Case report

Cardiac embolization of an implanted fiducial marker for hepatic stereotactic body radiotherapy: a case report

Hooman Hennessey¹ , David Valenti² , Tatiana Cabrera² , Valerie Panet-Raymond¹ and David Roberge¹

¹  Department of Oncology, Division of Radiation Oncology, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada

²  Department of Radiology, Division of Interventional Radiology, McGill University Health Centre, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada

author email corresponding author email

Journal of Medical Case Reports 2009, 3:140doi:10.1186/1752-1947-3-140

Published:	20 November 2009

Abstract

Introduction

In liver stereotactic body radiotherapy, reduction of normal tissue irradiation requires daily image guidance. This is typically accomplished by imaging a surrogate to the tumor. The surrogate is often an implanted metal fiducial marker. There are few reports addressing the specific risks of hepatic fiducial marker implantation. These risks are assumed to be similar to percutaneous liver biopsies which are associated with a 1-4% complication rate - almost always pain or bleeding. To the best of our knowledge, we present the first case of such a fiducial marker migrating to the heart.

Case presentation

An 81-year-old Caucasian man (5 years post-gastrectomy for a gastric adenocarcinoma) was referred post-second line palliative chemotherapy for radiotherapy of an isolated liver metastasis. It was decided to proceed with treatment and platinum fiducials were chosen for radiation targeting. Under local anesthesia, three Nester embolization coils (Cook Medical Inc., Bloomington, IN, USA) were implanted under computed tomography guidance. Before the placement of each coil, the location of the tip of the delivery needle was confirmed by computed tomography imaging. During the procedure, the third coil unexpectedly migrated through the hepatic vein to the inferior vena cava and lodged at the junction of the vena cava and the right atrium. The patient remained asymptomatic. He was immediately referred to angiography for extraction of the coil. Using fluoroscopic guidance, an EN Snare Retrieval System (Hatch Medical L.L.C., Snellville, GA, USA) was introduced through a jugular catheter; it successfully grasped the coil and the coil was removed. The patient was kept overnight for observation and no immediate or delayed complications were encountered due to the migration or retrieval of the coil. He subsequently went on to be treated using the remaining fiducials.

Conclusion

Implanted fiducial markers are increasingly used for stereotactic radiotherapy. There is sparse literature on the risks of such procedures. Although uncommon, the risk of migration does exist and therefore physicians (surgeons, oncologists and radiologists) and patients should be aware of this possibility.