Variant 1: 59-year-old woman presented with a 1.5-cm left mid–labia majora lesion not approaching midline. Clinically, she had no palpable groin nodes. She underwent left modified radical vulvectomy and left sentinel node dissection. Pathology revealed a 2.1-cm squamous cell carcinoma on left labia majora with negative margins >1 cm, no LVSI, and 3-mm stromal invasion. 2 sentinel nodes were removed from left inguinofemoral region; both were negative.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
| FDG-PET/CT whole body | Usually not appropriate | ☢☢☢☢ 10-30 mSv | ☢☢☢☢ 3-10 mSv [ped] | 3 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
Variant 2: 65-year-old woman presented with significant vulvar pruritus from a 2-cm lesion arising from the left labia minora and approaching the urethra. She had no urinary complaints. No palpable inguinal lymph nodes. CT pelvis was negative for any lymphadenopathy in the groins or pelvis. She underwent wide local excision and sentinel lymph node dissection. Pathology revealed 2.4-cm squamous cell carcinoma with a close margin (<2 mm) at the urethra, no LVSI, and 6-mm stromal invasion. Re-excision not possible without resection of the urethra. 2 left inguinal lymph nodes were removed, all negative.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: 71-year-old woman with a painful 4-cm mass arising in the right midlabia. Clinically, she has a palpable right groin mass, left groin has no clinically palpable adenopathy. CT pelvis shows multiple enlarged lymph nodes in bilateral groins. The right mass appears to be 3 cm in size radiographically. No enlarged lymph nodes in the pelvis. She underwent right modified radical vulvectomy and bilateral lymph node dissection. Pathology revealed a 3.8-cm squamous cell carcinoma on the right labia majora with 1.2-cm stromal invasion, negative margins. The right inguinofemoral dissection revealed a conglomerate of lymph nodes measuring 3.2 cm with extracapsular lymph node extension and LVSI. The left groin dissection revealed 1 positive lymph node with an 8-mm tumor deposit. 6 additional lymph nodes were negative. The patient has 2+ right lower extremity lymphedema.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
| FDG-PET/CT whole body | Usually appropriate | ☢☢☢☢ 10-30 mSv | ☢☢☢☢ 3-10 mSv [ped] | 8 | n/a | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
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.