Variant 1: 57-year-old woman, triple negative IDC, status postmastectomy: 3.5 cm inner quadrant primary, 7/12 LN (+). Focally positive deep margin. PET (+) IMN and supraclavicular nodes. Adjuvant anthracycline and taxane, with normalization of PET findings. Metastatic workup negative.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 2: 55-year-old woman with neglected primary. Large, fungating lesion and matted axilla. ER (–)/PR (+), Her2 (–). Metastatic workup negative. Not operable after three chemo regimens, including anthracyclines and taxanes.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 3: 40-year-old woman, 4 cm primary with diffuse suspicious microcalcifications in breast, direct skin invasion, satellite skin nodule, matted axilla (N2), ER (+)/PR (–), Her2 (–). Metastatic workup negative.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 4: 80-year-old woman, 4 cm primary, direct skin invasion, satellite nodule, matted axilla (N2), strongly ER/PR (+), Her2 (–). Metastatic workup negative. Medically fit.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 5: 45-year-old premenopausal woman, 4.5 cm IDC left breast, ER/PR (–), Her2 amplified, PET (+) in breast, axilla, and medial infraclavicular fossa. Palpable nodes in high axilla. Metastatic workup negative. Patient desires breast conservation.
Variant 7: 50-year-old woman, T3N2M0 disease, with clinical CR post 4-cycle multidrug chemotherapy. ER/PR (–), Her2 (–). Does not desire BCT.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 8: 50-year-old woman, stage T3N2M0 disease, with good clinical response following 4 cycles of multidrug neoadjuvant chemotherapy. She does not desire BCT and consents for mastectomy with reconstruction. Pathology from the mastectomy confirms ypT0N0M0 disease.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
Variant 9: 42-year-old woman with clinical stage T2N1M0 Her2 amplified left breast cancer. She undergoes a mastectomy with reconstruction and axillary dissection. Pathology notes 3.5-cm invasive cancer mastectomy margins are negative and 11/12 (+) nodes. Patient will receive chemotherapy and trastuzumab for 1 year.
Procedure
Appropriateness Category
SOE
Adult RRL
Peds RRL
Rating
Median
Final Tabulations
1
2
3
4
5
6
7
8
9
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.
