Multimodal imaging guided brachytherapy: the example of cervical cancer

Image-guided brachytherapy is crucial in the management of locally advanced cervical cancers and has benefited from advances in imaging over recent decades. The recommendations of the European Brachytherapy - European Society for Radiation Oncology (GEC-ESTRO) have resulted in harmonized practices and improved clinical outcomes in terms of efficacy and toxicity. Post-implant magnetic resonance imaging (MRI) has become the reference imaging modality to guide brachytherapy. There is an increasing interest for other multimodal imaging in these patients. The metabolic information provided by Positrons Emission Tomography/computed tomodensitometry (PET/CT) is also very promising approach to guide personalized dose escalation strategies. The prognostic values of MRI and PET scanner before brachytherapy make it possible to consider personalizing the dose delivered in brachytherapy and to propose a dose escalation to patients who really need it and to possibly consider a deescalation strategy in patients with a very good prognosis. However, further studies are needed to confirm this approach.