Variant 1: 25-year-old woman with clinical stage (CS) IA (right neck) nodular sclerosis Hodgkin lymphoma (NSHL) was treated with 2 cycles of ABVD + 20-Gy IFRT and achieved a CR. Two years after completion of treatment, a new 3-cm node was palpated in left neck. (Late nodal relapse after reduced-intensity therapy.)
Variant 2: 25-year-old woman with CS IIA (bilateral neck) NSHL was treated with 4 cycles of ABVD alone and achieved a CR. Two years after completion of treatment, a new 3-cm node was palpated in left neck. (Late nodal relapse after chemotherapy alone).
Variant 3: 25-year-old woman with CS IIIA (neck, mediastinum, and para-aortic) NSHL was treated with 6 cycles of ABVD alone and achieved a CR. Six months after completion of treatment, a new 3-cm node was palpated in left neck. (Early nodal relapse after chemotherapy alone).
Variant 4: 25-year-old woman with CS IIIAX (neck, bulky mediastinum, upper para-aortic) NSHL was treated with ABVD × 6 and IFRT (30 Gy to the mediastinum). Three years after completion of therapy, chest CT showed new mediastinal adenopathy with bilateral lung nodules. (Possible late relapse after combined-modality therapy).
Variant 5: 25-year-old woman with CS IIIAX (neck, bulky mediastinum, upper para-aortic) NSHL was treated with ABVD. After 6 cycles of ABVD, no significant decrease in mediastinal abnormality was seen and a new axillary node was palpated. (Progression on chemotherapy). PET Deauville 5.
Variant 6: 25-year-old woman with CS IIIAX (neck, bulky mediastinum, upper para-aortic) NSHL was treated with ABVD. After 6 cycles of ABVD, the mediastinal disease regressed by 33% and mass remains remained FDG avid [Deauville 4]. (Incomplete response to chemotherapy).
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.