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HumanaCommercial Clinical Policy

Humana Brachytherapy Form


brachytherapy

Notes: Brachytherapy is covered only for specific conditions according to the patient's Plan and is not eligible for reimbursement if used for experimental/investigational purposes or with certain non-covered types and methods.

Indications

(447339) Is the brachytherapy procedure for treating breast cancer? 
(447340) Is the brachytherapy procedure for treating soft tissue sarcoma? 

Contraindications

(447341) Is the brachytherapy procedure indicated for an experimental/investigational use not supported by nationally recognized peer-reviewed medical literature? 
(447342) Is the brachytherapy treatment utilizing types not covered under the Plan, including some types specific to breast cancer? 
(447343) Is the brachytherapy procedure being utilized with transperineal biodegradable material (e.g., Barrigel Hyaluronic Spacer, SpaceOAR)? 
YesNoN/A
YesNoN/A

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Effective Date

05/25/2023

Last Reviewed

NA

Original Document

  Reference



Description

Brachytherapy, also known as internal radiation therapy, is a treatment in which radioactive sources are placed inside an individual either temporarily (via a catheter or tube for a specific time and withdrawn) or permanently (seeds or pellets in or near the tumor which are not removed). Brachytherapy can be used to treat cancer throughout the body. Brachytherapy can also be utilized to prevent intracoronary restenosis after stent placement. Based on the technique, either high-dose rate (HDR) or low-dose rate (LDR) brachytherapy can be utilized.

There are two main types of brachytherapy, which include intracavity and interstitial. Intracavity treatment involves the placement of a radioactive source in the body cavity near the tumor (eg, cervix, trachea, vagina) and interstitial treatment is performed by placing the radioactive source in the form of seeds,

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pellets or sheets directly into or around the tissue. Examples of interstitial radiation therapy include, but may not be limited to, CivaSheet (eg, prostate cancer) or GammaTile (eg, brain tumors). Another type of treatment is surface brachytherapy (may also be known as plaque brachytherapy), which is performed when the radiation sources are placed directly on an external tumor or target surface (eg, eye, skin cancer).

Brachytherapy can be delivered using several methods including, but may not be limited to:

  • following a lumpectomy to the space left after the cancerous tumor is removed and to the tissue directly surrounding the cavity. By delivering radiation to the area directly surrounding the original tumor, radiation exposure is minimized to the rest of the breast and other organs. Examples of delivery systems include, but may not be limited to, the CONTURA Multi-Lumen Balloon (MLB) Catheter, MammoSite Radiation Therapy System (RTS), the and the SAVI applicator, which is a single-entry device that allows physicians to customize radiation treatments based on individual-specific anatomy.

source to apply brachytherapy to the cancerous site. Purportedly, EBT is utilized to provide intracavity, interstitial or surface brachytherapy. EBT is being studied for use during intraoperative radiation therapy (IORT) for brain tumors. Following surgical removal of the tumor and the placement of a radiation therapy applicator into the tumor cavity, EBT is reportedly delivered directly to the tumor bed. Examples of EBT devices include, but may not be limited to, the Xoft Axxent Electronic Brachytherapy System, the Esteya EBT system and the INTRABEAM system. (Refer to Coverage Limitations section)

  • Intracoronary brachytherapy is used to prevent restenosis of an artery after angioplasty or stent placement by delivering a small amount of radiation to the treated area, which may reduce the need for additional angioplasty or bypass surgery. The radiation is intended to discourage the overgrowth of normal tissue as the healing process occurs.

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Review Date: 05/25/2023
Policy Number: HUM-0348-028

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  • Intravascular brachytherapy has been investigated as an adjunct to angioplasty of the femoropopliteal segment to reduce the risk of restenosis.

(Refer to Coverage Limitations section)

  • Noninvasive brachytherapy of the breast involves the use of mammography, which reportedly provides real-time images of the lumpectomy cavity and identifies the size and location needed for the dosing applicators. Noninvasive HDR brachytherapy applicators are positioned on opposite sides of the breast and radiation is delivered directly to the target site. An example of a noninvasive brachytherapy device is the Accuboost system.

(Refer to Coverage Limitations section)

  • Selective internal radiation therapy (SIRT), also known as radioembolization, is a procedure in which tiny radiation-filled beads (eg, yttrium-90), called microspheres, are delivered directly to the tumor. The microspheres are delivered through a catheter placed in the femoral artery and threaded through the hepatic artery to the tumor site. Examples of this type of treatment include, but may not be limited to:
    • SIR-Spheres are resin spheres that are indicated for the treatment of unresectable metastatic liver tumors from primary colorectal cancer (CRC).
    • Theraspheres are spheres made of glass, which are indicated for unresectable primary hepatocellular carcinoma (HCC).

The placement of a transperineal biodegradable spacer (eg, Barrigel Hyaluronic Spacer, SpaceOAR) positions the anterior (frontal) section of the rectal wall away from the prostate during radiotherapy treatments for prostate cancer with the goal of limiting the radiation exposure to the anterior rectum. Because this material is biodegradable, it is absorbed over time by the individual’s body.

