J Radiosurg SBRT. 2020; 7(2): 165–167.

, MD,1, MD,2, MD,1, MD,3, MD,4, MD,4, MD,3, MD,2, MD,1 and , MD, PhDcorresponding author1

Stereotactic body radiotherapy (SBRT) is an increasingly used modality for the treatment of borderline resectable and locally advanced pancreas cancer1. Given the high daily radiotherapy dose and required accuracy in delivery, SBRT often employs the use of implanted radiopaque fiducial markers, most commonly a gold or metal alloy, to facilitate target localization, target motion assessment, and/or daily image guidance. Commercially available fiducial markers vary in their balance of visibility (contrast) and artifact, largely dependent on material composition (e.g. gold, platinum, carbon), shape (e.g. coiled, cylindrical), diameter, and length2. Importantly, however, the presence of metallic fiducial markers at the time of surgery may impede the use of irreversible electroporation (IRE) with Nanoknife (AngioDynamics, Latham, NY) by interfering with regional electric conductivity and potentially increasing the risk of thermal injury3. TraceIT (Augmenix, Waltham, MA) is a Food and Drug Administration (FDA)-approved iodinated polyethylene glycol hydrogel tissue marker that has been utilized in gynecologic and prostate cancers as a fiducial marker and hydrogel tissue spacer4,5. Notably, with its high water and iodine content, TraceIT can be readily visualized on MRI, CT, and ultrasound for approximately 3 months and is generally fully absorbed by 7 months.

Here we report the novel use of TraceIT as a fiducial marker for pancreas SBRT in a 38-year-old man with locally advanced pancreatic cancer following good clinical, radiographic, and serologic response to neoadjuvant FOLFIRINOX chemotherapy with planned use of IRE at the time of surgery. Informed consent was obtained from the patient regarding his inclusion in this report. After multidisciplinary discussion with the treating hepatobiliary surgeon and interventional gastroenterologist, TraceIT was injected via endoscopic ultrasound-guidance in the pancreatic head, requiring a 19-gauge FNA needle (EchoTip® Ultra, Cook Medical, USA) given the viscosity of the hydrogel, which could not be injected through a smaller 22 gauge needle as first attempted. Four sites of hydrogel were injected at a volume of 1 cc each. Endoscopic ultrasound identified TraceIT hydrogel fiducial markers, outlined in red in (Panels C and D). The tissue marker was readily visualized without artifact on both simulation CT (Panel A) and daily cone beam CT (CBCT) images (Panel B), facilitating optimal target localization and image guidance. We observed no significant migration or variation in position of the TraceIT fiducials, as maximum distance between furthest markers varied by <0.5 mm on daily CBCT compared to simulation CT. Subsequent IRE was performed successfully and uneventfully.

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Endoscopic ultrasound identified TraceIT hydrogel fiducial markers, outlined in red in panels c) and d). The tissue marker was readily visualized without artifact on both simulation CT [panel a)] and daily cone beam (CBCT) images [panel b)].

Acknowledgments

Authors disclosure of potential conflicts of interest

The authors have nothing to disclose.

Contributed by

Author contributions

Conception and design: Eric M Anderson, Mitchell Kamrava, Katelyn M Atkins

Data collection: Eric M Anderson, Kenneth Park, Diana J Lu, Mitchell Kamrava, Katelyn M Atkins

Data analysis and interpretation: Eric M Anderson, Kenneth Park, Mitchell Kamrava, Katelyn M Atkins

Manuscript writing: Eric M Anderson, Katelyn M Atkins

Final approval of manuscript: Eric M Anderson, Kenneth Park, Diana J Lu, Nicholas Nissen, Jun Gong, Andrew Hendifar, Alexandra Gangi, Simon Lo, Mitchell Kamrava, Katelyn M Atkins

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