Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

TandemandOvoidsprocedure
StructuralDesign
Traditionally,gynecologicintracavitaryirradiationhasbeendeliveredusing
lowdoserate(LDR)brachytherapy.However,todayhighdoserate(HDR)brachytherapyis
alsocommonpracticefortreatmentofgynecologicmalignancies.Aunitmadeupofatandem
andapairofovoidsisthecommonlyusedafterloadingapplicatorinthetreatmentoftheuterine
cervix.TheFletcherandSuittandemandovoidsystemisrigidbutflexibleenoughtobeused
formostpatients.1Atandemisanintrauterineapplicator.Itisdesignedtofitinsidetheuterine
canalandextendoutofthevagina.Thetandemisahollowtube,whichhasadiameterof6mm
andis27cmlong.1,2Oneendofthetubeissealedinordertoblocksourcesfromfallingout
insidethepatient.Acervicalstopfitsintothetandemtopreventperforatingtheuterus.2In
general,tandemsareconstructedofstainlesssteel.Theyareapproximately12inchesinlength
withanouterdiameterofapproximatelyinch.Theinternaldiameterisdesignedtoallowthe
plastictubeholdingthesourcetobeinsertedwithoutmeetingresistance.1Ingeneral,12low
doserate(LDR)sourcesareloadedintothetandem.Thenumberofsourcesdependsonthe
lengthofthepatientsuterus.2Whiletandemsareeitherstraightorofvariousdegreesof
angulation,15,30,45,or60degrees,itismostcommontotreatapatientusinganangled
tandem.Thepurposeoftheangleofthetandemistodrawtheuterustoacentrallocationwithin
thepelvis,thusawayfromthesigmoidcolon,aswellas,theanteriorrectalwall.Theanglealso
accountsfortheforwardtiltoftheuterus.2Whenatandemiscorrectlyinsertedintheuterine
canal,akeelissecuredtothetandem.Whenthetandemisfullyinsertedintotheuterus,thekeel
islocatedatthecervicalos.Thekeelservesasamarkeroftheexternalcervicaloswhen
referencepointsaredeterminedfordosecalculations.Thekeelalsokeepsthetandemfrom
accidentallybeingpushedfartherintotheuterus,whichcouldcauseperforation.
Theovoidsareovalshapedandapproximately20mmindiameterand30mminlength.
Theyarehollowandlikethetandemmadeofstainlesssteel.Theovoidsareattachedtoahollow
handlethroughwhichtheradioactivesourceisinserted.The2ovoidsareinsertedintotheright
andleftfornicesofthevagina.Onceinserted,the2ovoidsareheldtogetherviaascrew,which
allowstheovoidstomovelaterallywhenthehandlesatthedistalendarepressedtogether.
1

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Thehandleprotrudesoutsideofthevagina.Oncethetandemandovoidsareinsertedand
positioned,thephysicianpacksthevaginawithsterilegauzetoholdtheapplicatorinplace
duringthedurationoftheimplant.1
IntracavitarybrachytherapyalsousesHighdoserate(HDR)applicators.HDR
applicatorsaresimilartothoseusedforLDRprocedures.Itshouldbementionedthough,that
HDRapplicatorscanbeutilizedincomputedtomography(CT).Whiletheapplicatorscontain
metal,theartifactfiltermaybeusedsinceheterogeneitycorrectionsarenottakenintoaccountin
brachytherapytreatmentplanning.3

Figure1.Tandems.4

Figure2.Ovoids.4

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Figure3.Anteriorviewoftandemandovoidsplacement.5

Figure4.Sagittalviewoftandemandovoidsplacement.5

HowImplantisInserted
PerDr.ChristineFisherMDMPH(April2016),agynecologyradiationoncologist,atthe
UniversityofColoradoHospitaltheprocedurewasdescribedasfollows.AnHDRtandemand
ovoidinsertiontakesplaceintheoperatingroom(OR)underlightanesthesia.Thepatientisina
relaxedsleepwheretheywontremembertheprocedurebutcanberousedifmade
uncomfortable.UsingbetadineanexternalandinternalprepisdonebeforeaFoleycatheteris
insertedintothebladderandtheballoonisfilledwithcontrast.Thebladderisthenfilledwith
sterilesalinetopushanysmallbowelsuperiorandawayfromthetandemandovoidsystem.The
catheterisclampedtoholdtheliquidinplace,duetothecontinuedintravenoushydrationsome
fluidisletoutofthebladderbeforeleavingtheORtoensurepatientcomfort.Theattendingand
theresidentbothperformamanualexamtofeelfortheextentofthetumorandtheshape.The

