Rectal Cancer Treatment Guideline
Staging: AJCC 7th edition (2010)
Primary Tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ: intraepithelial or invasion of lamina propria
T1
Tumor invades submucosa
T2
Tumor invades muscularis propria
T3
Tumor invades through the muscularis propria into the pericolorectal
tissues
T4a
Tumor pentrates to the surface of the visceral peritoneum
T4b
Tumor directly invades or is adherent to other organ of structures
Regional Lymph Nodes (N) (at least 10~14 nodes dissection)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph nodemetastasis
N1
Metastasis in 1~3 regional lymph nodes
N1a
Metastasisi in 1 regional lymph node
N1b
Metastasis in 2~3 regional lymph nodes
N1c
Tumor deposits in the subserosa, mesentery or nonperitonealized pericolic
or perirectal tissues without regional node metatstasis.
N2
Metastasis in 4 or more regional lympho nodes
N2a
Metastasis in 4~6 regional lymph nodes
N2b
Metastasis in 7 or more regional lymph nodes
Distant Metastasis (M)
MX
Metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis
M1a
Metastasis confined to one organ or site
(eg. liver, lung, ovary, nonregional node)
M1b
Metastasis in more than one organ/site or the peritoneum
Staging
T
N
M
Stage 0
Tis
N0
M0
Stage I
T1~2
N0
M0
Stage IIA
T3
N0
M0
Stage IIB
T4a
N0
M0
Stage IIC
T4b
N0
M0
T1~2
N1/N1c
M0
T1
N2a
M0
T3~T4a
N1/N1c
M0
T2~3
N2a
M0
T1~T2
N2b
M0
T4a
N2a
M0
T3~T4a
N2b
M0
T4b
Any
M0
Stage IVA
Any
Any
M1a
Stage IVB
Any
Any
M1b
Stage
IIIA
Stage IIIB
Stage
IIIC
Treatment Guideline
References: NCCN rectal cancer guidelines 2011 V.2
Appropriate for resection
‧Transabdominal resection
a) pT1~2N0M0 => observe
b) pT3N0 or pT1~3, N1~2 => postoperative ChRT
cT1~2N0
cT3N0
cTanyN1~2
‧Transanal excision (cT1N0)
a) T1NXR0 => observe
b) T1NX with high risk feature or T2NX => Transabdominal
resection => back to above
*high risk feature include positive margin, LVSI and poorly
differentiated tumors
1) Preop. CCRT (preferred) (cate. 1 for node positive disease)
 Transabdominal resection => adjuvant C/T**
2) Transabdominal resection =>
a) pT1~2N0 => observe
b) *pT3N0* or pT1~3N1~2 => postoperative ChRT
‧If medical contraindication to combined modality therapy
=> Transabdominal resection
a) pT1~2N0 => observe
b) *pT3N0* or pT1~3N1~2 => postoperative ChRT
cT4 and
unresectable
CCRT (preop. setting)=> resection if possible => any T: adjuvant
C/T
‧Combination chemotherapy 2~3 months =>
a) Staged or synchronous resection => adjuvant CCRT
b) adjuvant CCRT=> Staged or synchronous resection
Resectable M1
‧Staged or synchronous resection =>
a) pT1~2N0M1 => advanced chemotherapy(category 2B)
b) pT3~4NanyM1 or TanyN1~2M1 => postoperative ChRT
‧CCRT (preop setting) => Staged or synchronous resection
=> advanced chemotherapy(category 2B)
*proximal pT3N0R0 with favorable prognostic features, the incremental benefit of RT is
likely to be small. Consider chemotherapy alone.
TanyNanyM1, unresectable synchronous metastasis or medically inoperable
Advanced chemotherapy (AC)  AC
5-FU/RT or capecitabine/RT(category 2B) or UFUR+LV/RT  AC
Resection of involved rectal segment  AC
Symtomatic
Laser recanalization  AC
Diverting colostomy  AC
Stenting  AC
Asymptomatic
Advanced chemotherapy  determine respectability
*proximal pT3N0R0 with favorable prognostic features, the incremental benefit of RT is
likely to be small. Consider chemotherapy alone.
