cases in the abdomen, in order to reduce the setup PTV margin, potentially reduce surrounding tissue dose, and achieve the same precision as SRS, image-guidance should be an essential component of abdomino-pelvic radiosurgery. In this series, the majority of patients’ setup was verified at the time of radiosurgery with radio-opaque markers implanted at the periphery Inhibitors,research,lifescience,medical of the target. These markers, along with bony anatomy, were used for on board imaging using kv-kv image matching. This procedure, which typically involved the placement of 3 markers, was performed by interventional radiology and no complications were reported its use. For those mTOR inhibitor patients who refused the implantable markers, or whose placement was deemed to encompass excessive procedural risk, image guidance was performed with cone beam CT for soft tissue matching. Significant intrafraction respiratory motion for targets in the upper abdomen has been demonstrated (25). While this motion may have a moderate effect of daily fractionated Inhibitors,research,lifescience,medical treatment, the uncertainty imposed by this organ motion could potentially compromise target coverage with relatively Inhibitors,research,lifescience,medical tight PTV margins. In order to maintain a small PTV margin and reduce normal tissue toxicity for lesions in the upper
abdomen, respiratory motion should be accounted for in the radiosurgical treatment of these lesions. In this series, patients with targets in the upper abdomen (pancreas, liver, small bowel) were simulated with a 4D-CT, and planned and treated at end expiration. The use of implanted fiducial radio-opaque markers has the added advantage of matching these markers with respiration using real time on board imaging to verify treatment location and respiration. While cone beam CT has the Inhibitors,research,lifescience,medical advantage of soft Inhibitors,research,lifescience,medical tissue matching, at least at our clinic, we have not been able to incorporate this technology with respiratory gating
for treatment. As such, cone beam CT was reserved for lower abdomen/pelvic targets, or those patients who could not receive the implanted fiducial markers. Using a combination of RECIST and the updated lymphoma response criteria(20)-(22), the overall response rate in Annual Review of Medicine this series was 48%. This value is a sum of the complete responders and partial responders, and incorporates the change in the diameter product on CT as well as change in maximum SUV on FDG-PET. Using the same criteria, the rate of disease progression at the treated site was 26%. Early response (PR or CR at 1-month) appeared to correlate with a durable response, as 84% of those patients with an early treatment response maintained local control at last follow-up. In addition, the based on change in maximum SUV on FDG-PET, the metabolic response rate was 85%, suggesting a strong functional response to the radiosurgery. Furthermore, no patients evaluable in this fashion showed evidence of metabolic progression after treatment.