Endoscopic ultrasound-guided fiducial marker placement in pancreatic cancer: A systematic review and meta-analysis

BACKGROUND: Pancreatic cancer (PC) mortality remains high despite advances in therapy. Combination chemoradiotherapy offers modest survival benefit over monotherapy with either. Fiducial markers serve as needed landmarks for image-guided radiotherapy (IGRT). Traditionally, these markers were placed surgically or percutaneously with limitations of each. Endoscopic ultrasound-guided placement overcomes these limitations. AIM: To evaluate the safety, efficacy, and feasibility of endoscopic ultrasound (EUS)-guided fiducial placement for PC undergoing IGRT. METHODS: Articles were searched in MEDLINE, PubMed, and Ovid journals. Pooling was conducted by fixed and random effects models. Heterogeneity was assessed using Cochran’s Q test based upon inverse variance weights. RESULTS: Initial search identified 1024 reference articles for EUS-guided fiducial placement in PC. Of these, 261 relevant articles were reviewed. Data was extracted from 11 studies (n = 820) meeting inclusion criteria. Pooled proportion of successful placement was 96.27% (95%CI: 95.35-97.81) with fiducial migration rates low at 4.33% (95%CI: 2.45-6.71). Adverse event rates remained low, with overall pooled proportion of 4.85% (95%CI: 3.04-7.03). CONCLUSION: EUS-guided placement of fiducial markers for IGRT of PC is safe, feasible, and efficacious. The ability to target deep structures under direct visualization while remaining minimally invasive are added benefits. Moreover, the ability to perform fine needle aspiration or celiac plexus neurolysis add value and increase patient-care efficiency. Whether EUS-guided fiducial placement improves outcomes in IGRT or offers any mortality benefits over traditional placement remains unknown and future studies are needed.