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Wang L, Sanders J, Ward JF, Lee SR, Poenisch F, Swanson DM, Sahoo N, Zhu XR, Ma J, Kudchadker RJ, Choi SL, Nguyen QN, Mayo LL, Shah SJ, Frank SJ. A Novel Polymer-Encapsulated Multi-Imaging Modality Fiducial Marker with Positive Signal Contrast for Image-Guided Radiation Therapy. Cancers (Basel) 2024; 16:625. [PMID: 38339376 PMCID: PMC10854757 DOI: 10.3390/cancers16030625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/22/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Current fiducial markers (FMs) in external-beam radiotherapy (EBRT) for prostate cancer (PCa) cannot be positively visualized on magnetic resonance imaging (MRI) and create dose perturbation and significant imaging artifacts on computed tomography (CT) and MRI. We report our initial experience with clinical imaging of a novel multimodality FM, NOVA. METHODS We tested Gold Anchor [G-FM], BiomarC [carbon, C-FM], and NOVA FMs in phantoms imaged with kilovoltage (kV) X-rays, transrectal ultrasound (TRUS), CT, and MRI. Artifacts of the FMs on CT were quantified by the relative streak artifacts level (rSAL) metric. Proton dose perturbations (PDPs) were measured with Gafchromic EBT3 film, with FMs oriented either perpendicular to or parallel with the beam axis. We also tested the performance of NOVA-FMs in a patient. RESULTS NOVA-FMs were positively visualized on all 4 imaging modalities tested. The rSAL on CT was 0.750 ± 0.335 for 2-mm reconstructed slices. In F-tests, PDP was associated with marker type and depth of measurement (p < 10-6); at 5-mm depth, PDP was significantly greater for the G-FM (12.9%, p = 10-6) and C-FM (6.0%, p = 0.011) than NOVA (4.5%). EBRT planning with MRI/CT image co-registration and daily alignments using NOVA-FMs in a patient was feasible and reproducible. CONCLUSIONS NOVA-FMs were positively visible and produced less PDP than G-FMs or C-FMs. NOVA-FMs facilitated MRI/CT fusion and identification of regions of interest.
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Affiliation(s)
- Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Jeremiah Sanders
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.S.); (J.M.)
| | - John F. Ward
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Stephen R. Lee
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Falk Poenisch
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (F.P.); (N.S.); (X.R.Z.); (R.J.K.)
| | - David Michael Swanson
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Narayan Sahoo
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (F.P.); (N.S.); (X.R.Z.); (R.J.K.)
| | - Xiaorong Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (F.P.); (N.S.); (X.R.Z.); (R.J.K.)
| | - Jingfei Ma
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.S.); (J.M.)
| | - Rajat J. Kudchadker
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (F.P.); (N.S.); (X.R.Z.); (R.J.K.)
| | - Seungtaek L. Choi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.L.C.); (Q.-N.N.); (L.L.M.); (S.J.S.)
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.L.C.); (Q.-N.N.); (L.L.M.); (S.J.S.)
| | - Lauren L. Mayo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.L.C.); (Q.-N.N.); (L.L.M.); (S.J.S.)
| | - Shalin J. Shah
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.L.C.); (Q.-N.N.); (L.L.M.); (S.J.S.)
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.L.C.); (Q.-N.N.); (L.L.M.); (S.J.S.)
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Chang PW, Sadik J, Sahakian AB, Kankotia R, Ko C, Serna J, Rodriguez A, Lee H, Kulkarni S, Genyk Y, Sheikh M, Buxbaum JL. A Preliminary Controlled Trial of Endoscopic Ultrasound-guided Fiducial Markers to Guide Pancreas Surgery. J Clin Gastroenterol 2023:00004836-990000000-00246. [PMID: 38112649 DOI: 10.1097/mcg.0000000000001952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/08/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE Endoscopic ultrasound (EUS) is routinely used for fiducial marker placement (FMP) to guide stereotactic radiation of pancreatic tumors, but EUS-FMP explicitly to guide surgery has not been studied in a prospective, controlled manner. Multipurpose EUS systems have been developed that facilitate simultaneous EUS-FMP at the time of biopsy. We aimed to evaluate the feasibility of EUS-FMP to guide pancreatic resection. METHODS In this prospective trial, we enrolled patients with resectable pancreas masses undergoing tissue sampling and placed preloaded fiducials immediately after biopsy. Intraprocedure confirmation of carcinoma, neuroendocrine, and nonlymphomatous neoplasia by rapid on-site evaluation and lesion size <4 cm was required. The main outcomes were the feasibility and ease of preoperative placement and intraoperative detection of the markers using predefined Likert scales. RESULTS In 20 patients, EUS-FMP was successful before planned surgery and placement was technically straightforward (Likert Scale: 9.1 ± 1.3; range: 1, most challenging to 10, most facile). Intraoperative detection was feasible and improved when compared with a pre-established comparator of 5 representing an equivalent lesion without a marker (Likert Scale: 7.8 ± 2.2; range: 1, most difficult to 10, most facile; P = 0.011). The mean tumor size on EUS was 1.7 ± 0.9 (range: 0.5 to 3.6) cm. CONCLUSION EUS-FMP is feasible and safe for resectable pancreatic tumors before surgery and may assist in perioperative detection. Preloaded fiducials may be considered for placement at the time of initial referral for EUS-fine needle biopsy.
