Very accelerated partial breast irradiation in 1 or 2 days: Late toxicity and early oncological outcome of the GEC-ESTRO VAPBI cohort.

PURPOSE: To analyze late toxicity after very accelerated partial breast irradiation (VAPBI) for low-risk breast cancer. MATERIALS: Methods: In this retrospective, observational, international multicenter study (HDH F20220713143949), patients with low-risk breast cancer underwent lumpectomy + vAPBI (high-dose rate multicatheter interstitial brachytherapy-MIBT). VAPBI was performed with 4(4x6.2 Gy/2d), 3(3x7.45 Gy/2d) or 1 fraction (1x16Gy or 1x18Gy/1d). Primary endpoint was late toxicity. Secondary endpoints were cumulative incidence of breast cancer local relapse (LR) and distant metastatic relapse (DMR) and specific (SS) and overall (OS) survivals. Prognostic factors for late toxicity were analyzed. RESULTS: From 01/2012 to 06/2022, 516 pts with early breast cancer were enrolled. Median follow-up was 44 months [95 %CI 39-46]. Median age was 71 years [40-100]. Median tumor size was 12 mm [1-35]. VAPBI delivered 1, 3 and 4 fractions for 205pts (39.7 %), 167pts (32.4 %) and 144pts (28 %) respectively. 221 late toxicity events were observed in 168pts (32.6 %) (Fibrosis, dyschromia, pain and telangiectasia). Grade 2 and 3 late toxicities were observed in 7.2 and 0.6 % respectively (no G4) with no difference between 1 and ≥ 2 treatment days. CTV > 50 cc (p = 0.007) and V150 > 40 % (p = 0.027) were prognostic factors for G ≥ 2 late toxicity. Four-year cumulative incidence rates of LR and DMR were 2 % [95 %CI 0-3] and 1 % [95 %CI 0-2] respectively. CONCLUSIONS: VAPBI based on 1 or ≥ 2 days of MIBT represents an attractive de-escalation of irradiation approach for low-risk breast cancer. Late toxicity profile appears acceptable while early oncological outcome shows encouraging local control. Longer follow-up is warranted in order to confirm these preliminary results.

Status of head and neck brachytherapy in Spain in 2022

Purpose Brachytherapy (BT) has been used for many years for disease control in tumours of the head and neck area (H&N). It is currently performed with high dose rate (HDR) or pulsed dose rate (PDR), but its use has been reduced due to the implementation of new non-invasive external beam radiotherapy techniques such as intensity modulation (IMRT) and volumetric modulated arc therapy (VMAT) and the improvement of surgical techniques. Methods The Spanish Brachytherapy Group (GEB) has carried out a survey to find out the number of centres in Spain that continue to use BT in H&N and its indications and expectations for the future. Results The results were presented at the XX GEB Consensus Meeting held on October 21, 2022, in Valencia (Spain) and it was confirmed that, although there are fewer and fewer centres that use BT in H&N, there are still units with extensive experience in this technique that should be positioned as referral centres. Conclusion It is necessary to carry out continuous work with other specialities involved, such as H&N surgeons, and other radiation oncologists, to improve the training of residents, both oncologists and medical physicists (AU)

Status of head and neck brachytherapy in Spain in 2022.

PURPOSE: Brachytherapy (BT) has been used for many years for disease control in tumours of the head and neck area (H&N). It is currently performed with high dose rate (HDR) or pulsed dose rate (PDR), but its use has been reduced due to the implementation of new non-invasive external beam radiotherapy techniques such as intensity modulation (IMRT) and volumetric modulated arc therapy (VMAT) and the improvement of surgical techniques. METHODS: The Spanish Brachytherapy Group (GEB) has carried out a survey to find out the number of centres in Spain that continue to use BT in H&N and its indications and expectations for the future. RESULTS: The results were presented at the XX GEB Consensus Meeting held on October 21, 2022, in Valencia (Spain) and it was confirmed that, although there are fewer and fewer centres that use BT in H&N, there are still units with extensive experience in this technique that should be positioned as referral centres. CONCLUSION: It is necessary to carry out continuous work with other specialities involved, such as H&N surgeons, and other radiation oncologists, to improve the training of residents, both oncologists and medical physicists.

Accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy compared with whole-breast irradiation with boost for early breast cancer: 10-year results of a GEC-ESTRO randomised, phase 3, non-inferiority trial.

