title: Fiducial marker placement using endobronchial ultrasound and navigational bronchoscopy for stereotactic radiosurgery: an alternative strategy.
abstract: BACKGROUND
  Stereotactic radiosurgery is being increasingly used to treat patients with early-stage non-small cell lung cancers (NSCLC) who are not candidates for surgical resection. Stereotactic radiosurgery usually needs fiducial markers (FMs) for the tracking process. FMs have generally been placed using percutaneous computed axial tomography scan guidance. We report the results of FM placement using endobronchial ultrasound (EBUS) in 43 patients.
  
  
  METHODS
  A multidisciplinary tumor board evaluates NSCLC patients before they are offered stereotactic radiosurgery. In patients selected for stereotactic radiosurgery, FMs were inserted into peripheral, central, and mediastinal tumors using EBUS and, in selected patients, navigational bronchoscopy. Patients underwent repeat computed axial tomography chest scans 2 weeks later to ensure stability of the FMs before beginning stereotactic radiosurgery.
  
  
  RESULTS
  Included were 43 consecutive patients (21 men, 22 women; mean age, 74.4 years). Forty-two (98%) had NSC carcinomas (5 recurrences); 1 had a carcinoid tumor. Twenty-two tumors were located in the left lung, 19 in the right lung, 1 at the carina, and 1 pretracheal. Two to 5 FMs were placed in and around all tumor masses using EBUS and, for peripheral lesions, EBUS combined with navigational bronchoscopy. Thirty patients had no displacement of FMs. In the 13 who had displaced 1 or more FMs, the ability to use the remaining FMs for stereotactic radiosurgery was unimpaired.
  
  
  CONCLUSIONS
  EBUS and navigational bronchoscopy are safe and effective methods to position FMs for preparing patients with both central and peripheral lung cancers for stereotactic radiosurgery.
authors.affiliation: Division of Thoracic Surgery, Franklin Square Hospital, Baltimore, Maryland, USA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Harley
authors.forename: William S
authors.initials: WS
authors.lastname: Krimsky
authors.forename: Saiyad
authors.initials: S
authors.lastname: Sarkar
authors.forename: David
authors.initials: D
authors.lastname: Highfield
authors.forename: Cengis
authors.initials: C
authors.lastname: Aygun
authors.forename: Burak
authors.initials: B
authors.lastname: Gurses
mesh_terms: D000368:Aged; D001999:Bronchoscopy / Q000379:methods*; D002276:Carcinoid Tumor / Q000473:pathology / Q000601:surgery; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D009367:Neoplasm Staging; D010348:Patient Care Team; D019736:Prostheses and Implants; D015900:Radiography, Dual-Energy Scanned Projection / Q000379:methods; D016634:Radiosurgery / Q000379:methods*; D012984:Software; D025321:Surgery, Computer-Assisted / Q000379:methods*; D036542:Tomography, Spiral Computed / Q000379:methods; D018084:Ultrasonography, Interventional / Q000379:methods*