Background: Radiotherapy (RT) plays an important role in the treatment of patients with previously irradiated locally recurrent rectal cancer (LRRC). Over the years, numerous technologies and different types of RT have emerged. The aim of our systematic literature review was to determine whether the new techniques have led to improvements in both outcomes and toxicities. Methods: A computerized search was performed by MEDLINE and the Cochrane database. The studies reported data from patients treated with carbon ion radiotherapy (CIRT), intensity-modulated photon radiotherapy (IMRT), and stereotactic radiotherapy (SBRT). Results: Seven publications of the 126 titles/abstracts that emerged from our search met the inclusion criteria and presented outcomes of 230 patients. OS was reported with rates of 90.0% and 73.0% at 1 and 2 years, respectively; LC was 89.0% and 71.6% at 1 and 2 years after re-RT, respectively. Toxicity data vary widely, with emphasis on acute and chronic gastrointestinal and urogenital toxicity, even with modern techniques. Conclusion: data on toxicity and outcomes of re-RT for LRRC with new technologies are promising compared with 3D techniques. Comparative studies are needed to define the best technique, also in relation to the site of recurrence.

Purpose: Radical resection (R0) represents the best curative treatment for local recurrence (LR) rectal cancer. Re-irradiation (re-RT) can increase the rate of R0 resection. Currently, there is a lack of guidelines on Re-RT for LR rectal cancer. The Italian Association of Radiation and clinical oncology for gastrointestinal tumors (AIRO-GI) study group released a national survey to investigate the current clinical practice of external beam radiation therapy in these patients. Material and methods: In February 2021, the survey was designed and distributed to members of the GI working group. The questionnaire consisted of 40 questions regarding center characteristics, clinical indications, doses, and treatment techniques of re-RT for LR rectal cancer. Results: A total of 37 questionnaires were collected. Re-RT was reported as an option for neoadjuvant treatment in resectable and unresectable disease by 55% and 75% of respondents, respectively. Long-course treatment with 30–40 Gy (1.8–2 Gy/die, 1.2 Gy bid) and hypofractionated regimen of 30–35 Gy in 5 fractions were used in most centers. A total dose of 90–100 Gy as EqD2 dose (α/β = 5 Gy) was delivered by 46% of the respondents considering the previous treatment. Modern conformal techniques and daily image-guided radiation therapy protocols were used in 94% of centers. Conclusion: Our survey showed that re-RT treatment is performed with advanced technology that allow a good management of LR rectal cancer. Significant variations were observed in terms of dose and fractionation, highlighting the need for a consensus on a common treatment strategy that could be validated in prospective studies.

Background: In our department, we provided guidelines to the radiation oncologists (ROs) regarding the omission, delay, or shortening of radiotherapy (RT). The purpose was to reduce the patients’ exposure to the hospital environment and to minimize the departmental overcrowding. The aim was to evaluate the ROs’ compliance to these guidelines. Methods: ROs were asked to fill out a data collection form during patients’ first visits in May and June 2020. The collected data included the ROs’ age and gender, patient age and residence, RT purpose, treated tumor, the dose and fractionation that would have been prescribed, and RT changes. The chi-square test and binomial logistic regression were used to analyze the correlation between the treatment prescription and the collected parameters. Results: One hundred and twenty-six out of 205 prescribed treatments were included in this analysis. Treatment was modified in 61.1% of cases. More specifically, the treatment was omitted, delayed, or shortened in 7.9, 15.9, and 37.3% of patients, respectively. The number of delivered fractions was reduced by 27.9%. A statistically significant correlation (p = 0.028) between younger patients’ age and lower treatment modifications rate was recorded. Conclusion: Our analysis showed a reasonably high compliance of ROs to the pandemic-adapted guidelines. The adopted strategy was effective in reducing the number of admissions to our department.

This systematic literature review aimed to evaluate treatment uncertainties associated with modern rectal cancer radiotherapy, focusing on systematic and random errors in setup and target volume (TV) shape variation, with the aim of supporting clinics in optimizing treatment accuracy and consistency in daily practice. A systematic literature review was conducted to quantify geometrical uncertainties with respect to setup and TV shape variations in the treatment of rectal cancer. It included studies reporting uncertainties for setup, CTV (Clinical Target Volume) shape variations (rectum and mesorectum), GTVp (Gross Tumor Volume – Primary Tumor), GTVn (Gross Tumor Volume − Nodes), and/or elective pelvic lymph nodes; excluding non-English language publications. 196 reports were assessed for full text screening and 32 publications were selected for final reporting. Most authors utilized on board imaging to calculate setup errors and TV shape variation, and all reported substantial uncertainties. Setup uncertainty was reported to be very different for prone (w/o belly board) vs supine position, in favour of supine position. TV shape variation showed large systematic and random errors, especially for GTVp and the upper anterior part of the mesorectum. A subset of publications analyzed the positional uncertainties of elective draining lymph nodes, which are typically not removed during surgery, showing their small positional variations in relation to bone structures. Setup and TV shape variation are significant and non-negligible geometric uncertainties. Setup errors can largely be minimized with daily (2D or 3D) IGRT, whereas TV shape variations—particularly in the mesorectum—needs to be assessed daily with 3D imaging and requires anisotropic margins.

Objectives: Image-guided radiation therapy (IGRT) plays a central role in modern radiotherapy. However, due to a lack of standardised guidelines for image acquisition, timing, and motion management protocols, considerable variation exists in clinical practice. To address this gap, we conducted a nationwide survey to evaluate IGRT practices in the treatment of upper gastrointestinal (Upper-GI) malignancies in Italian radiotherapy centres. Methods: A multidisciplinary working group developed a 60-item questionnaire in accordance with the CHERRIES guidelines, focusing on tumours of the liver, pancreas, and gastroesophageal junction (GEJ). The questionnaire included 15 general and 45 site-specific questions on imaging, immobilisation, organ motion management, target volume delineation, and delivery techniques. The survey was distributed via Google Forms to Italian Association of Radiotherapy and Clinical Oncology (AIRO)-affiliated centres, with one radiation oncologist from each centre invited to participate. Responses were collected anonymously and analysed descriptively. Results: A total of 44 centres responded. Most were public hospitals (50 %) with access to advanced IGRT instruments such as six degrees of freedom (6-DoF) couches (79 %) and four-dimensional cone beam computed tomography (4D-CBCT) (81 %), although their routine use varied. Image fusion with planning CT was widely used (95 %), while the use of fiducial markers and adaptive radiotherapy remained limited. Considerable heterogeneity was observed in fasting protocols, immobilisation methods, motion management strategies, and margin definitions. Daily IGRT was standard for most treatments. Conclusions: The survey shows both consolidated practices and significant variability in the implementation of IGRT for Upper-GI malignancies in Italy. These results support the need for national, consensus-based guidelines to promote standardisation and improve treatment quality.