Discuss the specifics of a vaginal cylinder procedure (everything from how the implant is inserted to patient

simulation, HDR/LDR for treatment, dose fractionation schemes, dose calculation systems, etc.). Use text,
internet resources, and pictures to convey the information to your classmates.

A vaginal cylinder procedure is a type of intracavitary brachytherapy used in treatment of

gynecological cancer, generally to boost the vaginal cuff following a hysterectomy and a course
of external beam radiation therapy (EBRT).1 Dose is prescribed to the surface of the vaginal
cylinder, which maximizes dose to the tumor volume and limits dose to organs-at-risk (OAR)
including the bladder, rectum, and sigmoid colon.2 Ra-226 was used as sources historically and
now Cs-137 is used with low dose rate (LDR) intracavitary brachytherapy and Ir-192 is used
with high dose rate (HDR) intracavitary brachytherapy.1

Prior to treatment planning of a vaginal cylinder procedure, patients undergo a CT

simulation in a supine and frog-legged position with the intracavitary applicator secured in place.
Rounded or dome-shaped vaginal cylinders are utilized in conjunction with a tandem, where
sources can be loaded and inserted to align with the axis of the vaginal cylinders. An optimal
diameter between 2cm to 4cm of the vaginal cylinders is chosen per patient based on the largest
vaginal cylinder that fits tightly and comfortably in the patient’s vagina. Some vaginal cylinders
have built-in shields that protect nearby critical structures.2

Dose fractionation for a vaginal cylinder procedure varies. The typical dose fractionation
for LDR is two 30Gy in 48-hour fractions after 40-50Gy of EBRT with the first fraction within
four to six weeks after the initiation of EBRT and the second fraction one to two weeks
following the first fraction.3 As for HDR, there are several dose fractionation schemes: with
EBRT, three fractions of 6Gy per fraction to the surface of the vaginal cylinder or one fraction of
7Gy per fraction to 5mm from the surface of the vaginal cylinder; without EBRT, four fractions
of 8.8Gy per fraction to the surface of the vaginal cylinder.4 All treatments including EBRT and
intracavitary brachytherapy should be completed in eight weeks or less.3

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

[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2016.
2. Lenards, N. Berner, P. Schmidt, K. LDR Intracavitary Implants. [SoftChalk]. La Crosse,
WI: UW-L Medical Dosimetry Program; 2016.
3. Lenards, N. Berner, P. Schmidt, K. Intracavitary Brachytherapy Dose Specifications.
[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2016.
4. Lenards, N. Berner, P. Schmidt, K. HDR Intracavitary Brachytherapy. [SoftChalk]. La
Crosse, WI: UW-L Medical Dosimetry Program; 2016.