Risks and Benefits of Fiducial Marker Placement in Tumor Lesions for Robotic Radiosurgery: Technical Outcomes of 357 Implantations

Fiducial markers (FM) inserted into tumors increase the precision of irradiation during robotic radiosurgery (RRS). This retrospective study evaluated the clinical complications, marker migration, and motion amplitude of FM implantations by analyzing 288 cancer patients (58% men; 63.1 ± 13.0 years) who underwent 357 FM implantations prior to RRS with CyberKnife, between 2011 and 2019. Complications were classified according to the Society of Interventional Radiology (SIR) guidelines. The radial motion amplitude was calculated for tumors that moved with respiration. A total of 725 gold FM was inserted. SIR-rated complications occurred in 17.9% of all procedures. Most complications (32.0%, 62/194 implantations) were observed in Synchrony®-tracked lesions affected by respiratory motion, particularly in pulmonary lesions (46.9% 52/111 implantations). Concurrent biopsy sampling was associated with a higher complication rate (p = 0.001). FM migration occurred in 3.6% after CT-guided and clinical FM implantations. The largest motion amplitudes were observed in hepatic (20.5 ± 11.0 mm) and lower lung lobe (15.4 ± 10.5 mm) lesions. This study increases the awareness of the risks of FM placement, especially in thoracic lesions affected by respiratory motion. Considering the maximum motion amplitude, FM placement remains essential in hepatic and lower lung lobe lesions located >100.0 mm from the spine.

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Planting the seeds of success: CT-guided gold seed fiducial marker placement to guide robotic radiosurgery

Journal of Medical Imaging and Radiation Oncology ◽

10.1111/j.1754-9485.2012.02445.x ◽

2012 ◽

Vol 57 (2) ◽

pp. 207-211 ◽

Cited By ~ 17

Author(s):

Aashish Patel ◽

Bhavraj Khalsa ◽

Bryce Lord ◽

Kumar Sandrasegaran ◽

Chandana Lall

Keyword(s):

Fiducial Marker ◽

Ct Guided ◽

Robotic Radiosurgery ◽

Gold Seed

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Residual Image Registration Error by Fiducial Markers in Accelerated Partial Breast Irradiation Using C-Arm Linac: A Phantom Study

10.21203/rs.3.rs-1080442/v1 ◽

2021 ◽

Author(s):

Ryohei Yamauchi ◽

Natsuki Murayoshi ◽

Shinobu Akiyama ◽

Norifumi Mizuno ◽

Tomoyuki Masuda ◽

...

Keyword(s):

Image Registration ◽

Respiratory Motion ◽

Fiducial Marker ◽

Accelerated Partial Breast Irradiation ◽

Partial Breast Irradiation ◽

Fiducial Markers ◽

Breast Irradiation ◽

Registration Error ◽

Surgical Clips ◽

Residual Image

Abstract Introduction: External beam accelerated partial breast irradiation (APBI) is an alternative treatment for patients with early-stage breast cancer. The efficacy of image-guided radiotherapy (IGRT) using fiducial markers, such as gold markers or surgical clips, has been demonstrated. However, the effects of respiratory motion during a single fraction have not been reported. This study aimed to evaluate the residual image registration error of fiducial marker-based IGRT by respiratory motion and propose a suitable treatment strategy.Materials & Methods: We developed an acrylic phantom embedded with surgical clips to verify the registration error under moving conditions. The frequency of the phase difference in the respiratory cycle due to sequential acquisition was verified in a preliminary study. Fiducial marker-based IGRT was then performed in 10 scenarios. The residual registration error (RRE) was calculated on the basis of the differences in the coordinates of clips between the true position if not moved and the last position.Results: The frequencies of the phase differences in 0.0–0.99, 1.0–1.99, 2.0–2.99, 3.0–3.99, and 4.0–5.0 mm were 23%, 24%, 22%, 20%, and 11%, respectively. When assuming a clinical case, the mean RREs for all directions were within 1.0 mm, even if respiratory motion of 5 mm existed in two axes.Conclusions: For APBI with fiducial marker-based IGRT, the introduction of an image registration strategy that employs stepwise couch correction using at least three orthogonal images should be considered.

