A puff to the cuff just isn’t enough.

Final results of the GOG 249 (presentation no: LBA-1) confirm the absence of benefit with chemo + vaginal brachytherapy in place of pelvic radiation alone in the adjuvant setting for high-intermediate risk endometrial cancer. Concerns over under-treatment of the pelvis with brachytherapy alone for HIR patients have been voiced for years. While this trial showed no difference in recurrence-free or overall survivals, there was (to no real surprise) a significant increase in the pelvic nodal recurrence rate with chemo + vaginal brachy from 2.0 -> 6.7%. More surprising was that chemo + vaginal brachy conferred almost 6x (!) the acute toxicity. Perhaps most surprising, among the pelvic radiation alone arm, IMRT techniques resulted in numerically higher rates of acute toxicity than with the Joe Blow 4-field box approach. Turns out, when it comes to HIR endometrial cancer, a puff to the cuff isn’t up to snuff...and the 4-field box still rocks.