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Appropriateness Criteria

Variant 1: Hepatocellular cancer: Solitary tumor less than 3 cm, cirrhotic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Liver transplantation Usually appropriate Strong N/A N/A 9 9 0 0 0 2 1 0 2 3 7
References Study Quality
1 (8594428) 2
10 (22424438) 4
7 (25921669) 4
11 (24606007) 2
12 (24347475) 3
2 (10518312) 4
9 (27416729) 4
Percutaneous ablation liver Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 4 8 3
References Study Quality
15 (16495695) 1
19 (18008357) 2
17 (23428356) 2
20 (22357902) 2
21 (23374361) 2
16 (22634125) 1
18 (21107100) 1
14 (19174803) M
9 (27416729) 4
13 (28351116) Not Assessed
Surgical liver resection Usually appropriate Strong N/A N/A 8 8 0 0 1 0 0 3 4 5 2
References Study Quality
1 (8594428) 2
5 (17617328) 2
7 (25921669) 4
2 (10518312) 4
3 (20385428) 4
4 (16332475) 3
6 (28053342) 4
8 (17981188) 3
Combination locoregional therapy May be appropriate Strong N/A N/A 5 5 0 0 1 2 6 4 0 2 0
References Study Quality
51 (23134976) M
49 (26342009) 2
50 (25577299) 1
9 (27416729) 4
38 (16978986) 4
52 (22157201) 1
53 (27362551) 1
54 (18688876) 2
55 (25409554) 2
External beam radiation therapy May be appropriate Strong N/A N/A 5 5 0 0 0 3 8 2 1 1 0
References Study Quality
23 (21645977) 2
34 (22467602) 3
24 (23547075) 1
32 (19552767) 2
22 (30068240) 4
25 (16982547) 2
26 (20231127) 2
33 (22172906) 3
35 (28799575) 2
Transarterial chemoembolization May be appropriate Limited N/A N/A 5 5 0 0 1 2 9 2 0 1 0
References Study Quality
36 (29354763) 4
37 (15633215) 2
38 (16978986) 4
Transarterial radioembolization May be appropriate Strong N/A N/A 5 5 0 1 0 2 5 5 0 2 0
References Study Quality
39 (19766639) 2
46 (17048240) 3
32 (19552767) 2
45 (28668402) 2
3 (20385428) 4
35 (28799575) 2
36 (29354763) 4
40 (22911442) 2
41 (30954184) 4
42 (29688155) 2
43 (24691943) 2
44 (20421150) 3
47 (29194711) 2
48 (25981135) 4
Bland transarterial embolization May be appropriate Limited N/A N/A 4 4 2 1 3 5 2 1 0 1 0
References Study Quality
36 (29354763) 4
Systemic therapies Usually not appropriate Expert Consensus N/A N/A 2 2 6 4 5 0 0 0 0 0 0
Variant 2: Hepatocellular cancer: Solitary tumor 3 to 5 cm, cirrhotic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Liver transplantation Usually appropriate Strong N/A N/A 9 9 0 0 0 2 0 0 3 3 7
References Study Quality
1 (8594428) 2
10 (22424438) 4
11 (24606007) 2
12 (24347475) 3
57 (21695773) 4
Combination locoregional therapy Usually appropriate Strong N/A N/A 7 7 1 0 0 0 1 2 8 2 1
References Study Quality
51 (23134976) M
49 (26342009) 2
50 (25577299) 1
9 (27416729) 4
52 (22157201) 1
53 (27362551) 1
54 (18688876) 2
55 (25409554) 2
83 (23216261) 2
84 (21966941) 2
Surgical liver resection Usually appropriate Limited N/A N/A 7 7 0 0 1 0 1 2 5 5 1
References Study Quality
1 (8594428) 2
56 (28130846) 4
7 (25921669) 4
2 (10518312) 4
8 (17981188) 3
Transarterial chemoembolization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 0 3 10 1 1
References Study Quality
69 (11981766) 1
68 (12049862) 1
62 (18503900) 2
61 (24493271) 2
63 (17103105) 4
75 (18936575) 2
76 (19912531) 4
78 (18696158) 2
79 (16939518) 4
74 (23041304) 4
77 (20373461) 2
80 (15004776) 4
64 (20213741) 2
66 (19908093) 1
73 (20740319) 2
65 (24224722) M
60 (26834067) 1
71 (9696501) 1
72 (7708069) 1
70 (18242076) 1
Transarterial radioembolization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 1 4 5 3 2
References Study Quality
46 (17048240) 3
32 (19552767) 2
45 (28668402) 2
81 (25921670) 4
3 (20385428) 4
41 (30954184) 4
42 (29688155) 2
43 (24691943) 2
44 (20421150) 3
47 (29194711) 2
48 (25981135) 4
82 (31233480) 2
Bland transarterial embolization May be appropriate Strong N/A N/A 6 6 1 0 0 4 1 5 3 0 1
References Study Quality
62 (18503900) 2
61 (24493271) 2
63 (17103105) 4
64 (20213741) 2
66 (19908093) 1
67 (22251546) 4
65 (24224722) M
60 (26834067) 1
External beam radiation therapy May be appropriate Strong N/A N/A 5 5 0 0 1 3 8 1 2 0 0
References Study Quality
23 (21645977) 2
34 (22467602) 3
24 (23547075) 1
32 (19552767) 2
22 (30068240) 4
25 (16982547) 2
26 (20231127) 2
33 (22172906) 3
35 (28799575) 2
Percutaneous ablation liver May be appropriate Strong N/A N/A 5 5 0 0 0 1 10 2 0 2 0
References Study Quality
51 (23134976) M
49 (26342009) 2
50 (25577299) 1
52 (22157201) 1
53 (27362551) 1
54 (18688876) 2
55 (25409554) 2
58 (26220125) 2
59 (25958973) 2
Systemic therapies Usually not appropriate Expert Consensus N/A N/A 3 3 2 5 7 1 0 0 0 0 0
Variant 3: Hepatocellular cancer: Multifocal, bilobar disease, at least 1 tumor greater than 5 cm, cirrhotic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Transarterial chemoembolization Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 7 6 2
References Study Quality
69 (11981766) 1
68 (12049862) 1
62 (18503900) 2
61 (24493271) 2
63 (17103105) 4
64 (20213741) 2
66 (19908093) 1
67 (22251546) 4
65 (24224722) M
60 (26834067) 1
100 (24549881) 2
101 (17377182) 2
71 (9696501) 1
72 (7708069) 1
70 (18242076) 1
Transarterial radioembolization Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 0 3 10 2
References Study Quality
102 (20066715) 2
103 (20022765) 2
104 (21983055) 2
106 (23093355) 2
107 (21044630) 2
46 (17048240) 3
32 (19552767) 2
45 (28668402) 2
105 (27586657) 4
109 (27315059) 3
3 (20385428) 4
35 (28799575) 2
36 (29354763) 4
41 (30954184) 4
42 (29688155) 2
43 (24691943) 2
44 (20421150) 3
47 (29194711) 2
108 (21618574) 2
110 (24332243) 3
Bland transarterial embolization Usually appropriate Strong N/A N/A 7 7 0 0 1 1 1 4 7 0 1
References Study Quality
62 (18503900) 2
61 (24493271) 2
63 (17103105) 4
64 (20213741) 2
66 (19908093) 1
67 (22251546) 4
65 (24224722) M
60 (26834067) 1
100 (24549881) 2
101 (17377182) 2
Systemic therapies Usually appropriate Strong N/A N/A 7 7 0 1 0 0 0 6 7 1 0
References Study Quality
85 (18650514) 1
86 (19095497) 1
90 (29875066) 2
91 (28434648) 2
89 (32847838) 1
88 (27932229) 1
87 (32402160) 1
Combination locoregional therapy May be appropriate Strong N/A N/A 5 5 0 0 1 3 5 2 3 1 0
References Study Quality
83 (23216261) 2
84 (21966941) 2
External beam radiation therapy May be appropriate Strong N/A N/A 4 4 0 1 1 8 3 2 0 0 0
References Study Quality
34 (22467602) 3
24 (23547075) 1
32 (19552767) 2
22 (30068240) 4
25 (16982547) 2
26 (20231127) 2
33 (22172906) 3
35 (28799575) 2
Percutaneous ablation liver Usually not appropriate Expert Consensus N/A N/A 3 3 0 6 7 2 0 0 0 0 0
Surgical liver resection Usually not appropriate Strong N/A N/A 3 3 4 2 5 1 1 2 0 0 0
References Study Quality
95 (19106671) 4
93 (21159100) 2
75 (18936575) 2
46 (17048240) 3
32 (19552767) 2
45 (28668402) 2
81 (25921670) 4
3 (20385428) 4
33 (22172906) 3
35 (28799575) 2
36 (29354763) 4
