Variant 1: 60-year-old man with stage IV non–small-cell lung cancer with KPS 80 and known asymptomatic spinal metastasis at T7 received first line systemic therapy then developed severe pain from the T7 metastasis (Brief Pain Inventory: 8 out of 10) associated with moderate epidural spinal cord compression leading to a gradual onset of sensory level above the umbilicus and bilateral lower extremity weakness (motor power 4 out of 5). MRI of the thoracic spine showed no cerebrospinal fluid (CSF) around the mildly deformed cord at T7. PET/CT shows stable primary tumor in the lung and lung metastases. No bony retropulsion.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: 65-year-old woman with known multiple myeloma but with no prior therapy, develops gradual onset of a sensory level in the lower chest and moderate bilateral lower-extremity weakness (motor power 3 out of 5) over one week from an epidural spinal cord compression at T5. There is associated moderate pain (Brief Pain Inventory: 6 of 10). MRI shows circumferential compression of the spinal cord by myeloma. There is no evidence of vertebral compression fracture. KPS is 70. Skeletal survey reveals several other sites of asymptomatic lytic metastases throughout the axial and appendicular skeleton.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: 75-year-old woman with known progressive metastatic colon cancer resistant to 2 lines of systemic therapy develops increased pain in the middle back and sudden onset of total paralysis of bilateral lower extremity weakness 1-week prior to admission to hospital from a nursing home. Her KPS is 50. The pain is rated 7 out of 10 on Brief Pain Inventory. The lower extremity power was 0 out of 5 and the sensory level was located above the umbilicus. MRI of the spine shows diffuse spinal metastasis and circumferential compression of the spinal cord at T8 from bulky metastasis with no surrounding CSF. She has no prior history of EBRT to T8. CT scan shows diffuse lung and liver metastases.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: 45-year-old man with known metastatic renal cell carcinoma develops increased pain in the lower back. He has received sunitinib for his systemic disease. His KPS is 80. The pain is rated 8 out of 10 on Brief Pain Inventory. There are no associated sensory or motor deficits in the lower extremities. He has a history of palliative EBRT to spinal levels T12-L2 to a dose of 30 Gy in 10 fractions one year prior to this presentation. MRI shows progression of spinal metastasis at L1 vertebral body and there is no epidural extension or vertebral compression fracture. CT scan shows that the lungs are the only other organs with metastatic renal cell carcinoma and they have demonstrated good response to sunitinib.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 5: 56-year-old post-menopausal woman with known metastatic breast carcinoma, estrogen and progesterone receptors and HER2 positive, develops increased pain in the upper back and gradual onset of bilateral lower extremity weakness (motor power 4+ out of 5) over the more than 2 weeks. Her KPS is 80. The pain is rated 7 out of 10 on Brief Pain Inventory. She has a history of palliative EBRT to spinal levels T2-T6 to a dose of 30 Gy in 10 fractions two years prior to this presentation. MRI shows progression of spinal metastasis at T4 and there is epidural extension from the vertebral body and left pedicle, compressing on the spinal cord with no CSF surrounding the cord. There is no associated vertebral compression fracture. She has received two lines of systemic therapy with stable metastatic disease in the lungs and in multiple sites in the bones apart from the T4 vertebra on PET/CT.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
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.