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PLoS One. 2017 Jun 21;12(6):e0179676. doi: 10.1371/journal.pone.0179676. eCollection 2017.

Efficacy and safety of ultrasound-guided implantation of fiducial markers in the liver for stereotactic body radiation therapy.

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Division of Abdominal Radiology, Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-Gu, Seoul, KOREA.
Department of Radiology, Gachon University, Gil Medical Center, Guwol-dong, Namdong-gu, Incheon, Korea.
Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-Gu, Seoul, KOREA.



Stereotactic body radiation therapy (SBRT) for the treatment of a malignancy in the liver requires the perilesional implantation of fiducial markers for lesion detection. The purpose of this study is to evaluate the efficacy and safety of ultrasound (US) -guided marker implantation for SBRT.


We retrospectively reviewed 299, US-guided, intrahepatic fiducial markers implanted in 101 patients between November 2013 and September 2014. SBRT-planning CT images were analyzed to determine the technical success of the implantation, the mean distance between the tumor margin and the marker, with the ideal location of fiducials defined as the distance between a marker and a tumor less than 3 cm and the distance between markers greater than 2 cm according to the tumor conspicuity seen on gray-scale US and the artifact obscuring tumor margins. We also evaluated procedure-related major and minor complications.


Technical success was achieved in 291 (97.3%) fiducial marker implantations. The mean distance between the tumor and the marker was 3.1 cm (S.D., 2.1 cm; range, 0-9.5 cm). Of 101 patients, 72 lesions (71.3%, 2.2 ± 1.0 cm; range, 0-3.0 cm) had fiducial markers located in an ideal location. The ideal location of fiducials was more common in visible lesions than in poorly conspicuous lesions (90.2% vs. 52.0%, P < 0.001). Seventeen markers (5.8%) developed beam-hardening artifacts obscuring the tumor margins. There were no major complications, although 12 patients (11.9%) developed minor complications.


US-guided implantation of fiducial markers in the liver is an effective and safe procedure with only rare complications.

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