Background
Phase III RCT (Princess Margaret Hospital). 231 patients with stage II epithelial ovarian cancer after primary surgery. Randomized to pelvic RT alone vs whole abdominal radiation therapy (WART) with pelvic boost. Pelvic RT: 45 Gy pelvis alone. WART: 22.5 Gy whole abdomen + 22.5 Gy pelvic boost (total 45 Gy pelvis). This early landmark trial established that coverage of the upper abdomen (WART) is important in stage II ovarian cancer, as intraperitoneal spread beyond the pelvis occurs frequently.
Interventions and follow up
Arm A: Pelvic RT alone: 45 Gy
Arm B: WART: 22.5 Gy whole abdomen + 22.5 Gy pelvic boost (45 Gy total pelvic dose)
Primary endpoint: Relapse-free survival, OS
mFollow up: 10 year
Arm B: WART: 22.5 Gy whole abdomen + 22.5 Gy pelvic boost (45 Gy total pelvic dose)
Primary endpoint: Relapse-free survival, OS
mFollow up: 10 year
Results
10-year relapse-free survival: ~44% (WART) vs ~30% (pelvic RT), P=.02
10-year OS: ~44% (WART) vs ~28% (pelvic RT), P=.01
Upper abdominal relapse: Significantly lower with WART
10-year OS: ~44% (WART) vs ~28% (pelvic RT), P=.01
Upper abdominal relapse: Significantly lower with WART
Adverse events
Main adverse events: WART was associated with higher rates of acute GI toxicity (nausea, diarrhea). Late bowel complications were manageable. Hepatic toxicity was a limiting factor at higher dose rates.
Conclusions
WART significantly improved relapse-free and overall survival compared to pelvic RT alone in stage II ovarian cancer, establishing whole abdominal coverage as necessary for adjuvant RT — since pelvic RT alone fails to prevent upper abdominal relapses along peritoneal surfaces.
Key Limitations
Key Limitations: Pre-platinum era trial. No modern surgical staging (retroperitoneal lymph node dissection was not standard). Stage definitions and imaging have evolved substantially. WART is technically demanding (moving-strip or open-field technique) and is rarely used today. The study predates CT-based planning and IMRT. Chemotherapy (platinum-based) was not the comparator arm.
Clinical Context
The Dembo trial, together with GOG 7602, helped define the principles of adjuvant RT for ovarian cancer in the pre-chemotherapy era. The superior efficacy of whole abdominal coverage reinforced the concept of intraperitoneal spread. These findings are now primarily of historical interest — platinum-based chemotherapy has replaced RT as adjuvant treatment. WART is occasionally used in select heavily pretreated patients at specialized centers.
References
References: 3.0.CO;2-4">Dembo AJ et al, Cancer 1985