Comparison of technical success and safety of transbronchial versus percutaneous CT-guided fiducial placement for SBRT of lung tumors.

ABSTRACT

OBJECTIVE: To evaluate the technical success and safety of transbronchial (bronchoscopic) fiducial placement compared to percutaneous CT-guided fiducial placement for stereotactic body radiotherapy (SBRT) of lung tumors. MATERIALS AND METHODS: This IRB-approved, HIPAA-compliant retrospective study was performed at a single tertiary institution. Consecutive patients undergoing lung fiducial placement for purposes of guiding SBRT (CyberKnife®, Accuray, Inc.) between September 2005 to January 2013 were included in the study. Fiducial seeds were placed percutaneously with CT guidance or transbronchially with bronchoscopic guidance. We compared procedure-related complications (pneumothorax, chest tube placement), technical success (defined as implantation enabling adequate treatment planning with CT simulation) and migration rate. The need for repeat procedures and their mode was noted. Statistical analysis was performed using Fisher exact and Chi square probability tests. RESULTS: Two hundred and forty-four patients with lung tumors and 272 fiducial seed placements were included in the study. Two hundred and twenty-one of the 272 (81.2%) fiducial markers were placed percutaneously and 51/272 (18.8%) were placed transbronchially. Pneumothorax was seen in 73/221 (33%) of percutaneously-placed fiducials and in 4/51 (7.8%) of transbronchial placements (p<0.001). No significant difference was seen in the rate of chest tube placement between the two groups 20/221 (9%) of percutaneously placed fiducials and 2/51 (3.9%) of transbronchially placed fiducials (p=0.39). Fifteen of the 51 (29%) of fiducial placements with transbronchial approach were unsuccessful, as discovered at radiotherapy planning session, and required a repeat procedure. Nine of the 15 (60%) of repeat procedures were performed percutaneously, 5/15 (33%) were placed during repeat bronchoscopy, and 1/15 (7%) was placed at transesophageal endoscopic ultrasound. No repeat fiducial placements were required for patients who had the fiducials placed percutaneously (p<0.001), with a technical success rate of 100%. CONCLUSION: Transbronchial fiducial marker placement has a significantly higher rate of failed seed placements requiring repeat procedures in comparison to percutaneous placement. Complication rate of pneumothorax requiring chest drain placement is similar between the two approaches.