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VMI + MAR\/no-MAR were reconstructed at energies ranging from 40 to 140\u00a0keV. CT attenuation and image noise (standard deviation) were measured to calculate the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) for the most prominent artifacts, and the artifact index (AI) for the cervix, bladder, and rectum. Objective metrics were compared between the VMI\u2009+\u2009MAR and VMI + no-MAR groups. Subjective image quality was evaluated using a 5-point Likert scale, focusing on artifact reduction, soft tissue contrast, and contouring preference. Geometric distortion was assessed by measuring the long axis, short axis, and long-to-short axis ratio (L\/S) of the titanium applicator. Contouring consistency was quantified using the Dice Similarity Coefficient (DSC) and 95th percentile Hausdorff Distance (HD95) between two radiation oncologists.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      VMI\u2009+\u2009MAR significantly reduced the AI for the cervix (relative 34.74%-88.51% reduction) and rectum (relative 11.31%-81.35% reduction) compared to VMI\u2009+\u2009no-MAR across all energies (all\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05). SNR increased from 0.70\u20131.00 to 1.75\u20131.97, and CNR improved significantly from 90\u00a0keV onwards (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.05). 140\u00a0keV\u2009+\u2009MAR achieved the highest SNR and CNR with the lowest AI. Subjective assessment further confirmed that 140\u00a0keV\u2009+\u2009MAR offered the best balance between artifact reduction and soft tissue contrast, with significantly higher scores for artifact reduction and contouring preference (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Distortion analysis showed that with increasing VMI energy, long (40-140\u00a0keV: from 8.10 to 6.17\u00a0mm) and short axes (40-140\u00a0keV: from 6.93 to 5.55\u00a0mm) decreased, and L\/S approached 1 (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Contouring consistency analysis further demonstrated that 140\u00a0keV\u2009+\u2009MAR achieved the highest DSC and lowest HD95 among all energy-MAR combinations, indicating superior reproducibility of target and organ-at-risk delineations.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>For the investigated cases and imaging procedures, high-energy VMI combined with MAR, particularly 140\u00a0keV\u2009+\u2009MAR, provided the most effective balance of artifact reduction, geometric accuracy, and clinical contouring suitability.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13014-025-02767-9","type":"journal-article","created":{"date-parts":[[2025,12,1]],"date-time":"2025-12-01T10:37:14Z","timestamp":1764585434000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Metal artifact reduction in spectral computed tomography for intracavity brachytherapy in cervical cancer patients: a prospective study"],"prefix":"10.1186","volume":"21","author":[{"given":"Yuliang","family":"Sun","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yining","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zheng","family":"Zeng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bing","family":"Zhou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haoran","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-8785-9948","authenticated-orcid":false,"given":"Junfang","family":"Yan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1079-5137","authenticated-orcid":false,"given":"Ke","family":"Hu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6856-2320","authenticated-orcid":false,"given":"Fuquan","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,1]]},"reference":[{"issue":"3","key":"2767_CR1","doi-asserted-by":"publisher","first-page":"229","DOI":"10.3322\/caac.21834","volume":"74","author":"F Bray","year":"2024","unstructured":"Bray F, Laversanne M, Sung H, et al. 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