Comparison Study in Pancreatic Fiducial Placement

A prospective multicenter study to compare the cost, time, complications, and migrations rate
of two commercially available FDA approved needles; 19 gauge endoscopic ultrasound (EUS) fine
needle aspiration (FNA) BNX needles to 22 gauge EUS FNA BNX needles.

There will be fiducials placed in the pancreas according to facility policy and procedure.

This is a randomized prospective multicenter trial. A minimum of 14 patients and a maximum of
30 patients will be enrolled at up to ten participating sites. Enrollment is projected to be
complete within approximately one year.

Adult subjects with a diagnosis of pancreatic cancer who will receive SBRT for pancreatic
cancer via Cyberknife or Tomotherapy will undergo EUS guided fiducial marker placement.

Subjects will be randomized to receive fiducial marker placement with either a 19 gauge EUS,
FNA BNX needle or a 22 gauge EUS, FNA BNX needle. For all patients, standard hospital
protocol will be followed for EUS procedures and patient care management.

The study duration will commence at the time of EUS guided fiducial marker placement and
conclude at the time of last SBRT to the pancreas.

Cost effectiveness will be evaluated by providing an itemized statement, including
anesthesiologist, and endoscopist charges. Time of procedure will be evaluated at time point
of first lead needle loaded to time of last marker placed. Time measurement will begin when
Endoscopist inserts the echoendoscope into the patient. Thus the patient is under anesthesia,
in position, and staff is ready for the case. The time ends once last fiducial marker is
placed. Complications will be reported and may include but not limited to pain, bleeding,
peritonitis, and pancreatitis. Migration will be reported during the timeframe from
simulation to the last day of SBRT.

The ability to receive SBRT from this EUS guided fiducial placement will be reported as
simply a yes or no. Sites will provide a de-identified itemized statement for EUS guided
fiducial placement procedure, prior to any discounted rate, including the endoscopist and
anesthesiologist.

Follow up evaluations and treatment for pancreatic cancer will be performed in accordance
with standard of care procedures and procedures deemed necessary by the attending physician.

Inclusion Criteria:

1. Subjects that plan to undergo CyberKnife treatment for pancreatic cancer

2. Subjects that are deemed physically able to undergo anesthesia (either Monitored
Anesthesia Care (MAC) or general anesthesia)

3. Subjects (or the subjects Legally Authorized Representative [LAR]) that have agreed to
participate in the study and have signed Informed Consent

4. Subjects 18 years of age or older

5. Subject must be able to hold anticoagulants as per institutional standard of care

6. Women of child bearing potential who are not pregnant as proven by a negative
pregnancy test

Exclusion Criteria:

1. Subjects that are unable to tolerate anesthesia for the procedure

2. Subjects 17 or under

3. Subjects that refuse treatment for pancreatic cancer d Subjects whose anticoagulants
cannot be held

e. Subjects who have distant metastatic disease f. Subjects who cannot or refuse EUS guided
procedures. g Subjects who are pregnant