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

doctorsneedtoknowwherethetumorextendsinalldirectionsandthesizeandintegrityofthe
vaginalfornices.Witharectalexamthepresenceoftumorextensionintotherectumcanbe
palpated.Oncetheexamisdone,thedecisioncanbemaderegardingwhichangleoftandemand
sizeofovoidtouse.Dr.Fishersaidthe30degreestandemfitsmostpatientsandmediumisthe
usualovoidsize.
Undertransabdominalultrasoundtheuterusissoundedwithaflexibledevicethathas
millimeterandcentimeterincrementsprinted.Soundingreferstomeasuringofthedepthofthe
uterusfromthecervicalOStothetopoftheuterus.Thissolidstrawlikedeviceispushedallthe
waytothetopoftheuterusandthedepthisrecorded.Thenthetandemisslideintothevaginal
cavity,throughthecervicalopeningandallthewaytothetopoftheuterus.35mmissubtracted
fromthesoundeddepthandthatisthedepthtowhichthetandemisinsertedoruntiltheuterus
tents.Allofwhichisvisualizedunderultrasoundtopreventperforatingtheuterus,which
accordingtheattendingiseasytododependentontheextentofthetumor.Ifforceisrequiredto
pusharoundthetumor,careneedstobetakentoavoidforcingthesteeltandemstraightthrough
thetopoftheuterus.Thisisavoidedwithcarefulstudyoftheultrasoundasthetandemis
inserted.Theflangeorkeelisthensecuredontothetandemtoholdthetandemintotheuterusat
therequireddepthatthecervicalOS.Theovoidsarethenpositionedandallthehardware
extendsoutsideofthevagina.Thesystemissecuredtogetherwithascrew.
Theresidentthenpacksthevaginalcavitywithgauzeribbonembeddedwithradiopaque
markers.Thispackinghasatwofoldpurposeposteriorlyitpushestherectumfurtherawayfrom
thetandemandovoidanditholdseverythinginplace.Thepackingisalsousedanteriorlyto
pushthebladderaway.Packingisanartbecauseitcanmovethesystemintoimproperalignment
whichwillbeanatomicallyunfavorable.Forexample,thecurvatureoftheuterusshouldbe
anteriorfallingsuperiorlyoverthebladderandnotposterior.Inthecasewheretheuterus
naturallyflopsbackwards,theattendingwillinsertthetandemandthenrotateittoforcethe
angleanteriorandsuperior.Oncethepackingandsystemarestabilized,thepatientisawakened
andtransportedtothedepartmentforthesimulation.

PatientSimulation

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Simulationforthetandemandovoidsbrachytherapyprocedureisunconventionalwhen
comparedtoexternalbeamradiationtherapy(EBRT).WhileEBRTperformsthesimulation
priortothetreatment,brachytherapysimulationisdoneafterthetandemandovoidshavebeen
placedinsidethepatient.6AseriesofCTscansorxraysareusedtoverifycorrectsource
positioninganddosecalculation.Oncethetandemandovoidshavebeenlocalized,themedical
physicistandphysicianplantheappropriateamountoftimerequiredtodeliverprescribeddose
tothetarget.DosetopointsonCTscansarecalculated(seeDoseCalculationsSection).There
havebeenquestionsaboutwhetherCTsimulationisnecessaryfortandemandovoidplacement.7
Patientstreatedwithtandemandovoidswithoutasimulationreceivedagreatersurfacedoseto
therectum,bladderandvagina,thepercentincreaseswere35%,30%and45%respectively.This
supportsthateachpatientshouldhaveasimulationpriortobrachytherapyplacement.

Figure3.TandemandOvoidsseenonxrays(A)andCT(B).8

A)

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

B)

