What is a safe dose to deliver to a gastric bed recurrence adjacent to the duodenal stump post total gastrectomy for gastric carcinoma?

We have published that gastric bleeding occurs commonly with volumes greater than 40cc receiving 50Gy or more, in patients receiving ablative radiation in 15% for large left lobe intrahepatic cholangiocarcinomas. Having a primary liver tumor is probably associated with unrecognized coagulopathy in some cases, and there may be a higher risk of bleeding. We now use 40cc < 45Gy as a guideline and 60Gy max point dose as the constraint, and have not had bleeding issues since then.

• Das P, Abboud MT, Haque W, Javle M, Kaseb A, Curley SA, Vauthey JN, Aloia TA, Beddar AS, Delclos ME, Krishnan S, Crane CH. Gastric Bleeding After Radiation Therapy for Intrahepatic cholangiocarcinoma. Prac Radiat Oncol. 3(4):344-348, 10/2013, 10/2013.

Also, we have pub...

I agree with @Dr. First Last on duodenal stump tolerance of 50-55 Gy/standard fractionation that prevents delivery of external beam treatment only with curative intent.

If imaging, including PET scan, shows no evidence of distant mets, I would consider treatment with curative intent delivering preoperative concurrent chemo-radiation (45-50 Gy/1.8 Gy fractions/5-5.5 weeks + concurrent chemo), followed by restaging, exploratory lap with marginal gross total resection, if feasible, and intra-operative boost with electrons (IOERT) or HDR brachytherapy. It would be reasonable to deliver several cycles of chemotherapy prior to the preoperative chemo-radiation.