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Affiliation(s)
- Patrick W Chang
- Department of Internal Medicine, Division of Gastroenterology
| | - Jonathan Sadik
- Department of Internal Medicine, Division of Gastroenterology
| | - Ara B Sahakian
- Department of Internal Medicine, Division of Gastroenterology
| | - Ravi Kankotia
- Department of Internal Medicine, Division of Gastroenterology
| | - Christopher Ko
- Department of Internal Medicine, Division of Gastroenterology
| | - Jessica Serna
- Department of Internal Medicine, Division of Gastroenterology
| | - Alex Rodriguez
- Department of Internal Medicine, Division of Gastroenterology
| | - Helen Lee
- Department of Internal Medicine, Division of Gastroenterology
| | - Sujit Kulkarni
- Department of Surgery, Division of Hepatobiliary, Pancreas and Abdominal Transplant Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Yuri Genyk
- Department of Surgery, Division of Hepatobiliary, Pancreas and Abdominal Transplant Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Mohd Sheikh
- Department of Surgery, Division of Hepatobiliary, Pancreas and Abdominal Transplant Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - James L Buxbaum
- Department of Internal Medicine, Division of Gastroenterology
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3
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Cazacu IM, Singh BS, Martin-Paulpeter RM, Beddar S, Chun S, Holliday EB, Koong AC, Das P, Koay EJ, Taniguchi C, Herman JM, Bhutani MS. Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Patients with Pancreatic Cancer. Cancers (Basel) 2023; 15:5355. [PMID: 38001615 PMCID: PMC10670468 DOI: 10.3390/cancers15225355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/18/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Accurate delivery of stereotactic body radiotherapy (SBRT) to pancreatic tumors relies on successful EUS-guided placement of fiducial markers. The aim of this study is to report the technical feasibility and safety of EUS-guided fiducial placement and to evaluate the characteristics and technical benefit of SBRT in a cohort of patients with pancreatic cancer (PC). A retrospective chart review was performed for all (n = 82) PC patients referred for EUS-guided fiducial placement by a single endosonographer at a tertiary cancer center. Data regarding EUS-related technical details, SBRT characteristics, adverse events, and continuous visibility of fiducials were recorded and analyzed. Most patients included in the study had either locally advanced disease (32 patients, 39%) or borderline resectable disease (29 patients, 35%). Eighty-two PC patients underwent the placement of 230 fiducial markers under EUS guidance. The technical success rate of the fiducial placement was 98%. No immediate EUS-related adverse events were reported. The average time to the simulation CT after fiducial placement was 3.1 days. Of the 216 fiducial markers used for the SBRT delivery, 202 fiducial markers were visible on both the simulation CT and the cone beam CT scan. A median dose of 40cGY was given to all the patients in five fractions. Of these, 41% of the patients reported no SBRT-related toxicities during the follow-up. Fatigue and nausea were the most reported SBRT-related toxicities, which were seen in 35% of the patients post-SBRT. Our results demonstrate that EUS-guided fiducial placement is safe and effective in target volume delineation, facilitating SBRT delivery in PC patients. Further clinical trials are needed to determine the SBRT-related survival benefits in patients with pancreatic cancer.
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Affiliation(s)
- Irina M. Cazacu
- Department of Oncology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ben S. Singh
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Rachael M. Martin-Paulpeter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.M.M.-P.); (S.B.)
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.M.M.-P.); (S.B.)
| | - Stephen Chun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Emma B. Holliday
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Albert C. Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Eugene J. Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Cullen Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (S.C.); (E.B.H.); (A.C.K.); (P.D.); (E.J.K.); (C.T.)
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health Cancer Institute, New Hyde Park, NY 11042, USA;
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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Kothari S. Top tips for successful EUS-guided fiducial placement (with video). Gastrointest Endosc 2023; 98:241-244. [PMID: 37354143 DOI: 10.1016/j.gie.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Shivangi Kothari
- Division of Gastroenterology & Hepatology, Center for Advanced Therapeutic Endoscopy, URMC/Strong Memorial Hospital, Rochester, New York, USA
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5
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Itonaga M, Kitano M, Ashida R. Development of devices for interventional endoscopic ultrasound for the management of pancreatobiliary diseases. Dig Endosc 2023; 35:302-313. [PMID: 36052861 DOI: 10.1111/den.14428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/30/2022] [Indexed: 02/08/2023]
Abstract
A variety of devices have been developed for interventional endoscopic ultrasound (EUS). EUS-guided drainage of the bile duct and pancreatic duct, as well as fluid collection adjacent to the gastrointestinal tract, is performed by a procedure involving puncture, guidewire manipulation, tract dilation, and stent placement. Devices specialized for interventional EUS are being developed for each step of the procedure. Mechanical dilators such as bougie, balloon, and electrocautery dilators are used for tract dilation. Various types of plastic stents, self-expandable metal stents, and lumen-apposing metal stents specifically designed for interventional EUS are now available, including one-step devices developed to improve the efficacy and safety of interventional EUS. In addition, radiofrequency ablation and the placement of fiducial markers and radioactive seeds under EUS guidance are now becoming established for pancreatic neoplasms. Such development of specialized devices has expanded the indications for interventional EUS, increased the success rate, and lowered the adverse event rate.