LDR/HDRforTreatment
Applicatorsusedinintracavitarybrachytherapy,canbeutilizedwithbothLDR(lowdose
rate)andHDR(highdoserate)brachytherapymethodsfortreatinggynecologicmalignancies.
TraditionallyLDRbrachytherapywasthestandardtreatmenttechniqueforgynecologic
malignanciesbutHDRmethodsarebecomingincreasinglypopularformany
reasons/advantages.ALDRsourceusedforintracavitarybrachytherapyisCesium137from
Radium226thatwasoriginallyusedinthepast.Cesium137asaclinicalsourceisapure
gammarayemitterandcomesinstainlesssteelencapsulatedneedlesandtubes.Thegammarays
emittedfromCesium137havealmostthesamepenetratingpowerasRadium226.9AHDR
sourceusedforintracavitarybrachytherapytodayisoftenIridium192.Iridium192emitsbeta
particlesthataretakenup/eliminatedbythestainlesssteelcapsuleandclinicallyusefulgamma
rayssuchsourceisoftenmanufacturedintheshapeofseedsandcancomeinnylonribbons
containingtheseseedsinwhichtheribbonsarethenplacedinsidehollowplastictubingto
delivertreatment.9LDRcorrelatestoaprescriptiondoserateontheorderof.52cGy/minand
HDRisclassifiedtodeliver20cGy/minorhigher.TheprincipleadvantageofHDRoverLDR
istheprocedurecanbeperformedasanoutpatientprocedureaswellasgreatercontroloverdose
distribution.10OtheradvantagesofHDRversusLDRbrachytherapyincludeseaseoftreatment,
minimalradiationexposuretopersonnel,andconsistentplusreproducibleapplicatorpositioning.
6

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Asidefromalltheadvantages,HDRcancausemoredamagewhenitcomestotoxicity,
surroundingORdoselevels,andlateeffectsforagivenleveloftumorcontrol.However,the
possibilityofoptimizingdosedistributionandthelesserchanceofapplicatordisplacementseem
tooutweighthesedisadvantages.DisadvantageswitnessedwithLDRbrachytherapyincludes
increasedexposureofradiationtopersonnel/staff,theneedforhospitalizationofuptoaweek,
theriskofanesthesia,bedimmobilizationthatcanleadtothromboembolism,discomfortof
vaginalpackingandapplicatorsduringbedimmobilization,anddisplacementofthe
applicators.11BecausethepatientneedstoliemotionlessforthedurationofLDRtreatment,it
couldleadtobloodclotsorpressureulcersfromlayinginthesamepositionforalongperiodof
time.ForthesescarydisadvantagesseenwithLDRbrachytherapy,itiseasytoseewhyHDR
brachytherapyshouldbeconsidered,andisbecomingastandardtreatmentstrategyforpatients
withcervicalcancer.
AliteraturereviewwasperformedbyViani,Manta,Stefano,Fendi11toevaluateHDR
intracavitarybrachytherapyversusLDRintracavitarybrachytherapy,whenbothmethodshave
beenaround/utilizedforyears.MortalityratesdidnotshowadifferencebetweenLDRandHDR
researcharmsandHDRdidnotshowanydifferenceindosetosurroundingORstructures
comparedwithLDR.11Althoughallstudiesprovedtoachievesimilarresults,HDRwasshownto
havejustslightlyincreasednumbersoflocalrecurrence,mortality,anddosetosurroundingOR.
Sincethelocalcontrolandsurvivalrateswereprovenverysimilarinthemetaanalysisof
literaturecurrentlypublished,HDRisagoodalternativetoLDRintracavitarybrachytherapyand
offersthemanyaforementionedadvantages.Althoughsomeoftheliteraturereviewproved
promisingtreatmentresultsandfavorableoutcomes,thisliteraturereviewalsofoundthatpoorer
outcomeaswellasoverallsurvivalanddiseasefreesurvivalwaslowerintheHDRgroupfor
stageIIIcervicalcancerpatients.

DoseFractionationSchemes
Thepracticeofusinghighdoserate(HDR)brachytherapytotreatgynecologicalcancers
byuseoftandemandovoidsallowsforamuchhigherdosetothetargetarea.Afterspeaking
withtheradiationoncologistatmycurrentfacility,Dr.OscarGarcia(April2016),heinformed