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Microscopic tumor spread beyond (echo)endoscopically determined tumor borders in esophageal cancer

Radiation Oncology ◽

10.1186/s13014-019-1419-5 ◽

2019 ◽

Vol 14 (1) ◽

Author(s):

Melanie Machiels ◽

Maurits L. van Montfoort ◽

Nikki B. Thuijs ◽

Mark I. van Berge Henegouwen ◽

Tanja Alderliesten ◽

...

Keyword(s):

Esophageal Cancer ◽

Residual Tumor ◽

Fiducial Marker ◽

Response To Therapy ◽

Adjuvant Chemoradiotherapy ◽

Esophageal Wall ◽

Fiducial Markers ◽

Tumor Spread ◽

Tumor Group ◽

Macroscopic Tumor

Abstract Objective The microscopic tumor spread (MS) beyond the macroscopic tumor borders of esophageal tumors is crucial for determining the clinical target volume (CTV) in radiotherapy. The question arises whether current voluminous CTV margins of 3–5 cm around the macroscopic gross tumor volume (GTV) to account for MS are still accurate when fiducial markers are used for GTV determination. We aimed to pathologically validate the use of fiducial markers placed on the (echo)endoscopically determined tumor border (EDTB) as a surrogate for macroscopic tumor borders and to analyse the MS beyond EDTBs. Methods Thirty-three consecutive esophageal cancer patients treated with neo-adjuvant chemoradiotherapy after (echo)endoscopic fiducial marker implantation at cranial and caudal EDTB were included in this study. Fiducial marker positions were detected in the surgical specimens under CT guidance and demarcated with beads, and subsequently analysed for macroscopic tumor spread and MS beyond the demarcations. A logistic regression analysis was performed to determine predicting factors for MS beyond EDTB. Results A total of 60 EDTBs were examined in 32 patients. In 50% of patients no or only partial regression of tumor in response to therapy (≥Mandard 3) or higher was seen (i.e., residual tumor group) and included for MS analysis. None had macroscopic tumor spread beyond EDTBs. In the residual tumor group, only 20 and 21% of the cranial and caudal EDTBs were crossed with a maximum of 9 mm and 16 mm MS, respectively. This MS was corrected for each individual determined contraction rate (mean: 93%). Presence of MS beyond EDTB was significantly associated with initial tumor length (p = 0.028). Conclusion Our results validate the use of fiducial markers on EDTB as a surrogate for macroscopic tumor and indicate that CTV margins around the GTV to compensate for MS along the esophageal wall can be limited to 1–1.5 cm, when the GTV is determined with fiducial markers.

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Function of lower lung lobe autograft in experimental animals

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/s0022-5223(19)40266-3 ◽

1976 ◽

Vol 71 (1) ◽

pp. 102-109

Author(s):

J.J. Rabinovich

Keyword(s):

Experimental Animals ◽

Lung Lobe ◽

Lower Lung

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Pulmonary venoconstriction caused by elevated cerebrospinal fluid pressure in the dog

Journal of Applied Physiology ◽

10.1152/jappl.1980.49.1.73 ◽

1980 ◽

Vol 49 (1) ◽

pp. 73-78 ◽

Cited By ~ 29

Author(s):

M. B. Maron ◽

C. A. Dawson

Keyword(s):