BACKGROUND: Several randomised, phase 3 trials have investigated the value of different techniques of accelerated partial breast irradiation (APBI) for patients with early breast cancer after breast-conserving surgery compared with whole-breast irradiation. In a phase 3 randomised trial, we evaluated whether APBI using multicatheter brachytherapy is non-inferior compared with whole-breast irradiation. Here, we present the 10-year follow-up results. METHODS: We did a randomised, phase 3, non-inferiority trial at 16 hospitals and medical centres in Austria, Czech Republic, Germany, Hungary, Poland, Spain, and Switzerland. Patients aged 40 years or older with early invasive breast cancer or ductal carcinoma in situ treated with breast-conserving surgery were centrally randomly assigned (1:1) to receive either whole-breast irradiation or APBI using multicatheter brachytherapy. Whole-breast irradiation was delivered in 25 daily fractions of 50 Gy over 5 weeks, with a supplemental boost of 10 Gy to the tumour bed, and APBI was delivered as 30·1 Gy (seven fractions) and 32·0 Gy (eight fractions) of high-dose-rate brachytherapy in 5 days or as 50 Gy of pulsed-dose-rate brachytherapy over 5 treatment days. Neither patients nor investigators were masked to treatment allocation. The primary endpoint was ipsilateral local recurrence, analysed in the as-treated population; the non-inferiority margin for the recurrence rate difference (defined for 5-year results) was 3 percentage points. The trial is registered with ClinicalTrials.gov, NCT00402519; the trial is complete. FINDINGS: Between April 20, 2004, and July 30, 2009, 1328 female patients were randomly assigned to whole breast irradiation (n=673) or APBI (n=655), of whom 551 in the whole-breast irradiation group and 633 in the APBI group were eligible for analysis. At a median follow-up of 10·36 years (IQR 9·12-11·28), the 10-year local recurrence rates were 1·58% (95% CI 0·37 to 2·8) in the whole-breast irradiation group and 3·51% (1·99 to 5·03) in the APBI group. The difference in 10-year rates between the groups was 1·93% (95% CI -0·018 to 3·87; p=0·074). Adverse events were mostly grade 1 and 2, in 234 (60%) of 393 participants in the whole-breast irradiation group and 314 (67%) of 470 participants in the APBI group, at 7·5-year or 10-year follow-up, or both. Patients in the APBI group had a significantly lower incidence of treatment-related grade 3 late side-effects than those in the whole-breast irradiation group (17 [4%] of 393 for whole-breast irradiation vs seven [1%] of 470 for APBI; p=0·021; at 7·5-year or 10-year follow-up, or both). At 10 years, the most common type of grade 3 adverse event in both treatment groups was fibrosis (six [2%] of 313 patients for whole-breast irradiation and three [1%] of 375 patients for APBI, p=0·56). No grade 4 adverse events or treatment-related deaths have been observed. INTERPRETATION: Postoperative APBI using multicatheter brachytherapy after breast-conserving surgery in patients with early breast cancer is a valuable alternative to whole-breast irradiation in terms of treatment efficacy and is associated with fewer late side-effects. FUNDING: German Cancer Aid, Germany.

Long-term results with custom-linked iodine-125 seeds and real-time brachytherapy in low- and intermediate-risk prostate cancer.

Purpose: Brachytherapy (BT) with iodine-125 (125I) seeds is effective in low- and intermediate-risk prostate carcinoma, with fewer side effects compared to other techniques, but relapses increase in long-term. In the present paper, 10-year biochemical relapse-free survival (BRFS) results are presented. Material and methods: Between 2007 and 2016, 706 patients were treated with real-time technique using Bard-ProLink™ system. 145 Gy was administered to the prostate with exclusive BT and 108 Gy after 46 Gy of external radiotherapy (EBRT). Androgen deprivation therapy was applied in 19.3% of patients. Results: Median follow-up was 96 months (range, 24-163 months). BRFS at 5 and 10 years was 95% and 91.1%, respectively. For 480 low-risk cases, BRFS at 5 and 10 years was 95.7% and 92.7%, and for 226 intermediate-risk cases, it was 92.7% and 88%, respectively (p < 0.05). With combined treatment of EBRT + BT, 133 cases (59%) of intermediate-risk were treated without differences with exclusive BT. Gleason score 4 + 3 cases dropped to 72.8% at 10 years (p < 0.001), with androgen deprivation therapy (ADT) to 90.9% and without ADT to 66.8%; it was worse if patients had exclusive BT. 10-year BRFS for T1c was 95% compared to 84% for T2 (p < 0.001). Initial prostate specific antigen (PSA) > or < 10 showed no differences. With > 50% biopsy cores positive, it fell to 80% at 10 years (p < 0.001). In 154 patients up to 60 years of age, 10-year BRFS was 97.6%. Urinary complications appeared in 16.9% of cases in exclusive BT vs. 26.1% in EBRT + BT. Grade 2+ urinary late complications were observed in 19.1% and grade 3+ in 5.8% of patients. Rectal toxicity was 4% (2.5% in BT alone and 10.1% in RT + BT), while G3+ was seen in 0.1%. Conclusions: Real-time BT with custom-linked 125I seeds is a very effective long-term treatment in low- and intermediate-risk prostate carcinoma. With Gleason score 4 + 3 or > 50% biopsy cores positive, we recommend combined treatment with additional ADT for 6 months.

High-dose-rate brachytherapy (interventional radiotherapy) in lip carcinoma with rigid needles: a simple technique with excellent results.

Lip carcinoma has been treated for years with low-dose-rate (LDR) brachytherapy, achieving local control greater than 90%. Comparison between LDR and high-dose-rate (HDR) showed that they are equivalently efficient in local control, but HDR results in fewer complications. Interstitial implant of rigid needles or plastic tubes (interventional radiotherapy) is the current standard. Lip carcinomas are usually exophytic, and rigid parallel needles allow for a better dose distribution with more homogeneity, by adding needles placed outside the tissue to cover protruding lesions. Treatment is administered in 5 days, B.I.D. 4.5-5 Gy × 9 fractions. This pictorial essay illustrates the technique of implanting rigid needles in post-operative cases of early and advanced carcinomas of the lip. This technique is straightforward to learn, and is practical and safe with appropriate training. It should be considered in selected patients with lip carcinoma as the first therapeutic option. Departments with HDR brachytherapy units and experienced in interventional radiotherapy should be offering such treatment, as it greatly benefits patients with lip cancer diagnosis.

H&N and Skin (HNS) GEC-ESTRO Working Group critical review of recommendations regarding prescription depth, bolus thickness and maximum dose in skin superficial brachytherapy with flaps and customized moulds.

The aim of this publication is the assessment of the existing guidelines for non-melanoma skin cancer (NMSC) superficial brachytherapy (BT) and make a critical review based on the existing literature about the maximum dose prescription depth, bolus thickness and maximum skin surface dose (Dmax) of the published clinical practice. A systematic review of NMSC superficial BT published articles was carried out by the GEC-ESTRO Head & Neck and Skin (HNS) Working Group (WG). 10 members and 2 external reviewers compared the published clinical procedures with the recommendations in the current guidelines and examined the grade of evidence. Our review verified that there is a large variation among centres with regards to clinical practice in superficial BT and identified studies where published parameters such as maximum dose prescription depth, bolus thickness and Dmax exceed the constraints recommended in the guidelines, while showing excellent results in terms of local control, toxicity and cosmesis. This review confirmed that current recommendations on skin superficial BT do not include published experience on tumours treated with superficial BT that require dose prescription depth beyond the recommended 5 mm under the skin surface and that the existing literature does not provide sufficient evidence to relate dosimetry of superficial BT to patient reported outcome measures. The GEC-ESTRO HNS WG considers acceptable to prescribe superficial BT dose at a depth above 5 mm beyond the skin surface, and modify the bolus thickness to optimize the treatment plan and adjust the acceptable maximum dose on the skin surface, all pending clinical situation.

Is perioperative brachytherapy effective in carcinoma of the tongue?

Purpose: To analyze the results of patients treated with perioperative interstitial brachytherapy (ISBT) in tongue carcinoma (TC). Material and methods: From April 2009 to May 2015, 43 squamous cell carcinoma consecutive patients diagnosed with TC were treated with limited partial glossectomy and perioperative ISBT, using high-dose-rate (HDR). Twenty- seven patients were treated by brachytherapy (BT), and sixteen received BT as a complement to subsequent external beam radiotherapy (EBRT) after results of lymph node dissection. Median age was 66 years. Distribution by stage, included 10 patients stage I, 14 stage II, 10 stage III, and 9 stage IV. Eighteen patients had negative margins, nineteen margin involvement, and in six cases, the margin was < 5 mm. Results: With a median follow-up of 54 months, LC at 3 and 5 years was 87% and 84%, respectively. LC was 95% at five years in patients with clear margins, and 75% with involved margins. LC in N0 patients treated with BT was 83% at 5 years, and in patients N+ with posterior EBRT treatment, LC was 86%. By tumor size, we found one local relapse in 13 cases T1, in 5 of 27 patients T2 was found, and no local relapse T3 with LC of 87%, 70%, and 100% respectively at five years. Regional control (RC) was 81% at 3 and 5 years. We found a metastasis-free survival of 91% at 3- and 5-year. Twenty-three patients have died, 11 of them due to other causes, with overall survival of 56% at three years and 53% at five years. Conclusions: Combined treatment with conservative surgery and ISBT shows similar results to radical surgery or RT alone, allowing a more patient-tailored approach, with good organ function preservation and cosmetic outcomes.

Choroidal Melanoma with Ultrasound-Guided Episcleral Brachytherapy: Long-Term Results and Risk of Metastasis.

INTRODUCTION: The aim of this study was to elucidate the long-term outcomes in patients with choroidal melanoma who received episcleral brachytherapy with 125-I seeds; analyse cause-specific survival (CSS), metastasis-free survival (MFS), and local control; and establish the relationship between tumour size and metastases. METHODS: From May 2007 to February 2013, 88 patients classified according to the American Joint Committee on Cancer guidelines underwent ultrasound-guided episcleral brachytherapy with a total prescribed dose of 72.40 Gy to the apex. RESULTS: Among the included cases, 47.7 and 44.3% had a clinical tumour stage of T2 and T3, respectively. With a median follow-up of 84 (range 7-153) months, local control at 5 and 10 years was 100 and 95%, respectively. Among the 88 patients, 9 (10.2%) were enucleated after brachytherapy. Those with T1-T2 and T3-T4 disease had a 10-year CSS of 100 and 87.3%, respectively (p = 0.017). MFS at 5 and 10 years was 100% in those with T1-T2 disease and 92.1 and 83.1% in those with T3-T4, respectively (p = 0.016). Five patients had liver metastases, all of whom had T3-T4 disease. CONCLUSION: Ultrasound-guided episcleral brachytherapy with 125-I seeds yielded excellent local control for choroidal melanoma, with low complication rates and 90% eye preservation. Given the association between tumour stage and liver metastases, which remain the main cause of death, stricter control should be employed for T3-T4 tumours for the early detection and treatment of relapses.

Very accelerated partial breast irradiation Phase I-II multicenter trial (VAPBI): Feasibility and early results.

PURPOSE: This is a multicenter Phase I-II trial endorsed by the GEC-ESTRO Breast Working Group, to analyze if very accelerated partial breast irradiation (VAPBI) with multicatheter interstitial brachytherapy is feasible and safe compared with the standard APBI treatment in 4-5 days for early stage breast carcinomas. METHODS AND MATERIALS: We have included 81 patients with pT1-2 pN0 invasive carcinomas after breast-conserving surgery. Between August 2017 and July 2019, 33 women received high-dose-rate brachytherapy, four fractions of 6.25 Gy in 2-3 days, and 48 patients received three fractions of 7.45 Gy in 2 days. Thirty-six patients were implanted perioperatively and 45 postoperatively. Mean age was 68 (51-90). Free surgical margins were of 2 mm or greater. RESULTS: Acute effects were 11% dermatitis, 18.5% hematoma, 3.7% infection, and 14.8% pain. At a median followup of 20 months (range 8-35), no relapse has occurred. Pigmentation changes in the entrance and exit of tubes were visible in 16%, but 1 year later, few cases remained. Patients developed G1-2 induration or fibrosis in 18.5% and 2.5%, respectively. No patient developed telangiectasia. The cosmetic outcome was good/excellent in 97.5% and fair in 2.5%. CONCLUSIONS: VAPBI with multicatheter interstitial brachytherapy using four fractions of 6.25 Gy or three fractions of 7.45 Gy in two or 3 days is feasible. No excess has been observed in acute effects. At a mean followup of 20 months, late side effects seem to be similar to standard fractionation. VAPBI in two to 3 days is beneficial for the patients and reduces the workload of the brachytherapy units.

INTERACTS (INTErventional Radiotherapy ACtive Teaching School) consensus conference on sarcoma interventional radiotherapy (brachytherapy) endorsed by AIRO (Italian Association of Radiotherapy and Clinical Oncology).

