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Table 2 70-year-old woman staged with EUS, aT2NX rectal cancer with caudal extent located 9 cm from verge, final pathology was T3N1 status post low anterior resection (LAR), KPS ≥70

From: ACR Appropriateness Criteria®  Resectable Rectal Cancer

Treatment Rating Comments
Treatment Options   
  RT + chemotherapy 9  
  RT alone 2  
  Chemotherapy alone 2  
If RT + Chemo: RT Dose to Primary   
  45 Gy/1.8 Gy 6  
  50.4 Gy/1.8 Gy 9  
  54 Gy/1.8 Gy 8 If small bowel is completely excluded after 50.4 Gy.
  59.4 Gy/1.8 Gy 3 If small bowel is completely excluded after 50.4 Gy.
Simulation   
  Patient prone 9 Unless physically unable. If using IMRT technique, may prefer supine.
  Small-bowel contrast at simulation 9 Not mandated with CT simulation.
  Patient immobilized 9  
  Use belly board 9 Only needed if prone.
  Anal marker 9  
  Bladder full at simulation 7  
If RT + Chemo: RT Volume   
  L5/S1 pelvis to include anal marker 2 CT simulation preferred. Use CT to ensure margin on inferior extent of tumor. Technically, the field should extend 2-3 cm below the anastomosis on the CT.
  L5/S1 pelvis to bottom of ischial tuberosity 5 CT simulation preferred. Bony landmark is an approximation. Use CT to ensure margin on inferior extent of tumor. Technically, the field should extend 2-3 cm below the anastomosis on the CT.
RT Technique   
  3 or 4 field with photons 9 Depending on clinical situation.
  AP/PA 1  
IMRT 6 May be appropriate depending on the clinical situation on a case-by-case basis. Enrollment in a clinical trial preferred.
  1. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate.