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. 2017 Jun 21;12(6):e0179676.
doi: 10.1371/journal.pone.0179676. eCollection 2017.

Efficacy and safety of ultrasound-guided implantation of fiducial markers in the liver for stereotactic body radiation therapy

So Hyun Park  1   2 , Hyung Jin Won  1 , So Yeon Kim  1 , Yong Moon Shin  1 , Pyo Nyun Kim  1 , Sang Min Yoon  3 , Jin-Hong Park  3 , Jong Hoon Kim  3
Affiliations

Efficacy and safety of ultrasound-guided implantation of fiducial markers in the liver for stereotactic body radiation therapy

So Hyun Park et al. PLoS One. .

Abstract

Objective: Stereotactic body radiation therapy (SBRT) for the treatment of a malignancy in the liver requires the perilesional implantation of fiducial markers for lesion detection. The purpose of this study is to evaluate the efficacy and safety of ultrasound (US) -guided marker implantation for SBRT.

Methods: We retrospectively reviewed 299, US-guided, intrahepatic fiducial markers implanted in 101 patients between November 2013 and September 2014. SBRT-planning CT images were analyzed to determine the technical success of the implantation, the mean distance between the tumor margin and the marker, with the ideal location of fiducials defined as the distance between a marker and a tumor less than 3 cm and the distance between markers greater than 2 cm according to the tumor conspicuity seen on gray-scale US and the artifact obscuring tumor margins. We also evaluated procedure-related major and minor complications.

Results: Technical success was achieved in 291 (97.3%) fiducial marker implantations. The mean distance between the tumor and the marker was 3.1 cm (S.D., 2.1 cm; range, 0-9.5 cm). Of 101 patients, 72 lesions (71.3%, 2.2 ± 1.0 cm; range, 0-3.0 cm) had fiducial markers located in an ideal location. The ideal location of fiducials was more common in visible lesions than in poorly conspicuous lesions (90.2% vs. 52.0%, P < 0.001). Seventeen markers (5.8%) developed beam-hardening artifacts obscuring the tumor margins. There were no major complications, although 12 patients (11.9%) developed minor complications.

Conclusions: US-guided implantation of fiducial markers in the liver is an effective and safe procedure with only rare complications.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. An example of radiotherapy planning using a respiratory-gated, volumetric-modulated, arc therapy technique for hepatocellular carcinoma in segment 3 of the liver.
Fig 2
Fig 2. Calculating the distance semi-automatically between the tumor margin and a marker in 3-dimensional space creating a curved line parallel to the outer margin of the tumor using planning CT workstation.
Firstly, draw a line along tumor margin. Second, create a curved line parallel to the outer margin of the tumor at marker site using workstation tool. And the distance between the tumor margin and a marker is automatically calculated as 1.6cm.
Fig 3
Fig 3. Beam hardening artifact created by the marker obscuring tumor margins.
(a) Hepatic metastasis (arrow, the longest tumor diameter: 1.4 cm) from rectal cancer in segment 4 of the liver. (b, c) Beam-hardening artifact of the marker obscured the tumor margin. The distance between the tumor and the marker was 0.4 cm.
Fig 4
Fig 4. Minor complications.
A 43-year-old male with hepatocellular carcinoma who underwent fiducial marker implants (arrowheads, a-b). After the procedure, a small, echogenic lesion (b) developed in the subcapsular portion of the liver, thus suggesting subcapsular hematoma (arrow).
See this image and copyright information in PMC

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