PURPOSE: To report the results of INTERACTS (INTErventional Radiotherapy ACtive Teaching School) consensus conference on sarcoma interventional radiotherapy (brachytherapy). MATERIAL AND METHODS: An international board of multidisciplinary experts was invited to a consensus conference on the state-of-the-art of sarcoma interventional oncology during the 9th Rome INTER-MEETING (INTERventional Radiotherapy Multidisciplinary Meeting), proposing 3 statements for each one speech. At the end of each lecture, the entire group of experts was invited to vote with an electronic device. The preliminary results were presented and discussed at the end of the meeting, during a dedicated session. After the meeting, a survey was distributed within the consensus conference board to share and definitively vote the statements. RESULTS: All the invited authors of the consensus conference board completed the final survey. All the 38 statements received more than 70% of agreement, 31 statements (82%) obtained an agreement of level higher or equal to 90%, 6 statements (15.8%) received an agreement level between 80% and 90%, and 1 statement (2.6%) had less than 80% of agreement. CONCLUSIONS: The consensus conference demonstrated that interventional radiotherapy must be considered by a multidisciplinary management of patients affected by sarcoma.

Should high-dose-rate brachytherapy boost be used in early nasopharyngeal carcinomas?

BACKGROUND: Radiation with or without chemotherapy is the main treatment of nasopharyngeal carcinomas (NPC). Local recurrence is difficult to manage. Local control is dose-dependent. AIM: To analyze the effect of an endocavitary brachytherapy boost after external beam radiation (EBRT) to decrease local recurrence. MATERIAL AND METHODS: Thirty patients with T0-T2 NPC were treated: 70% T1, 20% T2 and 10% T0; 33.3% N0, 20% N1, 43.3% N2 and 3.3% N3; 90% were undifferentiated carcinoma. All they received a 192-Ir high dose rate brachytherapy (HDR-BT) boost after 60 Gy of EBRT. The Rotterdam applicator was used in most cases, 3-4 fractions of 3.75-3 Gy in two days. RESULTS: With median follow-up (FU) of 63 months, a single parapharyngeal failure resulted in local control of 100% at 3 years and 95% at 5 years. Local control for T0-1 was 100% and for T2 67% at five years (p = 0.02). Regional-free recurrence survival was 92% at 5 years. Metastasis-free survival was 84% at 5 years. All cases of metastasis had histopathology of undifferentiated. The overall and cause-specific survival was 96% and 86% at 3 and 5 years. No late complications related to brachytherapy were described. CONCLUSION: A HDR-BT boost is useful to decrease the incidence of local recurrence of NPC to 5%. With a fractionated schedule of 3-4 fractions in two days, Rotterdam applicator and 3-D planning, no late complications are described. Therefore we recommend to use brachytherapy boost in all early NPC.

SKIN-COBRA (Consortium for Brachytherapy data Analysis) ontology: The first step towards interdisciplinary standardized data collection for personalized oncology in skin cancer.

PURPOSE: The primary objective of the SKIN-COBRA (Consortium for Brachytherapy data Analysis) ontology is to define a specific terminological system to standardize data collection for non-melanoma skin cancer patients treated with brachytherapy (BT, interventional radiotherapy). Through ontological characterization of information, it is possible to find, isolate, organize, and integrate its meaning. MATERIAL AND METHODS: SKIN-COBRA is a standardized data collection consortium for non-melanoma skin patients treated with BT, including 8 cancer centers. Its ontology was firstly defined by a multicentric and multidisciplinary working group and evaluated by the consortium, followed by a multi-professional technical commission involving a mathematician, an engineer, a physician with experience in data storage, a programmer, and a software expert. RESULTS: Two hundred and ninety variables were defined in 10 input forms. There are 3 levels, with each offering a specific type of analysis: 1. Registry level (epidemiology analysis); 2. Procedures level (standard oncology analysis); 3. Research level (radiomics analysis). The ontology was approved by the technical commission and consortium, and an ad-hoc software system was defined to be implemented in the SKIN-COBRA consortium. CONCLUSIONS: Large databases are natural extension of traditional statistical approaches, a valuable and increasingly necessary tool for modern healthcare system. Future analysis of the collected multinational and multicenter data will show whether the use of the system can produce high-quality evidence to support multidisciplinary management of non-melanoma skin cancer and utilizing this information for personalized treatment decisions.

Can invasive breast carcinoma with close or positive margins be managed without a new surgery?

