Patient A

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Patient A:

4-year-old gentleman with a history of high risk prostate cancer was referred for radiotherapy of HCC

Segment 8 of the liver with invasion of branch portal vein. It was decided to proceed with treatment via

SBRT, and calypso fiducials were chosen for radiation targeting. Under local anesthesia, three calypso

fiducial were implanted under ultrasonography guidance.

Ultrasound examination of the liver was initially performed. The entire extent of the tumor which is

better demonstrated on the MR study was not readily visible under ultrasound. The tumor extending

into the portal vein was well seen. Three Calypso fiducial markers were placed (17-gauge delivery

needles) under ultrasound guidance at separate sites along the margin of the visible tumor. Gelfoam

was used to embolize the needle tract following placement of each marker.

Fluoroscopic imaging of the liver following fiducial placement was performed and only two of the

radiopaque markers could be identified. The entire chest was scanned to exclude non target

embolization perhaps through a hepatic vein. No additional marker could be identified. Likewise, each

of the needles were assessed to determine if one had failed to deploy. I suspect beacon likely dropped

from the second insertion needle upon transfer from the surgical table to the operative table prior to

needle insertion within the patient.

The procedure was well tolerated, and no immediate complications were encountered.

CT-GUIDED LIVER FIDUCIAL MARKER INSERTION

Informed consent was obtained. A strict sterile technique was utilized. Local anesthetic was applied to

the skin subcutaneous tissues. Under CT fluoroscopic guidance two separate fiducial markers were

deployed along the posterior and inferior aspects of the hepatic mass. No complications were

encountered and the procedure was well tolerated.

At time of CT sim , pt found to have 3 markers instead of 4 , images revealed migration of one fiducial to

the rt lung. Pt asymptomatic.

Patient B :

69 yo with multifocal HCC with a background of alcohol induced cirrhosis , was referred for SBRT

radiotherapy after TACE failure. Calypso fiducials were chosen for radiation targeting.

Under CT fluoroscopic guidance the patient's right hepatic mass was identified. Three fiducial were

inserted under CT fluoroscopic guidance. A sterile technique was used. 1% lidocaine was used as local

anesthetic.

Fiducial one was inserted superior to the lesion. Fiducial two was inserted lateral to the lesion. Fiducial

three was inserted anterior to the lesion. The the patient tolerated procedure well. There was no

complication.

Total dose delivered 45 Gy in 5 fractions.

At time of CT sim , pt found to have 2 markers instead of 3 , images revealed migration of one fiducial to

the rt lung. Pt asymptomatic.

Patient C:

72 yo male with known history of metastatic colorectal carcinoma, treated previously with resection of

his liver metastases about 18 months ago. referred with new findings concerning for progression of his

liver metastases. . It was decided to proceed with treatment via SBRT, and calypso fiducials were chosen

for radiation targeting

Under CT fluoroscopic guidance. 150 mcg of Fentanyl and 1.5 mg of midazolam was administered as

conscious sedation. 1% lidocaine was used as local anesthetic.

Under CT fluoroscopic guidance the patients hepatic mass was accessed. The initial (#1) fiducial marker

was inserted with an attempt at an anterior approach. The marker air immediately Move to and found a

resting place within the posterior right lung base. A marker #2 was positioned lateral to the lesion.

Marker #3 was positioned anterior to the lesion. There was no additional complication. There has been

no other interval change.

At time of CT sim , pt found to have 2 markers instead of 3 , images revealed migration of one fiducial to

the rt lung. Pt asymptomatic.

Insersion 8 feb 2019 , migration 14 feb?

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Patient A: 4-year-old gentleman with a history of high risk prostate cancer was referred for radiotherapy of HCC Segment 8 of the liver with invasion of branch portal vein. It was decided to proceed with treatment via SBRT, and calypso fiducials were chosen for radiation targeting. Under local anesthesia, three calypso fiducial were implanted under ultrasonography guidance. Ultrasound examination of the liver was initially performed. The entire extent of the tumor which is better demonstrated on the MR study was not readily visible under ultrasound. The tumor extending into the portal vein was well seen. Three Calypso fiducial markers were placed (17-gauge delivery needles) under ultrasound guidance at separate sites along the margin of the visible tumor. Gelfoam was used to embolize the needle tract following placement of each marker. Fluoroscopic imaging of the liver following fiducia ...
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