Recurrence
Isolated
Resectable
metachronous
metastases
1) Resectable  op then ChRT or pre-op 5FU + RT then op +/IORT
2) Unresectable  C/T +/- RT
No previous C/T  op then AC or
Neoadjuvant C/T then op, if response then repeat neoadjuvant C/T
or FOLFOX; if no response then AC or OBS
2) Previous C/T  as above
1)
Unresectable
metachronous
metastases
1) Previous adjuvant FOLFOX within past 12 months
 FOLFIRI +/- beva. or FOLFIRI +/- cetuximab or panitumumab
(KRAS wild-type gene only)
2) Previous adjuvant FOLFOX >12 months, previous 5FU/LV or
capecitabine, no previous C/T  AC
 evaluate every 2 months for respectability
a) op then AC
b) AC if unresectable
Postoperative
ChRT (Op. as
primary Tx)
 1, 2
exchange
1) continuous 5-FU/RT or bolus 5-FU+leucovorin/RT or
capecitabine/RT , or UFUR+LV/RT =>
5-FU ± leucovorin or FOLFOX or capecitabine +/- oxaliplatin or
UFUR+LV
Or
2) 5-FU ± leucovorin or FOLFOX or capecitabine +/- oxaliplatin=>
continuous 5-FU/RT or bolus 5-FU+leucovorin/RT or capecitabine/RT
or UFUR+LV/RT
=> 5-FU ± leucovorin or FOLFOX or capecitabine +/- oxaliplatin or
UFUR+LV
Preoperative
CCRT
1) Continuous 5-FU/RT (category 1 for node positive disease)
or 2) bolus 5-FU+leucovorin/RT
or 3) capecitabine/RT or 4) UFUR+LV/RT
Adjuvant
CCRT
continuous 5-FU/RT or bolus 5-FU+leucovorin/RT or capecitabine/RT
or UFUR+LV/RT
**Adjuvant
Chemotherapy
5-FU ± leucovorin
or FOLFOX or capecitabine +/- oxaliplatin or UFUR+LV
Combination
Chemotherapy
a) FOLFIRI or FOLFOX or CapeOX ± bevacizumb or
b) KRAS wide-type gene only
FOLFIRI or FOLFOX or ± cetuximab or panitumumab
Radiation Dose
References: NCCN rectal cancer guidelines 2011 V.2
Definitive
CTV1 = 50-60Gy
CTV2 = 50Gy
Preoperative
CTV1 = 45 Gy (TCOG 45Gy then local boost 5.4Gy for T4 or
perirectal LAP)
CTV2 = 45Gy
Postoperative
CTV1 = 50-54Gy
CTV2 = 50Gy
Patient Set-up
References:
1) RTOG 0822
2) ASTRO 2008 (colorectal and anal cancer, EDU session)
CT simulation
 A custom immobilization device
 Arms up position
 Supine or prone
 Bowel compression if prone
 Full bladder (intake 500cc of water within 1Hr)
 Oral and IV contrast
 Anal marker
 <=5mm slices (3mm at MMH)
 Multiple fields
Target Delineation
References:
1) RTOG 0822
2) RTOG anorectal contouring ATLAS
3) DEFINITION AND DELINEATION OF THE CLINICAL TARGET VOLUME FOR
RECTAL CANCER, Int. J. Radiation Oncology Biol. Phys., Vol. 65, No. 4, pp.
1129–1142, 2006
.
