Int. J. Radiation Oncology Biol. Phys., Vol. 48, No. 3, pp.

779 790, 2000

Copyright 2000 Elsevier Science Inc.
Printed in the USA. All rights reserved
0360-3016/00/$see front matter

PII S0360-3016(00)00689-1

CLINICAL INVESTIGATION

Endometrium

THE AMERICAN BRACHYTHERAPY SOCIETY RECOMMENDATIONS FOR

HIGH-DOSE-RATE BRACHYTHERAPY FOR CARCINOMA OF THE
ENDOMETRIUM
SUBIR NAG, M.D.,* BETH ERICKSON, M.D., SUHRID PARIKH, M.B.B.S., M.S., M.CH.,
NILENDU GUPTA, PH.D.,* MAHESH VARIA, M.D., AND GLENN GLASGOW, PH.D.,
FOR THE AMERICAN BRACHYTHERAPY SOCIETY
*The Ohio State University, Columbus, OH; Medical College of Wisconsin, Milwaukee, WI; Weill Medical College of Cornell
University, New York, NY; University of North Carolina, Chapel Hill, NC; Loyola University, Chicago, IL
Purpose: To develop recommendations for use of high-dose-rate (HDR) brachytherapy in patients with endometrial cancer.
Methods: A panel of members of the American Brachytherapy Society (ABS) performed a literature review,
supplemented their clinical experience, and formulated recommendations for endometrial HDR brachytherapy.
Results: The ABS endorses the National Comprehensive Cancer Network (NCCN) guidelines for indications for
radiation therapy for patients with endometrial cancer and the guidelines on HDR quality assurance of the
American Association on Physicists in Medicine (AAPM). The ABS made specific recommendations for HDR
applicator selection, insertion techniques, target volume definition, dose fractionation, and specifications for
postoperative adjuvant vaginal cuff therapy, for vaginal recurrences, and for medically inoperable primary
endometrial cancer patients. The ABS recommends that applicator selection should be based on patient and
target volume geometry. The dose prescription point should be clearly specified. The treatment plan should be
optimized to conform to the target volume whenever possible while recognizing the limitations of computer
optimization. Suggested doses were tabulated for treatment with HDR alone, and in combination with external
beam radiation therapy (EBRT), when applicable. For intravaginal brachytherapy, the largest diameter applicator should be selected to ensure close mucosal apposition. Doses should be reported both at the vaginal surface
and at 0.5-cm depth irrespective of the dose prescription point. For vaginal recurrences, intracavitary brachytherapy should be restricted to patients with nonbulky (< 0.5-cm thick) disease. Patients with bulky (> 0.5-cm
thick) recurrences should be treated with interstitial techniques. For medically inoperable patients, an appropriate applicator that will allow adequate irradiation of the entire uterus should be selected.
Conclusion: Recommendations are made for HDR brachytherapy for endometrial cancer. Practitioners and
cooperative groups are encouraged to use these recommendations to formulate their treatment and dose
reporting policies. This will lead to meaningful comparisons of reports from different institutions and lead to
advances and appropriate use of HDR. 2000 Elsevier Science Inc.
Endometrial neoplasm, High-dose-rate, Brachytherapy, Radiotherapy.

INTRODUCTION

juvant therapy of selected patients and in the management of inoperable or recurrent endometrial cancers.
Brachytherapy, traditionally delivered by low-dose-rate
(LDR) techniques, is increasingly delivered by highdose-rate (HDR) techniques worldwide. However, there
are no standardized treatment recommendations. This
report was prepared to provide recommendations for
treating endometrial cancer with intracavitary HDR
brachytherapy. Details of interstitial HDR brachytherapy
will be discussed in a separate report.

Cancer of the endometrium is the most common gynecologic cancer in the United States, accounting for an
estimated 37,400 new patients in 1999 (1). The standard
management for endometrial cancer is a total abdominal
hysterectomy with bilateral salpingo-oophorectomy
(TAH/BSO) with or without pelvic lymph node sampling.
External beam radiation therapy (EBRT) and/or brachytherapy are integral components in the postoperative ad-

Brachytherapy Society and thank Drs. Manjeet Chadha, Laurie

Gaspar, Ihn Hahn, Dattatreyudu Nori, Daniel Petereit, Bruce Thomadsen, and Bhadrassain Vikram for their valuable suggestions.
Presented at the American Brachytherapy Society Meeting, May
19 21, 2000, Crystal City, VA.
Accepted for publication 8 May 2000.

