TABLE 2.
Sixty-Five-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. Clinical Condition: Local Excision in Rectal Cancer
| Treatment | Rating | Comments |
|---|---|---|
| Treatment options | ||
| LAR or APR | 9 | |
| Local excision alone | 2 | |
| Local excision followed by adjuvant chemoradiation | 7 | Depending on pathologic features of local excision, definitive surgery with LAR or APR may still be indicated |
| Neoadjuvant chemoradiation followed by local excision | 7 | For this treatment, consider surgical management after neoadjuvant chemoradiation based on response to therapy |
| Local excision and radiation alone | 2 | |
| If local excision with chemoradiation: radiation dose to primary (Gy) | ||
| 45/1.8 | 7 | This treatment is a preoperative dose. Infusional 5-FU or capecitabine should be used daily |
| 50.4/1.8 | 9 | This treatment is a preoperative dose. Infusional 5-FU or capecitabine should be used daily |
| 54/1.8 | 7 | This treatment is a postoperative dose. Infusional 5-FU or capecitabine should be used daily unless small bowel is in radiation field |
| 59.4/1.8 | 3 | This treatment is a postoperative dose. Infusional 5-FU or capecitabine should be used daily unless small bowel is in radiation field |
| Simulation | ||
| Patient prone | 9 | |
| Small bowel contrast at simulation | 9 | |
| Patient immobilized | 9 | |
| Use belly board | 9 | Consider this if the patient is prone |
| Anal marker | 9 | |
| Bladder full at simulation | 7 | |
| Patient supine | 6 | This iss usually appropriate with IMRT |
| If local excision with chemoradiation: radiation volume | ||
| L5/S1 to bottom of ischial tuberosity with gross tumor volume determined using CT/MRI-based treatment to 2–3 cm below tumor | 9 | |
| Radiation technique | ||
| IMRT | 6 | |
| 3-field with photons | 9 | |
| 4-field with photons | 9 | |
| Anterior-posterior/posterio-anterior | 1 | |
Rating Scale: 1, 2, 3 usually not appropriate; 4, 5, 6 may be appropriate; 7, 8, 9 usually appropriate.
Discussion: patients with uT2N0 rectal cancers may be less reliably staged with EUS,21 indicating a higher risk for subclinical nodal involvement and risk for recurrence. In addition, larger tumor size39 may increase risk for local recurrence even if margins are uninvolved and no other adverse features are identified on final pathology. The addition of pelvic radiation with or without chemotherapy may reduce the risk of local recurrence.5,9,11,41,46 Furthermore, neoadjuvant therapy should be considered for uT2N0 patients.13,44
APR indicates abdominoperineal resection; CT, computerized tomography; EUS, endorectal ultrasound; IMRT, intensity-modulated radiation therapy; LAR, low anterior resection; MRI, magnetic resonance imaging; 5-FU, 5-fluorouracil.