Definitive or
pre-operative
CTV1 = Tumor + 2.5 cm craniocaudally (CC) and 1.5 cm radially
(cover mesorectum), nodal GTV + 1 cm symmetrical
expansion
CTV2 = a) Superior extent of the peri-rectal component: the
rectosigmoid junction or 2 cm proximal to the superior
extent of macroscopic disease in the rectum/peri-rectal
nodes
b) The most cephalad aspect of CTVA should be where the
common iliac vessels bifurcate into external/internal iliacs
(approximate boney landmark: sacral promontory)
c) The caudad extent should be a minimum of 2 cm caudad
to gross disease, including coverage of the entire
mesorectum to the pelvic floor even for upper rectal
cancers
d) Coverage of distal common ilac LN, int. iliac LN,
obturator LN, presacral area (mid S1-S5), uninvolved
iliac vessels + 0.7 cm = CTV
e) The mesorectum and perirectal lymphatics CTV is
generated by utilizing anatomic landmarks:
 Posterior Border: anterior border of the sacrum and
gluteus maximus
 Lateral Border: ileum, piriformis and obturator
muscles
 Anteriorly extending CTV to ~0.3 cm into the
posterior bladder
f) External iliac nodes should be included for tumor
involving GYN and/or GU structures.
g) Cover IRF (ischiorectal fossa) for lower rectal tumor:
when tumor is within 6cm from the anal verge or s/p
APR.
PTV = ~0.5 to 1.0 cm, except at skin
Postoperative
CTV1 = Tumor bed + mesorectum
a) Upper limit: either of the below criteria
- 5cm above the anastomosis, or
- recto-sigmoid junction, or
- the bifurcation of the IMA into the SRA.
b) Lower limit: either of the below criteria
- 5cm below the anastomosis, or
- the border of the levator ani muscle, which makes a funnel
around the distal rectum.
c) Anterior: with 3mm-margin to the adjacent organ
- male: posterior wall of the prostate/seminal vesicles/
bladder
- female: posterior vaginal wall/uterus
d) Posterior: ant. sacral border
CTV2 = as definitive contouring
PTV = ~0.5 to 1.0 cm, except at skin
a)
Ischiorectal
fossa (IRF)
b)
c)
Inguinal lymph
nodes
Cover the internal and external anal sphincter, with the
penile bulb/ vestibular bulb.
The deeper part of the ischiorectal fossa, located above the
transversen septum and bounded laterally by the internal
obturator muscle and the ischium, is entirely at risk.
Lower limit: ischial tuberosity.
a) May consider electively irradiate the inguinal nodal region for
rectal adenocarcinomas that extend to the anal verge or
peri-anal skin
b) The caudad extent of the inguinal region should be 2 cm
caudad to the saphenous/femoral junction
c) The transition between inguinal and external iliac regions is at
the level of the bottom of the internal obturator vessels
(approximate boney landmark: upper edge of the superior
pubic rami)
IMRT plan criteria
References: RTOG 0822
PTV planning dose-volume constraints:
1) ≥ 98% of the PTV receives ≥ 93% of the prescribed dose
2) ≤ 10% of the PTV receives ≥ 105% of the prescribed dose
3) ≤ 5% of the PTV receives ≥ 110% of the prescribed dose
4) None of the PTV is to receive ≥ 115% of the prescribed dose
Normal Organ Constraints
References: QUANTEC (Radiation constraint and related toxicities)
Bladder (whole
organ)
Small bowel
Rectum (whole
organ)
Bladder ca.  Gr. ≧3 late RTOG, Dmax<65, rate<6%
Prostate ca.  Gr. ≧3 late RTOG, V65≤50%, V70≤35%,
V75≤25%, V80≤15% (RTOG 0415)
Individual Loops  Gr. ≧3 acute toxicity, V15<120cc, <10%
Entire potential space  Gr. ≧3 acute toxicity, V45<195cc, <10%
Prostate ca.  V50<50%, V60<35%, V65<25%, V70<20%,
V75<15% (Gr.≧2 late toxicity <15%, Gr.≧3 late toxicity<10%)