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

methatheprescribesHDRbrachytherapyoncethepatienthasreceivedtheirfullcourseof
externalbeamradiationof4500cGytotheprimaryfields,plusanadditional3fractionboostof
540cGyforatotaldoseof5040cGyforexternalbeamtreatments.HDRdosesatourcenterare
typicallyachievedin5fractionsthatconsistof500cGyandarerecommendedtobeginnolater
than2weeksfollowingtheterminationoftheexternalbeamradiationtreatments.Thepatient
willhavetwotreatmentsperweek,allowingforatotaldoseofupto7540cGy,ifthedosetothe
rectumandbladderarenotcompromisedbeyondthelimits.
Generallyspeaking,patientswithintactcervicalcancertraditionallyreceivelowdoserate
(LDR)brachytherapyin1or2separatetreatmentsessions.12Thesetreatmentsshouldalsotake
placebetweenthesecondandfourthweekfollowingtheircompletionofexternalbeamradiation
therapy.Ontheotherhand,patientswithintactcervicalcancerreceivingHDR,arenormally
prescribed46fractionsdependingontheextentofthediseaseanddosestosurrounding
structures.HDRshouldbeadministeredinthesecasesnolaterthan8weeksaftertheirinitial
externalbeamtreatment.
Thedesiredgoalisthatthepatientshouldreceiveatotaldoseof8085Gyforsmall
cervicaltumors,and8590Gyforlargetumors.12Toachievethisgoal,itisimportanttonote
thatthedosetothebladderandrectummuststaybelow80%ofthetotaldosetopointA,orless
than7580Gytothebladder,andlessthan7075Gytotherectum.
PointAisareferencepointdevelopedfortheManchestersystemsothatthe
brachytherapydosemaybeprescribedtothispointforpatientswithintactcervicalcancer.12
PointBisanotherreferencepointthatwasusedintheManchestersystemthatcorrelatedwith
thelocationoftheobturatorlymphnodes,howeveritisnowrecommendedbytheAmerican
BrachytherapySociety(ABS)touseasidewalldosepointratherthanPointB,dueto
inconsistenciesinpatientanatomy.PointsM,T,andHareadditionaldosepointsthatcanbe
used,howeverthesearesubjecttochangeatdifferentcentersofcare.
Belowyouwillfindseveraltables(14)publishedforthevariousfractionationschemes
availabletopatientsreceivingLDRorHDR.12Thesetablesvarydependingonextentofthe
disease,locationofthetumor,andwhetherthepatientwillreceiveLDRorHDR.
Table1:CervicalcancerLDRguidelines

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Table2:PostopHDRguidelinesforuterinecancer

Table3:InoperableuterinecancerHDRguidelines

Table4:CervicalcancerHDRguidelines

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

DoseCalculationSystems
Therehavebeenmanydosecalculationsystemsdevelopedinthelastcentury,butthe
onesthatarethemostnotablehistoricalsystemaretheStockholmsystem,Parissystem,andthe
Manchestersystem(PatersonParker).1Eachsystemvariesbytheirrulesofimplantationofthe
brachytherapyapplicator,doseuniformitystandards,andreferencedosespecification.1More
recentlytherehavebeenadvancementsindoseandvolumespecificationswiththeICRU38
reportandtheABSsystem.

TheStockholmsystemusedapplicatorsthatdidnotadjust,butwereeasytouse(less

uncertainty).10Theapplicatorwasmadeupofarubbertandemandagoldorsilvervaginal
applicatorbox.10Thesystemusedthree22hourinsertionsandunequalloadingtheinthe
applicator.10Theprescriptionswere3090mg226Rainuterusand6080mg226Rainthevagina
foratotalof65007100mg226Ra.Thissystemhasahighdoserateandhighrateofsideeffects
andcomplicationsforthepatient.
TheParissystemonlyusedoneinsertion,butforlengthof510days.Theamountof
226

Rausedintheuterusandvaginawereequalandthetotalmghourswerefixed.1,10Evenly

distributingthe226Rainthetandemresultedinanonuniformdosedistributiontowardsthe
centerofthetandem.1Morerecently,Ir192havebeenusedwiththeParissystemismgRaeq
10

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

values.TheParissystemgaverisetosomeoftherecommendationsfoundintheICRU38
guidelines.
TheManchestersystemwasalsoknownasthePatersonParkerandisthemostfrequently
usedsystem.1,10Thedosespecificationparametersforthissystemincludedthetotalnumberof
mgsofRadiumortheequivalentinallthesources,theplacementofthesesourcesmustbeinthe
tandemandovoids,andthetotaltreatmenttime.1Theprescriptionpointusedinthissystemis
knownasPointA.10In1938,PointAwasdefinedtobe2cmsuperiorand2cmlateralofthe
centeroftheuterinecanalwheretheuterinevesselscrossedtheureter.10PointAwasalso
believedtobetheinitialpointofradiationnecrosis.PointBwasoriginallydefinedasthe
locationoftheobturatornodesandwaslocated3cmlaterallytoPointA.10However,PointsA
andBwereeventuallyredefinedinthe1950s.10ThereviseddefinitionofPointAis2cm
superiortothelowerendofthetandemalongthetandemand2cmlateraltothecentralcanal.
TherevisedPointBdefinitionis2cmsuperiortotheexternalcervicalosand5cmlateralalong
thebodyplane.1Duetotherevisions,PointsAandBmaynotbeonthesameplaneasPointAis
moredependentontheangleofthetandem.PointAisusefulforreportingdose,butispoorly
relatedtothetumorlocationandvarieswithapplicatorplacement.Typically,PointAwas
limitedtoreceiving30%ofthetotaldoserateofthewholetandemandovoid.1

