American College of Radiology
ACR Appropriateness Criteria®

Resectable Stomach Cancer

Variant 1: 54-year-old man with EUS uT2NxM0 gastric cardia adenocarcinoma status post total gastrectomy, final pathology, pT3N0M0, negative margins, D0 lymph node dissection. No neoadjuvant therapy given. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemoradiotherapy + chemotherapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Observation Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy × 1 cycle + chemoradiotherapy + chemo x 3 cycles Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy × 4 cycles + chemoradiotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Chemoradiotherapy + chemotherapy × 4 cycles May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
5-FU +/- leucovorin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Capecitabine alone May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
5-FU + oxaliplatin May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Operative and tumor bed, anastomotic sites, adjacent pancreas, left hemidiaphragm, perigastric, periesophageal (3–5 cm of esophagus), celiac lymph node beds Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Operative and tumor bed, anastomotic sites, adjacent pancreas, left hemidiaphragm, periesophageal (3–5 cm of esophagus) May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Operative and tumor bed, anastomotic sites Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 60-year-old man with uT3N1M0 gastric body adenocarcinoma status post 3 cycles ECF chemotherapy, followed by total gastrectomy, pT3N2M0, with residual bulky tumor at surgery, D1 lymph node dissection, negative margins. KPS ≥70.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemoradiotherapy + chemotherapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone with different (not ECF regimen) May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone with continuation of ECF May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 3 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
Induction chemotherapy × 1 cycle + chemoradiotherapy + chemo x 3 cycles May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy × 4 cycles + chemoradiotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Chemoradiotherapy + chemotherapy × 4 cycles May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Continuous infusion 5-FU +/- leucovorin Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
5-FU + oxaliplatin May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Continuous infusion 5-FU +/- leucovorin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Capecitabine Monday–Friday May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomoses + celiac LN + perigastric LN + splenic + suprapancreatic + pancreaticoduodenal + porta hepatis Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomoses + celiac LN + perigastric LN + splenic + suprapancreatic Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomoses + celiac LN + perigastric LN May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 80-year-old woman with uT3N1M0 gastric body adenocarcinoma. Patient is not a surgical candidate due to KPS 60 and 15% weight loss over 6 months.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemoradiotherapy alone Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
RT alone May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone May be appropriate TBD TBD 6 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 8 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Stomach + involved LN Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole stomach + involved LN + celiac LN + perigastric LN + splenic + suprapancreatic + pancreaticoduodenal + porta hepatis May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Tumor + involved LN May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 63-year-old woman with uT2N1 antral adenocarcinoma status post partial gastrectomy, final pathology T2N1M0, with positive distal margin, D2 lymph node dissection. KPS ≥80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemoradiotherapy + chemotherapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone Usually not appropriate TBD TBD 3 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
Induction chemotherapy × 1 cycle + chemoradiotherapy + chemo x 3 cycles Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Chemoradiotherapy + chemotherapy × 4 cycles Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Induction chemotherapy × 4 cycles + chemoradiotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
5-FU +/- leucovorin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Capecitabine alone May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
5-FU + oxaliplatin May be appropriate 5 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 8 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
AP/PA photons May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomosis with boost to distal anastomosis + perigastric + pancreaticoduodenal + porta hepatis + celiac + suprapancreatic LN Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomosis with boost to distal anastomosis + perigastric + pancreaticoduodenal + porta hepatis LN Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + anastomosis with boost to distal anastomosis May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 57-year-old man with uT4N2M0 gastric body adenocarcinoma. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Chemoradiotherapy then surgery Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone then surgery Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy then chemoradiotherapy then surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Surgery then chemoradiotherapy and chemotherapy May be appropriate 5 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 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Tumor + involved LN + celiac LN + perigastric LN + splenic + suprapancreatic + pancreaticoduodenal + porta hepatis Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Whole stomach + involved LN + celiac LN + perigastric LN + splenic + suprapancreatic + pancreaticoduodenal + porta hepatis Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Stomach + involved LN May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Tumor + involved LN May be appropriate 5 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.