Top tips for successful EUS-guided fiducial placement (with video).

In the world of modern oncologic treatments, radiation therapy is one of our most powerful tools in the war against cancer. Although some tumors are large and easy for our colleagues in radiation oncology to identify and target, other lesions are subtle, ill-defined, and poorly demarcated. The placement of metal objects, known as fiducials, within a tumor or a lymph node to help precision radiation targeting has been practiced for many years. Recently, several manufacturers have marketed modified EUS-FNA needles that come preloaded with gold fiducials that can be easily and safely deployed in a variety of target tissues including the mediastinal lymph nodes, pancreatic masses, prostate cancers, and many other lesions in a plethora of locations. Still, despite the availability of these devices, many endosonographers have little experience with EUS-guided fiducial placement. Many simply do not think to use these devices, even when indicated. In this Top Tips article, Shivangi Kothari, MD, provides insight gleaned from experience on how, when, and why to use fiducials in EUS practice.