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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.
  1. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate.