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GEC-ESTRO Breast

 

The Breast Cancer Working Group (BCWG) of GEC-ESTRO deals with clinical and technical issues of breast brachytherapy. In the past the BCWG work mainly focused on the indications, techniques and quality assurance of traditional breast brachytherapy used as a boost after external beam whole breast irradiation. However, the new concept of accelerated partial breast irradiation (APBI) opened a new perspective for breast brachytherapy. Many groups in Europe have implemented multicatheter brachytherapy technique and 3-D CT image-based brachytherapy treatment planning for the management of breast cancer. Image-guided postoperative approach or per-operative implantation are the new standards for APBI. The new tendency is toward hypofractionation (3-4 fractions) or ultra-APBI (single shot). Reexcision followed by reirradiation using interstitial breast implants has been also implemented as a valid alternative to mastectomy to treat ipsilateral breast local recurrence after previous breast-conserving therapy. These developments all together opened new horizon for clinical research in breast brachytherapy.

Currently the group has 37 members from 13 countries, mainly in Europe, although we have also members from India. The Chair is Csaba Polgar, Professor in the National Institute of Oncology from Budapest, Hungary, and the Secretary is Cristina Gutiérrez, Professor in Hospital del Mar, Barcelona and Consultant at the Catalan Institute of Oncology.


Past trials and publications:


In the last years, we have finished several trials, that have originated these publications:

1. Randomised Multicentric Phase III APBI Trial

One of the most important projects of the BCWG was the development and conduction of the first European multicentric phase 3 breast brachytherapy trial comparing the efficacy of multicatheter APBI to conventional whole breast irradiation (WBI). The study was supported by a grant from the German Cancer Aid. Between May 2004 and July 2009, 1233 patients have been randomized in 16 centres from 7 European countries. The results confirm the non-inferiority of APBI compared to WBI: the 10-year local recurrence rates were 1·58% in the WBI group and 3·51% in the APBI group [1], with very low side effects [2] and excellent quality of life [3].

2. Very accelerated partial breast irradiation Phase I-II multicenter trial (VAPBI):

Following the actual tendency towards hypofractionation, this prospective study included 81 patients and proved that 4 or even 3 fractions is as effective and safe as the previous APBI studies with 7-10 fractions. After a median follow-up of 62 months, the 5-year actuarial breast recurrence was 3.4 %, with only fibrosis or slight induration (G1) in 22.2 % and G2 in 9.9 %. Cosmetic outcome was good or excellent in 95 % [4].

In the same line, we performed a big retrospective, observational, international multicenter study with APBI in 4, 3, or 1 fraction. 516 pts with early breast cancer were enrolled. With a median follow-up was 44 months, 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. Four-year cumulative incidence rates of LR was 2 % [5].

3. Salvage BT for relapses

In patients experiencing a relapse or a second tumour after a first conservative treatment with surgery and WBI, mastectomy is no longer the only option. We published a Propensity Score-Matched Cohort Analysis comparing 377 mastectomies and 377 conservative treatments. After a median follow-up of 74 months, no differences in 5-year overall survival and cumulative incidence of third breast event were noted between mastectomy and conservative treatment [6]. In the same line, an analysis of clinical practices was conducted across 7 academic hospitals/cancer centres in 6 European countries based on the GEC-ESTRO database. 508 patients received a 2nd CT, and after a median follow-up of 60.9 months, the 5-year second local relapse CI rate was 4% and the 5-year distant metastasis disease rate was 7%. G≥3 late toxicity rate was 12.1% [7].
 

Currents trials:


A trial on ultra-APBI, delivering a single shot of 16 Gy has just started in July 2025. We want to include 250 patients in 2 years from 22 centres. The primary endpoint is the five-year incidence of late ≥ grade 2 side effects, and as secondary endpoint the rate of ipsilateral breast recurrence.

We are working on new trials using ultra-APBI in very low breast cancer patients, for example avoiding axillary sentinel node or avoiding hormonal therapy.


Development of guidelines and recommendations for breast brachytherapy: 


The group has published different guidelines regarding different aspects of breast brachytherapy:

  1. Patient selection for accelerated partial breast irradiation (APBI) after breast-conserving surgery: Recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) Breast Cancer Working Group based on clinical evidence:  published in Radiotherapy and Oncology in 2009 [8]. Currently the group is actualizing the guidelines according the recent evidence.
  2. Risk factors and state-of-the-art indications for boost irradiation in invasive breast carcinoma [9].
  3. Recommendations from GEC ESTRO Breast Cancer Working Group: Target definition and target delineation for accelerated or boost partial breast irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery [10] or after open-closed cavity [11].
  4. 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 [12].
  5. Post- versus intra-operative implant for breast cancer interstitial brachytherapy: How to choose? [13].

The BCWG meets on-site twice a year (during annual ESTRO and GEC-ESTRO meetings) to discuss progress on current and proposals for future projects, and we also have on-line meetings in the interval. We would welcome new active members for a joint adventure for the future of breast brachytherapy!  

