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Updated: Apr 3, 2026
Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer
Published on: February 12, 2022
ACR Appropriateness Criteria® Local Excision in Early Stage Rectal Cancer
Suzanne Russo1, A William Blackstock, Joseph M Herman
1*Department of Radiation Oncology, University Hospitals Case Western Seidman Cancer Center, Cleveland, OH †Department of Radiation Oncology, Wake Forest University, Winston Salem, NC ‡Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, American Society of Clinical Oncology §Cleveland Clinic, Cleveland, OH ∥MD Anderson Cancer Center, Houston, TX, American College of Surgeons ¶Memorial Sloan-Kettering Cancer Center, New York, NY #Massachusetts General Hospital, Boston, MA **Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ ††University of Texas Health Science Center at San Antonio, San Antonio, TX ‡‡The Chester County Hospital, West Chester, PA §§Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA ∥∥Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD ¶¶Stritch School of Medicine, Loyola University Chicago, Maywood, IL ##Knight Cancer Institute, Oregon Health and Science University, Portland, OR ***Cancer Center of Santa Barbara, Santa Barbara, CA.
Abstract:
Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.