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Affiliation(s)
- Masahiro Itonaga
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Reiko Ashida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Wadhwa V, Patel N, Grover D, Ali FS, Thosani N. Interventional gastroenterology in oncology. CA Cancer J Clin 2022; 73:286-319. [PMID: 36495087 DOI: 10.3322/caac.21766] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
Abstract
Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nicole Patel
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Dheera Grover
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Faisal S Ali
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
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Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures. Curr Oncol 2022; 29:6211-6225. [PMID: 36135057 PMCID: PMC9497766 DOI: 10.3390/curroncol29090488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/20/2022] Open
Abstract
There is growing evidence supporting the substantial, essential and indispensable role of endoscopic ultrasound (EUS) as a key diagnostic armamentarium for upper GI oncologic surgery. Well described in countless publications, EUS holds that position in gastroenterological expert centers all over Europe. Despite its undisputable contributions to oncologic upper GI surgery, the availability of this technique at the expert level shows up in an irregular spread pattern. Endoscopic ultrasound’s primary use during the first few years after its creation was the detection of pancreatic cancer. From then on, EUS developed in different directions, becoming a diagnostic tool that increasingly better defines its status as a method of minimally invasive therapeutic applications and a useful addition to surgical options. As a result, several surgical interventions could even be replaced by ultrasound-targeted interventions. This process took place in just a few years and was made possible by technical development that sensibly combined high-resolution ultrasound with therapeutic endoscopy. The present article will serve to cover the most prevalent uses with supporting data considering the growing list of suggested indications for EUS while also examining cutting-edge initiatives that might soon become the standard of clinical practice. Endoscopic centers with high expertise are needed to train future experts in the growing field of EUS interventions.
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8
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Reidel CA, Horst F, Schuy C, Jäkel O, Ecker S, Henkner K, Brons S, Durante M, Weber U. Experimental Comparison of Fiducial Markers Used in Proton Therapy: Study of Different Imaging Modalities and Proton Fluence Perturbations Measured With CMOS Pixel Sensors. Front Oncol 2022; 12:830080. [PMID: 35402273 PMCID: PMC8990863 DOI: 10.3389/fonc.2022.830080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Fiducial markers are used for image guidance to verify the correct positioning of the target for the case of tumors that can suffer interfractional motion during proton therapy. The markers should be visible on daily imaging, but at the same time, they should produce minimal streak artifacts in the CT scans for treatment planning and induce only slight dose perturbations during particle therapy. In this work, these three criteria were experimentally investigated at the Heidelberg Ion Beam Therapy Center. Several small fiducial markers with different geometries and materials (gold, platinum, and carbon-coated ZrO2) were evaluated. The streak artifacts on treatment planning CT were measured with and without iMAR correction, showing significantly smaller artifacts from markers lighter than 6 mg and a clear improvement with iMAR correction. Daily imaging as X-ray projections and in-room mobile CT were also performed. Markers heavier than 6 mg showed a better contrast in the X-ray projections, whereas on the images from the in-room mobile CT, all markers were clearly visible. In the other part of this work, fluence perturbations of proton beams were measured for the same markers by using a tracker system of several high spatial resolution CMOS pixel sensors. The measurements were performed for single-energy beams, as well as for a spread-out Bragg peak. Three-dimensional fluence distributions were computed after reconstructing all particle trajectories. These measurements clearly showed that the ZrO2 markers and the low-mass gold/platinum markers (0.35mm diameter) induce perturbations being 2–3 times lower than the heavier gold or platinum markers of 0.5mm diameter. Monte Carlo simulations, using the FLUKA code, were used to compute dose distributions and showed good agreement with the experimental data after adjusting the phase space of the simulated proton beam compared to the experimental beam.
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Affiliation(s)
- Claire-Anne Reidel
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Felix Horst
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
| | - Christoph Schuy
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
- *Correspondence: Christoph Schuy,
| | - Oliver Jäkel
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Ion Beam Therapy Center (HIT), Heidelberg, Germany
| | - Swantje Ecker
- Heidelberg Ion Beam Therapy Center (HIT), Heidelberg, Germany
| | - Katrin Henkner
- Heidelberg Ion Beam Therapy Center (HIT), Heidelberg, Germany
| | - Stephan Brons
- Heidelberg Ion Beam Therapy Center (HIT), Heidelberg, Germany
| | - Marco Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
- Institut für Physik Kondensierter Materie, Technische Universität Darmstadt, Darmstadt, Germany
| | - Uli Weber
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, Darmstadt, Germany
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9
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Be KH, Khor R, Lim Joon D, Starvaggi B, Chao M, Ng SP, Ng M, Zorron Cheng Tao Pu L, Efthymiou M, Vaughan R, Chandran S. Long-term clinical outcomes of lipiodol marking using standard gastroscopy for image-guided radiotherapy of upper gastrointestinal cancers. World J Gastroenterol 2021; 27:7387-7401. [PMID: 34876797 PMCID: PMC8611208 DOI: 10.3748/wjg.v27.i42.7387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/26/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Image-guided radiotherapy (IGRT) has significantly improved the precision in which radiotherapy is delivered in cancer treatment. Typically, IGRT uses bony landmarks and key anatomical structures to locate the tumor. Recent studies have demonstrated the feasibility of peri-tumor fiducials in enabling even more accurate delineation of target and normal tissue. The use of gold coils as fiducials in gastrointestinal tumors has been extensively studied. However, placement requires expertise and specialized endoscopic ultrasound equipment. This article reports the long-term outcomes of using a standard gastroscopy to inject liquid fiducials for the treatment of oesophageal and gastric tumors with IGRT.
