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Appropriateness Criteria

Variant 1: Initial staging of pretreatment vulvar cancer: Primary tumor is less than or equal to 2 cm, confined to the vulva or perineum, and with less than or equal to 1 mm stromal invasion.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler and US-guided fine-needle aspiration biopsy groin Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 3 0 0 0 0 0 1
US duplex Doppler groin Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 2 0 0 0 0 1 0
US-guided fine needle aspiration biopsy groin Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 1 1 0 0 0 0 1
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 10 2 1 2 0 0 0 0 0
MRI pelvis without and with IV contrast Usually not appropriate Expert Opinion O 0 mSv O 0 mSv [ped] 3 3 2 5 1 1 5 0 0 1 0
MRI pelvis without IV contrast Usually not appropriate Expert Opinion O 0 mSv O 0 mSv [ped] 2 2 3 6 0 2 3 1 0 0 0
Lymphoscintigraphy groin Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 6 4 2 2 0 0 1 0 0
CT abdomen and pelvis with IV contrast Usually not appropriate Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 8 0 0 0 0 1 0 0
CT abdomen and pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 4 2 1 0 0 0 1 0
CT pelvis with IV contrast Usually not appropriate Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 9 0 0 0 0 0 1 0
CT pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 1 1 2 0 0 1 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 2 1 2 0 0 1 1 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 2 1 0 0 1 1 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 3 1 2 0 0 0 1 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 1 1 0 0 0 1 0
CT pelvis without and with IV contrast Usually not appropriate Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 0 0 0 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 1 1 0 1 0 1 0
Variant 2: Initial staging of pretreatment vulvar cancer: Primary tumor is less than or equal to 4 cm with greater than 1 mm stromal invasion, confined to vulva or perineum, or with minimal involvement of the urethra, vagina, or anus.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 8 3 3
References Study Quality
32 (20092880) 2
31 (11804896) 3
33 (16859737) 3
34 (16803503) 2
35 (12409110) 3
6 (-3165329) 4
US duplex Doppler and US-guided fine-needle aspiration biopsy groin May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 4 2 3 1 1
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
MRI pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 0 5 1 6 1 0
References Study Quality
32 (20092880) 2
31 (11804896) 3
33 (16859737) 3
34 (16803503) 2
35 (12409110) 3
6 (-3165329) 4
Lymphoscintigraphy groin May be appropriate Strong ☢☢ 0.1-1mSv 6 6 0 1 0 0 2 6 3 2 1
References Study Quality
23 (22753905) 2
21 (25703673) 4
19 (20537946) 2
6 (-3165329) 4
US duplex Doppler groin Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 4 3 2 2 0 0 1 0
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
US-guided fine needle aspiration biopsy groin Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 4 5 0 5 0 0 0 0
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 10 1 1 0 3 0 0 0 0
References Study Quality
26 (26059775) 3
CT abdomen and pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 8 1 0 1 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT abdomen and pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 1 1 0 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT pelvis with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 5 1 1 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 3 1 0 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 1 1 1 1 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT chest abdomen pelvis with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 8 0 0 1 0 0 1 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 0 1 1 1 0 0 1 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
CT chest abdomen pelvis without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 1 1 0 0 0 1 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 1 2 1 0 0 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 2 2 2 1 0 0 0 1
References Study Quality
30 (26790773) 3
27 (24984533) 3
29 (25477274) 2
28 (28930828) 3
6 (-3165329) 4
Variant 3: Initial staging of pretreatment vulvar cancer: Primary tumor is greater than 4 cm or tumor of any size with more than minimal involvement of the urethra, vagina, or anus.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 3 6 5
References Study Quality
32 (20092880) 2
31 (11804896) 3
33 (16859737) 3
34 (16803503) 2
35 (12409110) 3
6 (-3165329) 4
CT chest abdomen pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 3 3 4 4 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 1 0 0 0 1 1 8 3 1
References Study Quality
30 (26790773) 3
27 (24984533) 3
29 (25477274) 2
41 (28751058) 3
6 (-3165329) 4
US duplex Doppler and US-guided fine-needle aspiration biopsy groin May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 4 0 3 2 4 1 1
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
US-guided fine needle aspiration biopsy groin May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 6 0 3 2 1 0 0
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
MRI pelvis without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 3 6 1 0
References Study Quality
32 (20092880) 2
31 (11804896) 3
33 (16859737) 3
34 (16803503) 2
35 (12409110) 3
6 (-3165329) 4
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 6 4 4 0 1
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 4 3 4 1 0 1 1 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 2 6 3 3 0 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT chest abdomen pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 4 3 0 5 0 2 0 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
US duplex Doppler groin Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 2 2 2 2 1 0 1 0
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
37 (10453840) 3
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 4 4 2 1 3 0 1 0 0
References Study Quality
26 (26059775) 3
Lymphoscintigraphy groin Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 6 4 3 0 0 0 1 0 0
References Study Quality
36 (23932893) 3
38 (12727164) 3
25 (16445651) 3
CT pelvis without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 3 4 1 0 1 0 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 4 6 0 0 0 1 0 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 8 2 0 0 0 0 1 0
References Study Quality
26 (26059775) 3
25 (16445651) 3
6 (-3165329) 4
CT pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 4 5 0 0 0 1 0 0
References Study Quality
25 (16445651) 3
6 (-3165329) 4
Variant 4: Post-treatment assessment of clinically suspected recurrence of known vulvar cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 3 6 6
References Study Quality
32 (20092880) 2
6 (-3165329) 4
CT chest abdomen pelvis with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 2 3 6 3
References Study Quality
26 (26059775) 3
FDG-PET/CT skull base to mid-thigh Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 1 0 3 7 4
References Study Quality
30 (26790773) 3
29 (25477274) 2
46 (23369941) 2
45 (24257566) 2
41 (28751058) 3
US duplex Doppler and US-guided fine-needle aspiration biopsy groin May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 4 0 0 5 3 1 1 1
US-guided fine needle aspiration biopsy groin May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 3 7 2 0 1 0 1 1 0
MRI pelvis without IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 2 5 1 1
References Study Quality
32 (20092880) 2
6 (-3165329) 4
CT abdomen and pelvis with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 1 0 0 0 5 6 0 2 1
References Study Quality
26 (26059775) 3
CT abdomen and pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 4 3 0 4 1 2 0 0
CT pelvis with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 1 9 1 0 1 1
CT pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 4 2 4 1 0 1 0 1
CT chest abdomen pelvis without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 4 2 0 4 1 1 1 0
US duplex Doppler groin Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 7 2 0 0 0 0 1 0
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 7 2 3 0 2 0 0 1 0
References Study Quality
26 (26059775) 3
CT abdomen and pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 4 5 0 0 1 1 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 4 4 6 0 0 0 0 0 1
CT pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 9 2 0 0 0 0 1 0
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.