Contact:

 Csaba Polgar, Chairman, Breast Cancer Working Group of GEC-ESTRO: polgar.c@outlook.com

and/or

 Cristina Gutiérrez, Secretary: cristina.gutierrez@hmar.cat

 

References:
 

  1. Strnad V, Polgár C, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, Łyczek J, Guinot JL, Gutierrez Miguelez C, Slampa P, Allgäuer M, Lössl K, Polat B, Fietkau R, Schlamann A, Resch A, Kulik A, Arribas L, Niehoff P, Guedea F, Dunst J, Gall C, Uter W; Groupe Européen de Curiethérapie and European Society for Radiotherapy and Oncology. 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. Lancet Oncol. 2023 Mar;24(3):262-272. doi: 10.1016/S1470-2045(23)00018-9. Epub 2023 Feb 1. PMID: 36738756.
  2. Polgár C, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). Late side-effects and cosmetic results of accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: 5-year results of a randomised, controlled, phase 3 trial. Lancet Oncol. 2017 Feb;18(2):259-268. doi: 10.1016/S1470-2045(17)30011-6.
  3. Schäfer R, Strnad V, Polgár C, Uter W, Hildebrandt G, Ott et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 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. Lancet Oncol. 2018 Jun;19(6):834-844. doi: 10.1016/S1470-2045(18)30195-5.
  4. Guinot JL, Gonzalez-Perez V, Meszaros N, Major T,Najjari-Jamal D, Gutierrez-Miguelez C, Santos MA, Smanyko V, Laplana M, Polgar C; GEC-ESTRO Breast Working Group. Very accelerated partial breast irradiation Phase I-II multicenter trial (VAPBI): Feasibility and early results. Brachytherapy. 2020 Nov 19:S1538-4721(20)30229-4. doi: 10.1016/j.brachy.2020.10.010.
  5. Hannoun-Levi JM, Gimeno Morales M, Gal J, Anchuelo J, Guinot JL, Gaztañaga M, Meszaros N, Polgar C, Strnad V, Schiappa R, Gutierrez C. Very accelerated partial breast irradiation in 1 or 2 days: Late toxicity and early oncological outcome of the GEC-ESTRO VAPBI cohort. Radiother Oncol. 2024 May;194:110217. doi: 10.1016/j.radonc.2024.110217. Epub 2024 Mar 8. PMID: 38460552.
  6. Hannoun-Levi JM, Gal J, Van Limbergen E, Chand ME, Schiappa R, Smanyko Vet al. Salvage Mastectomy Versus Second Conservative Treatment for Second Ipsilateral Breast Tumor Event: A Propensity Score-Matched Cohort Analysis of the GEC-ESTRO Breast Cancer Working Group Database. Int J Radiat Oncol Biol Phys. 2020 Dec 29:S0360-3016(20)34722-2. doi: 10.1016/j.ijrobp.2020.12.029
  7. Hannoun-Levi JM, Gal J, Polgar C, Strnad V, Loessl K, Polat B, Kauer-Domer D, Schiappa R, Gutierrez C. Second Conservative Treatment for Local Recurrence Breast Cancer: A GEC-ESTRO Oncological Outcome and Prognostic Factor Analysis. Int J Radiat Oncol Biol Phys. 2023 Dec 1;117(5):1200-1210. doi: 10.1016/j.ijrobp.2023.06.075. Epub 2023 Jul 15. PMID: 37459998.
  8. Polgár C, Van Limbergen E, Pötter R, Kovács G, Polo A, Lyczek J, Hildebrandt G, Niehoff P, Guinot JL, Guedea F, Johansson B, Ott OJ, Major T, Strnad V: Patient selection for accelerated partial breast irradiation (APBI) after breast-conserving surgery: Recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) Breast Cancer Working Group based on clinical evidence (2009) Radiother Oncol 2010; 94:264-273  
  9. Polo A, Polgár C, Hannoun-Levi JM, Guinot JL, Gutierrez C, Galalae R, van Limbergen E, Strnad V. Risk factors and state-of-the-art indications for boost irradiation in invasive breast carcinoma. Brachytherapy. 2017 May-Jun;16(3):552-564. doi: 10.1016/j.brachy.2017.03.003. Epub 2017 Apr 1. PMID: 28377213.
  10. Strnad V, Hannoun-Levi JM, Guinot JL, Lössl K, Kauer-Dorner D, Resch A, Kovács G, Major T, Van Limbergen E; Working Group Breast Cancer of GEC-ESTRO. Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol. 2015 Jun;115(3):342-8. doi: 10.1016/j.radonc.2015.06.010. Epub 2015 Jun 20. PMID: 26104975.
  11. Major T, Gutiérrez C, Guix B, van Limbergen E, Strnad V, Polgár C; Breast Cancer Working Group of GEC-ESTRO. Recommendations from GEC ESTRO Breast Cancer Working Group (II): Target definition and target delineation for accelerated or boost partial breast irradiation using multicatheter interstitial brachytherapy after breast conserving open cavity surgery. Radiother Oncol. 2016 Jan;118(1):199-204. doi: 10.1016/j.radonc.2015.12.006. Epub 2016 Jan 8. PMID: 26776444.
  12. Strnad V, Major T, Polgar C, Lotter M, Guinot JL, Gutierrez-Miguelez C et al. 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. Radiother Oncol. 2018 Sep;128(3):411-420. doi: 10.1016/j.radonc.2018.04.009.
  13. Gimeno-Morales M, Motisi L, Rodriguez-Spiteri N, Martínez-Regueira F, Worthington T, Therapist R, Strnad V, Hannoun-Levi JM, Gutierrez C; Working Group Breast Cancer of GEC ESTRO. Post- versus intra-operative implant for breast cancer interstitial brachytherapy: How to choose? J Contemp Brachytherapy. 2024 Feb;16(1):72-83. doi: 10.5114/jcb.2024.135635. Epub 2024 Feb 23. PMID: 38584881; PMCID: PMC10993897.