Reprint requests to: Subir Nag, M.D., Chief of Brachytherapy,

Arthur G. James Cancer Hospital, The Ohio State University, 300
W. 10th Avenue, Columbus, OH 43210. Tel: 614-293-3246; Fax:
614-293-4044; E-mail: nag.1@osu.edu
AcknowledgmentsThe authors wish to express their gratitude to
Mr. David Carpenter for editorial assistance. The authors acknowledge the support of the Board of Directors of the American
779

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Table 1. Results of postoperative adjuvant cuff radiation therapy with EBRT and HDR
Author
Reference

Lybeert (6)

291 Postop

40-Gy EBRT 5-Gy HDR 4

Nori (2)

300

Algan (7)
Turner (8)

81
18 Papillary
serous

7 Gy 3 at 0.5 cm 40-Gy EBRT

(high-risk patients)
45-Gy EBRT 4 Gy 3 at 0.5 cm
HDR 7 Gy 2 or 3 at 0.5 cm in addition to
chemotherapy

Treatment

Control/survival

Recurrence
(%)

Complications

5-year NED
I: 88%
II: 69%
III/IV: 50%
90%

7.2

None

3.7

5-year OS 83%

Grade 12: 9%
No grade 3/4
Not stated
No Grade 3/4

5-year OS 94%

None

Abbreviations: n number of patients; EBRT external beam radiotherapy; HDR high-dose rate; NED no evidence of disease;
OS overall.

METHODS
A panel of the American Brachytherapy Society (ABS)
members with clinical experience in HDR endometrial
brachytherapy performed a literature review, supplemented
their clinical experience with biomathematical modeling,
and formulated recommendations for HDR brachytherapy
for endometrial carcinoma. These recommendations were
established by consensus and supported by available evidence in the literature whenever possible. Areas of controversy and lack of consensus were noted. External experts
who were not members of the panel reviewed this report.
The Board of Directors of the ABS approved this final
document.
RESULTS
The results of the deliberations of the panel members on
patient selection, applicators, quality assurance, dosimetry,
and HDR brachytherapy techniques are presented in the
following sections.
Patient selection
Treatment of vaginal cuff as postoperative adjuvant therapy. Given the increased use of comprehensive surgical

staging, the role of adjuvant EBRT, brachytherapy, chemotherapy, or no further therapy remains controversial. A
careful consideration of risk versus benefit is especially
important when considering adjuvant irradiation. The results of postoperative adjuvant therapy of the vaginal cuff
with HDR alone or in combination with EBRT (upon which
many of the recommendations of the panel are based) are
summarized in Tables 1 and 2, respectively (218). Overall
pelvic recurrence frequency of less than 10% is reported in
these series. However, it should be pointed out that with
contemporary surgical techniques, the incidence of vaginal
cuff recurrences might be very small in low-risk endometrial carcinoma, even without any adjuvant therapy.
Patient selection is determined by histopathologic factors
such as grade, myometrial invasion, lymphatic vascular
space invasion, tumor size, lymph node status, and tumor
extension, and the presence or absence of surgical staging,
as well as consideration of comorbidity that may predispose
patients to radiation-induced morbidity. Detailed discussions regarding patient selection are beyond the scope of
this report. The ABS endorses the recently formulated
guidelines by National Comprehensive Cancer Network
(NCCN) for patient selection for adjuvant radiation therapy
post-hystrectomy for endometrial cancer (Fig. 1) (19). It is

Table 2. Results of post-operative adjuvant cuff radiation therapy with HDR alone
Author/
Reference
Peschel (9)
Rattka (10)
Sorbe (4)
Thomas (11)
Noyes (12)
Fanning (13)
Kloetzer (14)
Hong (15)
MacLeod (16)
Weiss (17)
Petereit (5)
Chadha (18)

n
115
404
Not stated
63
60
108
44
141
122
191
38

Treatment
57 Gy 3 at 0.5-cm cylinder
10 Gy 4 3-day interval
Buchler HDR, doses not stated
16.2 Gy 2 ovoids surface dose
7 Gy 3 at 0.5 cm
10 Gy 4 cuff @ 1 cm/vagina @ 0.5 cm
HDR only*
8.5 Gy 4 surface
Cylinder; 7 Gy 3 @ surface
Ovoids, 16.2 Gy 2 @ surface
7 Gy 3 cuff 0.5 cm

Control/survival
3-year NED 99%
OS 88%
5-year OS 92%
5-year OS 94%
3-year
3-year
5-year
5-year
5-year
4-year
5-year

NED 100%
OS 96%
OS 92%
OS 88%
NED 94%
OS 95%
OS 93%

Recurrence
Not stated
0.7% vaginal
8%
0%
None
03%
None
1.4%
9.8%
0%
None at 30 mo

Complications
0.3%
7%
No grade 3/4
No grade 3/4
26%
None
No grade 3/4
None
1 grade 4
No grade 3/4

* Various fractionation schemes were used. N number of patients; HDR high-dose rate; NED no evidence or disease; OS
overall survival; mo. months.


S. NAG et al.

Fig. 1. Summary of NCCN guidelines for patient selection for post-hysterectomy adjuvant radiation therapy for endometrial cancer. Reproduced with permission of the NCCN. The NCCN
guidelines are a statement of consensus of its authors regarding currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN guideline is expected to
use independent medical judgment in the context of individual clinical circumstance to determine any patients care or treatment. The NCCN makes no warranties of any kind whatsoever
regarding their content, use, or application and disclaims any responsibility for their application or use in any way.

