Intracavitary Brachytherapy for Gynecologic Cancers – Tandem and Ovoid or Ring
What is brachytherapy?
Brachytherapy is a form of radiation treatment where a source of radiation is put inside your body. This allows a higher dose of radiation to directly reach the area where the tumor is or was before surgery. In the case of brachytherapy for gynecological cancers, it reduces radiation exposure to the surrounding healthy tissues, such as the bowel and bladder. Brachytherapy is administered after the placement of an applicator. An applicator helps guide where the treatment will be delivered.
In the treatment of gynecological cancers, brachytherapy may be given in addition to traditional external beam radiation. How often you receive brachytherapy will be determined by your care team. You may receive it several days in a row and in this case you would likely remain in the hospital for the duration of your treatments. In other cases, you may receive it once a week for several weeks. In this case, you could go home between treatments. Ask your providers what your schedule will look like before starting treatment.
What is a tandem and ovoid or ring?
The radiation needs to be placed near your cancer or where the cancer was removed. To be able to do that, applicators are used. Brachytherapy for gynecological cancers can be done using a "tandem and ovoid" (T&O) applicator or a "tandem and ring" (T&R) applicator. The tandem is a long, thin metal tube that is passed through the cervix, into the uterus. The ovoids are circular hollow capsules, and the ring is a hollow ring. Either is placed in the vagina, pressed against the cervix.
How is a tandem and ovoid or ring placed?
Each facility has different procedures when it comes to the placement of these applicators for brachytherapy. Your providers will give you the specific details of how the applicators will be placed.
In general, the applicators will be placed in an operating room while you are under some type of sedation. Before you are sedated, an IV will be placed to give you the medications needed for sedation and to manage pain and nausea. A catheter will be placed in your bladder to collect your urine. If you are receiving treatment for a few days straight, you may also have a rectal tube placed to collect your stool or you may be given medications to decrease your stool output.
The applicators will be placed with the tandem being placed through the cervix and into the uterus. The ovoid or ring is placed in the vagina and against the cervix. Balloons or gauze may be used to keep the applicators in place. At this time you will be woken up from your sedation. While the applicators are in place you will remain on bed rest to ensure that the applicators do not move. You may be allowed to elevate the head of your bed, but only slightly.
After the applicators are placed and you have woken up from sedation you will need imaging tests to ensure that the applicators are in the correct place. You may have a series of MRIs and/or CT scans to ensure placement. A treatment plan will also need to be done before receiving your brachytherapy. This can take a few hours. You can have a visitor with you during this time or you can bring some light activities to keep you distracted such as a book or tablet.
In some cases, your provider may use a "Smitt sleeve,” also called a stent, which is a plastic hollow tube that is fitted to your uterine cavity and placed under anesthesia. This is done in a surgical facility and you will be given instructions before the procedure on how to prepare. The Smitt sleeve goes through your cervix, into the uterus, and is sutured in place. This remains in place until after the last T&O or T&R procedure to allow for easier, more comfortable placement of the applicator during each treatment. You will likely not feel the Smitt sleeve once it is in place and it does not require anesthesia to be removed.
How is the brachytherapy administered?
Once placement has been confirmed and your treatment plan is complete, you will be taken into a lead-lined room where you will receive your brachytherapy. The applicator will be connected to a machine that automatically feeds a radiation source into the applicator, where it remains for a period of time, known as the dwell time. This can last anywhere from a few minutes up to 25 minutes depending on your treatment plan. Once the time is up, the machine removes the source from the applicator.
Keep in mind that you will be by yourself in this room as the brachytherapy is being delivered. This is to protect the staff from the effects of the radiation. Make sure that you have no needs before the therapy starts and that you are comfortable. You will be able to talk with the therapists the entire time and if you have any emergent needs you should tell them. The therapists will be monitoring you during treatment from the cameras in the room.
How is the applicator removed?
If you are receiving treatment a few days in a row the applicator will not be removed until after your last treatment. You will remain on bed rest for the duration of your treatment plan. If you are having weekly treatments the applicator will be removed after each brachytherapy session. In either case, the IV, any catheters, and the applicator will be removed by a provider. You may experience some bleeding which should not be more than a normal menstrual period. Pads should be used to manage this bleeding rather than tampons.
You will need to stay for a little while to be monitored for bleeding, to be sure you can urinate on your own after the catheter is removed and to be sure you can move around safely after any medications you received. You may not be able to drive a vehicle or do any strenuous activity, so be sure to have someone drive you home.
What can I expect after the treatment?
- You will likely experience some spotting, bleeding or vaginal discharge after the applicator is removed. This should not be more than a normal menstrual period.
- You may want to bring a sanitary pad with you to wear home or you may be given one. You should not use tampons, as you will have some irritation in the vagina and tampons could make this worse.
- Ask your provider when it is safe to douche, have intercourse, go swimming or take a tub bath.
- For some women, douching with vinegar and water will be recommended to help clean out any dead tissue after all brachytherapy treatments are completed. Your provider will tell you if this is right for you. You can buy a douche kit at your local pharmacy.
- You may have cramping, similar to menstrual cramps, for 24 hours after the procedure. You may use ibuprofen (Advil, Motrin, or Nuprin) or naproxen (Aleve or Naprosyn) to relieve the cramps. Be sure to follow the instructions on the bottle.
- If you had a foley catheter during the procedure, you may experience burning when you urinate for up to 24 hours. You should drink 8-10 glasses of nonalcoholic and caffeine-free beverages a day for a few days after the procedure to ease any burning.
- Some patients have diarrhea. Ask your provider if you can take medications to manage this.
- It is suggested that you refrain from sexual intercourse during treatment because of the tenderness and irritation you may have in your vagina.
- You will be given vaginal dilators to use once your treatment has been completed. These will help the vaginal tissue remain flexible, making intercourse more pleasant, but also making pelvic exams more comfortable. You will need to use the dilator for the rest of your life. See our teaching sheet on dilators to learn more about them.
- You are not in any way radioactive after the procedure and it is safe for friends and family to be around you.
- You may eat a normal diet and carry on your normal activities while on brachytherapy treatment.
When should I call my care team?
- If you develop a fever (temperature > 101°F / 38.3°C).
- You have pain that is not relieved with over-the-counter medication.
- You have excessive bleeding (more than a menstrual period) or develop a vaginal discharge.
- You have burning or blood in the urine more than 24 hours after the procedure.
- You do not have a bowel movement for 3-4 days after the procedure.
- You have more than 3-4 episodes of liquid diarrhea in one day.
The process and techniques used to deliver brachytherapy using a tandem and ovoid or ring can be very specific to the center where you are receiving your therapy. Do not hesitate to ask questions regarding your care.
Banerjee, Robyn and Kamrava, Mitchell. Brachytherapy in the treatment of cervical cancer: a review. International Journal of Women's Health. 2014. 6:555-564.
Han, K and Viswanathan AN. Brachytherapy is Gynecologic Cancers: Why is it underused? Current Oncology Report. 2016. 18(4):26.
Ma, JK et al. Short-term clinical outcome and dosimetric comparison of tandem and ring versus tandem and ovoids intracavitary applicators. Journal of Contemporary Brachytherapy. 2015. 7(3): 218–223.