Variant 1: 65-year-old man, diabetic (Type II), with adenocarcinoma of the prostate. Clinical T1c, PSA 6.5 ng/mL, and GS =6 (3+3) in 3/10 cores. IPSS 9, 65-cm3 gland by TRUS, postvoid residual volume =5 cc. No history of TURP and no pubic arch interference.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 2: 52-year-old healthy man, IPSS 5, 35-cm3 gland. Screening PSA 7.8 ng/mL. Digital rectal examination (DRE) finding of 1-cm apical nodule (T2a) confirmed by MRI of the prostate. Biopsy grade 3+4=7 in 4/12 cores. Negative metastatic workup. Concerned about sexual potency. No pubic arch interference.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 3: 52-year-old healthy man, IPSS 5, 35-cm3 gland. Screening PSA 7.8 ng/mL. DRE normal. MRI of the prostate shows no evidence of T3a/b prostate cancer. Biopsy grade 3+4=7 in 7/12 cores. Negative metastatic workup. Concerned about sexual potency. No pubic arch interference.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 4: 62-year-old man, mildly hypertensive, IPSS 3, 50-cm3 gland by TRUS. PSA 15.0 ng/mL. DRE, 0.5-cm right base nodule (T2a). Biopsy, grade 3+3=6 in 5/12 cores. MR of the prostate reveals no evidence of EPE or seminal vesicle invasion.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 5: 64-year-old healthy man, IPSS 6, 35-cm3 gland by TRUS. PSA 6.5 ng/mL. DRE, (T1c). Biopsy, grade 4+4=8 in 2/12 cores. Negative workup. MR of the prostate is suspicious for possible EPE but no seminal vesicle invasion.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 6: 67-year-old healthy man, IPSS 9, 55-cm3 gland by TRUS. PSA 18 ng/mL. DRE, right EPE (T3a). Biopsy, grade 4+4=8 in 8/12 cores. Negative workup.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 7: 63-year-old healthy man, IPSS 6, 40-cm3 gland by TRUS. PSA 35 ng/mL. DRE, EPE (T3a). Biopsy, grade 4+4=8 in 5/12 cores. Imaging demonstrates probable left seminal vesicle invasion, 2 suspicious lymph nodes. No distant metastases.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
Variant 8: 69-year-old healthy man, IPSS 11, 42-cm3 gland by TRUS. Initially presented with grade 3+4=7 in 3/12 cores, PSA 6, T1c prostate cancer. EBRT to 75.6 Gy 3 years ago to prostate and base of seminal vesicles only. Biopsy-proven recurrence with current PSA of 4.2 ng/mL with doubling time of 14 months. MRI shows single 2-cm lesion in right peripheral zone without EPE. Negative metastatic workup.
| Procedure | Appropriateness Category | SOE | Adult RRL | Peds RRL | Rating | Median | Final Tabulations | ||||||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |||||||
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.