AIM To assess the long-term outcomes of liquid fiducial-guided IGRT in a cohort of oesophageal and gastric cancer patients.
METHODS A retrospective cohort study of consecutive adults with Oesophagogastric cancers referred for liquid fiducial placement before definitive/neo-adjuvant or palliative IGRT between 2013 and 2021 at a tertiary hospital in Melbourne, Australia was conducted. Up to four liquid fiducials were inserted per patient, each injection consisting of 0.2-0.5mL of a 1:1 mixture of iodized oil (Lipiodol; Aspen Pharmacare) and n-butyl 2-cyanoacrylate (Histoacryl®; B. Braun). A 23-gauge injector (Cook Medical) was used for the injection. All procedures were performed by or under the supervision of a gastroenterologist. Liquid fiducial-based IGRT (LF-IGRT) consisted of computer-assisted direct matching of the fiducial region on cone-beam computerised tomography at the time of radiotherapy. Patients received standard-IGRT (S-IGRT) if fiducial visibility was insufficient, consisting of bone match as a surrogate for tumor position. Radiotherapy was delivered to 54Gy in 30 fractions for curative patients and up to 45Gy in 15 fractions for palliative treatments.
RESULTS 52 patients were referred for liquid fiducial placement within the study period. A total of 51 patients underwent liquid fiducial implantation. Of these a total of 31 patients received radiotherapy. Among these, the median age was 77.4 years with a range between 57.5 and 88.8, and 64.5% were male. Twenty-seven out of the 31 patients were able to have LF-IGRT while four had S-IGRT. There were no complications after endoscopic implantation of liquid fiducials in our cohort. The cohort overall survival (OS) post-radiotherapy was 19 mo (range 0 to 87 mo). Whilst the progression-free survival (PFS) post-radiotherapy was 13 mo (range 0 to 74 mo). For those treated with curative intent, the median OS was 22.0 mo (range 0 to 87 mo) with a PFS median of 14.0 mo (range 0 to 74 mo). Grade 3 complication rate post-radiotherapy was 29%.
CONCLUSION LF-IGRT is feasible in 87.1% of patients undergoing liquid fiducial placement through standard gastroscopy injection technique. Our cohort has an overall survival of 19 mo and PFS of 13 mo. Further studies are warranted to determine the long-term outcomes of liquid-fiducial based IGRT.
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Affiliation(s)
- Kim Hay Be
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne 3086, Victoria, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Ben Starvaggi
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Michael Chao
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, Heidelberg 3084, Victoria, Australia
- School of Cancer Medicine, La Trobe University, Melbourne 3086, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Michael Ng
- Genesis Care, East Melbourne 3002, Victoria, Australia
| | | | - Marios Efthymiou
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sujievvan Chandran
- Department of Gastroenterology and Hepatology, Austin Health, Heidelberg 3084, Victoria, Australia
- Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville 3010, Victoria, Australia
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Abstract
PURPOSE OF REVIEW To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. RECENT FINDINGS The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. SUMMARY Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Switzerland
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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11
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Lim Joon D, Chao M, Piccolo A, Schneider M, Anderson N, Handley M, Benci M, Ong WL, Daly K, Morrell R, Wan K, Lawrentschuk N, Foroudi F, Jenkins T, Angus D, Wada M, Sengupta S, Khoo V. Proximal seminal vesicle displacement and margins for prostate cancer radiotherapy. J Med Radiat Sci 2021; 68:289-297. [PMID: 33432719 PMCID: PMC8424309 DOI: 10.1002/jmrs.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/14/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Guidelines recommend that the proximal seminal vesicles (PrSV) should be included in the clinical target volume for locally advanced prostate cancer patients undergoing radiotherapy. Verification and margins for the prostate may not necessarily account for PrSV displacement. The purpose was to determine the inter-fraction displacement of the PrSV relative to the prostate during radiotherapy. METHODS Fiducials were inserted into the prostate, and right and left PrSV (RSV and LSV) in 30 prostate cancer patients. Correctional shifts for the prostate, right and left PrSV and pelvic bones were determined from each patient's 39 daily orthogonal portal images relative to reference digitally reconstructed radiographs. RESULTS There was a significant displacement of the RSV relative to the prostate in all directions: on average 0.38 mm (95% confidence interval (CI) 0.26 to 0.50) to the left, 0.80-0.81 mm (CI 0.68 to 0.93) superiorly and 1.51 mm (CI 1.36 to 1.65) posteriorly. The LSV was significantly displaced superiorly to the prostate 1.09-1.13 mm (CI 0.97 to 1.25) and posteriorly 1.81 mm (CI 1.67 to 1.96), but not laterally (mean 0.06, CI -0.06 to 0.18). The calculated PTV margins (left-right, superior-inferior, posterior-anterior) were 4.9, 5.3-5.6 and 4.8 mm for the prostate, 5.2, 7.1-8.0 and 9.7 mm for the RSV, and 7.2, 7.5-7.6 and 8.6 mm for the LSV. CONCLUSION There is a significant displacement of the PrSV relative to the prostate during radiotherapy. Greater margins are recommended for the PrSV compared to the prostate.
