Image-guided radiotherapy in upper gastrointestinal malignancies: an Italian survey by the AIRO gastrointestinal study group

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.