Risks associated with implantation of “fiducial markers” before radiation therapy

It is becoming commonplace for men who are going to get external beam radiotherapy to treat their prostate cancer to have some form of “fiducial marker” (often tiny gold rods or balls) inserted into their prostates under transrectal ultrasound guidance to help ensure that the radiotherapy can be administered with the greatest possible accuracy.

Now it needs to be appreciated that, just like a prostate biopsy, the insertion of fiducial markers is a surgical procedure, and like all surgical procedures, it does come with a (relatively low) level of risk.

Gill et al. have reported data from a retrospective survey of 234 patients who had fiducial markers inserted prior to their radiotherapy. The patients were all given a questionnaire that asked them about the severity and the duration of any symptoms suggesting side effects and complications associated with this procedure.

Here is what they found:

  • 75/234 men (32 percent) had at least one new symptom after the procedure.
  • 21/234 men (9 percent) had symptoms that lasted for > 2 weeks.
  • The most common new symptom that was reported after the procedure was urinary frequency (in 16 percent of patients who had not previously had this problem).
  • Haematuria (blood in the urine), rectal bleeding, dysuria (pain on urination) and haematospermia (blood in the sperm) affected 9 to 13 percent of patients, mostly at a low level (grade 1 or 2).
  • Between 3 and 4 percent of men reported pain, urinary tract obstruction, and fever and shivers.
  • Grade 3 rectal bleeding, haematuria, fever and shivers and urinary frequency affected between 1 and 4 patients (0.5 to 1.5 percent).
  • 1/234 patients had a grade 4 complication (i.e., fever and shivers) which was documented as sepsis.
  • Urinary frequency, dysuria, obstructive symptoms, and rectal bleeding were the symptoms that most commonly lasted for > 2 weeks.
  • The average (mean) pain score during the procedure was 1.1 (range, 0 to 5).

Prostate cancer patients who undergo transrectal ultrasound-guided insertion of fiducial markers to facilitate image-guided radiation therapy should be aware that this is a relatively safe and  well-tolerated procedure with some minor side effects. However, as with having a biopsy, it is not a completely benign procedure. It is a form of surgery, and significant side effects can occur in a small minority of prostate cancer patients.

10 Responses

  1. I received three gold rod fiducials under general anesthesia, which were implanted via TRUS guidance. I was prescribed 500 mg Levaquin 24 hours before the procedure, a second dose 1 hour before, and a final dose 24 hours later. I experienced no post-procedure side effects whatsoever and 33 days later began my IMRT/IGRT radiation therapy.

    The side effect numbers reported in this study seem very high, but I have read that with increasing bacterial resistance to all antibiotics, more sepsis is to be expected. If I were a patient whose PSA was rising, yet no malignancies had been discovered via an initial biopsy, I’d be certainly be concerned about the safety of repetitive biopsies.

  2. I have never heard of placement with a general anesthetic — a local like lidocaine is a lot more common. Just as with a biopsy, it is injected with a fine needle and stings slightly. It is good to make sure the urologist allows a few minutes for the lidocaine to take effect … ask him if he needs to pee. Men who experience pain often complain that either they never received anesthesia or the urologist was in too much of a hurry.

    Shinohara at UCSF inserted my fiduciaries; I felt a little stinging and was waiting patiently for him to insert the gold markers when he told me were all done. I thought he was kidding!!

  3. How can we find out where the fiducial markers were done for the 75 patients and how long ago? Did the other 159 patients not have any complications? I am scheduled to have the markers applied in June 2012.

  4. Rick D.

    I was given the choice of local or general anesthesia by my urologist for both my biopsy and my fiducial implantation procedure. Since that time other urologists at this facility have begun offering all their prostate patients this option. I suspect an unconscious patient may be less likely to twitch about or otherwise interfere with the urologist’s procedure than is an inadequately locally anesthetized patient. The only downside is that a standard pre-surgery workup must show that the patient can safely tolerate general anesthesia. As far as I’m concerned, it’s the only way to fly. LOL.

    BTW, I had a color Doppler ultrasound and DRE examination by Shinohara, but he neither found nor felt nothing abnormal. I opted to have my 79.2 Gy radiation treatment 15 minutes from home in Marysville instead of at the UCSF facility 3 hours away when I learned the very experienced local radiation oncologist would be utilizing the same model Varian linear accelerator as UCSF. Ironically, the urologist I had locally is now a new clinician at UCSF.

  5. Dear Mr. Sims:

    If you look at the link to the actual study in the article above, you will see that this paper comes from an Australian tertiary care center.

  6. With at least two words misspelled in this article re: fiducial implantation, and the carelessness that would be the cause of the spelling errors, I now doubt the veracity of any and all parts of this summary …. It’s virtually worthless.

  7. Dear Mr. Swanson:

    Thank you for pointing out the fact that there were typos in this article. Actually I found four, including the repeated use of the word “with” in the heading. They are all now corrected. You will also be pleased to know that I have double-checked all the data against the original. These are accurate.

    I apologize for being less than perfect. Clearly I was not having a good day.

  8. Could you possibly give an idea of what other “significant” side effects may occur?

    “However, as with having a biopsy, it is not a completely benign procedure. It is a form of surgery, and significant side effects can occur in a small minority of prostate cancer patients.”

    Is there risk of a blood clot? or any adverse reaction to the markers?

  9. after two liver tumors,were readied for radiation therapy I am very weakened even a week after….like a little kitten..

  10. Dear Edmund:

    I am not sure that I understand what you are telling us. Do you have metastatic prostate cancer that has spread to the liver, or do you have primary liver cancer? The two situations are very different. And what do you mean by “readied for” radiation therapy?

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