ABS panel on HDR for endometrial cancer

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Table 3. Results of treatment of cuff recurrence

Author/Reference

Treatment

Lybeert (6)

36

Pai (20)

13

40-Gy EBRT 5-Gy HDR 0.5-cm

depth vaginal vault 4
44-Gy EBRT 24 Gy HDR @
surface*
35-Gy HDR only @ surface*

Control/Survival

Recurrence

Complications

5-year NED 28%

Not stated

None

CR 90%
10-year local control
74%
10-year OS 71%

6/20

15%

* Various fractionation schemes were used.

Abbreviations: N number of patients; EBRT external beam radiotherapy; HDR high-dose-rate; NED no evidence of disease;
OS voerall survival; CR complete response.

to be noted that these guidelines are a work in progress that will

be refined as often as new significant data becomes available.
HDR treatment of recurrences at the vaginal cuff. Vaginal recurrences can present a particularly challenging problem, especially in the subgroup of patients who have already
received radiation therapy. A summary of the results with
HDR brachytherapy is given in Table 3 (6, 20).
Effective treatment requires a determination of the local
extent of the disease, as assessed by a careful pelvic examination in a relaxed patient (under anesthesia, if required).
Treatment recommendations will depend upon whether or
not the patient has received prior radiation therapy, thickness of the vaginal recurrence, and its location.
Treatment of inoperable primary endometrium. Patients
with endometrial cancer are often elderly and may be poor
surgical candidates because of morbid obesity and other
medical problems. These patients can be treated quite effectively with definitive radiation therapy (2125). However, the very problems that preclude surgery, also make
them high-risk candidates for external beam irradiation
LDR brachytherapy. The following reports from several
centers note high local control rates with acceptable morbidity using HDR brachytherapy in this patient subset (Table 4) (2125).
HDR applicators
Applicator selection is important in brachytherapy for
endometrial carcinoma. A single applicator cannot treat all

anatomical variants and disease presentations. Different applicators are required to accommodate these varied presentations. The applicators needed at any one institution depend on the patient case mix, the clinical expertise, and
preference of the radiation oncologist. Each HDR manufacturer offers its own set of applicators. The choice of available applicators, their design, clinical utility, and versatility
should be taken into account when considering a HDR unit
purchase. When budgeting for a HDR unit, one must also
consider the additional cost of the applicators and the need
for their periodic replacement.
HDR applicators for post-operative adjuvant therapy.
Cylinders and ovoids are commonly used for post-hysterectomy adjuvant brachytherapy of the vaginal cuff. These
are commercially available and closely model the LDR
cylinders and ovoids. The choice of applicator for treatment
of the vagina is both patient- and institution-dependent.
Some applicators, including vaginal ovoids and the Houdek
vaginal applicator, will treat only the vaginal cuff; whereas,
vaginal cylinders can treat the entire vaginal canal, including the introitus, if desired. Another factor that may determine applicator selection is the shape of the vagina. In most
patients, the postoperative vagina is cylindrical and can be
treated adequately by a vaginal cylinder. Additionally, vaginal cylinders are preferable for a narrow vagina. However,
cylinders give higher doses to the bladder and rectum for a
given vaginal dose. In some patients, the vagina may have a
dog-ear configuration that is better treated by vaginal ovoids.

Table 4. Results of treatment of primary inoperable endometrial cancer with radiotherapy

Author/Reference
Sorbe (25)

Nguyen (23)

91 RT
only
19

Kucera (22)

228

Huguenin (21)

18
17
36

Nguyen (24)

Treatment

Survival

Recurrence
(%)

Complications

CO-60 HDR 5 Gy

5-year OS 47%

29

7%

6.6 Gy 3 HDR only

42-Gy EBRT 6.6 Gy 3
HDR brachytherapy only
8.5-Gy 45 uterus
7 Gy 12 cylinder
5 Gy 5 at 0.5 cm vagina only
39.6 Gy EBRT 5 Gy 3 at 0.5 cm vagina
Different schedules with 5 HDRs

8-year NED 76%

None?

11%

5-year OS 60%

17.5

5%

5-year OS 64%

Grade 47% at 3 years

3-year OS 65%

12

21% (2 deaths)

Abbreviations: n number of patients; EBRT external beam radiotherapy; HDR high-dose-rate; NED no evidence of disease;
OS overall survival.