47 (29194711) 2
54 (18688876) 2
92 (22864644) 2
94 (12783395) 2
96 (19032223) 2
97 (15561225) 4
Liver transplantation Usually not appropriate Strong N/A N/A 2 2 6 4 5 0 0 0 0 0 0
References Study Quality
95 (19106671) 4
93 (21159100) 2
75 (18936575) 2
46 (17048240) 3
32 (19552767) 2
45 (28668402) 2
81 (25921670) 4
3 (20385428) 4
33 (22172906) 3
35 (28799575) 2
36 (29354763) 4
47 (29194711) 2
54 (18688876) 2
92 (22864644) 2
94 (12783395) 2
96 (19032223) 2
97 (15561225) 4
Variant 4: Hepatocellular cancer: Solitary or multifocal disease with vascular invasion, cirrhotic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic therapies Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 7 4 3
References Study Quality
85 (18650514) 1
86 (19095497) 1
90 (29875066) 2
91 (28434648) 2
89 (32847838) 1
88 (27932229) 1
87 (32402160) 1
Transarterial radioembolization Usually appropriate Strong N/A N/A 8 8 0 0 0 0 1 2 2 8 2
References Study Quality
102 (20066715) 2
103 (20022765) 2
104 (21983055) 2
106 (23093355) 2
46 (17048240) 3
105 (27586657) 4
109 (27315059) 3
81 (25921670) 4
108 (21618574) 2
110 (24332243) 3
Transarterial chemoembolization May be appropriate Strong N/A N/A 6 6 0 1 0 0 6 6 2 0 0
References Study Quality
114 (23566041) Good
115 (22200992) 2
116 (20839057) 1
Bland transarterial embolization May be appropriate Strong N/A N/A 5 5 1 1 0 3 7 2 1 0 0
References Study Quality
114 (23566041) Good
115 (22200992) 2
116 (20839057) 1
Combination locoregional therapy May be appropriate Limited N/A N/A 5 5 0 1 0 2 10 2 0 0 0
References Study Quality
117 (29543938) 1
External beam radiation therapy May be appropriate Strong N/A N/A 4 4 0 0 1 8 3 2 0 1 0
References Study Quality
24 (23547075) 1
25 (16982547) 2
26 (20231127) 2
Percutaneous ablation liver Usually not appropriate Expert Consensus N/A N/A 2 2 5 7 1 2 0 0 0 0 0
Surgical liver resection Usually not appropriate Moderate N/A N/A 2 2 6 5 4 0 0 0 0 0 0
References Study Quality
111 (24096763) 2
Liver transplantation Usually not appropriate Strong N/A N/A 1 1 9 3 2 0 1 0 0 0 0
References Study Quality
112 (27107252) 2
113 (26386273) 2
Variant 5: Intrahepatic cholangiocarcinoma: Peripheral hepatic lobar cholangiocarcinoma, less than 3 cm; no biliary ductal dilatation, macroscopic vascular invasion, regional lymphadenopathy, or distant metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical liver resection Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 5 4 6
References Study Quality
121 (29911912) 2
120 (28577720) 4
Percutaneous ablation liver Usually appropriate Strong N/A N/A 7 7 0 0 0 0 1 1 11 2 0
References Study Quality
123 (21257864) 2
125 (22374282) 1
124 (28343412) 4
Liver transplantation May be appropriate Limited N/A N/A 5 5 2 1 3 1 6 2 0 0 0
References Study Quality
122 (10836374) 4
121 (29911912) 2
Systemic therapies May be appropriate Limited N/A N/A 5 5 0 0 1 1 9 1 2 1 0
References Study Quality
119 (20375404) 1
Transarterial radioembolization May be appropriate Limited N/A N/A 5 5 0 0 0 4 5 4 1 1 0
References Study Quality
127 (19876691) 2
External beam radiation therapy May be appropriate Expert Consensus N/A N/A 4 4 0 5 3 2 4 1 0 0 0
Transarterial chemoembolization May be appropriate Expert Consensus N/A N/A 4 4 0 1 6 3 5 0 0 0 0
Bland transarterial embolization Usually not appropriate Expert Consensus N/A N/A 3 3 2 2 6 2 3 0 0 0 0
