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Appropriateness Criteria

Variant 1: Adult. Stable 1 to 3 cm solitary solid pulmonary nodule. Unchanged in diameter for 2 years. Person who smokes. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Follow-up imaging only May be appropriate Limited N/A N/A 6 6 0 1 0 0 5 4 1 1 0
References Study Quality
17 (37820837) 4
16 (36597231) 3
2 (36049538) 4
Percutaneous lung biopsy May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 2 4 2 1 0 1 2 0 0
References Study Quality
24 (25163758) 4
23 (31084480) 4
20 (34986006) 2
19 (35227506) 3
21 (34121343) 4
22 (34229043) 3
13 (25430528) 3
12 (34654044) 4
4 (35080453) 4
10 (24954230) 2
11 (24581458) 3
Endobronchial ultrasound and biopsy Usually not appropriate Strong N/A N/A 3 3 2 2 4 0 3 1 0 0 0
References Study Quality
13 (25430528) 3
12 (34654044) 4
10 (24954230) 2
11 (24581458) 3
9 (32967044) Good
8 (34481209) 2
6 (30103727) 4
4 (35080453) 4
5 (27886860) 2
7 (36640994) Good
Percutaneous ablation lung Usually not appropriate Limited N/A N/A 3 3 4 3 3 1 1 0 1 0 0
References Study Quality
18 (24952227) 2
Stereotactic body radiotherapy Usually not appropriate Limited N/A N/A 3 3 4 3 3 1 1 0 0 1 0
References Study Quality
25 (30226453) 4
Surgical management Usually not appropriate Moderate N/A N/A 3 3 4 3 3 0 2 0 0 1 0
References Study Quality
14 (30720402) 3
26 (30772108) Good
Fiducial marker and surgical management Usually not appropriate Limited N/A N/A 2 2 4 4 2 1 0 1 1 0 0
References Study Quality
14 (30720402) 3
15 (30819493) 2
Variant 2: Adult. Serially, enlarging solitary solid pulmonary nodule, now 1 to 3 cm in diameter. Person who smokes. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate Strong N/A N/A 8 8 0 0 0 1 0 0 2 4 6
References Study Quality
37 (38538978) 3
24 (25163758) 4
20 (34986006) 2
23 (31084480) 4
21 (34121343) 4
22 (34229043) 3
13 (25430528) 3
12 (34654044) 4
19 (35227506) 3
10 (24954230) 2
11 (24581458) 3
Endobronchial ultrasound and biopsy Usually appropriate Limited N/A N/A 7 7 0 0 0 1 1 1 4 4 2
References Study Quality
5 (27886860) 2
27 (28074327) 4
28 (31387600) 4
Fiducial marker and surgical management Usually not appropriate Moderate N/A N/A 3 3 1 4 2 1 3 1 0 0 0
References Study Quality
31 (26772183) 4
30 (34229986) 3
29 (30958102) 2
Follow-up imaging only Usually not appropriate Limited N/A N/A 3 3 3 3 4 1 1 0 1 0 0
References Study Quality
4 (35080453) 4
Stereotactic body radiotherapy Usually not appropriate Strong N/A N/A 3 3 1 5 5 1 0 0 0 0 0
References Study Quality
38 (33811997) 2
39 (29852037) 2
Surgical management Usually not appropriate Strong N/A N/A 3 3 1 3 6 0 1 0 0 1 0
References Study Quality
45 (37324102) 2
44 (29547899) 4
43 (30056040) 4
42 (30947705) 4
40 (29959940) 4
41 (37473998) 1
Percutaneous ablation lung Usually not appropriate Strong N/A N/A 2 2 1 6 5 0 0 0 0 0 0
References Study Quality
36 (34612679) 4
35 (30143031) 2
18 (24952227) 2
33 (36276106) 3
32 (33245066) 2
34 (36039430) 2
Variant 3: Adult. 1 to 3 cm solitary solid pulmonary nodule near the hilum. Identified on initial screening CT chest. Person who smokes. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Endobronchial ultrasound and biopsy Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 4 5 4
References Study Quality
47 (30059678) 3
46 (25611227) 1
27 (28074327) 4
5 (27886860) 2
Percutaneous lung biopsy May be appropriate Limited N/A N/A 6 6 0 0 1 0 3 8 0 0 0
References Study Quality
53 (20351523) 3
54 (25877365) 4
Follow-up imaging only May be appropriate Limited N/A N/A 5 5 0 0 0 0 8 4 0 0 0
References Study Quality
50 (30868898) 4
49 (-3197179) 4
Surgical management Usually not appropriate Limited N/A N/A 3 3 1 5 5 0 1 0 0 0 0
References Study Quality
58 (33485660) 4
59 (31163131) 4
Fiducial marker and surgical management Usually not appropriate Limited N/A N/A 2 2 1 6 3 1 1 0 0 0 0
References Study Quality
48 (29939888) 4
Percutaneous ablation lung Usually not appropriate Limited N/A N/A 2 2 1 6 5 0 0 0 0 0 0
