Variant 1: T2bN3M0 (IIIB): 60-year-old male smoker with NSCLC (adenocarcinoma with mutation in KRAS). Chest CT revealed a 6-cm mass in the right upper and middle lobes and right hilar, subcarinal, and bilateral paratracheal lymphadenopathy. All of these areas were intensely FDG-avid on PET scan. Karnofsky performance status (KPS) >70%, weight loss <5%.
Variant 2: T3N3M0 (IIIB): 60-year-old patient with NSCLC (squamous-cell cancer). Chest CT showed bilateral paratracheal and subcarinal adenopathy with postobstructive pneumonia due to an endobronchial lesion in the left mainstem bronchus. All of these areas were intensely FDG-avid on PET scan. KPS >70, weight loss <5%.
Variant 3: T4N3M0: 60-year-old man with a history of a few weeks of superior vena caval obstruction. Bronchoscopy revealed extrinsic compression of right upper lobe (RUL). Fine-needle aspiration (FNA) showed undifferentiated large-cell carcinoma. Chest CT showed 6-cm mass in RUL directly invading mediastinum with compression of superior vena cava, 3-cm left paratracheal node, and right pleural effusion too small to tap. KPS >70, weight loss <5%.
Variant 4: T2aN3M0: 43-year-old woman never-smoker in whom PET/CT showed an FDG-avid 3.5-cm mass in the medial basal segment of the right lower lobe and FDG-avid right infrahilar, subcarinal, right paratracheal, and right supraclavicular lymphadenopathy (all <2 cm). FNA of supraclavicular node revealed adenocarcinoma. A right pleural effusion had mild FDG avidity, but 2 taps were negative. Genetic testing revealed exon 19 deletion mutation in the EGFR. KPS >70, weight loss <5%.
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.