Variant 2.

A 60-y-old man, asymptomatic in PSA screening program^∗

Treatment	Rating	Comments
Use current simulation	5	This procedure may be appropriate but there was disagreement among panel members on the appropriateness rating as defined by the panel's median rating. Distended rectum results in worse dosimetry88 and clinical outcome.89 It may be controversial to not resimulate, but some patients will always have a distended rectum and image guidance methods may protect against negative effects.
Resimulate this case after intervention:
Patient walking, bowel movement, enema	8	Enema may be most appropriate.97

Rating scale: 1, 2, 3 = usually not appropriate; 4, 5, 6 = may be appropriate; 7, 8, 9 = usually appropriate.

Abbreviations as in Variant 1.

^∗PSA 5.2 ng/mL, prostate without palpable abnormalities. Multiple needle biopsies of the prostate showed adenocarcinoma. Gleason score 3 + 3 = 6. CT simulation reveals grossly distended rectum (gas and stool).