Variant 1: A 70-year-old man presents with a T3N2M0 EBV-positive nonkeratinizing nasopharyngeal carcinoma. He completes a definitive course of IMRT to a prescribed dose of 6996 cGy in combination with concurrent cisplatin (100 mg/m2 for 3 doses) but requires 2 dose reductions and experiences 1 brief hospitalization near the end of treatment due to severe mucositis, dehydration, and need for feeding tube placement.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: A 35-year-old woman presents with worsening otitis and a bulky right-sided neck mass extending into the supraclavicular fossa. Endoscopy of the nasopharynx reveals a 3-cm infiltrative-appearing tumor centered in the right fossa of Rosenmüller, and biopsy shows undifferentiated carcinoma of the nasopharynx that is EBV positive. MRI shows that the primary tumor is invading into the parapharyngeal space and there are bilateral 1-cm retropharyngeal nodes, 2-cm adenopathy on the left, and 5-cm adenopathy on the right (T2N3bM0, stage IVB). There is no evidence of distant disease on CT of the chest and bone scan. Karnofsky Performance Status (KPS) is 90%.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: A 38-year-old man presents with nasal congestion and left-sided otitis. Endoscopy shows a tumor centered in the left fossa of Rosenmüller, and the biopsy is read as undifferentiated nasopharyngeal carcinoma, EBV positive. An MRI shows erosion of the sphenoid sinus but no intracranial involvement, with 2-cm left retropharyngeal adenopathy and bilateral enlarged jugulodigastric nodes. The chest CT shows no pulmonary parenchymal metastasis, but a bone scan shows an isolated 2-cm lesion that is biopsy-proven metastatic disease in the lumbar spine with no compression (T3N2M1). He does not complain of back pain and his neurologic examination is normal. He is not interested in a clinical trial.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: A 22-year-old man is admitted to the hospital because of a 30-pound weight loss in a period of 3 months, with mild constant headaches. CT scan of the head reveals a nasopharyngeal lesion. MRI of the brain and orbits shows an infiltrating mass with extra-axial intracranial and extracranial extension. There is involvement along the dura, multiple cranial nerves, orbits, adjacent osseous structures, nasopharynx, and nasal cavity, with bilateral cervical lymphadenopathy. His tumor biopsy reveals an EBV-positive undifferentiated NPC. He undergoes 3 cycles of cisplatin with concurrent RT and has an excellent response, with resolution of symptoms. On a follow-up scan 6 months after completion of therapy, he does not have evidence of local progression, but there are 2 lung metastases as well as mediastinal nodal disease. He is asymptomatic and has an excellent PS.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 5: A 45-year-old man is diagnosed with T3N1M0 keratizing carcinoma of the nasopharynx. He is treated with definitive chemoradiation to a maximum prescribed dose of 70 Gy to the nasopharynx, given in conventional fractionation with 3D-CRT, with concurrent cisplatin at 100 mg/m(2) for 3 cycles, followed by 3 cycles of adjuvant cisplatin/5-FU. At 14 months after finishing his RT, the patient complains of worsening numbness in his face. MRI reveals an infiltrative tumor causing mild erosion of the clivus and an enlarging area of bone erosion at the right foramen ovale, with enhancement suggestive of perineural recurrence.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 6: A 22-year-old woman presents with severe headaches and left-sided diplopia. MRI reveals a large skull base tumor originating from the nasopharynx, with abutment against the posterior aspect of the bilateral optic nerves and partial engulfment of the optic chiasm. There is bilateral cavernous sinus involvement, worse on the left. There are bilateral 1–2 cm jugulodigastric lymph nodes that are FDG-avid on PET/CT scan (T4N2M0, stage IVB). Nasopharyngeal biopsy reveals keratinizing carcinoma. KPS is 80%. She is started on dexamethasone, with partial improvement of her symptoms.
| 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.