(Refer to Coverage Limitations section)

For information regarding transperineal biodegradable material (SpaceOAR) for other types of radiation therapy, please refer to the following medical coverage policies:

  • Intensity Modulation Radiation Therapy
  • Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy
  • Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Coverage Determination

Humana members may be eligible under the Plan for brachytherapy when the following criteria are met:

  • Breast cancer (refer to Coverage Limitations section for noncovered types of brachytherapy of the breast):
    • Accelerated partial breast irradiation (APBI) when the following criteria are met:50 years of age or older; AND Invasive carcinoma or ductal carcinoma in situ (DCIS); AND Node negative; AND Total tumor size less than or equal to 3 cm; AND Tumor removed with negative surgical margins; OR
    • Adjunctive boost to the tumor bed in an individual receiving whole breast radiation therapy (WBRT) following breast conserving surgery (eg, lumpectomy); OR
  • Cholangiocarcinoma as secondary or adjuvant treatment for the following indications:
    • Carcinoma in situ at margin; OR
    • Positive regional nodes; OR
    • Resected gross residual disease (R2); OR
    • Resected, positive margin (R1); OR
  • Esophageal cancer for the following indications:
    • Palliative treatment for dysphagia; OR
    • Unresectable, nonmetastatic disease; OR

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  • Gynecologic cancer (cervical, endometrial/uterine, vaginal or vulvar); OR
  • Head and neck cancer (brain, lip, nasopharyngeal, oral cavity, salivary gland, uveal melanoma); OR
  • Intracoronary application for in-stent restenosis following angioplasty or stent placement; OR
  • Lung cancer for the following indications:
    1. Endobronchial treatment of the central airway in an individual who are not candidates for surgical resection; OR
    2. Palliative treatment for an individual with unresectable disease and symptomatic airway obstruction; OR
  • Neuroendocrine tumors for the following indications:
    1. Metastasis to the liver when systemic therapy is contraindicated; OR
    2. Systemic therapy has failed to control symptoms (eg, carcinoid syndrome); OR
  • Penile cancer when the following criteria are met:
    1. Node negative; AND
    2. T1 or T2 disease; AND
    3. Tumors less than 4 cm confined to the glans and prepuce; OR
  • Prostate cancer for the following indications:
    1. Low-risk localized prostate cancer when the following criteria are met:
      • Grade group 1 (Gleason score less than 6); AND
      • Serum PSA less than 10 ng/ml; AND
      • Stage T1 or T2a; OR
    2. Intermediate-risk prostate cancer when the following criteria are met:
      • Grade group 2-3 (Gleason score 7); AND

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  • Serum PSA greater than or equal to 10 ng/ml and less than 20 ng/ml; AND
  • Stage T2b – T2c; OR
  • High-risk prostate cancer as a boost when the following criteria are met:
    • Grade group 4-5 (Gleason score 8-10); AND
    • Serum PSA greater than or equal to 20 ng/ml; AND
    • Stage T3 or greater;
  • Retinoblastoma when the following criteria are met:
    1. As a secondary treatment after local treatment failure (eg, cryoablation, external beam radiation therapy [EBRT], laser therapy, local or systemic chemotherapy); OR
  • SIRT for the following indications:
    1. SIR-Spheres for unresectable metastatic liver tumors from primary colorectal cancer (CRC) with adjuvant intra-hepatic artery chemotherapy177; OR
    2. TheraSphere when the following criteria are met:
      • Unresectable HCC of solitary tumor (1-8 cm in diameter); AND
      • Child-Turcotte-Pugh Score A cirrhosis; AND
      • Eastern Cooperative Oncology Group (ECOG) Performance status of 0-2178; AND
      • No macrovascular invasion; AND
      • Well-compensated liver function (eg, no signs or symptoms of decompensation such as ascites, hepatic encephalopathy, jaundice or variceal hemorrhage)
  • Soft tissue sarcoma when the following criteria are met:

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  • Positive margins; AND
  • Tumor size greater than 5 cm

Coverage Limitations

Humana members may NOT be eligible under the Plan for brachytherapy for any indications other than those listed above including, but may not be limited to:

  • Age-related macular degeneration; OR
  • Bladder cancer; OR
  • Intravascular brachytherapy following femoropopliteal angioplasty; OR
  • Pancreatic cancer

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for the following types of brachytherapy for ANY indications including, but may not be limited to, breast cancer:

  • Electronic brachytherapy (0394T, 0395T) and placement of the radiation therapy applicator (0735T); OR
  • Noninvasive brachytherapy

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for transperineal biodegradable material (eg, Barrigel Hyaluronic Spacer, SpaceOAR) when utilized with brachytherapy. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

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Robotic-assisted brachytherapy and/or the use of software in planning brachytherapy treatment (eg, Clarity System, Vitesse HDR Treatment Planning System) are considered integral to the primary procedure and not separately reimbursable.

Additional information about cancer or coronary disease may be found from the following websites:
Background
  • American Cancer Society
  • American Gastroenterological Association
  • American Heart Association
  • National Cancer Institute
  • National Comprehensive Cancer Network
  • National Library of Medicine
Medical Alternatives

Alternatives to brachytherapy include, but may not be limited to, the following:

  • Chemotherapy
  • Hormone therapy
  • Prescription drug therapy
  • Radiation therapy (also known as radiotherapy, X-ray therapy or irradiation)

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

CPT® Code(s)DescriptionComments
19296Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy
19297Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)
19298Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance
19499Unlisted procedure, breastNot Covered if used to report any treatment outlined in Coverage Limitations section
20555Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)
31643Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application

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41019Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application
55860Exposure of prostate, any approach, for insertion of radioactive substance;
55862Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy)
55865Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes
55874Transperineal placement of biodegradable material, peri- prostatic, single or multiple injection(s), including image guidance, when performedNot Covered if used to report any treatment outlined in Coverage Limitations section
55875Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
55876Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
55920Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
57155Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
57156Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy
58346Insertion of Heyman capsules for clinical brachytherapy
61770Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source

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77316Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)
77317Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2- 12 channels), includes basic dosimetry calculation(s)
77318Brachytherapy isodose plan; complex (calculations made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)Not Covered if used to report any treatment
77750Infusion or instillation of radioelement solution (includes 3- month follow-up care)
77761Intracavitary radiation source application; simple
77762Intracavitary radiation source application; intermediate
77763Intracavitary radiation source application; complex
77767Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
77768Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions
77770Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channelNot Covered if used to report any treatment outlined in Coverage Limitations section
77771Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channelsNot Covered if used to report any treatment outlined in Coverage Limitations section
77772Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channelsNot Covered if used to report any treatment outlined in Coverage Limitations section

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77778Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed
77789Surface application of low dose rate radionuclide source
77790Supervision, handling, loading of radiation source
77799Unlisted procedure, radiation therapy technique
Unlisted procedure, clinical brachytherapyNot Covered if used to report any treatment outlined in Coverage Limitations section92974Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure)CPT® Category III Code(s)DescriptionComments0394THigh dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performedNot Covered0395THigh dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performedNot Covered0735TPreparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with primary craniotomy (List separately in addition to code for primary procedure)Not Covered New Code Effective 07/01/2022Code(s)DescriptionCommentsA9527Iodine I-125, sodium iodide solution, therapeutic, per mCiC1715Brachytherapy needleC1716 Brachytherapy source, nonstranded, gold-198, per source1717Brachytherapy source, nonstranded, high dose rate iridium-192, per sourceNot Covered if used to report any treatment outlined in Coverage Limitations section

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C1719Brachytherapy source, nonstranded, nonhigh dose rate iridium-192, per source
C1728Catheter, brachytherapy seed administration
C2616Brachytherapy source, nonstranded, yttrium-90, per source
C2634Brachytherapy source, nonstranded, high activity, iodine-125, greater than 1.01 mCi (NIST), per source
C2635Brachytherapy source, nonstranded, high activity, palladium-103, greater than 2.2 mCi (NIST), per source
C2636Brachytherapy linear source, nonstranded, palladium-103, per 1 mm
C2637Brachytherapy source, nonstranded, ytterbium-169, per source
C2638Brachytherapy source, stranded, iodine-125, per source
C2639Brachytherapy source, nonstranded, iodine-125, per source
C2640Brachytherapy source, stranded, palladium-103, per source
C2641Brachytherapy source, nonstranded, palladium-103, per source
C2642Brachytherapy source, stranded, cesium-131, per source
C2643Brachytherapy source, nonstranded, cesium-131, per source
C2644Brachytherapy source, cesium-131 chloride solution, per mCi
C2645Brachytherapy planar source, palladium-103, per sq mm
©2698Brachytherapy source, stranded, not otherwise specified, per source
C2699Brachytherapy source, nonstranded, not otherwise specified, per source
C7533Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapyNew Code Effective 01/01/2023
9725Placement of endorectal intracavitary applicator for high intensity brachytherapy
C9726Placement and removal (if performed) of applicator into breast for intraoperative radiation therapy, add-on to primary breast procedure

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©9728Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter), for other than the following sites (any approach): abdomen, pelvis, prostate, retroperitoneum, thorax, single or multiple
G0458Low dose rate (LDR) prostate brachytherapy services, composite rate
Q3001Radioelements for brachytherapy, any type, each

References

  1. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Local nonsurgical therapies for stage I and symptomatic obstructive non-small-cell lung cancer. https://www.ahrq.gov. Published June 2013. Accessed April 28, 2023.
  2. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Therapies for clinically localized prostate cancer. https://www.ahrq.gov. Published September 2020. Accessed April 28, 2023.
  3. American Academy of Dermatology (AAD). Guidelines of care for the management of basal cell carcinoma. https://www.aad.org. Published March 2018.

