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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.