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Affiliation(s)
- Daryl Lim Joon
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Michael Chao
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Angelina Piccolo
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | | | - Nigel Anderson
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Monica Handley
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Margaret Benci
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Wee Loon Ong
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Karen Daly
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Rebecca Morrell
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Kenneth Wan
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | | | - Farshad Foroudi
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - Trish Jenkins
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | - David Angus
- Department of UrologyAustin HealthMelbourneVic.Australia
| | - Morikatsu Wada
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
| | | | - Vincent Khoo
- Department of Radiation OncologyOlivia Newton‐John Cancer Wellness and Research CentreAustin HealthMelbourneVic.Australia
- Monash UniversityMelbourneVic.Australia
- Royal Marsden NHS Foundation TrustLondonUK
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12
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Deshmukh A, Elmeligui AM, Okasha HH, Parsa N, Tejedor-Tejada J, Nieto J. EUS-guided fiducial gold marker placement in metastatic colon cancer to the spleen. Endosc Ultrasound 2021; 11:79-80. [PMID: 34213433 PMCID: PMC8887036 DOI: 10.4103/eus-d-21-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - Ahmed Mohammed Elmeligui
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hussein Hassan Okasha
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Endoscopy, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Nasim Parsa
- Division of Gastroenterology, Hepatology and Endoscopy, University of Missouri School of Medicine, Columbia, MO, USA
| | - Javier Tejedor-Tejada
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Jose Nieto
- Division of Gastroenterology, Hepatology and Endoscopy, Borland Groover Clinic, Jacksonville, FL, USA
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13
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Kim SH, Shin EJ. Endoscopic Ultrasound-Guided Fiducial Placement for Stereotactic Body Radiation Therapy in Pancreatic Malignancy. Clin Endosc 2021; 54:314-323. [PMID: 34082487 PMCID: PMC8182253 DOI: 10.5946/ce.2021.102] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/07/2021] [Indexed: 12/18/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is an important treatment option for pancreatic cancer, which is known to be one of the malignancies with the worst prognosis. However, the high radiation doses delivered during SBRT may cause damage to adjacent radiosensitive organs. To minimize such damage, fiducial markers are used for localization during SBRT for pancreatic cancer. The development of endoscopic ultrasound (EUS) has enabled fiducial markers to be inserted into the pancreas using an EUS fine-needle aspiration (FNA) needle, unlike in the past when percutaneous placement was generally performed. For successful EUS-guided fiducial marker placement, it is necessary for the fiducial markers to be loaded within the EUS-FNA needles to have a low probability of complications and a low migration risk, and to be stably observed in SBRT imaging. A systematic review has shown that the technical success rate of EUS-guided fiducial marker placement is 96.27%, whereas the fiducial marker migration and adverse event rates are 4.33% and 4.85%, respectively. Nonetheless, standardized techniques for fiducial marker placement and the characteristics of optimal fiducial markers have not yet been established. This review will introduce the characteristics (e.g., materials and shapes) of fiducial markers used in fiducial marker placement for pancreatic cancer and will discuss conventional techniques along with their success rates, difficulties, and adverse events.
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Affiliation(s)
- Seong-Hun Kim
- Department of Internal Medicine, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
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14
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Development of an Objective Scoring System for Endoscopic Assessment of Radiation-Induced Upper Gastrointestinal Toxicity. Cancers (Basel) 2021; 13:cancers13092136. [PMID: 33946696 PMCID: PMC8124711 DOI: 10.3390/cancers13092136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/27/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary High-dose radiation therapy techniques have gained increasing interest in pancreatic cancer treatment, but toxicity to the upper gastrointestinal (GI) organs remains a major concern. We aimed to develop an objective toxicity scoring system to be used during endoscopic evaluation that allows for direct assessment of the stomach and duodenum before and after radiation treatment. Our toxicity scoring takes into account the pathological categories of erythema, edema, ulceration, and stricture to determine radiation-related GI toxicity. We assessed and validated the upper GI toxicity of 19 locally advanced pancreatic cancer trial patients undergoing stereotactic body radiation therapy (SBRT). With future usage, we hope this scoring system will provide objective and reliable assessments of changes in GI toxicity during the radiation treatment of pancreatic cancer and for GI toxicity assessment during radiation therapy research trials. Abstract We developed and implemented an objective toxicity scoring system to be used during endoscopic evaluation of the upper gastrointestinal (GI) tract in order to directly assess changes in toxicity during the radiation treatment of pancreatic cancer. We assessed and validated the upper GI toxicity of 19 locally advanced pancreatic cancer trial patients undergoing stereotactic body radiation therapy (SBRT). Wilcoxon-signed rank tests were used to compare pre- and post-SBRT scores. Comparison of the toxicity scores measured before and after SBRT revealed a mild increase in toxicity in the stomach and duodenum (p < 0.005), with no cases of severe toxicity observed. Kappa and AC1 statistics analysis were used to evaluate interobserver agreement. Our toxicity scoring system was reliable in determining GI toxicity with a good overall interobserver agreement for pre-treatment scores (stomach, κ = 0.71, p < 0.005; duodenum, κ = 0.88, p < 0.005) and post-treatment scores (stomach, κ = 0.71, p < 0.005; duodenum, κ = 0.76, p < 0.005). The AC1 statistics yielded similar results. With future usage, we hope this scoring system will be a useful tool for objectively and reliably assessing changes in GI toxicity during the treatment of pancreatic cancer and for GI toxicity assessments and comparisons during radiation therapy research trials.