References Study Quality
52 (33957875) 3
51 (24808438) 3
Stereotactic body radiotherapy Usually not appropriate Limited N/A N/A 2 2 2 5 5 0 0 0 0 0 0
References Study Quality
57 (37924974) 4
56 (36027934) 4
55 (27131846) 3
Variant 4: Adult. Serially, enlarging solitary solid pulmonary nodule in the periphery of the lung, now 1 to 3 cm in diameter. High risk of poor surgical outcome. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 3 6 4
References Study Quality
24 (25163758) 4
19 (35227506) 3
13 (25430528) 3
12 (34654044) 4
10 (24954230) 2
11 (24581458) 3
Stereotactic body radiotherapy May be appropriate Limited N/A N/A 6 6 0 0 0 2 4 2 3 1 0
References Study Quality
57 (37924974) 4
67 (19251380) 2
Endobronchial ultrasound and biopsy May be appropriate Moderate N/A N/A 5 5 0 0 0 0 8 2 1 1 0
References Study Quality
28 (31387600) 4
60 (40300665) 2
Follow-up imaging only May be appropriate Limited N/A N/A 5 5 1 3 2 2 3 1 1 0 0
References Study Quality
50 (30868898) 4
Percutaneous ablation lung May be appropriate Strong N/A N/A 5 5 0 0 0 2 5 4 0 1 0
References Study Quality
66 (24239684) 4
65 (36892641) 4
62 (24042540) 4
64 (35704108) 4
36 (34612679) 4
63 (36647962) 4
18 (24952227) 2
33 (36276106) 3
32 (33245066) 2
34 (36039430) 2
Fiducial marker and surgical management Usually not appropriate Limited N/A N/A 3 3 2 6 2 1 0 2 0 0 0
References Study Quality
61 (23608462) 4
Surgical management Usually not appropriate Limited N/A N/A 2 2 2 7 3 0 0 0 0 0 0
References Study Quality
42 (30947705) 4
68 (32163551) 4
Variant 5: Adult. 1 to 3 cm solitary solid pulmonary nodule in the periphery of the lung. Previously treated nonpulmonary primary malignancy. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 1 8 4
References Study Quality
19 (35227506) 3
13 (25430528) 3
10 (24954230) 2
11 (24581458) 3
Endobronchial ultrasound and biopsy May be appropriate Limited N/A N/A 6 6 0 0 0 1 4 5 2 0 0
References Study Quality
28 (31387600) 4
Fiducial marker and surgical management May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 3 3 1 2 1 1 0 0
References Study Quality
69 (24529549) 4
Follow-up imaging only May be appropriate Limited N/A N/A 5 5 0 0 1 1 8 2 0 0 0
References Study Quality
16 (36597231) 3
Surgical management May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 3 4 0 1 1 2 0 0
References Study Quality
75 (29891107) 4
76 (33858453) 2
Percutaneous ablation lung Usually not appropriate Limited N/A N/A 3 3 1 5 3 1 1 1 0 0 0
References Study Quality
71 (36209996) 2
70 (36169242) 4
Stereotactic body radiotherapy Usually not appropriate Moderate N/A N/A 3 3 1 5 3 0 2 1 0 0 0
References Study Quality
74 (35490932) 4
73 (25968471) 3
72 (32819261) Good
Variant 6: Adult. 1 to 3 cm solitary ground glass pulmonary nodule which has persisted on short interval follow-up. Findings suspicious for primary lung adenocarcinoma. Next step.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Percutaneous lung biopsy Usually appropriate Limited N/A N/A 7 7 0 0 0 1 3 2 2 4 0
References Study Quality
78 (35305375) 4
77 (25406492) 3
Endobronchial ultrasound and biopsy May be appropriate Limited N/A N/A 6 6 0 0 0 2 3 2 5 0 0
References Study Quality
5 (27886860) 2
28 (31387600) 4
27 (28074327) 4
Fiducial marker and surgical management May be appropriate Moderate N/A N/A 6 6 0 0 0 0 6 5 1 0 0
References Study Quality
29 (30958102) 2
30 (34229986) 3
Follow-up imaging only May be appropriate Limited N/A N/A 6 6 0 0 0 2 4 3 2 1 0
References Study Quality
49 (-3197179) 4
Percutaneous ablation lung Usually not appropriate Limited N/A N/A 3 3 1 5 6 0 0 0 0 0 0
References Study Quality
33 (36276106) 3
Stereotactic body radiotherapy Usually not appropriate Limited N/A N/A 3 3 1 4 7 0 0 0 0 0 0
References Study Quality
73 (25968471) 3
74 (35490932) 4
Surgical management Usually not appropriate Limited N/A N/A 3 3 1 2 5 0 4 0 0 0 0
References Study Quality
33 (36276106) 3
79 (36219310) 3
80 (35965138) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.