We present the long-term outcome (FU 127 months) of a prospective study with 248 breast cancer patients with close or positive surgical margin, treated with 50 Gy whole breast irradiation plus high-dose-rate boost, 3 × 4.4 Gy. Actuarial breast failure at 10/15 years was 6.5%/11.6%; with positive margin (120) 6.8%/14.8%, with margin ≤2 mm (76) 9.8%/9.8%, with margin >2 mm <5 mm (52) 2%/2%. In 90 patients aged ≤50 was 11.9%/17.8%, between 51 and 70, 3.8%/8.2%, >70, 0%. Fibrosis appeared in 26.7%. Cosmetic outcome was excellent/good in 85.8%. This approach avoids a second surgery in women >50 with positive surgical margin, or with close margins in all ages.

ENT COBRA ONTOLOGY: the covariates classification system proposed by the Head & Neck and Skin GEC-ESTRO Working Group for interdisciplinary standardized data collection in head and neck patient cohorts treated with interventional radiotherapy (brachytherapy).

PURPOSE: Clinical data collecting is expensive in terms of time and human resources. Data can be collected in different ways; therefore, performing multicentric research based on previously stored data is often difficult. The primary objective of the ENT COBRA (COnsortium for BRachytherapy data Analysis) ontology is to define a specific terminological system to standardized data collection for head and neck (H&N) cancer patients treated with interventional radiotherapy. MATERIAL AND METHODS: ENT-COBRA is a consortium for standardized data collection for H&N patients treated with interventional radiotherapy. It is linked to H&N and Skin GEC-ESTRO Working Group and includes 11 centers from 6 countries. Its ontology was firstly defined by a multicentric working group, then evaluated by the consortium followed by a multi-professional technical commission involving a mathematician, an engineer, a physician with experience in data storage, a programmer, and a software expert. RESULTS: Two hundred and forty variables were defined on 13 input forms. There are 3 levels, each offering a specific type of analysis: 1. Registry level (epidemiology analysis); 2. Procedures level (standard oncology analysis); 3. Research level (radiomics analysis). The ontology was approved by the consortium and technical commission; an ad-hoc software architecture ("broker") remaps the data present in already existing storage systems of the various centers according to the shared terminology system. The first data sharing was successfully performed using COBRA software and the ENT COBRA Ontology, automatically collecting data directly from 3 different hospital databases (Lübeck, Navarra, and Rome) in November 2017. CONCLUSIONS: The COBRA Ontology is a good response to the multi-dimensional criticalities of data collection, retrieval, and usability. It allows to create a software for large multicentric databases with implementation of specific remapping functions wherever necessary. This approach is well-received by all involved parties, primarily because it does not change a single center's storing technologies, procedures, and habits.

Quality-of-life results for accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation in early breast cancer after breast-conserving surgery (GEC-ESTRO): 5-year results of a randomised, phase 3 trial.

BACKGROUND: Previous results from the GEC-ESTRO trial showed that accelerated partial breast irradiation (APBI) using multicatheter brachytherapy in the treatment of early breast cancer after breast-conserving surgery was non-inferior to whole-breast irradiation in terms of local control and overall survival. Here, we present 5-year results of patient-reported quality of life. METHODS: We did this randomised controlled phase 3 trial at 16 hospitals and medical centres in seven European countries. Patients aged 40 years or older with 0-IIA breast cancer were randomly assigned (1:1) after breast-conserving surgery (resection margins ≥2 mm) to receive either whole-breast irradiation of 50 Gy with a boost of 10 Gy or APBI using multicatheter brachytherapy. Randomisation was stratified by study centre, tumour type, and menopausal status, with a block size of ten and an automated dynamic algorithm. There was no masking of patients or investigators. The primary endpoint of the trial was ipsilateral local recurrence. Here, we present 5-year results of quality of life (a prespecified secondary endpoint). Quality-of-life questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30, breast cancer module QLQ-BR23) were completed before radiotherapy (baseline 1), immediately after radiotherapy (baseline 2), and during follow-up. We analysed the data according to treatment received (as-treated population). Recruitment was completed in 2009, and long-term follow-up is continuing. The trial is registered at ClinicalTrials.gov, number NCT00402519. FINDINGS: Between April 20, 2004, and July 30, 2009, 633 patients had accelerated partial breast irradiation and 551 patients had whole-breast irradiation. Quality-of-life questionnaires at baseline 1 were available for 334 (53%) of 663 patients in the APBI group and 314 (57%) of 551 patients in the whole-breast irradiation group; the response rate was similar during follow-up. Global health status (range 0-100) was stable in both groups: at baseline 1, APBI group mean score 65·5 (SD 20·6) versus whole-breast irradiation group 64·6 (19·6), p=0·37; at 5 years, APBI group 66·2 (22·2) versus whole-breast irradiation group 66·0 (21·8), p=0·94. The only moderate, significant difference (difference of 10-20 points) between the groups was found in the breast symptoms scale. Breast symptom scores were significantly higher (ie, worse) after whole-breast irradiation than after APBI at baseline 2 (difference of means 13·6, 95% CI 9·7-17·5; p<0·0001) and at 3-month follow-up (difference of means 12·7, 95% CI 9·8-15·6; p<0·0001). INTERPRETATION: APBI with multicatheter brachytherapy was not associated with worse quality of life compared with whole-breast irradiation. This finding supports APBI as an alternative treatment option after breast-conserving surgery for patients with early breast cancer. FUNDING: German Cancer Aid.

