Pattern of care for re-irradiation in locally recurrent rectal cancer: a national survey on behalf of the AIRO gastrointestinal tumors study group

Abstract

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.

Proton beam reirradiation for locally recurrent rectal cancer patients with prior pelvic irradiation

“…Therefore, reirradiation could be a treatment option if complete surgical resection is not feasible or the patient denies salvage surgery for LRRC. The results of an Italian national survey showed that reirradiation was an option for neoadjuvant treatment in resectable and unresectable LRRC in 55 and 75% of cases, respectively [ 19 ].…”

“…In an Italian national survey, the irradiation of the cumulative dose of EQD2 (equivalent dose in 2 Gy) was 90–100 Gy considering the previous RT dose [ 19 ]. In the present study, the dose with the median cumulative EQD2 (α/β = 10) was high, at 121 Gy ( Table 2 ); unfortunately, four patients (40%) had further local recurrence in the reirradiation field.…”

Modern Techniques in Re-Irradiation for Locally Recurrent Rectal Cancer: A Systematic Review

“…These reviews were mainly based on studies in which 3D techniques were used [17,18]. Regarding CIRT, the systematic review by Venkatesulu et al reports interesting results and describes CIRT as a promising new technology when re-irradiation is required [27] A recent Italian study published by the Italian Association of Radiation and Clinical Oncology for Gastrointestinal Tumors (AIRO-GI) showed that most Italian centers have advanced technologies such as VMAT/IMRT/SBRT and daily image monitoring, which have led to breakthroughs in dose and fractionation [13].…”

“…The trouble concerning re-RT in this group of patients is related both in terms of the received dose of the organs at risk (OARs) and the time elapsed between the two irradiations. There are not enough studies on dose constraints for OARs, so radiation oncologists do not have clear guidelines on the doses that can be administered to avoid acute and late side effects [13]. Administering a suboptimal dose for fear of side effects can result in failure to control the disease or leave patients permanently inoperable [14][15][16].…”

“…Unfortunately, most of these studies used 3D techniques. Nowadays, most RT centers have and use advanced technologies, so the literature data based on 3D techniques are no longer reliable for determining the doses that can be used to avoid the side effects of re-RT in this patient population [13].…”