Utility of fiducial markers for target positioning in proton radiotherapy of oesophageal carcinoma.

BACKGROUND AND PURPOSE Oesophageal mobility relative to bony anatomy is a major source of geometrical uncertainty in proton radiotherapy of oesophageal carcinoma. To mitigate this uncertainty we investigated the use of implanted fiducial markers for direct target verification in terms of safety, visibility, and stability. MATERIALS AND METHODS A total of 19 helical gold markers were endoscopically implanted in ten patients. Their placement at the proximal and distal tumour borders was compared to tumour demarcations derived from [18F]Fluorodeoxyglucose positron emission tomography, their visibility quantified via the contrast-to-noise ratio on daily orthogonal X-ray imaging, and their mobility relative to bony anatomy analysed by means of retrospective triangulation. RESULTS Marker implantation proceeded without complications, but the distal tumour border could not be reached in two patients. Marker locations corresponded reasonably well with metabolic tumour edges (mean: 5.4 mm more distally). Marker visibility was limited but mostly sufficient (mean contrast-to-noise ratio: 1.5), and sixteen markers (84%) remained in situ until the end of treatment. Overall, marker excursions from their planned position were larger than 5(10) mm in 59(17)% of all analysed fractions. On one occasion severe target displacement was only identified via markers and was corrected before treatment delivery. CONCLUSION Implanted helical gold fiducial markers are a safe and reliable method of providing target-centric positioning verification in proton beam therapy of oesophageal carcinoma.

[1]  E. Dieleman,et al.  Four-dimensional computed tomographic analysis of esophageal mobility during normal respiration. , 2007, International journal of radiation oncology, biology, physics.

[2]  K. Foley,et al.  Impact of Positron Emission Tomography and Endoscopic Ultrasound Length of Disease Difference on Treatment Planning in Patients with Oesophageal Cancer. , 2017, Clinical oncology (Royal College of Radiologists (Great Britain)).

[3]  T. Alderliesten,et al.  Endoscopy/EUS-guided fiducial marker placement in patients with esophageal cancer: a comparative analysis of 3 types of markers. , 2015, Gastrointestinal endoscopy.

[4]  S Yoo,et al.  Analysis of image quality for real-time target tracking using simultaneous kV-MV imaging. , 2008, Medical physics.

[5]  Oliver Jäkel,et al.  Evaluation of different fiducial markers for image-guided radiotherapy and particle therapy , 2013, Journal of radiation research.

[6]  R. Mohan,et al.  Monte Carlo simulations of the dosimetric impact of radiopaque fiducial markers for proton radiotherapy of the prostate , 2007, Physics in medicine and biology.

[7]  M. Herk.  Errors and margins in radiotherapy. , 2004 .

[8]  E. J. van der Jagt,et al.  Impact of 18-fluorodeoxyglucose positron emission tomography on computed tomography defined target volumes in radiation treatment planning of esophageal cancer: reduction in geographic misses with equal inter-observer variability: PET/CT improves esophageal target definition. , 2010, Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus.

[9]  M. Peroni,et al.  Practice patterns of image guided particle therapy in Europe: A 2016 survey of the European Particle Therapy Network (EPTN). , 2018, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[10]  Hong-yan Cheng,et al.  Impact of PET/CT on radiation treatment in patients with esophageal cancer: A systematic review. , 2016, Critical reviews in oncology/hematology.

[11]  E. Steyerberg,et al.  Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. , 2015, The Lancet. Oncology.

[12]  Arnaud Belard,et al.  Fiducial markers in prostate for kV imaging: quantification of visibility and optimization of imaging conditions , 2012, Physics in medicine and biology.

[13]  D. Tait,et al.  Cone beam CT verification for oesophageal cancer – impact of volume selected for image registration , 2011, Acta oncologica.

[14]  Liquid fiducial marker applicability in proton therapy of locally advanced lung cancer. , 2017, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[15]  P. Thall,et al.  Multi-institutional analysis of radiation modality use and postoperative outcomes of neoadjuvant chemoradiation for esophageal cancer. , 2017, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[16]  K. Goodman,et al.  EUS-guided fiducial placement for image-guided radiation therapy in GI malignancies by using a 22-gauge needle (with videos). , 2010, Gastrointestinal endoscopy.

[17]  Joe Y. Chang,et al.  Comparative Outcomes After Definitive Chemoradiotherapy Using Proton Beam Therapy Versus Intensity Modulated Radiation Therapy for Esophageal Cancer: A Retrospective, Single-Institutional Analysis. , 2017, International journal of radiation oncology, biology, physics.

[18]  Tanja Alderliesten,et al.  Marker-based quantification of interfractional tumor position variation and the use of markers for setup verification in radiation therapy for esophageal cancer. , 2015, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[19]  E W Steyerberg,et al.  Preoperative chemoradiotherapy for esophageal or junctional cancer. , 2012, The New England journal of medicine.

[20]  P. Balter,et al.  Dose perturbations from implanted helical gold markers in proton therapy of prostate cancer , 2009, Journal of applied clinical medical physics.