Variant 6: Ductal cholangiocarcinoma: Hilar cholangiocarcinoma, greater than 3 cm with poorly defined margins, vascular invasion, and periportal lymphadenopathy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic therapies Usually appropriate Limited N/A N/A 8 8 0 0 0 0 1 0 2 7 5
References Study Quality
119 (20375404) 1
Transarterial radioembolization May be appropriate Limited N/A N/A 5 5 0 2 4 1 3 5 0 0 0
References Study Quality
132 (31079715) 4
131 (27826686) 2
External beam radiation therapy May be appropriate Limited N/A N/A 4 4 0 0 2 7 4 1 1 0 0
References Study Quality
128 (26172136) 4
Bland transarterial embolization Usually not appropriate Limited N/A N/A 3 3 3 2 4 3 1 2 0 0 0
References Study Quality
129 (23846786) 3
Transarterial chemoembolization Usually not appropriate Moderate N/A N/A 3 3 1 2 5 1 5 1 0 0 0
References Study Quality
130 (23725793) Good
Percutaneous ablation liver Usually not appropriate Expert Consensus N/A N/A 2 2 6 7 0 1 1 0 0 0 0
Surgical liver resection Usually not appropriate Expert Consensus N/A N/A 2 2 7 5 3 0 0 0 0 0 0
Liver transplantation Usually not appropriate Expert Consensus N/A N/A 1 1 10 3 1 0 1 0 0 0 0
Variant 7: Metastatic liver disease: Multifocal metastatic neuroendocrine tumor (includes carcinoid tumors as well as islet cell tumors of the pancreas).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Long-acting somatostatin analogs Usually appropriate Strong N/A N/A 8 8 0 0 0 0 0 1 4 4 6
References Study Quality
133 (28132407) 2
134 (26731483) 1
Bland transarterial embolization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 3 3 7 2 0
References Study Quality
149 (16134179) 2
150 (17609443) 2
152 (22722717) 2
132 (31079715) 4
133 (28132407) 2
156 (27520932) 2
154 (25012459) Inadequate
151 (21107755) 2
153 (24385266) 2
155 (26663886) 2
Peptide receptor radionuclide therapy Usually appropriate Strong N/A N/A 7 7 0 0 1 0 1 2 7 3 1
References Study Quality
161 (18445841) 2
160 (22934111) 2
162 (28076709) 1
Transarterial chemoembolization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 3 2 8 2 0
References Study Quality
149 (16134179) 2
150 (17609443) 2
152 (22722717) 2
157 (22027582) 2
132 (31079715) 4
133 (28132407) 2
156 (27520932) 2
154 (25012459) Inadequate
151 (21107755) 2
153 (24385266) 2
155 (26663886) 2
Transarterial radioembolization Usually appropriate Strong N/A N/A 7 7 0 0 0 0 3 2 7 3 0
References Study Quality
149 (16134179) 2
150 (17609443) 2
152 (22722717) 2
132 (31079715) 4
133 (28132407) 2
156 (27520932) 2
158 (27738818) 2
154 (25012459) Inadequate
151 (21107755) 2
153 (24385266) 2
155 (26663886) 2
159 (29724520) 2
Systemic therapies May be appropriate Limited N/A N/A 6 6 0 0 0 0 2 8 4 1 0
References Study Quality
135 (16041556) 4
External beam radiation therapy May be appropriate Limited N/A N/A 4 4 0 1 2 6 5 1 0 0 0
References Study Quality
148 (26434846) 3
147 (20404793) 4
146 (26628466) 2
Percutaneous ablation liver May be appropriate Limited N/A N/A 4 4 0 1 2 5 6 1 0 0 0
References Study Quality
135 (16041556) 4
Surgical liver resection May be appropriate Limited N/A N/A 4 4 0 3 2 4 4 1 1 0 0
References Study Quality
141 (12831921) 2
140 (7817996) 3
142 (22658833) 4
143 (24655881) 3
144 (1701060) 4
Combination locoregional therapy Usually not appropriate Limited N/A N/A 3 3 1 2 10 2 0 0 0 0 0
References Study Quality