  1. American Academy of Dermatology (AAD). Guidelines of care for the management of cutaneous squamous cell carcinoma. https://www.aad.org. Published March 2018. Accessed May 2, 2023.
  2. American Academy of Dermatology (AAD). Guidelines of care for the management of primary cutaneous melanoma. https://www.aad.org. Published January 2019. Accessed May 2, 2023.
  3. American Academy of Dermatology (AAD). Position statement on electronic surface brachytherapy for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). https://www.aad.org. Published November 13, 2013. Updated November 6, 2021. Accessed May 2, 2023.
  4. American Association for the Study of Liver Diseases (AASLD). Diagnosis, staging and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. https://www.asld.org. Published August 2018. Accessed May 2, 2023.
  5. American Association for the Study of Liver Diseases (AASLD). Therapies for advanced stage hepatocellular carcinoma with macrovascular invasion or metastatic disease: a systematic review and meta-analysis. https://www.asld.org. Published January 2018. Accessed May 2, 2023.
  6. American Brachytherapy Society (ABS). American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part I: general principles. https://www.americanbrachytherapy.org. Published 2012. Accessed May 9, 2023.
  7. American Brachytherapy Society (ABS). American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose rate brachytherapy. https://www.americanbrachytherapy.org. Published 2012. Accessed May 9, 2023.

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  1. American Brachytherapy Society (ABS). American Brachytherapy Societyconsensus guidelines for locally advanced carcinoma of the cervix. Part III: low dose rate and pulsed dose rate brachytherapy. https://www.americanbrachytherapy.org. Published 2012. Accessed May 9, 2023.
  2. American Brachytherapy Society (ABS). American Brachytherapy Society consensus guideline for plaque brachytherapy of uveal melanoma and retinoblastoma. https://www.americanbrachytherapy.org. Published 2014. Accessed May 9, 2023.
  3. American Brachytherapy Society (ABS). American Brachytherapy Society consensus statement for electronic brachytherapy. https://www.americanbrachytherapy.org. Published 2019. Accessed May 9, 2023.
  4. American Brachytherapy Society (ABS). Consensus statement for brachytherapy for the treatment of medically inoperable endometrial cancer. https://www.americanbrachytherapy.org. Published 2015. Accessed May 9, 2023.
  5. American Brachytherapy Society (ABS). Intraoperative high-dose rate brachytherapy: an American Brachytherapy Society consensus report. https://www.americanbrachytherapy.org. Published 2017. Accessed May 9, 2023.
  6. American Brachytherapy Society (ABS). Low dose rate brachytherapy for primary treatment of localized prostate cancer: a systematic review and executive summary of an evidence-based consensus statement. https://www.americanbrachytherapy.org. Published 2021. Accessed May 9, 2023.

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  1. American College of Chest Physicians (ACCP). American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer. https://www.chestnet.org. Published December 2012. Accessed May 9, 2023.
  2. American College of Chest Physicians (ACCP). Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. https://www.chestnet.org. Published May 2013. Updated March 8, 2022. Accessed May 9, 2023.
  3. American College of Gastroenterology (ACG). Practice Guideline. The diagnosis and management of focal liver lesions. https://www.gi.org. Published September 2014. Accessed May 2, 2023.
  4. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin. Endometrial cancer. https://www.acog.org. Published August 2015. Updated 2021. Accessed May 2, 2023.

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  1. American College of Radiology (ACR). ACR-ABS-ACNM-ASTRO-SIR-SNMMI practice parameter for selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. https://www.acr.org. Published 2019. Accessed May 3, 2023.
  2. American College of Radiology (ACR). ACR-ABS-ASTRO practice parameter for transperineal permanent brachytherapy for prostate cancer. https://www.acr.org. Published 2015. Updated 2020. Accessed May 8, 2023.
  3. American College of Radiology (ACR). ACR Appropriateness Criteria. Management of liver cancer. https://www.acr.org. Published 2007. Updated 2022. Accessed May 8, 2023.
  4. American Gastroenterological Association (AGA). AGA clinical practice update on the optimal management of the malignant alimentary tract obstruction: expert review. https://gastro.org. Published September 2021. Accessed May 2, 2023.
  5. American Radium Society (ARS). ACR Appropriateness Criteria. Adjuvant management of early-stage endometrial cancer. https://www.americanradiumsociety.org. Published 2016. Accessed May 8, 2023.

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  1. American Radium Society (ARS). ACR Appropriateness Criteria. Advanced cervical cancer. https://www.americanradiumsociety.org. Published 2010. Updated 2012. Accessed May 8, 2023.
  2. American Radium Society (ARS). ACR Appropriateness Criteria. Aggressive nonmelanomatous skin cancer of the head and neck. https://www.americanradiumsociety.org. Published 2014. Accessed May 8, 2023.
  3. American Radium Society (ARS). ACR Appropriateness Criteria. Anal cancer. https://www.americanradiumsociety.org. Published 1999. Updated 2019. Accessed May 8, 2023.
  4. American Radium Society (ARS). ACR Appropriateness Criteria. Conservative surgery and radiation – stage I and II breast cancer. https://www.americanradiumsociety.org. Published 1996. Updated 2015. Accessed May 8, 2023.

