Background/Structural Design

A vaginal cylinder is a common applicator device used in intracavitary brachytherapy.

They are cylindrical in shape with a rounded tip to better conform to the vaginal canal.1 These
applicators are often made of a type of plastic and come in a variety of lengths and diameters to
achieve a tight fit within the vagina.2 The applicator can be designed with a single, centrallylocated channel, or with a customized multichannel format (Figure 1).1,3 In addition, the
applicator may be used as a vaginal cylinder alone, or in conjunction with a tandem, extending
into the uterus.3 After insertion of the device, different techniques have been used to secure it
into position including vulvar suturing or Velcro-enforced briefs.4,5 The applicator can be used
alone in either low dose-rate (LDR) or high dose-rate (HDR) brachytherapy treatments or in
combination with external beam radiation therapy. Vaginal cylinders are used to treat vaginal
cancers, extension of disease in the vaginal canal, and the vaginal cuff as a boost to minimize the
risk of surgical seeding. In addition, these can also be used a substitute for ovoids for when the
vaginal canal is too narrow.

Figure 1. The Miami multichannel vaginal cylinder

Implant Process
During the implant process, the tip of the cylinder usually reaches up to the vaginal cuff
and the radiation sources are placed inside the cylinder along its axis to give even dose
distribution throughout.6 The diameter of the cylinder usually ranges from 2 -4 cm. The largest
cylinder possible should be used without hurting the patient in order to reduce the surface dose of
the vagina. The patient will typically come for 3-4 fractions once a week for this type of
treatment and depending on the prescription, the isotope used, and its activity. The procedure
will last, with the cylinder in place, for around 15-30 minutes. Figure 2 shows an example of a
typical vaginal cylinder.

Figure 2. A picture of a typical vaginal cylinder

Simulation
According to a discussion with E. Fields, MD and L. Francis, CMD (April 2016), a
vaginal cylinder simulation can have multiple components. Before a vaginal cylinder is placed,
two gold marker seeds are placed in the vaginal cuff. This marks the most superior aspect of
where the cylinder should be placed. Once the device is in place on the day of treatment, a quick
AP fluoroscopy or x-ray can be taken. This is analyzed to ensure the cylinder is next to the gold
markers/the most superior possible point. The patient is then taken to CT to obtain scans to be
used for treatment planning. A lubricant or gel can be placed on the cylinder before insertion and
the outline of the device shows up well on the image. Dummy sources can be used to ensure that
channel is clear and the positioning of the seeds is where the doctor would like them.
It is also possible to just use x-ray films in the AP and lateral position to plan. The films
would just need to be digitized and planned accordingly. The use of CT is more common for
treating in order to assess the rectum and bladder positioning as well.
If the patient is being treated for actual gross disease of the vagina and not as a precaution
or microscopically, an MRI can be obtained with the cylinder in place to encompass the entire
disease in treatment. This is usually obtained before the start of treatments.

Figure 3. Fluoroscopy image of vaginal cylinder placement in the AP position. Lubrication gel
was used to highlight the edge of the cylinder. The gold marker seeds can be seen in the superior
aspect of the device. Dummy sources can also be seen in the film.

Treatment Planning
1. HDR
There are 2 types of brachytherapy treatments used in a vaginal cylinder procedure: LDR
and HDR. In a LDR brachytherapy, low dose rate (0.4-2 Gray (Gy)/h) radioactive seeds, such as
Cs137, and the applicator are usually left in place for days. While in an HDR brachytherapy, high
dose rate sources (>12 Gy/h), such as Ir192, are controlled by a remote afterloader to stop at
planned dwell positions and stay for planned dwell times. The treatment time is much shorter and
the cylinder applicator is removed from the patient after each treatment fraction.7,8
During simulation, a dummy radio opaque wire is placed into the catheter for easy
catheter reconstruction. The applicators position relative to surgical clip is checked by the
physician to ensure proper coverage of the target. Treatment planning for vaginal cylinder is
quite straightforward, due to the simple geometry of the applicator. The mostly used treatment
planning systems (TPS) for brachytherapy are BrachyVision from Varian and Oncentra
Brachy from Elekta. Planning can be either based on library plans (for most patients), or based
on CT imaging using normalization points and graphical optimization.
Library plans are pre-calculated plans, including dwell position and dwell time / Ci
source, for different diameter cylinders and treatment length. Table 1 listed an example of a
library plan from my clinical site for a 4.0 cm diameter cylinder. When treating patients, the
actual dwell time for each dwell position is calculated by dividing the tabulated values by current
activity.

