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Background Insertion of fiducials to outline the targeted lesion allows image-guided radiotherapy, and is best achieved by endoscopic ultrasound (EUS). This study is a performance comparison of the new EUS-guided preloaded fiducial needle against Visicoil fiducials. Methods Technical success, visibility score, procedural time, costs, and complications for patients who underwent EUS-guided fiducial placement in upper gastrointestinal malignancies were prospectively collected. Results 60 patients with upper gastrointestinal cancers had fiducials (14 Visicoil; 46 preloaded fiducials) inserted for image-guided radiotherapy. Technical success was 100 %, with a shorter mean (standard deviation) insertion time of 0.94 minutes (0.28 minutes) vs. 5.5 minutes (1.9 minutes; P < 0.001) and higher visibility score on fluoroscopy of 2 vs. 1.18 (P < 0.001) in the preloaded group. Neither group had major complications related to fiducial insertion. The cost of consumables per patient was lower in the preloaded group at US$480 (US$124) vs. US$643 (US$123; P < 0.001). Conclusion Fiducial insertion for image-guided radiotherapy using the new preloaded needle is associated with 100 % technical success, shorter insertion time, and higher visibility, and is more cost-effective than the Visicoil system.

Introduction: Australia's first proton beam therapy (PBT) service, The Australian Bragg Centre for Proton Therapy and Research, is scheduled to open in the near future providing PBT for patients closer to home. Patients currently access Commonwealth funding for PBT via the Medicare Medical Treatment Overseas Program (MTOP). Proton versus photon treatment planning is a prerequisite for the MTOP application. The Royal Adelaide Hospital (RAH) Department of Radiation Oncology has been providing this since 2016. We aim to provide a descriptive overview of our proton versus photon treatment planning process, presenting a summary of the comparative planning results and the treatment pathways selected for the patients referred. Methods: All patients referred to the RAH for comparative planning between January 2016 and December 2018 were included in the analysis. Comparative plans were generated for each case using Pinnacle or Eclipse treatment planning systems. The planning techniques used and plan quality metrics were reported. Results: Forty three patients were referred for comparative planning. The age range was 1-63 years, with the majority (72%) being paediatric patients (age ≤18 years). Of the 19 cases that have been submitted to MTOP, 16 have been accepted and 3 denied. Two of the accepted cases chose not to travel abroad for PBT. The other 14 cases have received PBT overseas. Conclusions: The RAH has provided an important service to demonstrate the dosimetric difference between PBT and photon therapy for Australian patients, an important step in supporting the funding of patients for treatment overseas.

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