ABS panel on HDR for endometrial cancer

Cylinders. The ABS recommends that institutions should

have available vaginal cylinders in various lengths and
diameters (ranging from 1.5 to 4 cm) to treat a variety of
patients. Individual cylinders of predetermined lengths, or
segmented cylinders that can be assembled to the required
length, are available. The ABS suggests that when only the
upper half of the vagina needs treatment, the cylinder should
not extend to the introitus to minimize patient discomfort.
Further, condoms can be placed over the cylinders when
they are inserted into the vagina to extend applicator longevity and to facilitate cleaning.
Most vaginal cylinders have a single, central channel.
The multichannel vaginal applicator is a variation of the
vaginal cylinder (26, 27). This applicator contains a central
channel and six peripheral channels along the surface of the
cylinder. The central and peripheral channels increase treatment options and compensate for single line source anisotropy at the vaginal apex. The cylinders are available with a
diameter of 3.0 cm; however, additional sleeves are available to increase the diameter to 3.5 and 4.0 cm to reduce the
mucosal dose. Differential loading of the channels allows
shaping of the isodose distributions to various clinical presentations. Numerous other vaginal applicators are also
described (28 31). Shielded cylinders with user-defined
shielding positions selectively decrease absorbed dose to
adjacent normal structures (32).
Ovoids. Fletcher-like shielded and unshielded vaginal
ovoids are available in diameters of 2.0, 2.5, and 3.0 cm.
Rectal retractors can displace the rectum; bladder displacement can be achieved with vaginal packing. Henschke-like
hemispherical colpostats of 2.5- and 3.0-cm diameter with
or without tungsten shielding are also available; these are
useful especially for irradiation of narrow vaginas. The ABS
deems the choice of applicators to be a personal or institutional preference as long, providing that the desired segment
of vagina is adequately irradiated.
HDR applicators for inoperable primary endometrial
carcinoma. For inoperable endometrial carcinoma, the applicators previously described for cervical carcinoma (including the tandem and ovoids, tandem and ring, and tandem and cylinder applicators) can be used (33). Dedicated
endometrial applicators can offer more homogeneous irradiation of the endometrial cavity and uterine walls. Dual and
triple tandem (34, 35) placed in each cornu of the uterus
optimize the dose distribution at the fundus. To reduce the
vaginal mucosa dose, vaginal packing or tandems that incorporate a vaginal cylinder (e.g., Martinez) must be used to
displace the vaginal mucosa from the radiation source.
Multiple-channel endometrial applicators, such as the Bauer
endometrial applicator, have also been described (36). A
variation of the LDR Heymans capsules with radio-opaque
markers and different diameters are available for HDR (37).

Dosimetry and quality assurance

Several documents that provide excellent general quality
assurance (QA) guidelines for HDR brachytherapy also

S. NAG et al.

783

apply to treatment of endometrial cancer and should be

reviewed. These reports may be categorized as follows:
Brachytherapy Code of Practice - AAPM Task Group 56
(38) QA of HDR Devices - AAPM 41 (39) QA of
Treatment Planning Systems - AAPM Report 53 (40)
HDR Treatment Delivery, Training and Staffing - AAPM
Report 59 (40)
Many of the general ABS recommendations for HDR
brachytherapy of the cervix (33) are also applicable for
endometrial cancer.
Prescription. The ABS recommends a clear, dated, and
signed written directive specifying the treatment site, the
radionuclide, the prescribed absorbed dose, and fractionation. The prescription point for the absorbed dose must be
stated clearly and unambiguously. The type of applicator,
optimization points, the method of optimization, the number
of dwell positions, relative dwell weights, and the isodose
distribution should be documented.
Applicators. The ABS recommends periodic quality assurance of HDR applicators including specific checks of the
integrity of the applicators, their source guide tubes, and the
position of the shields, if present.
Localization. Fluoroscopy and plain-film radiography,
with dummy sources in the applicator, are commonly used
to document applicator placement. Methods of localization
include the use of portable x-ray units, conventional radiotherapy simulators, or, in some instances, CT imaging. The
best method of localization is the one that produces the least
movement of the patient and the applicator during the
planning period. A dedicated HDR suite with in-room localization that allows radiographs to be obtained immediately after applicator placement, with the patient in the
treatment position, is ideal, but not widely available. Both
two- and three-film methods of radiograph for isodose computations are available (40).
Localization radiographs should be obtained in the treatment position with radio-opaque contrast material in bladder foley catheter balloon and standard rectal markers to
allow the bladder and rectal doses to be estimated as per
ICRU 38 (41) recommendations. The ABS recognizes that
with the use of fixed geometry applicators, such as vaginal
cylinders, localization radiographs need not be performed
routinely for dosimetry purposes, but are useful for documentation. However, the radiographs only show the applicator in relation to the pelvic bony structures and not in
relation to the vaginal vault, unless radio-opaque marker
seeds or clips have been placed at the vaginal vault.
Dosimetry: precalculated vs. patient specific. The ABS
recognizes that although customized treatment plans for
every fraction are ideal, they are time-consuming. Hence, it
may not be necessary to calculate customized treatment
plans for every fraction for fixed geometry applicators. A
customized treatment plan can be calculated once for each
patient, and the same plan used for all the fractions. The
assumption in these patients is that the geometry of the
implant remains the same for every insertion. Another al-

