Real-World Pattern of Care Analysis of Liver Reirradiation Among European Organisation for Research and Treatment of Cancer Members.
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BACKGROUND AND PURPOSE: Liver re-irradiation is an increasingly used treatment for hepatocellular carcinoma (HCC), liver metastases, and intrahepatic cholangiocarcinoma (ICCA). Technological advances now enable precise delivery with improved organ sparing, yet practice remains heterogeneous, and evidence is scarce. This study evaluated the real-world pattern of care of liver re-irradiation among EORTC (European Organisation for Research and Treatment of Cancer) professionals. MATERIALS AND METHODS: A cross-sectional survey was distributed through the EORTC network in May 2025, with a reminder sent in June 2025. The questionnaire was designed based on key controversies identified in the current literature and clinical practice related to liver re-irradiation in radiotherapy. Type 1 re-irradiation was defined as a new course of radiotherapy overlapping the previously irradiated volume, whereas type 2 referred to non-overlapping re-irradiation. RESULTS: A total of 74 professionals from 28 countries completed the survey. Re-irradiation was performed for HCC by 35 professionals (47%), for liver metastases by 31 (42%), and for ICCA by 9 (12%). For HCC (n=35), type 2 re-irradiation was performed by 24% of respondents, typically delivered ≥6 months after the previous course (45%), and with a similar total dose (55%). For HCC, re-irradiation in Child Pugh B7 patients was evaluated on a case-by-case basis (76%), and half do not perform it in Child-Pugh B8 (52%), and ≤2 simultaneous targets (64%). For liver metastases (n=31), type 2 re-irradiation predominated (36%), with dose reduction compared with the initial course (92%), and ≤2 simultaneous liver metastases (44%). In ICCA (n=9), type 2 re-irradiation was preferred by 33%, with reduced dose (67%), and ≤2 targets (56%). For HCC, liver metastases, and ICCA, practitioners (n=75) considered the previously delivered dose to the uninvolved liver (86%, 92%, and 67%, respectively) and emphasized the proximity of luminal organs and bile ducts as key limiting factors (59%, 64%, and 56%, respectively). The most important determinant for re-irradiation was the anatomical location of the new lesion (54%). The recommended mean liver dose ranged from 10-15Gy for HCC (82%) and liver metastases (76%), decreasing to <10Gy for ICCA (44%). Liver dose guidance of V<15Gy >700-1000cc was applied by 55%, 64% and 89%, HCC, liver metastases and ICCA respectively. Preferred regimens were 41-50Gy in 5-8 fractions for HCC, and <30Gy in 5-8 fractions for liver metastases and ICCA. CONCLUSION: There is marked heterogeneity in liver re-irradiation practice, and its systematic implementation remains limited. Prospective studies are needed to determine optimal patient selection criteria, dose guidance, and evidence-based best practices for liver re-irradiation.