American College of Radiology
ACR Appropriateness Criteria®

Local Excision in Rectal Cancer

Variant 1: 57-year-old man with preoperative stage uT1N0 freely mobile, moderately differentiated adenocarcinoma. Tumor is 2 cm in diameter, involves <25% of circumference, and is located 6 cm from anal verge. No lymphovascular space invasion is noted.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Observation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Chemoradiation Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
LAR or APR Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Chemoradiation Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Observation Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 65-year-old otherwise healthy woman with preoperative stage uT2N0 moderately differentiated adenocarcinoma. Tumor is 3 cm in diameter, freely mobile, and is located 4 cm from anal verge. No lymphovascular space invasion is noted.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
LAR or APR Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Local excision alone Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Local Excision followed by adjuvant chemoradiation Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Neoadjuvant chemoradiation followed by local excision Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Local excision and radiation alone Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Patient prone Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Small-bowel contrast at simulation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Patient immobilized Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Use belly board Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Anal marker Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Bladder full at simulation Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Patient supine May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
L5/S1 to bottom of ischial tuberosity with GTV determined using CT/MRI based treatment to 2–3 cm below tumor Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
IMRT May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
3 field with photons Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
4 field with photons Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
AP/PA Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 60-year-old woman with uT3Nx adenocarcinoma located 4 cm from anal verge.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Neoadjuvant chemoradiation followed by LAR or APR Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
Neoadjuvant chemoradiation followed by local excision Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Local excision alone Usually not appropriate 1 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.