Would you add a brachytheray boost to a locally advanced cervical cancer after surgical resection and pelvic RT?

In general, a brachytherapy boost following external radiation is not standard when treating women for locally advanced cervical cancer post hysterectomy.  Neither of the 2 major adjuvant GOG trials (92 and 109) allowed a brachytherapy boost, and even the currently open GOG trial, GOG 263, does not include brachytherapy.  In cases where you may be concerned regarding more high risk disease, raising the dose of pelvic RT from 45 to 50.4 Gy can be justified.  Considering the primary area of concern for adjuvant treatment often deals with microscopic seeding of the parametria and subsequent spread to nodes (which is not going to be covered using a vaginal cylinder), there hasn't seemed to be much benefit in the routine use of vaginal brachytherapy.

From a personal standpoint, I would use a brachytherapy boost in situations where the surgeon performed a non-radical hysterectomy (in which case I also will try to generate a parametrial boost using IMRT of 5.4-9 Gy, and I use brachy to treat the upper vagina due to not having enough length resected), or in the situation of close/positive margins at the cuff.  In these circumstances, I tend to use the same dose and fractionation that I typically use for endometrial cancer - 2 x 6-7Gy to the surface, or equivalent.