Table 2.

Recommendations of the SOCHIRA for radiotherapy treatment in cervical cancer

Recommendations	Grade of recommendation	Level of evidence	Percentage of agreement
The use of adjuvant EBRT is recommended in the following situations: WITHOUT platinum based CCT: Sedlis criteria: 1) ILV+ and deep third, any T 2) ILV+ middle third and tumor larger than 2 cm 3) ILV + superficial third and tumors greater than or equal to 5 cm 4) ILV−, middle third and tumor of 4 cm also 5) ILV+, deep third and 4 cm tumor. WITH platinum based CCT: Peters criteria 1) lymphadenopathy (+) 2) parametrium (+) 3) margin (+)	A	1	98%
IMRT technique in adjuvant EBRT is recommended. Conventional 3D technique is a valid option, considerations of a higher acute and late toxicity must be taken	B	1	86%
45 Gy in 25 fractions is recommended as adjuvant schedule dose Other accepted fractionation schedules are 50.4 Gy in 28 fractions, 50 Gy in 25 fractions of 2 Gy day, 46 Gy in 23 fractions	B	2	95%
Routine use of brachytherapy as a boost dose in adjuvant setting is not recommended. Its use can be considered in the case of a close or positive vaginal margin, for a total EQD2 dose of 65–70 Gy	C	4	90%
The use of definitive radiotherapy (EBRT plus brachytherapy) is recommended in patients with an early stage (IB1, IIA1) in the case of surgical contraindication or patient rejection	B	1	100%
The use of definitive radiation therapy (external RT plus brachytherapy) with concomitant chemotherapy is recommended in patients with an advanced stage: IB2 and ≥ IIA2 to IVA	A	1	100%
3D conformal technique is recommended as standard for definitive radiotherapy IMRT is an option to consider given its theoretical and clinical benefits derived from other pelvic neoplasms, with the use of an appropriate IGRT protocol and consideration of internal movements	B	3	81%
45 Gy in 25 fractions is recommended as definitive radiotherapy schedule dose Other accepted fractionation schedules are 50.4 Gy in 28 fractions, 50 Gy in 25 fractions, 46 Gy in 23 fractions	B	2	95%
Total treatment time ≤ 50–56 days is recommended Early referral to BT is recommended	A	2	100%
Parametrial boost with external radiation therapy is not recommended. For its omission consider: 1) Clinical and imaging evaluation of parametrial involvement. 2) To have the ability to perform interstitial brachytherapy if required In case of not complying with the previous points, it is accepted to perform a sequential parametrial boost up to 54–59.4 Gy or its equivalent with integrated simultaneous boost, considering the increased risk of acute and mainly late complications	A	2	93%
The inclusion of lumbo-aortic (LAo) lymph nodes is recommended in selected high-risk patients, according to the EMBRACE II protocol: ≥ 1 common iliac lymph node matastases, ≥ 3 pelvic lymph node matastases. In the case of lymph node metastases in Lao, it should be extended to at least 3 cm above the highest	B	3	85%
Sequential Boost to pelvic lymph node macroscopic disease is recommended up to 55–60 Gy or its equivalent with integrated simultaneous boost (SIB) (preferably SIB with IMRT technique) In LAo lymph nodes macroscopic disease, without evidence of systemic spread on PET/CT, sequential boost of up to 60 Gy or its equivalent with integrated simultaneous boost is recommended, ideally using the IMRT technique in both cases	B	2	100%
The use of HDR technique is recommended LDR technique is accepted as an option	A	2	97%
Brachytherapy treatment planning based on 3D images (CT and/or MRI) with volumetric prescription and evaluation is recommended Use applicator adapted to residual disease or anatomy of the patient. Interstitial brachytherapy is recommended if required 2D dosimetry prescription A point and report rectal and bladder point accepted. In case of using the LDR technique, a prescription should be made for point A and a report of the rectal and bladder point should be made	A	2	98%
It is recommended to have an initial pelvic MRI evaluation (before EBRT) and one immediately before brachytherapy. It can be a simulation MRI or fused diagnostic MRI. Prioritize MRI prior to brachytherapy. If there is no access to MRI, treatment based on simulation CT or ultrasound performed by an expert is accepted	A	2	98%

EBRT — external beam radiotherapy; CCT — concomitant chemotherapy; ILV — ipsilateral lung volume IMRT — intensity modulated radiation therapy; EQD2 — equivalent dose at fractionation of 2 Gy; IGRT — image-guided radiation therapy; HDR — high dose rate; LDR — low dose rate PET — positron emission tomography; CT — computed tomography; MRI — magnetic resonance imaging