In intracavitary brachytherapy, radioactive sources are placed inside body cavities with

the help of applicators to irradiate the walls of the body cavity and adjacent tissues.1 All
intercavitary implants are temporary and are removed immediately after the prescribed dose is
delivered.2 Historically, 226Ra was used for intracavitary implants until its replacement with the
use of 137Cs for low dose rate (LDR) brachytherapy and 192Ir for high dose rate (HDR)
brachytherapy. For gynecologic cancers, intracavitary brachytherapy is used for treatment of the
vagina, cervix, and endometrium, with the vaginal cylinder being the most commonly used
surface-dose applicator. Vaginal cylinders come in a variety of diameters ranging from 2 cm to 4
cm with the distal end of the cylinder usually rounded or dome shaped, making it more
comfortable for patients during insertion and treatment (Figure 1).3,4 For treatment, the largest
cylinder diameter should be used, as long as the patient can tolerate the device, in order to help
minimize vaginal surface dose. If a smaller cylinder is used, the ratio of the prescription depth to
the cylinder radius is greater creating higher surface doses due to the inverse square law.5 Two
types of vaginal cylinders that can be used in brachytherapy include a single channel vaginal
cylinder and a multichannel vaginal cylinder (Figure 2). Although both applicators can be used
for intracavitary implants, the multichannel cylinder allows for more flexibility in isodose
distribution and dose control to various points and critical structures compared to the single
channel cylinder. Figure 3 demonstrates an isodose line distribution for two plans using a
multichannel cylinder and a single channel cylinder. The multichannel cylinder provides better
dose control and can help minimize dose to surrounding critical structures.

At my clinical site, we use vaginal cylinders to treat patients using HDR brachytherapy
alone or in combination with external beam radiation therapy (EBRT). For both types of
treatments, an 192Ir source is used and the patient undergoes a simulation procedure to determine
the placement of the vaginal cylinder and a CT scan is completed for treatment planning. During
simulation, the patient lays supine with their legs placed in stirrups during the insertion of the
applicator. A staple or cervical marker is placed inside the vagina at the top of the cervix. After,
the physician measures the length and diameter of the vaginal canal and selects the appropriate
size of the vaginal cylinder. Once the cylinder has been assembled, it is inserted into the vagina
and the applicator is attached to a belt that is positioned around the patient’s waist to secure the
device from any movement. The patient’s legs are slowly lowered from the stirrups and placed
flat on the CT table. A CT scan is performed to verify the cylinder placement, the location of the
staple, and if there are any air gaps that may alter the dose. After reviewing the CT scan, the
dataset is exported, and the treatment planning process begins.

The recommended dose fractionation for vaginal brachytherapy can vary slightly.
According to Quinn et al,7 the current treatment regimen consists of 7 Gy for 3 fractions or 6 Gy
for 5 fractions with some physicians prescribing to a depth of 5 mm and others prescribing to the
vaginal surface. At my clinical site for HDR alone, our physicians prescribed to a 5 mm depth
(100% isodose line covers planning target volume) and treatment is given every 3 days with a
daily dose of 5 Gy for 6 fractions, equaling a total dose of 30 Gy. If the patient is receiving an
HDR boost in combination with EBRT, the dose received with brachytherapy is lower. The
patient will usually undergo EBRT to the whole pelvis with a daily dose of 1.8 Gy for 25
fractions and then receive an additional daily dose of 4 Gy for 3 fractions with brachytherapy.
Regardless of the treatment regimen, whether a patient receives HDR alone or EBRT plus HDR
brachytherapy, the duration of elapsed treatment time should be less than 8 weeks.3

Figures

Figure 1. Vaginal cylinder applicator showing various sizes depending on the length and
diameter of the vaginal cavity.4
Figure 2. Comparison of a multichannel vaginal cylinder (left) and a single channel vaginal
cylinder (right).5

Figure 3. Isodose line distribution of a multichannel vaginal cylinder (left) and a single channel
vaginal cylinder (right).6

References

1. Lenards N, Berner P, Schmidt K. Introduction to Intracavitary Brachytherapy.

[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2016.
2. St. Germain J. Radiation safety and protection. In: Washington CM, Leaver D, eds.
Principles and Practice of Radiation Therapy. 4th ed. St. Louis, MO: Mosby-Elsevier;
2016: 338-349.
3. Lenards N, Berner P, Schmidt K. HDR Intracavitary Brachytherapy. [SoftChalk]. La
Crosse, WI: UW-L Medical Dosimetry Program; 2016.
4. Brachytherapy. Asian American Radiation & Oncology Web site.
https://www.aamg.co/aaro/comprehensive-cancer-service/radiation-
therapy/brachytherapy/. 2018. Accessed July 31, 2018.
5. Glaser SM, Beriwal S. Brachytherapy for malignancies of the vagina in the 3D era. J
Contemp Brachytherapy. 2015;7(4):312-318. http://dx.doi.org/10.5114/jcb.2015.54053
6. 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. https://doi.org/10.1120/jacmp.v14i1.4098
7. Quinn BA, Kim NK, Romano K, et al. Dose/fractionation regimens of vaginal cylinder
brachytherapy correlate with increased radiation toxicity and vaginal stenosis. Int J
Radiat Oncol Biol Phys. 2017;99(2):S226. https://doi.org/10.1016/j.ijrobp.2017.06.55