Cerebrospinal Fluid ◽

Fluid Pressure ◽

Cerebrospinal Fluid Pressure ◽

Epinephrine Infusion ◽

Pressure Drops ◽

Lung Lobe ◽

Pulmonary Vasoconstriction ◽

Lower Lung ◽

Occlusion Technique ◽

Highly Correlated

Previously we found that raising cerebrospinal fluid pressure (PCSF) caused pulmonary vasoconstriction mediated by adrenal catecholamines. To localize the site of this vasoconstriction we used the outflow occlusion technique to divide changes in the pulmonary arteriovenous pressure gradient (Pa-v) into upstream and downstream pressure drops. Experiments were conducted in 10 dogs in which the animal's left lower lung lobe was denervated and perfused at constant flow and outflow pressure with blood pumped from the dog's pulmonary artery. Raising PCSF to 218 Torr caused Pa-v to rise from 9.0 to 12.5 Torr. Most (83%) of this increase resulted from an increase in the downstream pressure drop. Previous studies have indicated that changes in the upstream and downstream pressure drops, as measured by this technique, are highly correlated with changes in the resistance of the arterial and venous sides of the vascular bed. Thus, it appears that elevated PCSF caused primarily pulmonary venoconstriction. Similar results were obtained with norepinephrine and epinephrine infusion. This is consistent with previous studies, indicating that adrenal catecholamines are responsible for the increase in Pa-v in response to PCSF in this preparation.

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PS02.186: EUS-GUIDED FIDUCIAL MARKER INSERTION TO GUIDE RADIOTHERAPY IN ADVANCED ESOPHAGEAL CARCINOMA.

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps02.186 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 174-175

Author(s):

Shannon Chan ◽

Anthony Teoh ◽

Hon Chi Yip ◽

Vivien Wong ◽

Philip Chiu ◽

...

Keyword(s):

Esophageal Carcinoma ◽

Tumor Response ◽

Conflicts Of Interest ◽

Concurrent Chemotherapy ◽

Fiducial Marker ◽

Esophageal Tumor ◽

Fiducial Markers ◽

Migration Rates ◽

The Mean ◽

Esophageal Carcinomas

Abstract Background The use of radiotherapy with or without concurrent chemotherapy is frequently required in treatment of advanced esophageal carcinomas. It can be given in an adjuvant, neoadjuvant or definitive setting. However, the margins of the tumor are often difficult to ascertain on computed tomography. Thus, EUS-guided fiducial marker insertion has an important role to aid the localization of the proximal and distal margins of the esophageal tumor. However, the optimal technique of the procedure is still uncertain. Methods This was a retrospective study of all patients who received EUS-guided fiducial marker insertion between March 2015 and October 2017. All patients suffering from esophageal carcinoma scheduled for radiotherapy underwent the procedure within one week of the scheduled appointment. Gold fiducial markers 5mm x 0.35mm (Visicoil, IBA Dosimetry, USA) were back loaded onto a 22-gauge needle (Vizishot, Olympus Medical, Japan) or (Expect, Boston Scientific, USA). The markers were placed under EUS guidance either intratumorally or in the normal submucosa just proximal and distal to the tumor.The submucosal planes were raised with diluted hyaluronic acid before insertion of the marker. Outcome parameters included tumor characteristics, early and late migration rates and tumor response rates. Results 35 patients were included in the study. The mean (S.D.) age was 61.0 (9.9) years old. The mean (S.D.) length of the tumor were 7.2 (6.0) cm and and 86.2% of the patients had stage 3 disease. 27 patients had markers inserted by EBUS and 71.4% in the submucosa. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly more fiducials had early (30% vs 0%, P = 0.004) and late migration (80% vs 0%, P < 0.001) in the intratumoral group. There were no differences in the stage of disease (P = 0.870), percentage of patients that completed radiotherapy (P = 0.063) and response rate (P = 0.197). There were no adverse effects in both groups. Conclusion In esophageal carcinomas planned for radiotherapy, EUS-guided fiducial markers should be placed in the submucosa just proximal and distal to the tumor instead of intratumorally. This may be able to increase the precision for radiotherapy. Disclosure All authors have declared no conflicts of interest.

