Variant 1: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago patient underwent a low anterior resection (pT3N0) and 6 months of adjuvant chemotherapy. Endoscopic ultrasound (EUS) now shows an anastomotic recurrence 6 cm above the anal verge. Biopsy positive for adenocarcinoma. No sites of metastatic disease. Tumor currently unresectable and nonobstructing. KPS 90.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago the patient underwent a low anterior resection (pT3N0) and 6 months of adjuvant chemotherapy. EUS now shows an anastomotic recurrence 6 cm above anal verge. Biopsy positive for adenocarcinoma. Lesion not fixed to the pelvic sidewall on physical examination and CT. Patient now has a biopsy-proven resectable liver metastasis involving the right lobe (5 cm). KPS 90.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: 56-year-old patient with recurrent rectal bleeding and pain with defecation. Two years ago the patient underwent a low anterior resection after preoperative chemotherapy and radiotherapy for a (pT3N1) rectal cancer and 6 months of adjuvant chemotherapy. Endoscopic ultrasound (EUS) now shows an anastomotic recurrence 6 cm above the anal verge. Biopsy positive for adenocarcinoma. No sites of metastatic disease. KPS 90.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: 56-year-old male with severe pain that radiates to perineal region. Two years ago the patient was diagnosed with T3N1 rectal cancer 6 cm from anal verge. Underwent an abdominal-perineal resection, pelvic RT totaling 50.4 Gy plus 5-FU, followed by 6 months of adjuvant chemotherapy. CT of abdomen and pelvis reveal rectal mass (4 cm) invading bony pelvis at sciatic notch. No sites of metastatic disease. KPS 90.
| 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.