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ternative is to store an array of precalculated treatment plans

for various applicators. The preplan that best matches the
target geometry can be recalled and modified for the current
treatment. One drawback of preplanned dosimetry is that
patient specific points such as the bladder and rectum cannot
be added easily to the plan during each application. This
drawback may now be overcome with newer features of
treatment planning systems.
Optimization. Optimization is defined as the manipulation of the dwell positions or the dwell times, or both, so
that the resultant dose distribution best conforms to the
target volume. It is important to recognize that optimization
is a tool to provide additional dose shaping capabilities for
a good implant and should not be used to compensate for an
improperly placed applicator or an inappropriate applicator.
The choice of optimization algorithm and optimization
points affects the dose distribution profoundly. An inappropriately optimized treatment plan can have grave adverse
consequences as illustrated in the recent article by Nag and
Samsami (42). The treating physician should therefore be
able to critically evaluate an optimized plan to ensure that
it meets the desired requirements.
An optimized plan must satisfy various general criteria as
summarized below:
1. The dose distribution should satisfy the physicians requirements; it should not just satisfy the optimization
specifications.
2. To avoid overdosing normal structures outside the target,
dwell positions should not extend beyond the target.
3. An optimized plan that delivers optimum target coverage
at the cost of high-dose heterogeneity within normal
tissues is not acceptable.
4. To be useful for clinical applications, the optimization
process should not be too time-consuming.
5. In some cases, as with a vaginal cylinder, the dose
heterogeneity may be inconsequential in that the plastic
applicator comprises a majority of the volume.
6. Applicator-specific optimization specifications and
guidelines are presented in the site-specific applications
below.
Treatment. An independent review of the proposed plan
of therapy by a second individual (physicist or medical
dosimetrist) should include checks, if applicable, that:
1. Dosimetry data are correct and consistent with institutional treatment guidelines.
2. The absorbed dose prescription point, absorbed dose
per fraction, and number of fractions satisfy the facilitys protocol.
3. The absorbed dose distribution from the plan matches
the prescription.
4. Reconstructed applicator geometry matches that on the
radiograph.
5. The distance from machine reference point to the most
distal dwell position is consistent with treatment plan.
6. Absorbed doses to normal tissues are within tolerances.

Volume 48, Number 3, 2000

7. The dwell times for the generated plan falls within a

range consistent with those for similar patients.
8. Treatment data (dwell times, locations, step sizes) programmed match those on the plan.
9. Subsequent fractions using the same plan stored in the
HDR unit are performed with the correct data and with
the current source activity, and the treatment time adjusted accordingly.
10. The HDR source activity for the treatment day is corrected for source decay in the treatment planning system/treatment console computer and verified by a separate independently calculated source decay chart or
method.
A few other checks must be in place for multiple fraction
treatments using the initial treatment plan or for the use of
precalculated dosimetry. Among them are checks to ensure
that the correct applicator is used for each fraction and
applicator position is reproduced. The applicator size should
be measured prior to each application to ensure the correct
applicator is being used.
Brachytherapy techniques
Treatment of vaginal cuff as postoperative adjuvant therapyapplicator insertion. Both a visual and manual examination of the vagina should precede applicator insertion.
Placement of a radio-opaque seed or clip at the vaginal apex
to verify that the applicator is in contact with the vaginal
mucosa is suggested. However, it should be realized that
these clips or seeds sometimes fall off or migrate deep to the
mucosa and therefore may not always indicate the position
of the apex. After applicator placement, an external immobilizing device is recommended to minimize movement
between planning and treatment.
Vaginal cylinders. It is imperative for the vaginal mucosa
to be in contact with the applicator surface to have an
effective dose distribution. The ABS recommends use of the
largest diameter cylinder or ovoids that can comfortably fit
in the vagina. It is usually possible to confirm that the
applicator is in direct contact with the vaginal apex mucosa
by exerting gentle cephalad pressure on the applicator handle while assessing for patient discomfort. The applicator
should be subsequently secured only after it returns to a
more neutral position. The applicator should be positioned
in the midline of the patient. The position of the applicator
should be rechecked before treatment, and the position
should be adjusted as required.
Vaginal ovoids. When ovoids are inserted, they should
touch at their medial aspects to avoid a cold spot in the
vagina between the two ovoids. A rectal retractor or radioopaque packing should be used to displace the rectum.
Additionally, radio-opaque gauze packing should also be
used to displace the bladder. It is important to verify that the
packing is not displacing the applicators away from the
vaginal apex.
Doses. The HDR dose depends on the dose specification
point and whether EBRT is given. The ABS recommends
that the dose specification point be clearly documented in

ABS panel on HDR for endometrial cancer

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785

Table 5. Suggested doses of HDR alone to be used for adjuvant treatment of postop endometrial cancer
No. of HDR
fractions

