Variant 1: A 66-year-old woman with vaginal bleeding undergoes total abdominal hysterectomy, salpingo-oophorectomy and pelvic/para-aortic lymphadenectomy, peritoneal cytology. Pathology review of the specimens reveals uterine endometrioid carcinoma FIGO grade 3, invading 19 mm out of 20 mm myometrial thickness, with involvement of cervical stroma, right ovary, and negative peritoneal cytology. There was no lymphovascular space involvement. All 32 examined lymph nodes were negative for metastatic involvement. (Stage IIIA).
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: A 65-year-old woman undergoes modified radical hysterectomy and salpingo-oophorectomy. Pelvic and para-aortic sampling was not performed. Preoperative imaging did not show pathologic adenopathy. Pathology review of the pathologic specimens reveals uterine clear cell carcinoma involving >50% of myometrial thickness and involving cervical stroma and serosa of the uterus. Lymphovascular space involvement was present. Peritoneal cytology was negative.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: A 69-year-old woman undergoes complete surgical staging including omentectomy. Preoperative staging CT was negative for metastatic disease. Pathology review of the specimens reveals uterine serous carcinoma, invading > 50% of myometrial thickness, without involvement of cervical stroma or adnexa. Two out of 29 lymph nodes were involved with metastatic disease (one right obturator and one para-aortic node). Peritoneal cytology and omental specimen were negative of malignant cells. There was no lymphovascular space involvement. Patient agreed to receive multimodality treatment (chemotherapy and radiation therapy).
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: A 67-year-old woman undergoes complete surgical staging. Pathology revealed 2009 FIGO stage IIIC2 endometrioid carcinoma grade 3. Radiologic restaging after 3 cycles of carboplatin and Taxol chemotherapy alone and before starting adjuvant radiation treatment showed interval disease progression with pelvic and para-aortic lymphadenopathy. The patient is healthy otherwise.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 5: A 51-year-old woman undergoes complete surgical staging. Pathology showed uterine endometrioid carcinoma FIGO grade 2, >50% of myometrial thickness, with involvement of cervical stroma and left fallopian tube. Two pelvic lymph nodes out of 30 pelvic/para-aortic lymph nodes were positive for metastatic involvement. Assume adjuvant chemotherapy and radiation treatment (pelvic and vaginal cuff) have been completed.
| 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.