|IMAGE IN EUS
|Year : 2015 | Volume
| Issue : 2 | Page : 156-157
Convex probe endobronchial ultrasound placement of fiducial markers for central lung nodule (with video)
Kassem Harris1, Jorge Gomez2, Samjot Singh Dhillon1, Abdul Hamid Alraiyes3, Anthony Picone4
1 Department of Medicine, Interventional Pulmonary Section, Roswell Park Cancer Institute; Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, State University of New York, Buffalo, New York, USA
2 Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
3 Department of Medicine, Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, New York, USA
4 Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York, USA
|Date of Submission||06-Sep-2014|
|Date of Acceptance||09-Oct-2014|
|Date of Web Publication||8-May-2015|
Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, State University of New York, Buffalo, New York
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Harris K, Gomez J, Dhillon SS, Alraiyes AH, Picone A. Convex probe endobronchial ultrasound placement of fiducial markers for central lung nodule (with video). Endosc Ultrasound 2015;4:156-7
|How to cite this URL:|
Harris K, Gomez J, Dhillon SS, Alraiyes AH, Picone A. Convex probe endobronchial ultrasound placement of fiducial markers for central lung nodule (with video). Endosc Ultrasound [serial online] 2015 [cited 2020 Jan 27];4:156-7. Available from: http://www.eusjournal.com/text.asp?2015/4/2/156/156757
An 80-year-old man was found to have a 1.4 cm lesion on right side of the lower lobe central parenchymal lung nodule on chest computed tomogram (CT) while undergoing evaluation for a cough [Figure 1]a and b. The lesion was metabolically active on positive emission tomography without any evidence to suggest involvement of mediastinal/hilar nodes or distant metastasis. Flexible bronchoscopy with transbronchial biopsies confirmed this lesion to be lung adenocarcinoma. The patient's comorbidities precluded surgical resection, and he was scheduled to have stereotactic body radiation therapy (SBRT). Given the central location of the nodule and its close proximity to the esophageal wall, fiducial markers placement inside the tumor was recommended. Convex probe endobronchial ultrasound (CP-EBUS) was used to place three fiducial gold markers (0.35 mm × 5 mm, Visicoil, IBA) using a 22 Gauge EBUS needle (Olympus, NA-201SX-4022). The fiducials were loaded into the EBUS needle distally (front-load), and bone wax was applied to secure the fiducials in place [Figure 1]c and d. Under real-time CP-EBUS guidance [Video 1], each fiducial was placed inside the tumor at a peripheral location forming a triangular shape inside the tumor [Figure 2]a-c. Color Doppler was used to prevent vascular puncture or accidental intravascular fiducial placement. The procedure time was about 30 min, and the patient reported no operation-related complications and the fiducials showed no evidence of migration [Figure 2]d-f. The patient underwent SBRT (how many fractions) without any complications.
|Figure 1. (a and b) Chest computed tomography axial and coronal views showing the right lower lobe central nodule. (c) Convex probe endobronchial ultrasound (CP-EBUS) image showing the fi ducial marker inside the tumor (arrow). (d) Intraoperative fluoroscopic image showing the tip of the EBUS scope (red arrow) and the three fi ducial markers that were placed using CP-EBUS (white arrows)|
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|Figure 2. (a-c) Convex probe endobronchial ultrasound images showing the EBUS needle (arrows) at different locations inside the tumor representing where the three fi ducials markers were deployed. (d-f) Images from the stereotactic body radiation therapy planning scan showing the fi ducial markers inside the tumor (arrows)|
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Surgical resection remains the first-line treatment for early-stage peripheral lung cancer.
In patients with multiple comorbidities that preclude surgery, alternative therapy such as SBRT is considered. Fiducial markers placement for lung cancers is commonly performed to guide SBRT or surgical resection. Percutaneous CT-guided fiducial placement is associated with pneumothorax rate up to 48%.  Since advanced bronchoscopic techniques provide improved diagnostic accuracy and fewer complications over conventional bronchoscopy, they are now more commonly used for fiducial markers placement to guide radiation therapy. Both radial probe EBUS and electromagnetic navigation have been used for implanting of fiducial markers.  These devices may be used as markers to guide radiation therapy. The complication rate such as migration and pneumothorax is, usually, low.  In one group, 90% of the markers remained in place during the time of radiosurgery. 
CP-EBUS is widely used for the diagnosis and mediastinal staging of lung cancer. CP-EBUS has been also used to guide fiducial markers placement in the peribronchial and mediastinal lymph nodes.  CP-EBUS can be utilized for diagnosis of central parenchymal lung nodules and masses, along with simultaneous mediastinal staging. In these cases, fiducial markers placement can be performed in the same setting using CP-EBUS as no complications have been reported. ,
Convex probe endobronchial ultrasound placement of fiducial markers is a safe and useful procedure to guide stereotactic radiosurgery for centrally located lung cancers.
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[Figure 1], [Figure 2]