Version 2 2019 05 15 19 2019 National Comprehensive Cancer Network NCCN All rights reserved NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Clinical Practice Guidelines in Oncology NCCN Guidelines Rectal Cancer Version 2 2019 May 15 2019 Continue NCCN org NCCN Guidelines for Patients available at www nccn org patients NCCN Guidelines Version 2 2019 Rectal Cancer Version 2 2019 05 15 19 2019 National Comprehensive Cancer Network NCCN All rights reserved NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines Index Table of Contents Discussion Continue NCCN Guidelines Panel Disclosures Diagnostic Interventional radiology Gastroenterology Hematology Hematology oncology Internal medicine Medical oncology Pathology Patient advocate Radiotherapy Radiation oncology Surgery Surgical oncology Discussion Section Writing Committee Al B Benson III MD Chair Robert H Lurie Comprehensive Cancer Center of Northwestern University Alan P Venook MD Vice Chair UCSF Helen Diller Family Comprehensive Cancer Center Mahmoud M Al Hawary MD University of Michigan Rogel Cancer Center Mustafa A Arain MD UCSF Helen Diller Family Comprehensive Cancer Center Yi Jen Chen MD PhD City of Hope National Medical Center Kristen K Ciombor MD Vanderbilt Ingram Cancer Center Stacey Cohen MD Fred Hutchinson Cancer Research Center Seattle Cancer Care Alliance Harry S Cooper MD Fox Chase Cancer Center Dustin Deming MD University of Wisconsin Carbone Cancer Center Paul F Engstrom MD Fox Chase Cancer Center Ignacio Garrido Laguna MD PhD Huntsman Cancer Institute at the University of Utah Jean L Grem MD Fred T1 2 N1 2 REC 5 T3 N Any with Involved CRM by MRI T4 N Any REC 6 Locally Unresectable or Medically Inoperable REC 6 Suspected or Proven Metastatic Synchronous Adenocarcinoma REC 7 Surveillance REC 11 Recurrence and Workup REC 12 Metachronous Metastases REC 12 Principles of Imaging REC A Principles of Pathologic Review REC B Principles of Surgery REC C Principles of Adjuvant Therapy REC D Principles of Radiation Therapy REC E Systemic Therapy for Advanced or Metastatic Disease REC F Principles of Survivorship REC G Staging ST 1 The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient s care or treatment The National Comprehensive Cancer Network NCCN makes no representations or warranties of any kind regarding their content use or application and disclaims any responsibility for their application or use in any way The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network All rights reserved The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN 2019 Printed by Maria Chen on 5 21 2019 11 16 32 PM For personal use only Not approved for distribution Copyright 2019 National Comprehensive Cancer Network Inc All Rights Reserved NCCN Guidelines Version 2 2019 Rectal Cancer Version 2 2019 05 15 19 2019 National Comprehensive Cancer Network NCCN All rights reserved NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN NCCN Guidelines Index Table of Contents Discussion Updates in Version 1 2019 of the NCCN Guidelines for Rectal Cancer from Version 3 2018 include General BRAF WT added as an indication for treatment where KRAS and NRAS WT are noted REC 1 Fragmented specimen or margin cannot be assessed or unfavorable histologic features The following workup added Consider rigid proctoscopy Chest CT and abdominal CT or MRI CBC chemistry profile CEA Pelvic MRI with contrast Endorectal ultrasound if MRI is contraindicated or consider for superficial lesions Enterostomal therapist as indicated for preoperative marking of site teaching PET CT scan is not indicated REC 2 Rectal cancer appropriate for resection non metastatic Bullet 7 modified Pelvic MRI with or without contrast Bullet 8 modified Endorectal ultrasound only if MRI is contraindicated e g pacemaker or consider for superficial lesions The following added to the workup Multidisciplinary team evaluation Consider fertility risk discussion counseling in appropriate patients REC 3 pT1 NX with high risk features or pT2 NX Chemo RT Clarification added to Transabdominal resection if evidence of disease REC 5 The following treatment option added Short course RT followed by 12 16 weeks of chemotherapy FOLFOX preferred or CAPEOX preferred or 5 FU leucovorin or capecitabine Footnote t modified with addition of this sentence Short course RT is not recommended for low lying tumors 5 cm from anal verge also applies to REC 6 REC 7 Bullet 4 modif