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  1. American Radium Society (ARS). ACR Appropriateness Criteria. Definitive therapy for early-stage cervical cancer. https://www.americanradiumsociety.org. Published 2012. Accessed May 8, 2023.
  2. American Radium Society (ARS). ACR Appropriateness Criteria. Early-stage non-small-cell lung cancer. https://www.americanradiumsociety.org. Published 2013. Accessed May 8, 2023.
  3. American Radium Society (ARS). ACR Appropriateness Criteria. External beam radiation therapy treatment planning for clinically localized prostate cancer. https://www.americanradiumsociety.org. Published 1996. Updated 2016. Accessed May 8, 2023.
  4. American Radium Society (ARS). ACR Appropriateness Criteria. High dose rate brachytherapy for prostate cancer. https://www.americanradiumsociety.org. Published 2013. Accessed May 8, 2023.
  5. American Radium Society (ARS). ACR Appropriateness Criteria. Locally advanced, high-risk prostate cancer. https://www.americanradiumsociety.org. Published 1996. Updated 2016. Accessed May 8, 2023.
  6. American Radium Society (ARS). ACR Appropriateness Criteria. Local-regional recurrence (LRR) and salvage surgery – breast cancer. https://www.americanradiumsociety.org. Published 1996. Updated 2013. Accessed May 8, 2023.

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  1. American Radium Society (ARS). ACR Appropriateness Criteria. Management of recurrent endometrial cancer. https://www.americanradiumsociety.org. Published 2016. Accessed May 8, 2023.
  2. American Radium Society (ARS). ACR Appropriateness Criteria. Management of uterine carcinosarcoma. https://www.americanradiumsociety.org. Published 2020. Accessed May 8, 2023.
  3. American Radium Society (ARS). ACR Appropriateness Criteria. Management of vaginal cancer. https://www.americanradiumsociety.org. Published 2013. Updated February 17, 2021. Accessed May 8, 2023.
  4. American Radium Society (ARS). ACR Appropriateness Criteria. Nasopharyngeal cancer. https://www.americanradiumsociety.org. Published 2015. Accessed May 8, 2023.
  5. American Radium Society (ARS). ACR Appropriateness Criteria. Nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent. https://www.americanradiumsociety.org. Published 1999. Updated 2012. Accessed May 8, 2023.
  6. American Radium Society (ARS). ACR Appropriateness Criteria. Permanent source brachytherapy for prostate cancer. https://www.americanradiumsociety.org. Published 2016. Accessed May 8, 2023.
  7. American Radium Society (ARS). ACR Appropriateness Criteria. Recurrent rectal cancer. https://www.americanradiumsociety.org. Published 1998. Updated 2014. Accessed May 8, 2023.
  8. American Radium Society (ARS). ACR Appropriateness Criteria. Retreatment of recurrent head and neck cancer after prior definitive radiation therapy. https://www.americanradiumsociety.org. Published 2010. Updated 2014. Accessed May 8, 2023.

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  1. American Radium Society (ARS). ACR Appropriateness Criteria. Single brain metastases. https://www.americanradiumsociety.org. Published 1999. Updated 2012. Accessed May 8, 2023.
  2. American Society for Radiation Oncology (ASTRO). Accelerated partial breast irradiation: update of an ASTRO evidence-based consensus statement.
  1. American Society for Radiation Oncology (ASTRO). American Society for Radiation Oncology (ASTRO) brachytherapy model policy. https://www.astro.org. Published January 21, 2012. Updated January 25, 2019. Accessed May 2, 2023.
  2. American Society for Radiation Oncology (ASTRO). A review of safety, quality management and practice guideline for high-dose-rate brachytherapy. https://www.astro.org. Published March 2014. Accessed May 2, 2023.
  3. American Society for Radiation Oncology (ASTRO). Clinically localized prostate cancer: AUA/ASTRO guideline 2022. https://www.astro.org. Published 2022. Accessed May 2, 2023.
  4. American Society for Radiation Oncology (ASTRO). Definitive and postoperative radiation therapy for basal and squamous cell cancers of the skin: an ASTRO clinical practice guideline. https://www.astro.org. Published January/February 2019. Accessed May 2, 2023.
  5. American Society for Radiation Oncology (ASTRO). Palliative thoracic radiotherapy in lung cancer: an American Society for Radiation Oncology evidence-based clinical practice guideline. https://www.astro.org. Published 2011. Updated July 2018. Accessed May 2, 2023.
  6. American Society for Radiation Oncology (ASTRO). Radiation therapy for cervical cancer: an ASTRO clinical practice guideline. https://www.astro.org. Published July/August 2020. Accessed May 2, 2023.
  7. American Society for Radiation Oncology (ASTRO). Radiation therapy for endometrial cancer: an American Society for Radiation Oncology clinical practice guideline. https://www.astro.org. Published February 2023. Accessed May 2, 2023.
  8. American Society for Radiation Oncology (ASTRO). Radiation therapy for glioblastoma: an ASTRO evidence-based clinical practice guideline. https://www.astro.org. Published July 2016. Accessed May 2, 2023.
  9. American Society for Radiation Oncology (ASTRO). The role of postoperative radiation therapy for endometrial cancer: an ASTRO evidence-based guideline. https://www.astro.org. Published June 2014. Accessed May 10, 2023.
  10. American Society for Radiation Oncology (ASTRO). Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO guideline. https://www.astro.org. Published December 2020. Accessed May 2, 2023.
  11. American Society of Breast Surgeons (ASBS). Consensus guideline on accelerated partial breast irradiation. https://www.breastsurgeons.org. Published June 5, 2018. Accessed May 2, 2023.
  12. American Society of Clinical Oncology (ASCO). Brachytherapy for patients with prostate cancer: American Society of Clinical Oncology/Cancer Care Ontario joint guideline update. https://www.asco.org. Published May 20, 2017. Accessed May 3, 2023.
  13. American Society of Clinical Oncology (ASCO). Clinically localized prostate cancer: ASCO clinical practice guideline endorsement of an American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guideline. https://www.asco.org. Published November 10, 2018. Accessed May 3, 2023.
  14. American Society of Clinical Oncology (ASCO). Management and care of women with invasive cervical cancer: American Society of Clinical Oncology resource-stratified clinical practice guideline. https://www.asco.org. Published October 2016. Accessed May 3, 2023.