Table 1. A library plan for a 4.0cm diameter cylinder applicator. Dwell

times are for a 1.0 Ci source. (Beaumont Health System)
When planning a vaginal cylinder HDR treatment based on CT images, normal tissue
structures are contoured on the CT images.9 Then the cylinder catheter is reconstructed from the
tip end. Source dwell positions can be manually activated along the prescribed treatment length
with a predefined step size between every two positions. Dose normalization points are added at

the prescribed distance 5 mm away from the surface of the cylinder, as shown in Figure 4. The
prescription is normalized to these points. The plan can be further adjusted by dragging the
isodose lines using graphical optimization method, as shown in Figure 5. The TPS will calculate
the source dwell time at the chosen dwell positions.

Figure 4. CT based treatment planning for vaginal cylinder applicator with Oncentra Brachy.

Figure 5. CT based treatment planning for vaginal cylinder applicator with Oncentra Brachy.

Recently, studies have shown advantages in plan dosimetry with a multichannel HDR
vaginal cylinder applicator.10,11 Instead of cylindrical symmetrical dose distribution associated
with single channel cylinder, the dose distribution for multichannel cylinder can be modulated
with inverse planning, which poses a big advantage in critical organ sparing without sacrificing
the coverage.

2. LDR
The dose distribution for LDR brachytherapy varies with size of the vaginal cylinder,
and the number, position , and strength of the sources. Historically, the different isotopes used
were radium-226 or cesium-137. The dose for LDR treatments are prescribed to the surface of
the applicator. Table 4 and 5 displays some common doses delivered during an LDR procedure.
Depending on the dose, the patient can be hospitalized between 1-3 days. According to J.
Wochos, Senior Physicist, (April, 2016) back when our facility did LDR treatments, there wasnt
a treatment planning system that was used for vaginal cylinders. The dose is prescribed to the
vaginal surface, so a general protocol was used to determine the amount of time for the source to
dwell to get the appropriate dose.
For vaginal cylinders, these treatments were done in a single fraction. This consisted of
the patient being hospitalized and lying down for the duration of the treatment. Some risks
include the chance of developing deep vein thrombosis, due circulation issues throughout the
treatment. Sometimes the vaginal cylinder included shielding to help protect some of the
sensitive structures like the bladder or rectum. These cylinders need to be carefully placed to
ensure they are not blocking areas with disease. Some studies have shown that LDR treatments
may cause less complications compared to HDR, but some of the disadvantages include higher
cost and the inconvenience of hospitalization versus an outpatient procedure.12

Fractionation Schemes (for both HDR/LDR)

Fractionation schemes vary for LDR and HDR alone as well as for HDR following
EBRT. Tables 2 and 3 show HDR fractionation schemes recommended by the American
Brachytherapy Society (ABS). Tables 4 and 5 reflect common fractionation schemes for LDR
vaginal cylinder brachytherapy as stated by Radiation Therapy Oncology Group (RTOG) trials
and practice surveys performed by the ABS. The doses are specified to treat the upper proximal
3-5 cm of the vagina.

HDR Alone
(ABS recommendations)13
Fractions

Dose/fx

Depth

7.0 Gy

0.5 cm

5.5 Gy

0.5 cm

4.7 Gy

0.5 cm

Table 2. Recommended fractionation schemes for HDR vaginal cylinder brachytherapy alone.

