American College of Radiology
ACR Appropriateness Criteria®

Anal Cancer

Variant 1: 45-year-old patient, T3N0M0. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
RT + 5-FU Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
External beam + brachytherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
APR Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/2.0 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
PA + laterals + electron boost to inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
4 field box Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + medial inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + lateral inguinal LNs Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Primary alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If progressive disease observed Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
If clinical regression observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If stable disease observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 50-year-old patient, T1N2M0 right inguinal 2-cm node + M0. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
5-FU + MMC Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
5-FU + CDDP Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
APR Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Groin dissection + RT + chemo Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/2.0 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
PA + laterals + electron boost to inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
4 field box May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + medial inguinal LNs Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + lateral inguinal LNs Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Primary alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If progressive disease observed Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
If clinical regression observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If stable disease observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 73-year-old patient, T1N0M0. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
APR Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Brachytherapy alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Re-excision Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
APR Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/2.0 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
PA + laterals + electron boost to inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
4 field box Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + medial inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + lateral inguinal LNs May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Primary alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If progressive disease observed Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
If clinical regression observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If stable disease observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 65-year-old patient, T2N0M0. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT + 5-FU May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
RT alone May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
External beam + brachytherapy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
APR Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
40 Gy/2.0 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
PA + laterals + electron boost to inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
4 field box Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + medial inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + lateral inguinal LNs May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Primary alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If progressive disease observed Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
If clinical regression observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If stable disease observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 45-year-old patient, T4N3M0. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
5-FU + MMC Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
5-FU + CDDP Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
RT + 5-FU + MMC Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
RT alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
APR + node dissection Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
APR + node dissection + chemo RT Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
55.8 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
70.2 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
PA + laterals + electron boost to inguinal LNs Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
4 field box Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + medial inguinal LNs Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Pelvis + primary + lateral inguinal LNs Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Primary alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If progressive disease observed Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
If clinical regression observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
If stable disease observed Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 6: 56-year-old patient, T3N0M0, 50.4 Gy dose with 5-FU + MMC with initial complete response, now with biopsy of primary at 7 months = positive (recurrent).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
APR Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Postoperative chemo + APR Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Additional RT + chemo Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Brachytherapy alone Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Local excision Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.