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• W2145468051 abstract "Three- to 5-mm–long, radiopaque, metal markers (fiducials) can be safely and effectively placed into the tumor by loading them into a 19-gauge EUS needle.In this issue of Gastrointestinal Endoscopy, Pishvaian et al1Pishvaian A.C. Collins B. Gagnon G. et al.EUS-guided fiducial placement for CyberKnife radiotherapy of mediastinal and abdominal malignancies.Gastrointest Endosc. 2006; 64: 412-417Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar describe a novel method of inserting radiopaque markers into pancreatic and peri-intestinal tumors by using EUS-guided fine-needle injection techniques to guide stereotactic radiosurgery. This preliminary report shows that 3- to 5-mm radiopaque metal markers (fiducials) can be placed by loading them into a 19-gauge EUS needle and then using the stylet to push them into the tumor. This technique of placing markers was safe and effective.This technique of EUS injection of fiducials seems fairly simple. The only difficulty they had was in pushing the 5-mm–long fiducials through the 19-gauge needle, because the angulation of the needle sometimes prevented passage. In those difficult cases, 3-mm fiduciaries passed without problems. If this technique were to become more widely used, ideally, markers could be developed that pass through a 22-gauge needle; therefore, dedicated therapeutic scopes would not be needed. Also, it is possible that by priming the needle with saline solution, the fiducials could slide by more easily. This also might prevent the passage of air bubbles as the stylet pushes the fiducials into the tumor.Cholangitis developed in 1 patient 25 days after placement, but it seems unlikely that this was caused by the fiducial placement. After this complication, all patients received intravenous antibiotics, followed by 3 days of oral antibiotics. This seems like a reasonable approach to follow.This small case series did not describe whether CyberKnife radiosurgery (Accuray, Sunnyvale, Calif) was actually performed on the patients, and, therefore, we do not know the clinical outcome. Radiosurgery involves delivering high doses of focused radiation to a specific area in the body. Target location is determined stereotactically, through the use of a reference system in 3-dimensional space. The reference system can either be anatomic structures (such as the bony skull) or implanted radiographic markers (fiducials). The potential advantages over conventional radiation therapy are (1) it is possible to concentrate radiation precisely on the tumor while limiting radiation to normal tissue, and (2) lesions can be treated in a single radiation treatment or a small number of fractionated treatments.The important question to be answered is whether image-guided radiosurgery has any clinical advantage compared with standard chemoradiation for malignancies such as pancreas, esophageal, rectal, or lung, which would be amenable to EUS-guided marking. The use of radiosurgery for nonbrain lesions is fairly recent, and, therefore, we need to wait for oncology clinical trials to help answer this question. However, early data suggest that, although local control may be achieved for pancreatic cancer, there may not be an impact on survival because of a progression of metastatic disease.2Koong A.C. Le Q.T. Ho A. et al.Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer.Int J Radiat Oncol Biol Phys. 2004; 58: 1017-1021Abstract Full Text Full Text PDF PubMed Scopus (351) Google Scholar, 3Koong A.C. Christofferson E. Le Q.T. et al.Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer.Int J Radiat Oncol Biol Phys. 2005; 63: 320-323Abstract Full Text Full Text PDF PubMed Scopus (268) Google ScholarIf radiosurgical techniques prove to benefit patients compared with standard radiation therapy, then the next question would be how best to place the markers. Given the extremely precise visualization provided by EUS, it would be expected that EUS-guided fiduciary placement would be more accurate and safer than percutaneous CT or US-guided placement. In addition, for small lesions not well-visualized by CT or US or that are in difficult positions because of intervening vascular structures, EUS-guided fiduciary placement might be the only way for minimally invasive placement of these markers.This case series is important in that it demonstrates a technique to expand the ability of endoscopists to mark lesions. We frequently mark luminal GI-tract lesions with videoendoscopy-guided submucosal injection of a permanent ink tattoo by using a sclerotherapy needle.4Askin M.P. Waye J.D. Fiedler L. et al.Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound.Gastrointest Endosc. 2002; 56: 339-342Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar Endoscopic mucosal clips have been used to mark lesions and to assist in localizing esophageal tumors for radiation.5Weyman R.L. Rao S.S. A novel clinical application for endoscopic mucosal clipping.Gastrointest Endosc. 1999; 49: 522-524Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Luminal marking has also been reported by using technetium-labeled albumin macroaggregates, which are injected with a sclerotherapy needle into a tumor and then are detected during surgery with a gamma-detecting probe.6Rezzo R. Scopinaro G. Gambaro M. et al.Radioguided occult colonic lesion identification (ROCLI) during open and laparoscopic surgery.Tumori. 2002; 88: S19-S22PubMed Google Scholar Submucosal injection of radiologic contrast media has also been used to mark tumor borders before fluoroscopic-guided self-expanding metal stent placement.EUS-guided tumor marking could become important in cancer management. One could imagine marking a small pancreatic endocrine for easy localization at surgery. A similar technique has been reported with EUS injection of ink tattoo into these tumors, but injecting radiopaque markers seems easier to visualize and safer.7Gress F.G. Barawi M. Kim D. et al.Preoperative localization of a neuroendocrine tumor of the pancreas with EUS-guided fine needle tattooing.Gastrointest Endosc. 2002; 55: 594-597Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Markers could be used to make sure that malignant lymph nodes are included in resection specimens. For patients undergoing standard radiation therapy, perhaps marking the borders of luminal tumors or pancreatic cancer could improve the accuracy or safety of treatment. Marking tumors or malignant nodes might also allow for more precise evaluation of tumor response to treatment.This technique also adds to the armamentarium of potential EUS-guided tumor therapies. Tumors have been treated with viral vectors and alcohol ablation.8Hecht J.R. Bedford R. Abbruzzese J.L. et al.A phase I/II trial of intratumoral endoscopic ultrasound injection of ONYX-015 with intravenous gemcitabine in unresectable pancreatic carcinoma.Clin Cancer Res. 2003; 9: 555-561PubMed Google Scholar, 9Gan S.I. Thompson C.C. Lauwers G.Y. et al.Ethanol lavage of pancreatic cystic lesions: initial pilot study.Gastrointest Endosc. 2005; 61: 746-752Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar There have been reports of EUS-guided brachytherapy that works by injecting radiation seeds into a tumor.10Lah J.J. Kuo J.V. Chang K.J. et al.EUS-guided brachytherapy.Gastrointest Endosc. 2005; 62: 805-808Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 11Sun S. Qingjie L. Qiyong G. et al.EUS-guided interstitial brachytherapy of the pancreas: a feasibility study.Gastrointest Endosc. 2005; 62: 775-779Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar In the future, perhaps if magnetized markers were injected into tumors, they could be used with drugs attached to magnetic-targeted carriers.12Leakakos T. Ji C. Lawson G. et al.Intravesical administration of doxorubicin to swine bladder using magnetically targeted carriers.Cancer Chemother Pharmacol. 2003; 51: 445-450PubMed Google Scholar, 13Nobuto H. Sugita T. Kubo T. et al.Evaluation of systemic chemotherapy with magnetic liposomal doxorubicin and a dipole external electromagnet.Int J Cancer. 2004; 109: 627-635Crossref PubMed Scopus (135) Google ScholarIn conclusion, this case series demonstrates that placement of radiopaque markers within tumors by an EUS-guided fine-needle injection technique is feasible and relatively safe. The ability to mark lesions with fluoroscopically visualized markers could have great utility in the future. We need to wait for the oncologists to tell us when and where image-guided radiotherapy will be of benefit. When they do, we are ready and able to help. Three- to 5-mm–long, radiopaque, metal markers (fiducials) can be safely and effectively placed into the tumor by loading them into a 19-gauge EUS needle.In this issue of Gastrointestinal Endoscopy, Pishvaian et al1Pishvaian A.C. Collins B. Gagnon G. et al.EUS-guided fiducial placement for CyberKnife radiotherapy of mediastinal and abdominal malignancies.Gastrointest Endosc. 2006; 64: 412-417Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar describe a novel method of inserting radiopaque markers into pancreatic and peri-intestinal tumors by using EUS-guided fine-needle injection techniques to guide stereotactic radiosurgery. This preliminary report shows that 3- to 5-mm radiopaque metal markers (fiducials) can be placed by loading them into a 19-gauge EUS needle and then using the stylet to push them into the tumor. This technique of placing markers was safe and effective. Three- to 5-mm–long, radiopaque, metal markers (fiducials) can be safely and effectively placed into the tumor by loading them into a 19-gauge EUS needle. Three- to 5-mm–long, radiopaque, metal markers (fiducials) can be safely and effectively placed into the tumor by loading them into a 19-gauge EUS needle. This technique of EUS injection of fiducials seems fairly simple. The only difficulty they had was in pushing the 5-mm–long fiducials through the 19-gauge needle, because the angulation of the needle sometimes prevented passage. In those difficult cases, 3-mm fiduciaries passed without problems. If this technique were to become more widely used, ideally, markers could be developed that pass through a 22-gauge needle; therefore, dedicated therapeutic scopes would not be needed. Also, it is possible that by priming the needle with saline solution, the fiducials could slide by more easily. This also might prevent the passage of air bubbles as the stylet pushes the fiducials into the tumor. Cholangitis developed in 1 patient 25 days after placement, but it seems unlikely that this was caused by the fiducial placement. After this complication, all patients received intravenous antibiotics, followed by 3 days of oral antibiotics. This seems like a reasonable approach to follow. This small case series did not describe whether CyberKnife radiosurgery (Accuray, Sunnyvale, Calif) was actually performed on the patients, and, therefore, we do not know the clinical outcome. Radiosurgery involves delivering high doses of focused radiation to a specific area in the body. Target location is determined stereotactically, through the use of a reference system in 3-dimensional space. The reference system can either be anatomic structures (such as the bony skull) or implanted radiographic markers (fiducials). The potential advantages over conventional radiation therapy are (1) it is possible to concentrate radiation precisely on the tumor while limiting radiation to normal tissue, and (2) lesions can be treated in a single radiation treatment or a small number of fractionated treatments. The important question to be answered is whether image-guided radiosurgery has any clinical advantage compared with standard chemoradiation for malignancies such as pancreas, esophageal, rectal, or lung, which would be amenable to EUS-guided marking. The use of radiosurgery for nonbrain lesions is fairly recent, and, therefore, we need to wait for oncology clinical trials to help answer this question. However, early data suggest that, although local control may be achieved for pancreatic cancer, there may not be an impact on survival because of a progression of metastatic disease.2Koong A.C. Le Q.T. Ho A. et al.Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer.Int J Radiat Oncol Biol Phys. 2004; 58: 1017-1021Abstract Full Text Full Text PDF PubMed Scopus (351) Google Scholar, 3Koong A.C. Christofferson E. Le Q.T. et al.Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer.Int J Radiat Oncol Biol Phys. 2005; 63: 320-323Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar If radiosurgical techniques prove to benefit patients compared with standard radiation therapy, then the next question would be how best to place the markers. Given the extremely precise visualization provided by EUS, it would be expected that EUS-guided fiduciary placement would be more accurate and safer than percutaneous CT or US-guided placement. In addition, for small lesions not well-visualized by CT or US or that are in difficult positions because of intervening vascular structures, EUS-guided fiduciary placement might be the only way for minimally invasive placement of these markers. This case series is important in that it demonstrates a technique to expand the ability of endoscopists to mark lesions. We frequently mark luminal GI-tract lesions with videoendoscopy-guided submucosal injection of a permanent ink tattoo by using a sclerotherapy needle.4Askin M.P. Waye J.D. Fiedler L. et al.Tattoo of colonic neoplasms in 113 patients with a new sterile carbon compound.Gastrointest Endosc. 2002; 56: 339-342Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar Endoscopic mucosal clips have been used to mark lesions and to assist in localizing esophageal tumors for radiation.5Weyman R.L. Rao S.S. A novel clinical application for endoscopic mucosal clipping.Gastrointest Endosc. 1999; 49: 522-524Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Luminal marking has also been reported by using technetium-labeled albumin macroaggregates, which are injected with a sclerotherapy needle into a tumor and then are detected during surgery with a gamma-detecting probe.6Rezzo R. Scopinaro G. Gambaro M. et al.Radioguided occult colonic lesion identification (ROCLI) during open and laparoscopic surgery.Tumori. 2002; 88: S19-S22PubMed Google Scholar Submucosal injection of radiologic contrast media has also been used to mark tumor borders before fluoroscopic-guided self-expanding metal stent placement. EUS-guided tumor marking could become important in cancer management. One could imagine marking a small pancreatic endocrine for easy localization at surgery. A similar technique has been reported with EUS injection of ink tattoo into these tumors, but injecting radiopaque markers seems easier to visualize and safer.7Gress F.G. Barawi M. Kim D. et al.Preoperative localization of a neuroendocrine tumor of the pancreas with EUS-guided fine needle tattooing.Gastrointest Endosc. 2002; 55: 594-597Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Markers could be used to make sure that malignant lymph nodes are included in resection specimens. For patients undergoing standard radiation therapy, perhaps marking the borders of luminal tumors or pancreatic cancer could improve the accuracy or safety of treatment. Marking tumors or malignant nodes might also allow for more precise evaluation of tumor response to treatment. This technique also adds to the armamentarium of potential EUS-guided tumor therapies. Tumors have been treated with viral vectors and alcohol ablation.8Hecht J.R. Bedford R. Abbruzzese J.L. et al.A phase I/II trial of intratumoral endoscopic ultrasound injection of ONYX-015 with intravenous gemcitabine in unresectable pancreatic carcinoma.Clin Cancer Res. 2003; 9: 555-561PubMed Google Scholar, 9Gan S.I. Thompson C.C. Lauwers G.Y. et al.Ethanol lavage of pancreatic cystic lesions: initial pilot study.Gastrointest Endosc. 2005; 61: 746-752Abstract Full Text Full Text PDF PubMed Scopus (221) Google Scholar There have been reports of EUS-guided brachytherapy that works by injecting radiation seeds into a tumor.10Lah J.J. Kuo J.V. Chang K.J. et al.EUS-guided brachytherapy.Gastrointest Endosc. 2005; 62: 805-808Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 11Sun S. Qingjie L. Qiyong G. et al.EUS-guided interstitial brachytherapy of the pancreas: a feasibility study.Gastrointest Endosc. 2005; 62: 775-779Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar In the future, perhaps if magnetized markers were injected into tumors, they could be used with drugs attached to magnetic-targeted carriers.12Leakakos T. Ji C. Lawson G. et al.Intravesical administration of doxorubicin to swine bladder using magnetically targeted carriers.Cancer Chemother Pharmacol. 2003; 51: 445-450PubMed Google Scholar, 13Nobuto H. Sugita T. Kubo T. et al.Evaluation of systemic chemotherapy with magnetic liposomal doxorubicin and a dipole external electromagnet.Int J Cancer. 2004; 109: 627-635Crossref PubMed Scopus (135) Google Scholar In conclusion, this case series demonstrates that placement of radiopaque markers within tumors by an EUS-guided fine-needle injection technique is feasible and relatively safe. The ability to mark lesions with fluoroscopically visualized markers could have great utility in the future. We need to wait for the oncologists to tell us when and where image-guided radiotherapy will be of benefit. When they do, we are ready and able to help. DisclosureThe author has no conflicts of interest to disclose. The author has no conflicts of interest to disclose." @default.
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• W2145468051 title "EUS-guided fine-needle insertion of radiopaque fiducials: X marks the spot" @default.
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