Richard Pötter a , 1 , Kari Tanderup b , 1 , * , Christian Kirisits a , Astrid de Leeuw c , Kathrin Kirchheiner a , Remi Nout d , Li Tee Tan e , Christine Haie-Meder f , Umesh Mahantshetty g , Barbara Segedin h , Peter Hoskin i , Kjersti Bruheim j , Bhavana Rai k , Fleur Huang l , Erik Van Limbergen m , Max Schmid a , Nicole Nesvacil a , Alina Sturdza a , Lars Fokdal b , Nina Boje Kibsgaard Jensen b , Dietmar Georg a , Marianne Assenholt b , Yvette Seppenwoolde a , Christel Nomden c , Israel Fortin a , o , Supriya Chopra g , Uulke van der Heide n , Tamara Rumpold a , Jacob Christian Lindegaard b , Ina Jürgenliemk-Schulz c , the EMBRACE Collaborative Group 2
11 January 2018
Image guided adaptive brachytherapy (IGABT) is changing clinical practice.
The EMBRACE studies benchmark IGABT in cervix cancer.
A multi-parametric dose prescription protocol is being validated in EMBRACE II.
EMBRACE II is hypothesised to improve outcome: disease, morbidity, quality of life.
The publication of the GEC-ESTRO recommendations one decade ago was a significant step forward for reaching international consensus on adaptive target definition and dose reporting in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Since then, IGABT has been spreading, particularly in Europe, North America and Asia, and the guidelines have proved their broad acceptance and applicability in clinical practice. However, a unified approach to volume contouring and reporting does not imply a unified administration of treatment, and currently both external beam radiotherapy (EBRT) and IGABT are delivered using a large variety of techniques and prescription/fractionation schedules.
With IGABT, local control is excellent in limited and well-responding tumours. The major challenges are currently loco-regional control in advanced tumours, treatment-related morbidity, and distant metastatic disease. Emerging evidence from the RetroEMBRACE and EMBRACE I studies has demonstrated that clinical outcome is related to dose prescription and technique. The next logical step is to demonstrate excellent clinical outcome with the most advanced EBRT and brachytherapy techniques based on an evidence-based prospective dose and volume prescription protocol.
The EMBRACE II study is an interventional and observational multicentre study which aims to benchmark a high level of local, nodal and systemic control while limiting morbidity, using state of the art treatment including an advanced target volume selection and contouring protocol for EBRT and brachytherapy, a multi-parametric brachytherapy dose prescription protocol (clinical validation of dose constraints), and use of advanced EBRT (IMRT and IGRT) and brachytherapy (IC/IS) techniques (clinical validation). The study also incorporates translational research including imaging and tissue biomarkers.