American College of Radiology
ACR Appropriateness Criteria®

Rectal Cancer—Metastatic Disease at Presentation

Variant 1: Initial treatment of a 52-year-old man without a significant past medical history, with an asymptomatic, nonobstructing, uT3N0 primary rectal tumor 8 cm from the anal verge and a solitary, resectable, 4-cm metastasis in the right lobe of the liver. Karnofsky performance status (KPS) 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Resection of the liver lesion only Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI), then short-course pelvic RT, then surgery Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI), then long-course chemoradiation, then surgery Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI) then surgery Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Initial resection of the rectal primary by total mesorectal excision and of the liver lesion (either concurrent or sequential) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Initial long-course chemoradiation May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Variant 2: Initial treatment of a 60-year-old woman without a significant past medical history, with uT3N0 rectal cancer 4 cm from the anal verge causing pain and early symptoms of obstruction, bilobar hepatic metastases (50% liver replacement), and bilateral pulmonary metastases. A colonoscope can be passed through the lesion. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best supportive care Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Liver directed therapies (transarterial embolization, radiation, RFA) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI) Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Initial systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI plus bevacizumab) May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Initial resection of rectal primary Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Initial palliative stent or loop colostomy to relieve obstruction May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Initial palliative pelvic RT alone Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Initial long-course chemoradiation Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Variant 3: Initial treatment of a 60-year-old woman without a significant past medical history, with an asymptomatic, nonobstructing, uT3N0 rectal cancer, bilobar hepatic metastases (50% liver replacement), and bilateral pulmonary metastases. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best supportive care Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI ± bevacizumab) followed by short-course pelvic RT (± surgery) May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI ± bevacizumab) followed by long-course chemoradiation (± surgery) May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic 5-FU-based chemotherapy (FOLFOX/FOLFIRI ± bevacizumab) ± surgery Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Surgical debulking of metastatic disease Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Resection of rectal primary Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Liver directed therapies (transarterial embolization, radiation, RFA) Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Initial treatment of a 74-year-old woman with a history of coronary artery disease, severe emphysema, and diabetes, now with an asymptomatic, nonobstructing uT3N0 rectal primary cancer, extensive hepatic metastases, and abdominal carcinomatosis. KPS 50.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Best supportive care Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Preoperative pelvic RT + concurrent 5FU-based chemotherapy Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Resection of metastatic disease Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Resection of rectal primary Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Systemic biologic or chemotherapy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Palliative pelvic RT Usually not appropriate 3 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.