Assessment of Per-Endoscopic Placement of Fiducial Gold Markers for Small Peripheral Lung Nodules < 20 mm Before Stereotactic Radiation Therapy.

Stereotactic radiotherapy is used to treat peripheral lung cancer in inoperable patients. Placement of fiducial gold markers (FMs) is crucial for tracking small lesions that are not visible on chest X-ray. Our objective was to assess endoscopic FM placement in small peripheral lung nodules (PLN) that are not trackable using automated tracking software.All patients benefiting from virtual bronchoscopy and radial endobronchial ultrasound (r-EBUS) guided placement of FM for PLN of less than 20mm were included. After confirmation by biopsy sampling, a gold-seed FM was inserted into the nodule using a bronchial brush, without use of fluoroscopy. The performances and complications of the procedure were recorded.From May 2010 to June 2015, FMs were placed in the PLN of 54 consecutive patients, 34 of whom presented with a nodule of less than 20mm. 76% of procedures were performed under local anesthesia, on an outpatient basis. Median long and short axis diameters of nodules were 15mm (9-20mm) and 11mm (6-20mm), respectively, with 31 of 34 nodules exhibiting a short axis of less than 15mm. In 23 cases (79%), histology was obtained during the procedure that allowed FM placement. Migration occurred in 6 cases, including 2 in the hours following the procedure. FMs were in place and visible in 80% of cases on CT scan performed 3 months after radiation therapy. No complications were reported.Diagnosis of peripheral nodules of less than 20mm and FM placement using r-EBUS are efficient and safe in a single procedure.