HDR dose/fx

Dose-specific point

Equiv. dose for

tumor effects

Equiv. dose (late effects

with DRF)

3
4
5
2*
3
4
5

7.0
5.5
4.7
16.2*
10.5
8.8
7.5

0.5-cm depth
0.5-cm depth
0.5-cm depth
Vaginal surface
Vaginal surface
Vaginal surface
Vaginal surface

29.8
28.4
28.8
70.7
53.8
55.1
54.7

23.2
21.1
20.7
65.0
45.6
45.1
43.3

* 2 fractions of 16.2 Gy at vaginal surface using ovoids have been used by University of Madison and is given for comparison only. There
was no consensus regarding its use amongst the panel members.

the patients treatment record and be stated in any published

reports. The usual EBRT dose (when given) is 45 Gy to the
whole pelvis. Suggested doses of HDR alone to be used for
vaginal cylinders are given in Table 5, while suggested
doses of HDR to be given in combination with 45-Gy EBRT
are given in Table 6. Because some institutions specify the
dose at surface, while others specify the dose at 0.5-cm
depth, suggested equivalent HDR doses have been given for
either specification methods. To allow comparisons, the
HDR doses have been converted, using the linear quadratic
model (43), to give the LDR equivalent doses for tumor
effects. A dose-modifying factor (DMF) of 0.7 was used to
calculate the equivalent dose for late effects, assuming that
the normal tissues (bladder, rectum) are getting 70% of the
prescription dose (43).
Dose specification and optimization. It is recommended
that the proximal 35 cm of the vagina be treated. For
serous and clear cell histologies, treatment of the entire
vaginal canal should be considered. The dose distribution
should be optimized to deliver the prescribed dose either at
the vaginal surface or at 0.5-cm depth, depending on the
institutional policy. Regardless of the prescription point, the
ABS recommends reporting doses at both the vaginal surface and at 0.5-cm mucosal depth.
Vaginal cylinders. If vaginal cylinders are used, placing
optimization points only on the lateral surface of the vagina
without having optimization points at the apex would produce unacceptably high doses at the vaginal apex and any
overlying small bowel (42, 44) (Fig. 2). The ABS recommends placing optimization points at the apex and along the
curved portion of the cylinder dome, in addition to the
lateral vaginal mucosa. Examples of isodose distribution
and dwell weights of a manually optimized treatment plan

for treating the vaginal cuff with a vaginal cylinder are

given in Fig. 3 and Table 7, respectively. Source anisotropy
can produce a lower dose at the vaginal apex (44, 45) and
isotropic dose calculation model can result in as much as
30% underdosing at the vaginal apex. However, its clinical
significance is not known. The ABS recommends the use of
proper anisotropic dose calculation model (44). Multichannel cylinders may be used to minimize the effect of anisotropy (26, 27).
Vaginal ovoids. For ovoids, optimization points are
placed at the surface of the ovoids or at 0.5-cm depth into
vaginal mucosa according to the institutional prescription
policy. If the ovoids are separated, additional optimization
points must be placed at the apex, midway between the
ovoids, to avoid cold spots between them.
HDR treatment of recurrences at the vaginal cuff. Radiation therapy should generally consist of a combination of
pelvic EBRT and brachytherapy. With distal vaginal recurrences, the entire vagina and the medial inguinal nodes
should be considered for inclusion in the EBRT field. There
was no consensus regarding the use of a midline block. In
addition to the general recommendations made for postoperative adjuvant therapy, the ABS recommends the following
for the treatment of vaginal recurrences:
1. Intracavitary brachytherapy (with an appropriate vaginal
applicator) should be used only for non-bulky recurrences (thickness 5 mm after the completion of
EBRT).
2. Interstitial brachytherapy should be considered for bulky
recurrences (thickness 5 mm after the completion of
external radiation) and for previously irradiated patients.
Interstitial brachytherapy has been traditionally per-

Table 6. Suggested doses of EBRT and HDR to be sued for adjuvant treatment of postop endometrial cancer
EBRT (Gy) @ 1.8
Gy/fx

No. of HDR
fractions

HDR dose/fx

Dose-specific point

Equiv. dose for

tumor effects

Equiv. dose (late effects

with DRF)

45
45
45
45

2
3
2
3

5.5
4.0
8.0
6.0

0.5-cm depth
0.5-cm depth
Vaginal surface
Vaginal surafce

58.5
58.3
68.3
68.3

53.7
52.9
62.5
61.3

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Volume 48, Number 3, 2000

Fig. 2. Demonstrates an isodose distribution of a treatment plan for treating the post-hysterectomy vaginal cuff with a
vaginal cylinder if the dose optimization points are placed only along the lateral vaginal wall. The dose at the apex at
0.5-cm depth (750 cGy) is higher than the prescribed dose of 500 cGy at 0.5-cm depth within the lateral vaginal wall.

formed using LDR techniques in this setting. These

patients are best treated at centers with considerable
experience in interstitial brachytherapy.