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Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. American Society of Clinical Oncology (ASCO). Management of salivary gland malignancy: ASCO guideline. https://www.asco.org. Published April 26, 2021. Accessed May 3, 2023.
  2. American Society of Clinical Oncology (ASCO). Postoperative radiation therapy for endometrial cancer: American Society of Clinical Oncology clinical practice guideline endorsement of the American Society for Radiation Oncology evidence-based guideline. https://www.asco.org. Published September 10, 2015. Accessed May 3, 2023.
  3. American Society of Clinical Oncology (ASCO). Radiation therapy for glioblastoma: American Society of Clinical Oncology clinical practice guideline endorsement of the American Society for Radiation Oncology guideline. https://www.asco.org. Published November 28, 2016. Accessed May 3, 2023.
  4. American Urological Association (AUA). Clinically localized prostate cancer: AUA/ASTRO guideline 2022. https://www.auanet.org. Published 2022. Accessed May 9, 2023.
  5. American Urological Association (AUA). Treatment of non-metastatic muscle- invasive bladder cancer: AUA/ASCO/SUO guideline. https://www.auanet.org. Published December 2020. Accessed May 9, 2023.
  6. ClinicalKey. Clinical Overview. Cervical cancer. https://www.clinicalkey.com. Updated April 25, 2023. Accessed April 28, 2023.
  7. ClinicalKey. Clinical Overview. Esophageal cancer.https://www.clinicalkey.com. Updated April 13, 2023. Accessed April 28, 2023.
  8. ClinicalKey. Clinical Overview. Prostate cancer. https://www.clinicalkey.com. Updated August 8, 2022. Accessed April 28, 2023.
  9. ClinicalKey. Guadalupe G. Cirrhosis and its sequelae. In: Goldman L, Schafer A. Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:990-998.e3. https://www.clinicalkey.com. Accessed May 10, 2023.

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  1. ClinicalKey. Kim J, Berry J, Murphree L. Retinoblastoma. In: Sadda S, Sarraf D, Freund KB, et al. Ryan’s Retina. 7th ed. Elsevier; 2023:2517-2556. https://www.clinicalkey.com. Accessed April 28, 2023.
  2. ClinicalKey. Popovtzer A, Eisbruch A. Radiotherapy for head and neck cancer: radiation physics, radiobiology and clinical principles. In: Flint P, Francis H, Haughey B, et al. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Elsevier; 2021:1049-1069.e4. https://www.clinicalkey.com. Accessed April 28, 2023.
  3. ClinicalKey. Usuki K, Milan M, David M, Okunieff P. Metastatic disease: bone, spinal cord, brain, liver and lung. In: Tepper J, Foote R, Michalski J. Gunderson & Tepper’s Clinical Radiation Oncology. 5th ed. Elsevier; 2021:461-477.e6. https://www.clinicalkey.com. Accessed April 28, 2023.
  4. Congress of Neurological Surgeons (CNS). Congress of Neurological Surgeons systematic review and evidence-based guideline on the role of emerging and investigational therapies for the treatment of adults with metastatic brain tumors. https://www.cns.org. Published 2019. Accessed May 2, 2023.
  5. ECRI Institute. Clinical Evidence Assessment. Axxent electronic brachytherapy system (iCAD, Inc.) for gynecologic cancer. https://ecri.org. Published June 3, 2019. Updated May 21, 2021. Accessed April 25, 2023.
  6. ECRI Institute. Clinical Evidence Assessment. Axxent electronic brachytherapy system (iCAD, Inc.) for nonmelanoma skin cancer. https://ecri.org. Published June 1, 2021. Accessed April 25, 2023.
  7. ECRI Institute. Clinical Evidence Assessment.
  1. ECRI Institute. Clinical Evidence Assessment. Barrigel hyaluronic spacer (Palette Life Sciences) for reducing exposure during prostate cancer therapy. https://ecri.org. Published September 7, 2022. Accessed April 25, 2023.
  2. ECRI Institute. Clinical Evidence Assessment. Electronic brachytherapy for nonmelanoma skin cancer. https://ecri.org. Published April 3, 2023. Accessed April 25, 2023.

