Multidisciplinary Delphi consensus-based recommendations on the use of image-guided radiotherapy for upper gastrointestinal tumours: an AIRO–AITRO–AIFM study

Abstract

Abstract Objectives Upper gastrointestinal (GI) malignancies represent one of the most challenging scenarios for image-guided radiotherapy (IGRT). Despite technological advances, clinical practice remains heterogeneous among centres. This national, multidisciplinary Delphi consensus, jointly promoted by AIRO, AITRO, and AIFM, aimed to harmonise IGRT implementation in upper-GI radiotherapy (RT) and define shared recommendations. Methods A two-round modified Delphi process was conducted between May and August 2025 among 20 Italian experts (radiation oncologists, medical physicists, and radiation therapists) with ≥10 years of experience in upper-GI RT. 16 key questions were organised into thematic areas. Agreement was rated using a five-point Likert scale; consensus was predefined as ≥75 %. Following Round 1, the steering committee reviewed closed-ended responses, open-ended answers, and panel feedback, and formulated 13 statements for Round 2. Results All experts completed both rounds, and consensus was achieved for all final statements. Key sources of geometric uncertainty were identified as respiratory motion, rotational setup errors, and anatomical variability. The panel supported the use of dedicated immobilisation systems and advanced imaging tools, including auto-contouring for OAR delineation. Respiratory control strategies were considered the most effective approaches, while fiducial markers were recognised as valuable tools for tumour tracking in selected cases. Daily cone-beam CT was identified as the minimum standard for treatment verification. Conclusions This national, multidisciplinary consensus provides a structured framework for defining IGRT standards in upper-GI malignancies. The high agreement levels confirm a shared vision and practice, supporting harmonised and precision-oriented RT delivery.