3. Marker seeds or surgical clips should be placed at the

margins of gross disease to delineate disease extent.
4. If the relapse is limited to one wall of the vagina,

Fig. 3. Demonstrates an isodose distribution of an optimized treatment plan for treating the post-hysterectomy vaginal
cuff with a vaginal cylinder. Dose optimization points have been placed at the apex and along the curved portion of the
cylinder dome in addition to the lateral vaginal mucosa to produce a more homogenous dose.

ABS panel on HDR for endometrial cancer

S. NAG et al.

787

Table 9. Suggested doses of HDR only for treatment of

inoperable primary endometrial cancer

Table 7. Dwell weights for an optimized treatment plan for

adjuvant treatment of postop endometrial cancer using a vaginal
cylinder
Dwell
position

Relative
dwell weight

No. of HDR
fractions

1
2
3
4
5
6
7
8
9
10
11

0.45
0.71
0.76
0.71
0.62
0.56
0.56
0.63
0.75
0.89
1.00

4
5
6
7

HDR dose/fx*
8.5
7.3
6.4
5.7

Gy
Gy
Gy
Gy

at
at
at
at

2
2
2
2

cm
cm
cm
cm

Equiv. dose
for tumor
effects

Equiv. dose
(late effects
with DRF)

52.4
52.6
52.5
52.2

42.6
41.4
40.3
39.0

* HDR doses are specified at 2 cm from the midpoint of intrauterine sources.

Note that dwell points are 0.5-cm apart and dwell position #1 is
superior (at apex) and dwell position #11 is inferior.

consideration should be given to limiting the dose to the

opposite wall.
5. The suggested HDR doses after an EBRT dose of 4,500
cGy are stated in Table 8. The dose specification and
optimization follows that given in the previous section
for the post-operative adjuvant treatment of endometrial
cancer.
Treatment of inoperable primary endometriumtechnique. The ABS recommends determining the uterine wall
thickness using CT, MRI, or ultrasound wherever possible.
MRI additionally gives information regarding the depth of
myometrial and cervical invasion.
Most patients are best treated with a combination of
pelvic EBRT followed by HDR intracavitary brachytherapy. However, it was recognized that EBRT may not be
feasible or may be associated with unacceptable morbidity
in some patient subsets. Selected patients with early-stage,
low-grade disease (e.g., IA, grades 1, 2) have a very low risk
of pelvic lymph node disease and may be treated with
intracavitary brachytherapy alone.
The ABS recommends performing the procedure under
spinal anesthesia or intravenous, conscious sedation. It is
useful to have anesthesia stand-by, in case of any problems
with airway compromise, in the high-risk patients. A paracervical block offers very good analgesia while minimizing
risk of complications.
The uterine cavity is sounded to determine the length of
the uterine canal. Given the small diameter of the HDR

applicators, the cervical canal usually does not need dilatation. The postmenopausal uterus has a relatively thin wall,
and it is important to be gentle during the insertion of any
applicators to avoid uterine perforation. Similarly, a downward traction on the uterus (by holding the cervix with a
tenaculum) helps prevent the uterus from being pushed
superiorly (and close to the bowel) as the applicators are
being inserted.
When two or more intrauterine applicators are inserted,
fluoroscopy or ultrasound is helpful in directing the applicators into the uterine cornuae.
These patients are often obese, and good treatment planning localization radiographs (especially laterals) are difficult to obtain. AP stereoshift radiographs may be useful.
They often need to be treated quickly due to their poor
medical condition. A fixed geometry applicator system is
helpful, because it allows for a reproducible set-up and
obviates the need for complex and time-consuming treatment planning with each fraction.
Table 9 gives the suggested dose-fraction schemes for
cases treated with only intracavitary brachytherapy, and
Table 10 for brachytherapy in combination with EBRT.
While several authors (2, 23) have successfully employed
doses of 20 Gy in 2 fractions (1 week apart), the ABS does
not recommend such large fraction sizes, given the potential
for late rectosigmoid toxicity.
Dose specification and optimization. The irregular shape
of the uterine cross-section in the coronal and sagittal planes
presents a challenge to satisfactory isodose distribution
from intracavitary brachytherapy.
1. The target volume is the entire uterus, cervix, and upper
35 cm of the vagina.
2. The required length of the vagina to be treated cannot be

Table 8. Suggested doses of EBRT and HDR to be used for treating vaginal cuff recurrences from endometrial cancer
EBRT (Gy) @ 1.8
Gy/fx

No. of HDR
fractions

HDR dose/fx

Dose-specification
point

Equiv. dose for

tumor effects

Equiv. dose (late effects

with DRF)

45
45
45
45

3
4
5
4

7.0
6.0
6.0
7.0

0.5-cm depth
0.5-cm depth
Vaginal surface
Vaginal surface

74.0
76.3
84.3
83.9

66.4
67.4
73.4
74.2

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Volume 48, Number 3, 2000

Table 10. Suggested doses of external beam HDR for treatment of inoperable primary endometrial cancer
EBRT (Gy)
@ 1.8 Gy/fx