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  1. ECRI Institute. Clinical Evidence Assessment. GammaTile therapy (GT Medical Technologies, Inc.) for recurrent brain cancer. https://ecri.org. Published November 29, 2021. Accessed April 25, 2023.
  2. ECRI Institute. Clinical Evidence Assessment. TheraSphere (Boston Scientific Corp.) for treating hepatocellular carcinoma. https://ecri.org. Published July 2, 2015. Updated August 27, 2021. Accessed April 25, 2023.
  3. ECRI Institute. Clinical Evidence Assessment. Transarterial radioembolization for treating metastases to the liver. https://ecri.org. Published April 26, 2021. Accessed April 25, 2023.
  4. Hayes, Inc. Health Technology Assessment. Absorbable perirectal spacer (SpaceOAR system; Boston Scientific) during radiation therapy for prostate cancer. https://evidence.hayesinc.com. Published September 27, 2021. Updated November 4, 2022. Accessed April 26, 2023.
  5. Hayes, Inc. Health Technology Assessment. Radioactive Yttrium-90 microspheres for the treatment of primary unresectable liver cancer for downstaging or as a bridge to transplantation or surgery. https://evidence.hayesinc.com. Published September 11, 2019. Updated September 29, 2022. Accessed April 25, 2023.
  6. Hayes, Inc. Health Technology Brief (ARCHIVED). Interstitial brachytherapy for the treatment of nonmelanoma skin cancer. https://evidence.hayesinc.com. Published September 29, 2016. Updated September 19, 2018. Accessed April 26, 2023.
  7. Hayes, Inc. Health Technology Brief (ARCHIVED). Surface brachytherapy for the treatment of nonmelanoma skin cancer. https://evidence.hayesinc.com. Published September 29, 2016. Updated September 20, 2018. Accessed April 26, 2023.
  8. Hayes, Inc. Health Technology Brief (ARCHIVED). Transarterial hepatic yttrium-90 radioembolization for treatment of unresectable intrahepatic cholangiocarcinoma. https://evidence.hayesinc.com. Published December 24, 2012. Updated December 22, 2014. Accessed April 25, 2023.

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  1. Hayes, Inc. Health Technology Brief (ARCHIVED). Xoft Axxent eBx electronic brachytherapy (iCAD Inc.) for early-stage breast cancer. https://evidence.hayesinc.com. Published January 24, 2014. Updated January 24, 2014. Accessed April 26, 2023.
  2. Hayes, Inc. Medical Technology Directory. Comparative effectiveness review of radiation Yttrium-90 microspheres for treatment of primary unresectable liver cancer. https://evidence.hayesinc.com. Published June 11, 2019. Updated June 8, 2022. Accessed April 25, 2023.
  3. Hayes, Inc. Medical Technology Directory (ARCHIVED). Accelerated partial breast irradiation for breast cancer using brachytherapy. https://evidence.hayesinc.com. Published December 22, 2016. Updated April 30, 2021. Accessed April 26, 2023.
  1. Hayes, Inc. Medical Technology Directory (ARCHIVED). Brachytherapy for lung cancer. https://evidence.hayesinc.com. Published May 8, 2000. Updated December 28, 2005. Accessed April 26, 2023.
  2. Hayes, Inc. Medical Technology Directory (ARCHIVED). Brachytherapy for malignant gliomas. https://evidence.hayesinc.com. Published December 22, 2006. Updated February 17, 2010. Accessed April 26, 2023.
  3. Hayes, Inc. Medical Technology Directory (ARCHIVED). Intracoronary radiation therapy. https://evidence.hayesinc.com. Published November 22, 2000. Updated July 11, 2006. Accessed April 26, 2023.
  4. Hayes, Inc. Medical Technology Directory (ARCHIVED). Radioactive Yttrium-90 microspheres for treatment of secondary liver cancer. https://evidence.hayesinc.com. Published March 31, 2015. Updated April 29, 2019. Accessed April 26, 2023.

