**3.2. Vaginal brachytherapy**

The efficacy of adjuvant vaginal brachytherapy (VB) was evaluated in two randomized clinical trials [72, 73]. Patients with serous or clear cell histology were exempted from the studies and only patients with endometrioid adenocarcinomas were included. In low-risk patients with endometrial cancer (stage IA−B, grades 1–2), vaginal brachytherapy did not add benefit over observation [72]. However, in PORTEC-2 clinical trial, in high-intermediate risk patients, vaginal brachytherapy was demonstrated to be non-inferior to EBRT and provided comparable loco-regional control (less than 2% at 5-year period for both arms), disease-free survival and overall survival [63, 73]. Vaginal brachytherapy is associated with considerably fewer gastrointestinal tract toxicities (less diarrheal attacks and stool incontinence) and a better functioning social quality of life [72-74]. Sorbe and colleagues [63] compared combination of EBRT and brachytherapy versus brachytherapy alone: there was no 5-year overall survival benefit (89% and 90%, respectively; p=0.548). However, the 5-year pelvic and loco-regional recurrences were much more common in the vaginal brachytherapy alone group (1.5% and 5%, respec‐ tively; p=0.013). It was concluded that combined radiation therapy (EBRT and vaginal brachytherapy) should possibly be reserved for high-risk patients, whereas vaginal brachy‐ therapy alone should be reserved for purely medium-risk patients.

In conclusion, vaginal brachytherapy, to a certain degree, effectively decreases the risk of vaginal recurrence in patients with risk factors while minimizing the radiation-related toxicities. In patients with early-stage endometrial cancer, vaginal brachytherapy should the adjuvant treatment of choice over EBRT.