No. of
HDR
fractions

HDR dose/fx

Equiv. dose
for tumor effects

Equiv. dose
(late effects with DRF)

45
45
45

2
3
4

8.5 Gy at 2 cm
6.3 Gy at 2 cm
5.2 Gy at 2 cm

70.5
69.9
70.6

64.5
62.8
62.5

* HDR doses are specified at 2 cm from the midpoint of intrauterine sources.

encompassed by ovoids. The use of ovoids should be

limited to cases with lower uterine segment involvement
or Stage II disease where the medial parametrium is a
part of the target volume. For a tandem and ovoid assembly the dose may be prescribed to point A.
3. Ideally, the treatment plan should be image- or targetbased and should ensure that the entire uterine serosa
and the vaginal wall (to a depth of 0.5 cm) are enclosed
within the prescription isodose. The optimization points
are to be placed along the serosa to conform the dose
distribution to the target volume. At the level of the
vagina, the dose distribution should be optimized to
deliver the prescribed dose at 0.5-cm depth within the
vaginal mucosa. The rather obvious need to include the
entire uterine wall within the prescription isodose is
underscored by poor results from series that have prescribed to a fixed distance of only 1 cm from the source.
4. The logistics of doing an elaborate planning often clash
with the need for expediency in these patients in poor
general health. Further, imaging facilities may not be
readily available to determine the thickness of the uterine
wall. In the absence of CT/MRI-based treatment planning, the following method is suggested which generally
works well in the average patient, in spite of its limitations. The dose should be specified at a point 2 cm from
the central axis at the midpoint along the uterine appli-

Table 11. Dwell weights for an optimized treatment plan for

treating inoperable primary endometrial cancer with a Y-shaped
tandem
Dwell
position

Relative
dwell weight

1
3
5
7
9
11
13
15
17
19
21

1.00
0.73
0.55
0.43
0.36
0.31
0.29
0.28
0.29
0.34
0.44

Note that dwell position #1 is superior (at fundus) and dwell

position #21 is inferior (at vagina). Dwell weights for only one of
the two identical tandems is shown.

cator. The isodose should be widened at the uterine

fundus to account for the increased uterine width at the
fundus. At the level of the vagina, the dose distribution
should be optimized to deliver the prescribed dose at
0.5-cm depth within the vaginal mucosa. Most patients
accommodate a 3-cm diameter cylinder, and if the dose
is prescribed at 2 cm from the central axis of the tandem,
at its midpoint, the 2-cm prescription point translates into
a prescription at 0.5 cm from the vaginal mucosa. An
example of isodose distribution and dwell weights of an
optimized treatment plan for treating primary endometrial cancer with a Y-shaped tandem is given in Fig. 4
and Table 11, respectively. If a smaller diameter cylinder
is used, the prescription at the vaginal level is adjusted so
that the prescribed dose is delivered at a depth of 0.5 cm
from the mucosal surface.
5. It is important to identify the vaginal surface, either by
using radio-opaque gauze packing or by the surface of
the cylinder (if a cylinder is a part of the applicator
assembly) to allow for appropriate dose-prescription and
optimization.
6. Computer optimization is difficult when multiple divergent tandems are used for treatment, and cold-spots
may result between the tandems. In such cases, additional dose optimization points need to be placed between the tandem tips, or one may need to start off with
computer optimization and then manually adjust the
dwell weights to produce the desired dose distribution
(Fig. 4).
7. Doses at ICRU reference points for the bladder and
rectum should be calculated and reported for each case.
Sigmoid colon localization may permit a more accurate
estimate of the sigmoid dose.

CONCLUSION
Recommendations are made for HDR brachytherapy for
endometrial cancer. Practitioners and cooperative groups
are encouraged to use these recommendations as a guide to
formulate their treatment and dose reporting policies realizing that the final responsibility for the medical decisions
ultimately rests with the treating radiation oncologist. These
recommendations will be modified, as image-based treatment becomes more widely available.

ABS panel on HDR for endometrial cancer

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789

Fig. 4. Examples of isodose distribution of an optimized treatment plan for treating inoperable primary endometrial
cancer with a Y-shaped applicator.

DISCLAIMER
These guidelines represent consensus of the authors
regarding currently accepted treatment. The suggested
doses have been derived from a combination of literature
review, the individual clinical experiences of the authors
and modified by biomathematical modeling. While these
doses seem reasonable to the authors, some of the dose
fractionation schemes given may not have been exten-

sively tested in clinical practice. These guidelines will be

updated as significant new outcome data becomes available. Any clinician following these guidelines is expected
to use their clinical judgment to determine an individual
patients treatment. The American Brachytherapy Society
makes no warranties of any kind regarding their use and
disclaims any responsibility for their application in any
way.

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