Gynecological cancers can be treated using a multidisciplinary approach of surgery

and/or therapy. Typically, surgery (hysterectomy or salpingo-oophorectomy) is followed

by post-operative external beam radiation therapy and boost via brachytherapy depending
on physician. The boost is done using low dose rate (LDR) or high dose rate (HDR)
treatments using an intracavitary applicator. One of the most common GYN
brachytherapy applicators is the vaginal cylinder. Vaginal cylinders come is varying
diameters, usually ranging from 2-4 cm.1 The largest cylinder that is deemed comfortable
for the patient should be used so that surface dose of the vagina is spared in the process.
Cylinders irradiate the entire vagina, which can be a drawback or beneficial as recurrence
can often be in the lower vagina as well as the cuff.2

Before the actual treatment can take place, patients must first go through simulation in
order to verify applicator size, positioning, and obtain CT images for planning purposes.
Patients are treated in the supine position with their legs in the frog-legged position.
Patients are changed into a special under-garment that holds the cylinder into place via a
slit with elastic straps. The physician then places a condom over the cylinder and applies
lubrication to the cylinder so that is easier to insert. Once the cylinder is inserted and
deemed to be the correct size, CT images are obtained and verified by the physician and
sent to the treatment planning system. For planning, the dosimetrist/physicist will only
need to contour the bladder and rectum. The planner manually enters dwell positions
along the cylinder length as well as step size.

Cesium-137 is the most common source used for LDR treatments.2 LDR treatments
require the patient to remain at hospital for 2-3 days where they typically receive low
dose rate seeds (0.4-2 Gy/hr).1 HDR treatments (>12 Gy/hr) are an outpatient basis and
the most common source is iridium-192.1,2 Treatment time for HDR is very short and the
source is removed from the patient after each fraction. Typical HDR fractionation
without external beam radiation is 600 cGy x 5 fractions at 0.5 cm depth at my facility.
Typical LDR alone fractionation is 50-60 Gy in 72 hours at 0.5 cm depth.

Before treatment can even begin, it is very important that proper QA is performed and all
components are running correctly. At my clinical site, measurements and emergency QAs
(visual, audio, door, etc) must be checked by physics before patient arrival. Before each
fraction, the primary physician and physics must be present. There is no room for error in
brachy cases so it is imperative that cylinder positioning and measurements are correct
for optimal results.
Figure 1: Sagittal and coronal view of cylinder

Figure 2: Special undergarment with slit for cylinder

References:
1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 4th ed.
St. Louis, MO: Elsevier-Mosby; 2017: chap 14.
2. Lenards, N. Introduction to intracavitary brachytherapy. [SoftChalk]. La Crosse,
WI: UW-L Medical Dosimetry Program; 2016.