11

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Figure1:PointAandBwhenapplicatorperpendiculartobodyplane.Theimageonrightshowsthelocation
ofPointAwhentandemistilted.ThisisbecausetheredefinitionofPointAismoredependentontheTandem
asopposedtopatientanatomy.1

ICRU38developedasystemforreportingdoseforgynecologicalbrachytherapy.The

systemisbasedonthetotalairkermastrengthofallthesourcesintheimplantmultipliedbythe
numberofhourstheapplicatorwasinthepatient.10ICRU38definesthedoseasisodosesurface
thatsurroundthetargetvolumewhichknownasthereferencevolume.10Thereferencevolumeis
definedtobethe60GyisodosesurfaceincludesanyEBRTcontributionandisbasedonthe
Parissystem.10ICRU38hasdeterminedotherpointsofinterestthatareimportantfortheorgans
atriskthebladderpoint,rectalpoint,andpelvicwallpoints.Thebladderandrectumpoints
mustbelimitedto70%oftheprescribeddose.10

TheAmericanBrachytherapySociety(ABS)alsodevelopedguidelinesthatincludedose

calculationinformation.TheABSsystemdefinestreatmentvolumesinadifferentwaythanthe
ICRU38reportbyaddinginCTVsthataretoincludespecificanatomicstructuresbasedon
high,intermediate,andlowrisk.TheorgansatriskfortheABSarethesameastheICRU38
recommendationsinregardstobladderandrectalpoints.10TheprescriptionpointsaretheHigh
riskCTVorPointA.Nowthatbrachytherapycalculationsarebecomingmorecomputerized,the
ABShasintroducedguidelinesforLDRandPDR.10PointAshouldreceive8090Gy,Sigmoid
colonandrectumshouldbe7075Gy,andbladderlessthan90GyincludingtheEBRT
contribution.10

Resources:
1. BentelGC.RadiationTherapyPlanning.2nded.NewYorkNY:McGrawHill1995.
2. Lenards,N.LDRIntracavitaryImplants.[SoftChalk].LaCrosse,WI:Medical
DosimetryProgram2016.
3. Lenards,N.HDRIntracavitaryBrachytherapy.[SoftChalk].LaCrosse,WI:Medical
DosimetryProgram2016.

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Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

4. DwyerK.FletchersuitTandemandOvoid.McLarenCancerCenterFlint,MI.Taken
April262016.
5. MillerR.AboutCancerWebsite.
http://www.aboutcancer.com/intracavitary_radiation_treatments.htm.AccessedApril27,
2016.
6. MassachusettsGeneralHospitalCancerCenter.WhatYouNeedToKnowAboutTandem
AndOvoidImplantsForCervicalCancer.1sted.Boston,MA:TheGeneralHospital
Corporation2015.Availableat:
http://www.massgeneral.org/radiationoncology/assets/pdfs/Tandem_and_Ovoid_Implants
_for_Cervical_Cancer_MGH_2015.pdf.AccessedApril26,2016.
7. JonesN,RankinJ,GaffneyD.Issimulationnecessaryforeachhighdoseratetandem
andovoidinsertionincarcinomaofthecervix?.Brachytherapy.20043(3):120124.
doi:10.1016/j.brachy.2004.07.001.
8. TypesofImageGuidedBrachytherapy|UCLARadiationOncology|Radiation
OncologyUCLA.Radoncuclaedu.2016.Availableat:
http://radonc.ucla.edu/imageguidedbrachytherapytypes.AccessedApril26,2016.
9. KhanFM,GibbonsJP.ThePhysicsofRadiationTherapy.5th ed.Philadelphia,PA:
LippincottWilliamsandWilkins,aWoltersKluwerbusiness2014.
10. LenardsN,SchmidtD,BernerP.Brachytherapyimplantsintroduction.[SoftChalk].La
Crosse,Wi:UWLMedicalDosimetryProgram2016.
11. VianiGA,MantaGB,StefanoEJ,FendiL.Brachytherapyforcervixcancer:lowdose
rateorhighdoseratebrachytherapyametaanalysisofclinicaltrials.JExpClin
CancerRes.200928(47).DOI:10.1186/175699662847.
http://jeccr.biomedcentral.com/articles/10.1186/175699662847
12. KhanFM,GerbiBJ.TreatmentPlanninginRadiationOncology.3rded.Philadelphia,
PA:LippincottWilliams&Wilkins2012.

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