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. 2019 Feb 22;3(3):344-353.
doi: 10.1002/bjs5.50140. eCollection 2019 Jun.

Evaluation of a strategy using pretherapeutic fiducial marker placement to avoid missing liver metastases

V Kepenekian  1 , A Muller  2 , P J Valette  2 , P Rousset  2 , M Chauvenet  3 , G Phelip  3 , T Walter  4 , M Adham  5 , O Glehen  1 , G Passot  1
Affiliations

Evaluation of a strategy using pretherapeutic fiducial marker placement to avoid missing liver metastases

V Kepenekian et al. BJS Open. .

Abstract

Background: Hepatic surgery is appropriate for selected patients with colorectal liver metastases (CRLM). Advances in chemotherapy have led to modification of management, particularly when metastases disappear. Treatment should address all initial CRLM sites based on pretherapeutic cross-sectional imaging. This study aimed to evaluate pretherapeutic fiducial marker placement to optimize CRLM treatment.

Methods: This pilot investigation included patients with CRLM who were considered for potentially curative treatment between 2009 and 2016. According to a multidisciplinary team decision, lesions smaller than 25 mm in diameter that were more than 10 mm deep in the hepatic parenchyma and located outside the field of a planned resection were marked. Complication rates and clinicopathological data were analysed.

Results: Some 76 metastases were marked in 43 patients among 217 patients with CRLM treated with curative intent. Of these, 23 marked CRLM (30 per cent), with a mean(s.d.) size of 11·0(3·4) mm, disappeared with preoperative chemotherapy. There were four complications associated with marking: two intrahepatic haematomas, one fiducial migration and one misplacement. After a median follow-up of 47·7 (range 18·1-144·9) months, no needle-track seeding was noted. Of four disappearing CRLM that were marked and resected, two presented with persistent active disease. Other missing lesions were treated with thermoablation.

Conclusion: Pretherapeutic fiducial marker placement appears useful for the curative management of CRLM.

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Figures

Figure 1
Figure 1
Strategy for fiducial marker placement for lesions at risk of disappearance. CRLM, colorectal liver metastases; DWI, diffusion‐weighted imaging
Figure 2
Figure 2
Overview of patient selection and treatment of marked colorectal liver metastases. CRLM, colorectal liver metastases; RFA, radiofrequency ablation; MWA, microwave ablation
Figure 3
Figure 3
Fiducial marker placement‐related complications. a,b Fiducial marker migration: a premarking CT scan with metastases of segment VII close to the hepatic vein; b postmarking CT scan with fiducial marker migration in the subsegmental branch of the posterobasal segment from the inferior right lobe with no evidence of pulmonary embolism. c–f Hepatic parenchymal haematoma: c premarking CT and d premarking MRI scans showing a 10‐mm metastasis in segment III (white arrow); e control CT scan the day after marking showing a hepatic parenchymal haematoma; f control CT scan after radiofrequency ablation (RFA)
Figure 4
Figure 4
Left colonic adenocarcinoma with four liver metastases in segments IV, VI, VII and VIII. Before chemotherapy, cross‐sectional images from a CT, b MRI contrast‐enhanced fat‐saturated T1‐weighted image and c MRI inverted contrast diffusion‐weighted image showed liver metastasis at risk of being missed (white arrow) in segment IV. After CT‐guided marking (d) a control CT scan confirmed good fiducial marker placement (e). f After four cycles of FOLFOX–bevacizumab, the marked lesion disappeared from the CT scan. g The fiducial marker allowed the location of the missing metastasis to be identified easily by intraoperative ultrasonography (IOUS), allowing radiofrequency ablation in addition to a right hepatectomy. h A postoperative control CT scan confirmed the good targeting of the ablation
See this image and copyright information in PMC

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