Li Tee Tan

Image guided brachytherapy in locally advanced cervical cancer: Improved pelvic control and survival in RetroEMBRACE, a multicenter cohort study

PURPOSE Image guided brachytherapy (IGBT) for locally advanced cervical cancer allows dose escalation to the high-risk clinical target volume (HRCTV) while sparing organs at risk (OAR). This is the first comprehensive report on clinical outcome in a large multi-institutional cohort. PATIENTS AND METHODS From twelve centres 731 patients, treated with definitive EBRT±concurrent chemotherapy followed by IGBT, were analysed. Kaplan-Meier estimates at 3/5years were calculated for local control (LC, primary endpoint), pelvic control (PC), overall survival (OS), cancer specific survival (CSS). In 610 patients, G3-4 late toxicity (CTCAEv3.0) was reported. RESULTS Median follow up was 43months, percent of patients per FIGO stage IA/IB/IIA 22.8%, IIB 50.4%, IIIA-IVB 26.8%. 84.8% had squamous cell carcinomas; 40.5% lymph node involvement. Mean EBRT dose was 46±2.5Gy; 77.4% received concurrent chemotherapy. Mean D90 HRCTV was 87±15Gy (EQD210), mean D2cc was: bladder 81±22Gy, rectum 64±9Gy, sigmoid 66±10Gy and bowel 64±9Gy (all EQD23). The 3/5-year actuarial LC, PC, CSS, OS were 91%/89%, 87%/84%, 79%/73%, 74%/65%. Actuarial LC at 3/5years for IB, IIB, IIIB was 98%/98%, 93%/91%, 79%/75%. Actuarial PC at 3/5years for IB, IIB, IIIB was 96%/96%, 89%/87%, 73%/67%. Actuarial 5-year G3-G5 morbidity was 5%, 7%, 5% for bladder, gastrointestinal tract, vagina. CONCLUSION IGBT combined with radio-chemotherapy leads to excellent LC (91%), PC (87%), OS (74%), CSS (79%) with limited severe morbidity.

Image guided adaptive brachytherapy with combined intracavitary and interstitial technique improves the therapeutic ratio in locally advanced cervical cancer: Analysis from the retroEMBRACE study

BACKGROUND AND PURPOSE Image guided adaptive brachytherapy (IGABT) using intracavitary applicators (IC) has led to a significant improvement of local control in locally advanced cervical cancer (LACC). Further improvement has been obtained with combined intracavitary/interstitial (IC/IS) applicators. The aim of this analysis was to evaluate the impact on local control and late morbidity of application of combined IS/IC brachytherapy in a large multicentre population. MATERIAL/METHODS 610 patients with LACC from the retroEMBRACE study were included. Patients were divided into an IC group (N=310) and an IC/IS group (N=300). The IC/IS group was defined from the time point, when a centre performed IC/IS brachytherapy in more than 20% of cases. RESULTS With systematic usage of IC/IS the D90 of CTVHR increased from 83±14Gy to 92±13Gy (p<0.01). No difference in doses to organs at risk was found. The 3-year local control rate in patients having a CTVHR volume⩾30cm3 was 10% higher (p=0.02) in the IC/IS group. No difference was found for CTVHR<30cm3 (p=0.50). No significant difference in late morbidity was found between the IC/IS group and IC group. CONCLUSION Combined IC/IS brachytherapy improves the therapeutic ratio in LACC by enabling a tumour specific dose escalation resulting in significantly higher local control in large tumours without adding treatment related late morbidity.

The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies

Graphical abstract

Image-guided Adaptive Brachytherapy for Cervix Cancer — A Story of Successful Collaboration within the GEC-ESTRO GYN Network and the EMBRACE Studies

Image-guided adaptive brachytherapy (IGABT) is the new gold standard for cervix cancer brachytherapy. A survey of UK practice showed that the proportion of centres offering computed tomography or magnetic resonance imaging (MRI)-based IGABT rose from 26% in 2008 to 71% in 2011 [1]. This interest is reflected worldwide, with >250 publications on the subject over the past 5 years according to PubMed. The uptake of IGABT is particularly notable as it has occurred without the benefit of a single randomised clinical trial. The spread of IGABT is a story of successful collaboration, as chronicled in a recent publication in Clinical and Translational Radiation Oncology [2]. The story begins with the establishment of the GEC-ESTRO GYN Working Group in 2000; clinicians from pioneering European IGABT centres (Leuven, Paris, Vienna) with different historical traditions met to discuss and agree a common language for prescribing, recording and reporting MRI-based IGABT for cervix cancer. This resulted in the publication of two recommendations on contouring and dose reporting in 2005 and 2006. In 2005, the GEC-ESTRO GYN Working Group founded a network to promote collaboration between the increasing number of institutions with research and development activities in IGABT. The GEC-ESTRO GYN network published a further two recommendations on applicator reconstruction and imaging in 2010 and 2012. The GYN GEC-ESTRO Recommendations IeIV have been used as the conceptual framework for the implementation of IGABTworldwide and are embedded into the new ICRU Report 89 ‘Prescribing,