ESTRO-ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated Partial Breast Irradiation alone or as boost - GEC-ESTRO Breast Cancer Working Group practical recommendations.

PURPOSE: This consensus statement from the Breast Cancer Working Group of Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) aims at generating practical guidelines for multi-catheter image-guided brachytherapy in the conservative management of breast cancer patients used for either Accelerated Partial Breast Irradiation (APBI) or for a breast boost. METHODS: Recent advances in techniques of multi-catheter brachytherapy were summarized and all the relevant literature was reviewed by a panel of experts. Panel members of the GEC-ESTRO experts participated in a series of conferences, supplemented their clinical experience, were surveyed to determine their current practices and patterns, performed a literature review, and formulated recommendations for implementing APBI with multi-catheter brachytherapy, focusing on treatment planning issues, catheter insertion, dosimetry and quality assurance. This document was reviewed and approved by the full panel, the GEC-ESTRO executive board and by the ACROP (Advisory Committee on Radiation Oncology Practice). RESULTS: Three-dimensional (3D) treatment planning, catheter insertion techniques, dosimetry and methods of quality assurance for APBI and boost with multi-catheter image-guided brachytherapy after breast conserving surgery are described. Detailed recommendations for daily practice including dose constraints are given. CONCLUSIONS: Recent standards and guidelines for the use of APBI with different multi-catheter image-guided brachytherapy techniques have been defined. Different techniques are used to insert the catheters. Guidelines are mandatory to assure precise catheter insertion for coverage of the target volume and to guarantee high-quality dosimetry. The same rules apply for brachytherapy based boost irradiation for breast cancer after whole breast irradiation as well as for partial breast re-irradiation.

High-dose-rate interstitial brachytherapy boost in inoperable locally advanced tongue carcinoma.

PURPOSE: Locally advanced tongue carcinomas (LATCs) in inoperable lesions are managed with external beam radiation therapy (EBRT) and chemotherapy. In our institution, the boost to the gross tumor volume is delivered with high-dose-rate brachytherapy (HDR-BT) after EBRT. We review the outcome of these patients when HDR-BT is added as a boost. METHODS AND MATERIALS: From May 2000 to December 2014, a total of 24 patients with LATC, nonsurgical oral tongue, and base of tongue carcinomas were treated with EBRT and with interstitial plastic tubes for brachytherapy; median dose was 18-24 Gy in 6-8 fractions after 50-60 Gy of EBRT. Mean age was 60 years, 20 men and 4 women. The distribution by stages was 11 patients in Stage III and 13 patients in Stage IV. All cases but one received chemotherapy. RESULTS: With a median followup of 44 months, local control (LC) rate at 4 years was 80% for the entire group, 78% in Stage III, and 90% in Stage IV. The cause-specific survival was 68% at 4 years; the regional control was 76%. Four patients developed distant metastasis with disease free from distant metastasis of 77% at 4 years. The overall survival was 68% at 4 years. CONCLUSIONS: HDR-BT yields similar results to low dose rate in treatment of patients with LATC, with better results than those reported with exclusive EBRT. HDR-BT allows to increase the local dose, with good LC rates. In patients with large tumors requiring very mutilating surgery and patients who refuse surgery, EBRT with HDR-BT boost is a good option to increase the LC and cause-specific survival while keeping a better functional outcome.