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15
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Carrara S, Rimbas M, Larghi A, Di Leo M, Comito T, Jaoude JA, Taniguchi CM, Dietrich CF, Bhutani MS, Hollerbach S. EUS-guided placement of fiducial markers for image-guided radiotherapy in gastrointestinal tumors: A critical appraisal. Endosc Ultrasound 2021; 10:414-423. [PMID: 33666180 PMCID: PMC8785666 DOI: 10.4103/eus-d-20-00116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We present here a new chapter of the series of papers on how to perform specific EUS techniques. In this manuscript, we discuss on how to perform EUS-guided placement of fiducial markers in gastrointestinal tumors. The aim is to present the scientific evidence of fiducials placement before radiation therapy, including an accurate revision of the literature, to give some advices on the technical approach, and to discuss Pros and Cons from the point of view of gastroenterologists and radiation oncologist.
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Affiliation(s)
- Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Mihai Rimbas
- Department of Gastroenterology, Clinic of Internal Medicine, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Tiziana Comito
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, UTMD Anderson Cancer Center Houston, Texas, USA
| | - Cullen M Taniguchi
- Department of Radiation Oncology, UTMD Anderson Cancer Center Houston, Texas, USA
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin der Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, UTMD Anderson Cancer Center, Houston, Texas, USA
| | - Stephan Hollerbach
- Department of Gastroenterology/GI Endoscopy, AKH Celle, Academic Teaching Hospital of Medizinische Hochschule, Hannover, Germany
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16
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Larghi A, Rimbaș M, Rizzatti G, Carbone C, Gasbarrini A, Costamagna G, Alfieri S, Tortora G. Endoscopic ultrasound-guided therapies for pancreatic solid tumors: An overview. Semin Oncol 2021; 48:95-105. [PMID: 33608132 DOI: 10.1053/j.seminoncol.2021.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
The close proximity of the endoscopic ultrasound (EUS) probe to the pancreas, coupled with the ease with which a needle can be inserted into a pancreatic lesion, have contributed to the development of EUS-guided therapies for both adenocarcinoma and neuroendocrine pancreatic neoplasms. EUS-guided fine needle injection of different types of drugs, implantation of fiducial markers to facilitate stereotactic body radiation therapy or of radioactive seeds to perform brachytherapy, and the use of different thermal and nonthermal ablation devices and techniques have all been tested in preliminary human studies. This manuscript will present the available evidence accumulated thus far in the field of EUS-guided oncological treatment of pancreatic solid tumors, along with a look into possible future applications.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Carmine Carbone
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy; IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Giampaolo Tortora
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
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17
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Figueiredo M, Bouchart C, Moretti L, Mans L, Engelholm JL, Bali MA, Van Laethem JL, Eisendrath P. EUS-guided placement of fiducial markers for stereotactic body radiation therapy in pancreatic cancer: feasibility, security and a new quality score. Endosc Int Open 2021; 9:E253-E257. [PMID: 33553589 PMCID: PMC7857973 DOI: 10.1055/a-1324-2892] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background and study aims In borderline resectable/locally advanced pancreatic ductal adenocarcinoma (PDAC), stereotactic body radiation therapy (SBRT) is an emerging neoadjuvant treatment option. Endoscopic ultrasound (EUS)-guided insertion of fiducial markers being a prerequisite, our aim was to assess its feasibility and safety and also to evaluate its success, from both the endoscopist's and radiotherapist's perspectives. Patients and methods We prospectively collected data concerning PDAC patients submitted to EUS-guided fiducial placement, from February 2018 to November 2019. Technical success was defined as at least one marker presumed inside the tumor. Quality success was assessed at pre-SBRT computed tomography, accordingly to the number of markers inside or < 1 cm from the tumor, number of markers at the tumor extremity, their location in different planes, the distance between them, and their distance from the biliary stent (if present). A new quality score was then proposed and high-quality success defined as at least six of 12 points. Results Thirty-seven patients were enrolled. A total of 97 fiducials were implanted, with a median of three fiducials per patient (0-4). The technical success rate was 92 %, with failure of fiducial placement in three patients. Three patients (8 %) had adverse events (fever, mild acute pancreatitis, and biliary stent migration). At pre-SBRT evaluation, two patients' markers had migrated. The high-quality success rate was 62.5 %. Conclusions Our results contribute to demonstrating the feasibility and safety of EUS-guided fiducial placement for SBRT treatment in PDAC. It is hoped that the newly proposed quality score will pave the way for improving fiducial positioning and SBRT delivery.
