Table 4 45-year-old woman with EUS staged T4N0, 4 cm lesion at 3 cm from verge with extensive involvement of the anal canal, KPS ≥70
From: ACR Appropriateness Criteria® Resectable Rectal Cancer
Treatment | Rating | Comments |
|---|---|---|
Treatment Options | ||
Preoperative RT + chemo followed by surgery | 9 | LAR if possible. |
Preoperative RT followed by surgery | 2 | |
Surgery followed by adjuvant treatment if pT3+ and/or LN+ | 1 | |
If Preoperative RT: RT Dose | ||
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. For fixed lesions only. |
5 Gy x 5 | 1 | Will not provide sufficient downstaging. |
Simulation | ||
Patient prone | 9 | 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 Preoperative RT: RT Volume | ||
Pelvis to L5/S1 + boost | 8 | |
Pelvis to L5/S1 + inguinal LN + boost | 9 | With extensive involvement of anal canal. |
RT Technique | ||
3 or 4 field with photons | 9 | Depending on clinical situation. |
AP/PA | 1 | |
3 field with electron boost to perineum | 3 | |
4 field with electron boost to perineum | 3 | |
IMRT | 8 | Using atlas for target delineation. Based on anal cancer data. May be helpful to treat inguinal lymph nodes and to reduce side effects. |
If Preoperative RT + Chemo: Time between RT and Surgery | ||
2-4 weeks | 2 | |
>4-6 weeks | 5 | |
>6-8 weeks | 8 | |
>8 weeks | 5 | Extended length of time without therapy is discouraged. Strongly encourage enrollment in clinical trial. |