American College of Radiology
ACR Appropriateness Criteria®

Recurrent Rectal Cancer

Variant 1: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago patient underwent a low anterior resection (pT3N0) and 6 months of adjuvant chemotherapy. Endoscopic ultrasound (EUS) now shows an anastomotic recurrence 6 cm above the anal verge. Biopsy positive for adenocarcinoma. No sites of metastatic disease. Tumor currently unresectable and nonobstructing. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
30 Gy/3.0 Gy to pelvis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/3.0 Gy to pelvis with 5-FU-based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
30.6 Gy in 1.8 Gy to pelvis with 5-FU based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
40.8 Gy in 1.2 Gy BID with 5-FU based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with 5-FU-based chemotherapy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with FOLFOX chemotherapy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
59.4-64.8 Gy/1.8 Gy to pelvis Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
59.4-64.8 Gy/1.8 Gy to pelvis with 5FU-based chemotherapy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
SBRT to rectal lesion Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
External beam RT +/- concurrent chemotherapy with IORT May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Preoperative RT +/- 5-FU-based chemotherapy and reevaluate operability Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Tumor excision and abdominal-perineal resection (APR) before external beam RT Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
No surgery Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
4-6 months after therapy to primary Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
12 months after therapy to primary Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy prior to RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago the patient underwent a low anterior resection (pT3N0) and 6 months of adjuvant chemotherapy. EUS now shows an anastomotic recurrence 6 cm above anal verge. Biopsy positive for adenocarcinoma. Lesion not fixed to the pelvic sidewall on physical examination and CT. Patient now has a biopsy-proven resectable liver metastasis involving the right lobe (5 cm). KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
30 Gy/3.0 Gy to pelvis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/3.0 Gy to pelvis with 5-FU-based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
30.6 Gy in 1.8 Gy to pelvis with 5-FU based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
40.8 Gy in 1.2 Gy BID with 5-FU based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with 5-FU-based chemotherapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with FOLFOX chemotherapy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT to rectal lesion Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
External beam RT +/- concurrent chemotherapy with IORT May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Preoperative RT +/- 5-FU-based chemotherapy and reevaluate operability Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Resection of primary rectal tumor +/- IORT boost followed by adjuvant chemoradiation (5-FU-based) Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
No surgery Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
After resection of primary rectal tumor May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
At the same time as the resection of the primary rectal tumor Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
After 3-6 months post-surgical chemotherapy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Before resection of primary site, after preoperative RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Before resection of primary site, before preoperative RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
4-6 months after therapy to primary Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
12 months after therapy to primary Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy prior to RT/surgery May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago the patient underwent a low anterior resection after preoperative chemotherapy and radiotherapy for a (pT3N1) rectal cancer and 6 months of adjuvant chemotherapy. Endoscopic ultrasound (EUS) now shows an anastomotic recurrence 6 cm above the anal verge. Biopsy positive for adenocarcinoma. No sites of metastatic disease. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
30 Gy/3.0 Gy to pelvis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
30 Gy/3.0 Gy to pelvis with 5-FU-based chemotherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
30.6 Gy in 1.8 Gy to pelvis with 5-FU based chemotherapy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
40.8 Gy in 1.2 Gy BID with 5-FU based chemotherapy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with 5-FU-based chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy to pelvis with FOLFOX chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
59.4-64.8 Gy/1.8 Gy to pelvis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
59.4-64.8 Gy/1.8 Gy to pelvis with 5FU-based chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
SBRT to rectal lesion Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
External beam RT +/- concurrent chemotherapy with IORT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Preoperative RT +/- 5-FU-based chemotherapy and reevaluate operability Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Tumor excision and adominoperineal resection (APR) before external beam RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
No surgery Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
4-6 months after therapy to primary Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
12 months after therapy to primary Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy prior to RT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 56-year-old male with severe pain that radiates to perineal region. Two years ago the patient was diagnosed with T3N1 rectal cancer 6 cm from anal verge. Underwent an abdominal-perineal resection, pelvic RT totaling 50.4 Gy plus 5-FU, followed by 6 months of adjuvant chemotherapy. CT of abdomen and pelvis reveal rectal mass (4 cm) invading bony pelvis at sciatic notch. No sites of metastatic disease. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
10-30 Gy/2.0 Gy to pelvis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
10-30 Gy/2.0 Gy to pelvis with 5-FU-based chemotherapy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
10-30 Gy/2.0 Gy to pelvis with 5-FU-based chemotherapy + IORT boost to pelvic sidewall Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Permanent radioactive implant of symptomatic lesion Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Hyper or standard dose radiation fractionated to 30-40 Gy with 5-FU based chemotherapy followed by reevaluation for surgical resection +/- IORT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
SBRT to rectal lesion Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Reevaluate operability after external beam RT +/- 5-FU Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Surgery post external beam RT +/- 5-FU + IORT boost Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Attempt tumor removal + IORT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Reevaluate operability after permanent implant Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.