Radiation Therapy and Techniques for Fiducial Placement

  • Martin L. MayseEmail author


The ideal radiation treatment for cancer would deliver a lethal dose of radiation to the entire tumor while simultaneously minimizing radiation dose delivered to surrounding tissues. Technologic advances in imaging and radiation delivery have enabled relatively precise determination of the size and shape of the tumor and the delivery of a tightly focused dose of radiation to a volume of tissue that can be contoured to match the shape and size of a tumor. When this focused and contoured volume of irradiated tissue is coincident with the actual tumor target, then the ideal radiation treatment has been approximated.

Fiducial markers act as visible surrogates of tumor location, and they can provide accurate localization and tracking of tumors, even when the tumor is difficult to see on fluoroscopy or CT scan. A wide variety of fiducials with an equally wide range of shapes, sizes, and surface treatments are currently available for use in the body. Some basic guidelines to follow when implanting fiducials include the following: 4–6 should be implanted to so that three remain in place, they should be placed in and around the tumor such that the bulk of the tumor is bracketed by the fiducials, those placed outside the tumor should be placed as close to the edge of the tumor as possible, and they should not be placed collinearly. By selecting the appropriate fiducial, implantation in the lung and in accordance with these guidelines can be achieved transthoracically or bronchoscopically using a variety of imaging guidance techniques.

Additionally, in the current indexed literature, 583 patients have had more than 1,004 fiducial markers placed percutaneously and 236 patients who had 658 fiducial markers placed bronchoscopically in or near lung tumors. With the exception of a relatively high (17 %) rate of pneumothorax requiring chest tube placement following transthoracic placement, fiducial placement appears quite safe with a low (0.5 %) rate of pneumothorax requiring a chest tube following bronchoscopic fiducial placement and no pneumonias related to the fiducials reported with either implantation technique. Unfortunately, this literature does not contain sufficient data to draw any conclusions about long-term survival following treatment when radiation therapy is provided with internal fiducials versus no fiducials or when fiducials are placed by bronchoscopy versus transthoracic needles.


Fiducial Marker Radiation Delivery Coiled Wire Endobronchial Ultrasound Needle Catheter 
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Suggested Reading

  1. 1.
    Bradley JD, Wahab S, Lockett MA, et al. Elective nodal failures are uncommon in medically inoperable patients with stage I non-small-cell lung carcinoma treated with limited radiotherapy fields. Int J RadiatOncol Biol Phys. 2003;56:342–7.CrossRefGoogle Scholar
  2. 2.
    Noordijk EM, van den Poest CE, Hermans J, et al. Radiotherapy as an alternative to surgery in elderly patients with respectable lung cancer. Radiother Oncol. 1988;13:83–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Krol ADG, Aussems P, Noorduk V, et al. Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation. Int J Radiat Oncol Biol Phys. 1996;34:297–302.PubMedCrossRefGoogle Scholar
  4. 4.
    Bradley J, Graham MV, Winter K, et al. Toxicity and outcome results of RTOG 9311: a phase I-II dose escalation study using three-dimensional conformal radiotherapy in patients with inoperable non-small-cell lung carcinoma. Int J Radiat Oncol Biol Phys. 2005;61:318–28.PubMedCrossRefGoogle Scholar
  5. 5.
    Harley DP, Krimsky WS, Sarker S, et al. Fiducial marker placement using endobronchial ultrasound and navigational bronchoscopy for stereotactic radiosurgery: an alternative strategy. Ann Thorac Surg. 2010;89:368–74.PubMedCrossRefGoogle Scholar
  6. 6.
    Imura M, Yamazaki K, Kubota KC, et al. Histopathologic consideration of fiducial gold markers inserted for real-time tumor-tracking radiotherapy against lung cancer. Int J Radiat Oncol Biol Phys. 2008;70:382–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Kupelian PA, Forbes A, Willoughby TR. Implantation and stability of metallic fiducials within pulmonary lesions. Int J Radiat Oncol Bio Phys. 2007;69:777–85.CrossRefGoogle Scholar
  8. 8.
    Nelson C, Balter P, Morice RC, et al. A technique for reducing patient setup uncertainties by aligning and verifying daily positioning of a moving tumor using implanted fiducials. J Appl Clin Med Phys. 2008;9:110–22.CrossRefGoogle Scholar
  9. 9.
    Nelson C, Starkschall G, Balter P, et al. Assessment of lung tumor motion and setup uncertainties using implanted fiducials. Int J Radiat Oncol Biol Phys. 2007;63:915–23.CrossRefGoogle Scholar
  10. 10.
    Anatham D, Feller-Kopman D, Shanmugham LN, et al. Electromagnetic navigation bronchoscopy-guided fiducial placement for robotic stereotactic radiosurgery of lung tumors: a feasibility study. Chest. 2007;132:930–5.CrossRefGoogle Scholar
  11. 11.
    Shirato H, Suzuki K, Sharp GC, et al. Speed and amplitude of lung tumor motion precisely detected in four-dimensional setup and in real-time tumor-tracking radiotherapy. Int J Radiat Oncol Biol Phys. 2006;64:1229–36.PubMedCrossRefGoogle Scholar
  12. 12.
    Imura M, Yamazaki K, Shirato H, et al. Insetion and fixation of fiducial markers for setup and tracking of lung tumors in radiotherapy. Int J Radiat Oncol Biol Phys. 2005;63:1442–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Onimaru R, Shirato H, Fujino M, et al. The effect of tumor location and respiratory function on tumor movement estimated by realtime tracking radiotherapy system. Int J Radiat Oncol Biol Phys. 2005;63:164–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Shirato H, Harada T, Harabayashi T, et al. Feasibility of insertion/implantation of 2.0-MM-diameter gold internal fiducial markers for precise setup and real-time tumor tracking in radiotherapy. Int J Radiat Oncol Biol Phys. 2003;56:240–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Harada T, Shirato H, Ogura S, et al. Real-time tumor-tracking radiation therapy for lung carcinoma by the aid of insertion of a gold marker using bronchofiberscopy. Cancer. 2002;95:1720–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Pennathur A, Luketich JD, Heron DE, et al. Stereotactic radiosurgery for the treatment of lung neoplasm: experience in 100 consecutive patients. Ann Thorac Surg. 2009;88:1594–600.PubMedCrossRefGoogle Scholar
  17. 17.
    Pennathur A, Luketich JD, Heron DE, et al. Stereotactic radiosurgery for the treatment of stage I non–small cell lung cancer in high-risk patients. J Thorac Cardiovasc Surg. 2009;137:597–604.PubMedCrossRefGoogle Scholar
  18. 18.
    Brown WT, Wu X, Fayad F, et al. Application of robotic stereotactic radiotherapy to peripheral stage I non-small cell lung cancer with curative intent. Clin Oncol. 2009;21:623–31.CrossRefGoogle Scholar
  19. 19.
    Kothary N, Heit JJ, Louie JD, et al. Safety and efficacy of percutaneous fiducial marker implantation for image-guided radiation therapy. J Vasc Interv Radiol. 2009;20:235–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Collins BT, Erickson K, Reichtner CA, et al. Radical stereotactic radiosurgery with real-time tumor motion tracking in the treatment of small peripheral lung tumors. Radiat Oncol. 2007;2:39.PubMedCrossRefGoogle Scholar
  21. 21.
    Kupelian PA, Forbes A, Willoughby TR. Implantation and stability of metallic fiducials within pulmonary lesions. Int J Radiat Oncol Bio Phys. 2007;69:777–85.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Innovative Pulmonary SolutionsBellevueUSA

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