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Open Access Highly Accessed Review

ACR Appropriateness Criteria®  Resectable Rectal Cancer

William E Jones1, Charles R Thomas2*, Joseph M Herman3, May Abdel-Wahab4, Nilofer Azad5, William Blackstock6, Prajnan Das7, Karyn A Goodman8, Theodore S Hong9, Salma K Jabbour10, Andre A Konski11, Albert C Koong12, Miguel Rodriguez-Bigas13, William Small14, Jennifer Zook15 and W Warren Suh16

Author Affiliations

1 UT Health Science Center San Antonio, San Antonio, Texas, USA

2 Knight Cancer Institute at Oregon Health and Science University, Portland, Oregon, US

3 Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, Maryland, USA

4 University of Miami, Miami, Florida, USA

5 Sidney Kimmel Cancer Center at Johns Hopkins, American Society of Clinical Oncology, Baltimore, Maryland, USA

6 Wake Forest University, Winston Salem, North Carolina, USA

7 MD Anderson Cancer Center, Houston, Texas, USA

8 Memorial Sloan-Kettering Cancer Center, New York, New York, USA

9 Massachusetts General Hospital, Boston, Massachusetts, USA

10 Cancer Institute of New Jersey, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey, USA

11 Wayne State University School of Medicine, Detroit, Michigan, USA

12 Stanford University Medical Center, Stanford, California, USA

13 MD Anderson Cancer Center, American College of Surgeons, Houston, Texas, USA

14 The Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois, USA

15 Indiana University School of Medicine, Indianapolis, Indiana, USA

16 Cancer Center of Santa Barbara, Santa Barbara, California, USA

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Radiation Oncology 2012, 7:161  doi:10.1186/1748-717X-7-161

Published: 24 September 2012

Abstract

The management of resectable rectal cancer continues to be guided by clinical trials and advances in technique. Although surgical advances including total mesorectal excision continue to decrease rates of local recurrence, the management of locally advanced disease (T3-T4 or N+) benefits from a multimodality approach including neoadjuvant concomitant chemotherapy and radiation. Circumferential resection margin, which can be determined preoperatively via MRI, is prognostic. Toxicity associated with radiation therapy is decreased by placing the patient in the prone position on a belly board, however for patients who cannot tolerate prone positioning, IMRT decreases the volume of normal tissue irradiated. The use of IMRT requires knowledge of the patterns of spreads and anatomy. Clinical trials demonstrate high variability in target delineation without specific guidance demonstrating the need for peer review and the use of a consensus atlas. Concomitant with radiation, fluorouracil based chemotherapy remains the standard, and although toxicity is decreased with continuous infusion fluorouracil, oral capecitabine is non-inferior to the continuous infusion regimen. Additional chemotherapeutic agents, including oxaliplatin, continue to be investigated, however currently should only be utilized on clinical trials as increased toxicity and no definitive benefit has been demonstrated in clinical trials.

The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Keywords:
Appropriateness criteria; Rectal cancer; Chemoradiotherapy; Radiotherapy; Chemotherapy