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  1. Hayes, Inc. Medical Technology Directory (ARCHIVED). Transperineal ultrasound-guided brachytherapy for early-stage prostate cancer. https://evidence.hayesinc.com. Published September 6, 2002. Updated September 3, 2007. Accessed April 26, 2023.
  2. MCG Health. Brachytherapy. 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  3. MCG Health. Brachytherapy (cardiovascular). 26th edition. https://www.mcg.com. Accessed April 6, 2023.
  4. Merck Manual: Professional Version. Endometrial cancer. https://www.merckmanuals.com. Updated September 2022. Accessed April 28, 2023.
  5. Merck Manual: Professional Version. Radiation therapy for cancer. https://www.merckmanuals.com. Updated September 2022. Accessed April 28, 2023.
  6. National Cancer Institute (NCI). Adult central nervous system tumors treatment (PDQ) - health professional version. https://www.cancer.gov. Updated January 20, 2023. Accessed May 3, 2023.
  7. National Cancer Institute (NCI). Adult soft tissue sarcoma treatment (PDQ) - health professional version. https://www.cancer.gov. Updated March 3, 2023. Accessed May 3, 2023.
  8. National Cancer Institute (NCI). Bile duct cancer (cholangiocarcinoma) treatment (PDQ) - health professional version. https://www.cancer.gov. Updated January 20, 2023. Accessed May 3, 2023.
  9. National Cancer Institute (NCI). Cervical cancer treatment (PDQ) - health professional version. https://www.cancer.gov. Updated January 20, 2023. Accessed May 3, 2023.

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  1. National Cancer Institute (NCI). Childhood brainstem glioma treatment (PDQ) - health professional version. https://www.cancer.gov. Updated February 23, 2022. Accessed May 3, 2023.
  2. National Cancer Institute (NCI). Childhood liver cancer treatment (PDQ) - health professional version. https://www.cancer.gov. Updated April 7, 2023. Accessed May 3, 2023.
  3. National Cancer Institute (NCI). Childhood rhabdomyosarcoma treatment (PDQ) - health professional version. https://www.cancer.gov. Updated January 10, 2023. Accessed May 3, 2023.
  4. National Cancer Institute (NCI). Childhood soft tissue sarcoma treatment (PDQ) - health professional version.
  1. National Cancer Institute (NCI). Endometrial cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated March 13, 2023. Accessed May 3, 2023.
  2. National Cancer Institute (NCI). Esophageal cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated March 30, 2023. Accessed May 3, 2023.
  3. National Cancer Institute (NCI). Intraocular (uveal) melanoma treatment (PDQ) – health professional version. https://www.cancer.gov. Updated October 14, 2022. Accessed May 3, 2023.
  4. National Cancer Institute (NCI). Lip and oral cavity cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated October 15, 2021. Accessed May 3, 2023.
  5. National Cancer Institute (NCI). Non-small cell lung cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated February 17, 2023. Accessed May 3, 2023.

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  1. National Cancer Institute (NCI). Penile cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated February 10, 2023. Accessed May 3, 2023.
  2. National Cancer Institute (NCI). Prostate cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated February 13, 2023. Accessed May 3, 2023.
  3. National Cancer Institute (NCI). Retinoblastoma treatment (PDQ) – health professional version. https://www.cancer.gov. Updated April 11, 2023. Accessed May 3, 2023.
  4. National Cancer Institute (NCI). Small cell lung cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated March 2, 2023. Accessed May 3, 2023.
  5. National Cancer Institute (NCI). Urethral cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated August 19, 2022. Accessed May 3, 2023.
  6. National Cancer Institute (NCI). Vaginal cancer treatment (PDQ) – health professional version. https://www.cancer.gov. Updated March 13, 2023. Accessed May 3, 2023.

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  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Cervical cancer. https://www.nccn.org. Updated April 28, 2023. Accessed May 4, 2023.
  2. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Cutaneous melanoma. https://www.nccn.org. Updated March 10, 2023. Accessed May 8, 2023.
  3. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Esophageal and esophagogastric junction cancer. https://www.nccn.org. Updated March 10, 2023. Accessed May 4, 2023.
  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Head and neck cancers cancer. https://www.nccn.org. Updated December 20, 2022. Accessed May 4, 2023.
  2. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Hepatocellular carcinoma. https://www.nccn.org. Updated March 10, 2023. Accessed May 4, 2023.
  3. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Malignant pleural mesothelioma. https://www.nccn.org. Updated December 15, 2022. Accessed May 8, 2023.
  4. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Neuroendocrine and adrenal tumors. https://www.nccn.org. Updated December 21, 2022. Accessed May 8, 2023.
  5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Non-small cell lung cancer. https://www.nccn.org. Updated April 13, 2023. Accessed May 8, 2023.
  6. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Penile cancer. https://www.nccn.org. Updated December 1, 2022. Accessed May 8, 2023.

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  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Prostate cancer. https://www.nccn.org. Updated September 16, 2022. Accessed May 8, 2023.
  2. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Rectal cancer. https://www.nccn.org. Updated April 25, 2023. Accessed May 8, 2023.
  3. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Soft tissue sarcoma. https://www.nccn.org. Updated April 25, 2023. