The Role of Fiducial Placement in the Treatment of Pancreatic Cancer: The Expanding Role of Endoscopic Ultrasound

Pancreatic adenocarcinoma is the second most common gastrointestinal malignancy and the fourth leading cause of cancer mortality in the United States [1]. Both local and systemic therapies are integral in the treatment of pancreatic cancer. Aggressive local treatment leads to improved local control which can translate into improved overall survival [2]. For patients with locally advanced pancreatic cancer, chemoradiation provides improvement in survival when compared with chemotherapy alone [3,4]. The chemotherapy may be administered together or sequentially with the radiation therapy. In radiotherapy for pancreatic cancer, adequate dose delivery to target tissue is hampered by the radiosensitivity of healthy adjacent organs. Several studies have demonstrated that aggressive local therapy with radiation dose escalation can improve local control. Radiation dose escalation has been attempted through the use of intraoperative radiotherapy, stereotactic body radiotherapy, and intensity-modulated radiotherapy (IMRT) [5-7]. IMRT is a recent advancement in the delivery of radiotherapy, facilitating improved radiation dose delivery to the tumor [8]. IMRT delivers high-precision radiotherapy using a computer-controlled linear accelerator to deliver precise radiation doses to specific areas. The presence of the small bowel within the “lymphatic volume” limits traditional radiotherapy to maximal doses of 50 Gy (5000 rads). The use of IMRT enables delivery of doses as high as 54 Gy (5400 rads) to the tumor. This permits the ability to escalate radiation doses to the tumor while maintaining or reducing healthy tissue exposure. This advancement in radiation technique improves the chance of secondary resection, improves local control for unresectable disease, and reduces symptoms related to local progression.