In Humanitas, for the first time, in a patient with non-operational (locally advanced) pancreatic cancer, the positioning of fiducial markers was performed, which allow precise tumor identification, before subjecting the patient to stereotactic radiotherapy.

An innovative and very advantageous combination, as we are told by Dr. Silvia Carrara, Head of the Ecoendoscopy Programme, and Dr. Tiziana Comito, specialist in Radiotherapy and Surgery.

Locally advanced, non-operational pancreatic tumors have no treatment options other than chemotherapy, which does not always allow good local control of the disease. On the other hand, standard radiotherapy is not sufficiently effective in these cases due to its long duration, lower dose of radiation delivered and risk of toxicity.

Stereotactic radiotherapy has been developed over the last ten years, in which a high dose of radiation is concentrated in a few sessions, usually 3-6 fractions; the aim of treatment is the targeted ablation of the disease. This procedure is very effective, painless, rapid and non-invasive. “We need to be very precise, to the millimeter – explains Dr. Comito – because it is essential to avoid the so-called organs at risk, that is, healthy tissues close to the tumor, especially the gastro-intestinal apparatus”. Humanitas has a clinical protocol of stereotactic radiotherapy (SBRT) for patients with non-operational pancreatic cancer, which can then be treated with this innovative local therapy.


Help from the positioning of fiducials

Ecoendoscopy is an additional aid to the precision required for stereotactic radiotherapy. “We place gold markers compatible with the organism, the size of about 5mm, which delimit the disease under endoscopic eco-guidance of fiducials, performed at the edge of the tumor. The procedure is conducted in deep sedation, and it is performed using a technique very similar to that of the endoscopic eco-guided pancreatic biopsy, using a needle of the latest generation, preloaded with 4 gold markers, dedicated to this maneuver,” explains Dr. Carrara.

“The patient is then subjected to a centering or simulation CT to plan the stereotactic radiant treatment,” adds Dr. Comito. “The positioned fiducials are visible on CT and therefore contribute to an even more precise localization of the tumor mass.

“Before each session of stereotactic radiotherapy – continues Dr. Comito – a new CT is performed, integrated with the device that provides the radiant treatment, to verify that the data acquired during the centering phase and the subsequent technical planning of treatment, are in accordance with the patient’s current situation. This is done by superimposing the two CTs and correcting the patient’s position to the millimeter if necessary.


Advantages for the patient

“The positioning of the fiducials is an important technical improvement, because it strengthens the millimeter accuracy of the radiant treatment, without weighing down the patient’s process. Ecoendoscopy is a minimally invasive procedure, which we also use in diagnosis, and it is therefore familiar to the patient. From this protocol, once again, emerges the importance of multidisciplinary integration in the approach to pancreatic cancer and the centrality of the patient for whom therapeutic choices are discussed and approved by all the specialists involved”, explains Dr. Carrara.

“We hope that we will be able to apply this procedure in the future on other places of illness,” the specialists conclude.