Table 6.

Recommendations for brachytherapy technique

KQ5 Recommendations	Strength of Recommendation	Quality of Evidence (Refs)
Optimal imaging and technique for the delivery of brachytherapy
1. For women receiving brachytherapy for cervical cancer, intra-procedure imaging is recommended if available.	Strong	Low 67
2. For women receiving brachytherapy for cervical cancer, MRI or CT-based planning to a volume-based prescription is recommended.	Strong	Moderate 56,62,63,68−72
3. For women receiving brachytherapy for cervical cancer, if volume-based planning cannot be performed, then 2-D/point-based planning is rec006Fmmended.	Strong	Moderate 8,11–13,73
Optimal dose/fractionation schedule for the delivery of brachytherapy
4. For women treated with definitive RT for cervical cancer, the total EQD210 of EBRT and brachytherapy should be ≥8000 cGy. (Table 9 in the full-text guideline)	Strong	Moderate 56,74
5. For women with cervical cancer receiving volume-based brachytherapy, HR-CTV D90 greater than or equal to prescription dose (≥8000 cGy) is conditionally recommended, with careful consideration of normal tissue constraints. (Table 7)
Implementation remark: ● For patients with poor response or large-volume (>4 cm) disease, D90 ≥8500 cGy is reasonable. ● Utilization of a hybrid intracavitary/interstitial technique can help improve the dose distribution when not achieving appropriate target and/or OAR dose constraints with an intracavitary alone approach.	Conditional	Moderate 57,75−77
Optimal OAR constraints of brachytherapy
6. In women treated with brachytherapy for intact cervical cancer, volumetric contouring of the OARs and use of appropriate dose constraints are recommended.	Strong	Moderate 60,63,72,77−79
7. If volumetric planning is not available for women treated with brachytherapy for intact cervical cancer, 2-D/point-based dose constraints should be applied.	Strong	Moderate 8,11−13

Abbreviations: 2-D = 2-dimensional; CT = computed tomography; EBRT = external beam radiation therapy; EQD2₁₀ = dose calculation to an equivalent dose of 2 Gy with an α-to-β ratio of 10; HR-CTV = high-risk clinical target volume; MRI = magnetic resonance imaging; OARs = organs at risk; RT = radiation therapy.