159 (29724520) 2
Liver transplantation Usually not appropriate Limited N/A N/A 3 3 3 3 2 4 1 2 0 0 0
References Study Quality
145 (28624178) 4
Variant 8: Metastatic liver disease: Solitary colorectal liver metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic therapies Usually appropriate Strong N/A N/A 9 9 1 0 0 0 1 0 2 2 9
References Study Quality
163 (29589315) 4
164 (29910669) 4
165 (23352604) 1
166 (17947725) 1
167 (14665611) 1
168 (26338525) 1
Surgical liver resection Usually appropriate Limited N/A N/A 8 8 0 0 0 0 0 0 3 6 6
References Study Quality
170 (17981429) 4
169 (27003990) 4
171 (22441614) 4
Percutaneous ablation liver Usually appropriate Strong N/A N/A 7 7 0 0 0 1 0 3 6 4 1
References Study Quality
174 (22288086) 4
175 (27269232) 2
173 (15599547) 2
176 (26267832) 2
Combination locoregional therapy May be appropriate Moderate N/A N/A 6 6 0 0 0 1 4 8 2 0 0
References Study Quality
179 (27999917) 2
External beam radiation therapy May be appropriate Limited N/A N/A 6 6 0 0 0 1 4 9 1 0 0
References Study Quality
177 (29934790) 2
Transarterial chemoembolization May be appropriate Limited N/A N/A 5 5 0 0 2 5 2 5 1 0 0
References Study Quality
178 (8629387) 1
Transarterial radioembolization May be appropriate Expert Consensus N/A N/A 4 4 1 1 3 3 5 1 1 0 0
Bland transarterial embolization Usually not appropriate Expert Consensus N/A N/A 3 3 1 3 4 5 2 0 0 0 0
Hepatic arterial chemotherapy infusion Usually not appropriate Expert Consensus N/A N/A 3 3 1 2 8 2 2 0 0 0 0
Liver transplantation Usually not appropriate Limited N/A N/A 2 2 7 4 3 1 0 0 0 0 0
References Study Quality
172 (28544246) 2
Variant 9: Metastatic liver disease: Multifocal bilobar colorectal carcinoma (liver dominant or isolated).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Systemic therapies Usually appropriate Strong N/A N/A 9 9 0 0 0 0 0 0 0 3 12
References Study Quality
164 (29910669) 4
169 (27003990) 4
180 (24585720) 2
165 (23352604) 1
166 (17947725) 1
167 (14665611) 1
168 (26338525) 1
Hepatic arterial chemotherapy infusion May be appropriate Strong N/A N/A 6 6 0 0 0 3 3 4 4 1 0
References Study Quality
186 (26133575) 4
183 (28433600) 2
184 (28293087) 2
185 (24646562) 2
187 (22922040) 2
Transarterial chemoembolization May be appropriate Strong N/A N/A 6 6 0 0 0 1 4 10 0 0 0
References Study Quality
69 (11981766) 1
68 (12049862) 1
189 (20830766) 2
188 (23885916) 4
Transarterial radioembolization May be appropriate Strong N/A N/A 6 6 0 0 1 0 2 8 2 2 0
References Study Quality
192 (30033117) 2
190 (28781171) 1
191 (26903575) 1
193 (21800231) 2
194 (20628388) 2
Bland transarterial embolization May be appropriate (Disagreement) Expert Opinion N/A N/A 5 5 1 2 4 3 2 3 0 0 0
Combination locoregional therapy May be appropriate Moderate N/A N/A 5 5 0 0 0 2 9 4 0 0 0
References Study Quality
179 (27999917) 2
Percutaneous ablation liver May be appropriate Moderate N/A N/A 5 5 0 0 1 3 8 3 0 0 0
References Study Quality
181 (28376151) 1
Surgical liver resection May be appropriate Moderate N/A N/A 5 5 0 0 1 0 10 4 0 0 0
References Study Quality
180 (24585720) 2
External beam radiation therapy Usually not appropriate Moderate N/A N/A 3 3 1 5 3 2 4 0 0 0 0
References Study Quality
182 (21432842) 2
Liver transplantation Usually not appropriate Expert Consensus N/A N/A 1 1 8 3 3 0 0 1 0 0 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.