Variant 1: 40-year-old woman with a 2 cm cervical tumor undergoes radical hysterectomy and pelvic lymphadenectomy. Pathological review of the surgical specimens reveals the following: moderately differentiated squamous cell carcinoma of the cervix, middle third cervical stromal invasion, positive capillary-lymphatic space invasion, negative nodal metastases, and negative surgical margins.
Variant 2: 30-year-old woman with a 4 cm cervical tumor undergoes radical hysterectomy and pelvic lymphadenectomy. Pathological review of the surgical specimens reveals the following: poorly differentiated adenocarcinoma, positive right parametrial invasion, positive capillary-lymphatic space invasion, 3 positive pelvic nodes in the right external iliac region, and negative surgical margins.
Variant 3: 40-year-old woman with a 2 cm cervical tumor undergoes radical hysterectomy and retroperitoneal pelvic/para-aortic lymphadenectomy. Pathological review of the surgical specimens reveals the following: well differentiated squamous cell carcinoma, no parametrial invasion, positive capillary-lymphatic space invasion, outer third cervical stromal invasion, 0 out of 16 positive nodes, and negative surgical margins. Assume adjuvant radiation has been recommended.
Variant 4: 50-year-old woman with a 3 cm cervical tumor undergoes radical hysterectomy and retroperitoneal pelvic/para-aortic lymphadenectomy. Pathological review of the surgical specimens reveals poorly differentiated squamous cell carcinoma with positive left parametrial invasion, positive capillary-lymphatic space invasion, outer third cervical stromal invasion, 4 out of 10 positive left pelvic nodes, 3 out of 6 positive bilateral para-aortic nodes, and negative surgical margins. Assume adjuvant chemoradiation has been recommended.
Variant 5: 30-year-old woman with a 2.5 cm cervical mass undergoes radical hysterectomy and retroperitoneal pelvic/para-aortic lymphadenectomy along with oophorpexy. Pathological review of the surgical specimens reveals the following: moderately differentiated squamous cell carcinoma, no parametrial invasion, positive capillary-lymphatic space invasion, outer third cervical stromal invasion, 0 out of 16 positive nodes, and negative surgical margins. Assume adjuvant chemoradiation (pelvic external beam) has been completed.
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.