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
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.