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Affiliation(s)
- Mariana Figueiredo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Belgium
| | - Laura Mans
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Jean-Luc Engelholm
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Belgium
| | - Maria-Antonietta Bali
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium,Department of Gastroenterology, Saint-Pierre University Hospital, Université Libre de Bruxelles, Belgium
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18
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Moningi S, Abi Jaoude J, Kouzy R, Lin D, Nguyen ND, Garcia Garcia CJ, Phan JL, Avila S, Smani D, Cazacu IM, Singh BS, Smith GL, Holliday EB, Koay EJ, Das P, Bhutani MS, Herman JM, Minsky BD, Koong AC, Taniguchi CM. Impact of Fiducial Marker Placement Before Stereotactic Body Radiation Therapy on Clinical Outcomes in Patients With Pancreatic Cancer. Adv Radiat Oncol 2020; 6:100621. [PMID: 33912734 PMCID: PMC8071717 DOI: 10.1016/j.adro.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Localized pancreatic cancer is commonly treated with stereotactic body radiation therapy (SBRT), which often requires the placement of fiducial markers. We compared the clinical outcomes of patients with and without fiducial markers. Methods and Materials We retrospectively collected data on patients with pancreatic cancer treated with neoadjuvant SBRT at a single institution. Patients were divided into 2 groups based on the placement of a fiducial marker. Local recurrence was the primary outcome. Time to event endpoints were analyzed using COX regression. Results We included 96 patients with unresectable pancreatic cancer: 46 patients (47.9%) did not have a fiducial marker, and 50 patients (52.1%) had a fiducial placed. Patients in the fiducial group were older and had more locally advanced pancreatic cancer compared with those who did not have a fiducial placed. Most patients in both groups (92.7%) received chemotherapy before SBRT treatment. SBRT was delivered to a median of 36 Gy over 5 fractions in the no-fiducial group, and 38 Gy over 5 fractions in the fiducial group. At a median follow-up of 20 months, local recurrence was similar irrespective of fiducial placement (adjusted hazard ratio [aHR] 0.6, 95% CI 0.3-1.3, P = .59). Furthermore, no difference in overall survival was noted between the 2 groups (aHR 0.8, 95% CI 0.3-1.9, P = .65). In patients who eventually underwent surgery post-SBRT, no difference in surgical margins (P = .40) or lymphovascular invasion (P = .76) was noted between the 2 groups. No patient developed acute pancreatitis after fiducial placement. Conclusions Our data suggest that the use of fiducial markers does not negatively affect clinical outcomes in patients with localized pancreatic cancer. Prospective confirmation of our results is still needed.
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Affiliation(s)
- Shalini Moningi
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ramez Kouzy
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Lin
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Jae L Phan
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Santiago Avila
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Smani
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Irina M Cazacu
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ben S Singh
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Bruce D Minsky
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- University of Texas MD Anderson Cancer Center, Houston, Texas
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19
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Kerdsirichairat T, Shin EJ. Role of endoscopic ultrasonography guided fiducial marker placement in gastrointestinal cancer. Curr Opin Gastroenterol 2020; 36:402-408. [PMID: 32740001 DOI: 10.1097/mog.0000000000000662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Dose escalation radiation therapy such as those delivered by stereotactic body radiation therapy (SBRT) has shown to improve local disease control in multiple types of malignancies. This requires fiducial placement to improve accuracy of treatment and avoid adverse events to adjacent radiosensitive organs during respiration phases. The purpose of this review is to provide updates of recent high-quality articles related to endoscopic ultrasonography (EUS)-guided fiducial placement for gastrointestinal malignancies, particularly in pancreatic cancer, which is expected to be the second leading cause of cancer-related deaths in the USA within this decade. RECENT FINDINGS A recent systematic review and meta-analysis has shown that EUS-guided fiducial placement for gastrointestinal malignancies has excellent technical success and safety profile. Comparative studies of most commercially available fiducial types via a 22-gauge needle system showed that a 0.035 mm diameter and 10 mm long gold fiducial with coiled configuration, hollow core and external helical design might be favoured due to its most balanced performance of visibility, artifact and migration. SUMMARY A fine balance of performance characteristics of fiducials should be discussed with radiation oncologists to select a suitable and preferred type of fiducials. The comparative studies of other newly developed platinum fiducials and liquid fiducial are pending.
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Affiliation(s)
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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20
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Abstract
PURPOSE OF REVIEW The aim of this review is to evaluate the emerging role of endoscopic ultrasound (EUS) in the guidance of tumor-targeted therapies for patients with pancreatic cancer (PC). RECENT FINDINGS EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described to date. EUS-guided fiducial placement for SBRT in pancreatic cancer has entered the clinical practice and is performed at many centers clinically without a research protocol. EUS-guided brachytherapy and RFA have been shown to be feasible and safe procedures, and potentially offer local disease control. Other potential techniques of EUS-guided treatment of pancreatic cancer are still considered experimental, with many of them appearing to be safe and reasonably well tolerated. However, their effectiveness and exact role in oncological treatment have yet to be established. Clinical trials with many of the techniques/agents described are underway and multicentric randomized trials with prospective design are eagerly awaited.
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21
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Slagowski JM, Colbert LE, Cazacu IM, Singh BS, Martin R, Koay EJ, Taniguchi CM, Koong AC, Bhutani MS, Herman JM, Beddar S. Evaluation of the Visibility and Artifacts of 11 Common Fiducial Markers for Image Guided Stereotactic Body Radiation Therapy in the Abdomen. Pract Radiat Oncol 2020; 10:434-442. [PMID: 31988039 DOI: 10.1016/j.prro.2020.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of this study was to quantitatively evaluate the visibility and artifacts of commercially available fiducial markers to optimize their selection for image guided stereotactic body radiation therapy. METHODS AND MATERIALS From 6 different vendors, we selected 11 fiducials commonly used in image guided radiation therapy. The fiducials varied in material composition (e.g., gold, platinum, carbon), shape (e.g., cylindrical, notched/linear, coiled, ball-like, step), and size measured in terms of diameter (0.28-1.0 mm) and length (3.0-20.0 mm). Each fiducial was centered in 4-mm bolus within a 13-cm-thick water-equivalent phantom. Fiducials were imaged with the use of a simulation computed tomography (CT) scanner, a CT-on-rails system, and an onboard cone beam CT system. Acquisition parameters were set according to clinical protocols. Visibility was assessed in terms of contrast (Δ Hounsfield unit [HU]) and the Michelson visibility metric. Artifacts were quantified in terms of relative standard deviation and relative streak artifacts level (rSAL). Twelve radiation oncologists ranked each fiducial in terms of clinical usefulness. RESULTS Contrast and artifacts increased with fiducial size. For CT imaging, maximum contrast (2722 HU) and artifacts (rSAL = 2.69) occurred for the largest-diameter (0.75 mm) platinum fiducial. Minimum contrast (551 HU) and reduced artifacts (rSAL = 0.65) were observed for the smallest-diameter (0.28 mm) gold fiducial. Carbon produced the least severe artifacts (rSAL = 0.29). The survey indicated that physicians preferred gold fiducials with a 0.35- to 0.43-mm diameter, 5- to 10-mm length, and coiled or cylindrical shape that balanced contrast and artifacts. CONCLUSIONS We evaluated 11 different fiducials in terms of visibility and artifacts. The results of this study may assist radiation oncologists who seek to maximize contrast, minimize artifacts, or balance contrast versus artifacts by fiducial selection.
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Affiliation(s)
- Jordan M Slagowski
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Irina M Cazacu
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ben S Singh
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachael Martin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cullen M Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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22
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Machicado JD, Obuch JC, Goodman KA, Schefter TE, Frakes J, Hoffe S, Latifi K, Simon VC, Santangelo T, Ezekwe E, Edmundowicz SA, Brauer BC, Shah RJ, Hammad HT, Wagh MS, Attwell A, Han S, Klapman J, Wani S. Endoscopic Ultrasound Placement of Preloaded Fiducial Markers Shortens Procedure Time Compared to Back-Loaded Markers. Clin Gastroenterol Hepatol 2019; 17:2749-2758.e2. [PMID: 31042578 DOI: 10.1016/j.cgh.2019.04.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/15/2019] [Accepted: 04/19/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND & AIMS Fiducial markers are inert radiopaque gold or carbon markers implanted in or near pancreatic tumor to demarcate areas for image-guided radiation therapy. Endoscopic ultrasound (EUS) pre-loaded fiducial needles (PLNs) have been developed to circumvent technical issues associated with traditional back-loaded fiducials (BLNs). We performed a randomized controlled trial to compare procedure times in patients with pancreatic adenocarcinoma undergoing EUS-guided placement of BLNs vs PLNs. METHODS In a prospective study, 44 patients with pancreatic adenocarcinoma referred for fiducial marker placement at 2 tertiary care centers were assigned to groups that received PLNs (n = 22) or BLNs (n = 22); each group had the same proportion of patients with tumors of different locations (head or neck vs body or tail).The procedure was standardized among all endoscopists and placement of a minimum of 3 markers inside the tumor was defined as technical success. The times for procedure and fiducial placement were recorded, total number of fiducial markers used documented, and grade of procedure difficulty ranked by passing the needle or deploying the fiducials. Other recorded variables included tumor characteristics, fluoroscopy use, and the number of fiducials clearly seen by EUS and fluoroscopy. The primary aim was to compare the duration of EUS-guided fiducial insertion of BLNs vs PLNs. RESULTS The median placement time was significantly shorter in the PLN group (9 min) than the BLN group (16 min) (P < .001). However, the 44% reduction in time did not reach pre-specified levels (≥60%). Similar results were found after stratifying by tumor location. Deployment of BLNs was easier than deployment of PLNs (P = .03). There was no significant difference between groups in technical success, number of fiducials placed, EUS or fluoroscopic visualization, or adverse events. During simulation computed tomography and image-guided radiation therapy, there was no difference between groups in visualization of fiducials, migration rate, or accuracy of placement. CONCLUSIONS In a randomized controlled trial of 44 patients with pancreatic adenocarcinoma, we found EUS-guided placement of PLNs to require less time and produce similar results compared with BLNs. Further refinements in PLN delivery system are needed to increase the ease of deployment. Clinicaltrials.gov no: NCT02332863.
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Affiliation(s)
- Jorge D Machicado
- Division of Gastroenterology and Hepatology, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Joshua C Obuch
- Division of Gastroenterology and Hepatology, Geisinger Wyoming Valley Medical Center, Wilkes Barre, Pennsylvania
| | - Karyn A Goodman
- Department of Radiation Oncology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Jessica Frakes
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Kutjim Latifi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Violette C Simon
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Tess Santangelo
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Eze Ezekwe
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Hazem T Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Augustin Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Jason Klapman
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado.
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23
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24
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Abstract
Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.
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Affiliation(s)
- Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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