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Pulmonary vasoconstriction in a canine model of neurogenic pulmonary edema

Journal of Applied Physiology ◽

10.1152/jappl.1990.68.3.912 ◽

1990 ◽

Vol 68 (3) ◽

pp. 912-918 ◽

Cited By ~ 18

Author(s):

M. B. Maron

Keyword(s):

Pulmonary Edema ◽

Canine Model ◽

Neurogenic Pulmonary Edema ◽

Plasma Catecholamine ◽

Pulmonary Hemodynamics ◽

Lung Lobe ◽

Pulmonary Vasoconstriction ◽

Lower Lung ◽

Severe Degree ◽

Plasma Catecholamine Concentrations

The intracisternal administration of veratrine to the chloralose-anesthetized dog produces pulmonary hypertension (PH) and neurogenic pulmonary edema (NPE). To determine whether pulmonary vasoconstriction, mediated by a circulating agent, contributes to the PH, the left lower lung lobe (LLL) perfusion of seven splenectomized (to keep hematocrit and blood viscosity constant) dogs was isolated so the LLL could be perfused at constant flow and outflow pressure with blood pumped from the pulmonary artery. The LLL was denervated by removing it from the dog. Veratrine (40-160 micrograms/kg) increased LLL arterial pressure by 39.2% and produced large increases in plasma catecholamine concentrations. The double-occlusion technique indicated that 74% of the increase in the LLL arteriovenous pressure gradient was due to an increase in venous tone. This pattern of vasoconstriction was similar to that previously observed during the infusion of exogenous catecholamines and suggested that catecholamines mediated the LLL response. The more severe degree of PH observed in the intact animal in NPE, however, suggests that passive rather than active changes in pulmonary hemodynamics are predominantly responsible for the development of PH in this disorder.

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SU-E-J-40: Lung Lesion Tracking Using Fixed-Spaced Non-Migrating Fiducial Markers in Robotic Radiosurgery

Medical Physics ◽

10.1118/1.4734875 ◽

2012 ◽

Vol 39 (6Part6) ◽

pp. 3661-3661

Author(s):

J Gersh ◽

K Reynolds ◽

M DeWeese

Keyword(s):

Lung Lesion ◽

Fiducial Markers ◽

Robotic Radiosurgery

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Phasic capillary pressure determined by arterial occlusion in intact dog lung lobes

Journal of Applied Physiology ◽

10.1152/jappl.1989.67.6.2205 ◽

1989 ◽

Vol 67 (6) ◽

pp. 2205-2211 ◽

Cited By ~ 8

Author(s):

Y. Yamada ◽

M. Suzukawa ◽

M. Chinzei ◽

T. Chinzei ◽

N. Kawahara ◽

...

Keyword(s):

Capillary Pressure ◽

Vascular Resistance ◽

Control Period ◽

Arterial Occlusion ◽

Lung Lobe ◽

Pulmonary Capillary ◽

Pulmonary Capillary Pressure ◽

Lower Lung ◽

Pulmonary Arterial ◽

Electrocardiogram Ecg

In six open-chest dogs, electrocardiogram- (ECG) controlled pulmonary arterial occlusion was performed during the control period and during the infusions of serotonin and histamine. A temporal series of instantaneous pulmonary capillary pressure and the longitudinal distributions of vascular resistance and compliance were evaluated in the intact left lower lung lobe. In the control period, we found a significant phasic variation of pulmonary capillary pressure (Pc) with the cardiac cycle. The ratio of arterial to venous resistances (Ra/Rv) was 6:4, and the ratio of arterial to capillary compliances (Ca/Cc) was 1:11. During the infusions of serotonin and histamine, Pc showed similar phasic variations, despite significant hemodynamic changes induced by these agents. Serotonin predominantly increased Ra, whereas histamine predominantly increased Rv. The ratio of Rv to the total resistance decreased significantly from 0.42 to 0.32 during the infusion of serotonin and increased significantly to 0.62 during the infusion of histamine. The data suggest that phasic Pc determined by ECG-controlled arterial occlusion reflects the pulsatility in the pulmonary microvascular bed under control conditions and after alterations of the pulmonary vascular resistance by serotonin and histamine.

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