: a robotic radiosurgery system. Clin J Oncol Nurs 6:149–156CrossRefGoogle Scholar
  13. 13.
    Lee C (2012) Airway migration of lung fiducial marker after autologous blood-patch injection. Cardiovasc Intervent Radiol 35:711–713CrossRefGoogle Scholar
  14. 14.
    Kupelian P, Forbes A, Willoughby T et al (2007) Implantation and stability of metallic fiducials within pulmonary lesions. Int J Radiat Oncol Biol Phys 69:777–785Google Scholar
  15. 15.
    Shirato H, Harada T, Harabayshi T et al (2003) Feasibility of insertion/implantation of 2.0 –mm-diameter gold internal fiducial markers for precise setup and real-time tumor tracking in radiotherapy. Int J Radiat Oncol Biol Phys 56:240–247Google Scholar
  16. 16.
    Sotiropoulou E, Stathochristopoulou I, Stathopoulos K et al (2010) CT-guided fiducial placement for CyberKnife stereotactic radiosurgery: an initial experience. Cardiovasc Intervent Radiol 33:586–589CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.Oncology Radiotherapy Center of 302Military HospitalBeijingChina

Personalised recommendations