EBRT 45 Gy + HDR
(ABS recommendations)13
Fractions

Dose/fx

Depth

5.5 Gy

0.5 cm

4.0 Gy

0.5 cm

Table 3. Recommended fractionation schemes for HDR vaginal cylinder brachytherapy after
EBRT to 45 Gy.
LDR Alone
(ABS Practice Survey) 14
Dose

Time

Depth

50-60 Gy

72 hours

Surface

47-60 Gy

72 hours

0.5 cm

Table 4. Recommended fractionation schemes for LDR vaginal cylinder brachytherapy alone.

EBRT 45-50.4 Gy + LDR14

(RTOG 99-05/GOG 0194, RTOG 97-08)
Dose

Dose Rate

Depth

20 Gy

0.8-1.2
Gy/hr

0.5 cm

30 Gy

0.8/1.2
Gy/hr

Surface

Table 5. Recommended fractionation schemes for LDR vaginal cylinder brachytherapy after
EBRT to 45 Gy or 50.4 Gy.

References:
1. Cohen GN. Aspects of brachytherapy. In: Washington CM, Leaver D, eds. Principles
and Practice of Radiation Therapy. 4th ed. St. Louis, MO: Elsevier-Mosby; 2016:chap
14.
2. Lenards N, Berner P, Schmidt K. LDR Intracavitary Implants. [SoftChalk]. La Crosse,
WI: UW-L Medical Dosimetry Program; 2016.
3. Iftimia I, Cirino ET, Mower HW, McKee AB. Treatment planning methodology for the
Miami Multichannel Applicator following the American Brachytherapy Society recently
published guidelines: the Lahey Clinic experience. J Appl Clin Med Phys.
2013;14(1):214-227. doi:10.1120/jacmp.v14i1.4098
4. Bentel GC, Nelson CE, Noell KT. Treatment Planning & Dose Calculation in Radiation
Oncology. 4th ed. New York, NY: McGraw-Hill; 1993.
5. Radiation Implant Brief Model M-100 Instructions. The Radiation Implant Brief Web
site. http://www.dmmedical.com/radiation_implant_brief.html. Accessed April 25, 2016.
6. Dutta P, Vachani C. Internal Radiation Therapy (Brachytherapy). Oncolink Web site.
http://www.oncolink.org/treatment/article.cfm?id=35. Updated December 4, 2006.
Accessed April 26, 2016.
7. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.
8. Viani GA, Manta GB, Stefano EJ, de Fendi LI. Brachytherapy for cervix cancer: lowdose rate or high-dose rate brachytherapy a meta-analysis of clinical trials. J Exp Clin
Cancer Res. 2009;28:47. doi:10.1186/1756-9966-28-47
9. Lenards N, Berner P, Schmidt K. HDR Intracavitary Brachytherapy. [SoftChalk]. La
Crosse, WI: UW-L Medical Dosimetry Program; 2016.
10. Demanes DJ, Rege S, Rodriquez RR, Schutz KL, Altieri GA, Wong T. The use and
advantages of a multichannel vaginal cylinder in high-dose-rate brachytherapy. Int J
Radiat Oncol Biol Phys. 1999;44(1):211-219.
11. Bahadur YA, Constantinescu C, Hassouna AH, Eltaher MM, Ghassal NM, Awad NA.
Single versus multichannel applicator in high-dose-rate vaginal brachytherapy optimized
by inverse treatment planning. J Contemp Brachytherapy. 2015;6(4):362-370.
doi:10.5114/jcb.2014.47816
12. Harkenrider M, Block A, Siddiqui Z, Small W. The role of vaginal cuff brachytherapy in
endometrial cancer. Gynecologic Oncology. 2015;136(2):365-372.
doi:10.1016/j.ygyno.2014.12.036
13. Nag S, et al. The American Brachytherapy Society recommendations for high-dose-rate
brachytherapy for carcinoma of the endometrium. Int J Radiat Oncol Biol Phys.
2000;48(3):779-790.
14. Small W, et al. American Brachytherapy Society survey regarding practice patterns of
postoperative irradiation for endometrial cancer: current status of vaginal brachytherapy.
Int J Radiat Oncol Biol Phys. 2005;63(5):1502-1507.