The GI GEC working group covers brachytherapy throughout the GI tract, including hepatobiliary. The group aim to promote the use of brachytherapy in the GI tract, encouraging clinical trials, outcomes publications, training courses and scientific meetings.
Rectal brachytherapy has an established role which has been further strengthened by the publication of the OPERA trial (clinical trials.gov NCT02505750) 5 year outcomes earlier this year[1]. It was a phase 3 multi-centre European trial evaluating the role of contact brachytherapy (CXB) for cT2cT3a /cN0cN1 rectal cancers measuring < 5cm. The end point of organ preservation at 5 years showed 79% (CXB boost) versus 56% (EBRT boost) with a rate of 93% organ preservation in patients with tumours <3cm. With the publication of the OPRA trial [2] showing that chemoradiotherapy followed by consolidation chemotherapy resulted in higher rates of organ preservation than induction chemotherapy, the OPERA trial has added further confidence in a non-operative approach. Further trials will examine the role of chemotherapy, immunotherapy and local surgery in combination with CXB.
The Morpheus trial in the US will be an interesting addition when recruitment completes, as it is examining the role of high dose rate (HDR) rectal brachytherapy in a patient population similar to OPERA [3]. The GI GEC group are writing guidelines for HDR rectal brachytherapy. During the development process, it was noted that there is no standardisation of target definition and dose reporting so the first stage of the guideline process has been to standardise target volume and organ at risk definition [4]. This stage of the guidelines will be published soon and be followed by dose and volume reporting and finally patient selection, dose prescription and treatment planning.
The Guildford database has been developed to enter demographics and outcomes for rectal cancer patients, including those receiving HDR or CXB. Please visit www.colorectaldatabase.com to sign up for use. The database was developed using charity funding and is free to use. The GI GEC group have used this database to publish outcomes on patients receiving CXB and short course radiotherapy [5], CXB as sole treatment [6] and a meta-analysis of CXB use [7]. The CITRuS trial recruited 380 patients from 26 centres, including 4 delivering CXB, examining PROs using an electronic database [8]. CITRuS2 will incorporate interventions delivered electronically triggered by responses on the PRO questionnaires, endeavouring to determine if delivery of early electronic interventions confers a benefit in health economics.
Anal cancer brachytherapy has somewhat fallen by the wayside with the advent of simultaneous integrated boost and IMRT. However it remains a very useful tool in the armamentarium so it is very important that the skill of anal cancer brachytherapy is not lost. GI GEC are developing an anal cancer boost trial and looking to develop a database to start reporting combined outcomes and prospective data.
Liver brachytherapy is increasing in uptake, particularly in Germany [9]. GI GEC would like to see this trend spread across Europe. There’s a role for stereotactic radiotherapy and radio-frequency ablation so where does brachytherapy fit? The GI GEC liver brachytherapy guidelines will be published soon which will help to answer this question and to support departments to develop this technique. We’d love to see more brachytherapy outcomes and trials for oesophageal and biliary brachytherapy and are working towards that.
If you are interested in any of our activities and would like to join the group please contact:
Dr Alex Stewart, Royal Surrey Cancer Centre, Royal Surrey Hospital, Guildford, UK
Alexandra.stewart@nhs.net
We are particularly keen to grow the input for GI brachytherapy for disease sites other than rectum so please step forward and get involved.
References
1. Baron D, et al., A phase III randomised trial on the addition of a contact X-ray brachytherapy boost to standard neoadjuvant chemo-radiotherapy for organ preservation in early rectal adenocarcinoma: 5 year results of the OPERA trial. Ann Oncol, 2025. 36(2): p. 208-215.
2. Garcia-Aguilar J, et al., Organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy. J Clin Oncol, 2022. 40(23): p. 2546–2556.
3. Garant A, et al., MORPHEUS Phase II-III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results. Cancers (Basel), 2022. 14(15): p. 3665.
4. Van Limbergen EJ, et al., Endorectal contact radiation boosting: Making the case for dose AND volume reporting. Brachytherapy, 2022. 21(6): p. 887-895.
5. Steinke J, et al., Planned organ preservation for patients with rectal cancer using short course radiotherapy and a Papillon boost-an international multi-institution analysis. Clin Transl Radiat Oncol, 2023. 39: p. 100580.
6. Wah Than N, et al., Contact X-ray Brachytherapy as a sole treatment in selected patients with early rectal cancer - Multi-centre study. Clin Transl Radiat Oncol, 2024. 49: p. 100851.
7. Powell SG, et al., Contact X-ray brachytherapy in rectal cancer: A systematic review and meta-analysis. Eur J Surg Oncol, 2025. 51(7): p. 109976.
8. Baird P, et al., Assessment of Quality of Life in Rectal Cancer with Organ-Preservation Treatment: Are We There yet? Clin Oncol (R Coll Radiol). 35(2): p. e110-e120.
9. Tselis N, et al., Computed tomography-guided interstitial high dose rate brachytherapy for centrally located liver tumours: a single institution study. Eur Radiol, 2013. 23: p. 2264-2270.