Variant 1: 66-year-old woman who had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymph node dissection for uterine endometrioid cancer a year ago. The tumor was staged as 2009 FIGO IA grade 2 and she was managed with surveillance. Recently she started to complain of vaginal spotting, and pelvic examination showed a small lesion (about 2 cm in diameter) limited to the mucosa at the vaginal apex. Biopsy confirmed recurrent uterine endometrioid carcinoma. Restaging workup was negative for pelvic adenopathy or extrapelvic metastatic disease. She is otherwise a healthy woman.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: 68-year-old woman underwent surgical staging with total abdominal hysterectomy, salpingo-oophorectomy, pelvic and para-aortic lymph node dissection (total of 54 lymph nodes removed), and peritoneal cytology 9 months ago. The tumor was staged as 2009 FIGO stage IB, grade 3 uterine endometrioid carcinoma with lymphovascular space involvement. She declined any adjuvant therapy. Recent CT of the abdomen and pelvis showed 2 pathologic right obturator lymph nodes measuring 1.8 and 2.4 cm in size as well as a 4-cm enhancing mass at the vaginal vault. PET/CT scan showed hypermetabolic activity in the right obturator nodes as well as the vaginal vault lesion. Biopsy was consistent with recurrent uterine endometrioid carcinoma.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: 60-year-old woman who underwent complete surgical staging and was staged as 2009 FIGO IIIC1 uterine endometrioid carcinoma. She received 6 cycles of chemotherapy consisting of carboplatin and paclitaxel as a participant in a randomized trial. A recent CT scan of the abdomen 7 months after completion of chemotherapy showed bilateral pelvic and para-aortic adenopathy and a vaginal vault lesion. A biopsy of 1 of these lymph nodes confirmed the diagnosis of metastatic uterine carcinoma. She is healthy otherwise. She declined any further surgery.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: A healthy 55-year-old woman who had complete surgical staging for 2009 FIGO IIIC1 uterine endometrioid carcinoma. She received adjuvant pelvic RT to 45 Gy with concurrent cisplatin chemotherapy followed by 4 more cycles of chemotherapy (carboplatin and paclitaxel). One year later, she had a pelvic CT scan that showed an infiltrative left pelvic sidewall mass measuring 5.8 cm in size as well as an infiltrative rectovaginal mass 6.0 cm in size. Biopsy from the rectovaginal mass was consistent with recurrent uterine endometrioid carcinoma. Staging workup was negative.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 5: 65-year-old woman who underwent complete surgical staging followed by adjuvant RT to the pelvis and para-aortic area up to L1 to 45 Gy with chemotherapy for her 2009 FIGO stage IIIC2 uterine endometrioid carcinoma. She was diagnosed with a biopsy-proven solitary nodal recurrent lesion at L2 (within the previous RT field) 9 months after completion of her adjuvant RT. 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 6: 75-year-old woman who was diagnosed with 2009 FIGO stage IIIC2 uterine serous carcinoma 9 months ago. She received adjuvant RT to the pelvic and para-aortic regions with concurrent cisplatin chemotherapy followed by 4 cycles of carboplatin and paclitaxel chemotherapy. Because she was complaining of back pains, follow-up CT and nuclear bone scans showed a new single metastatic disease in the thoracic spine (T6). Biopsy from T6 lesion confirmed metastatic uterine serous carcinoma.
| 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.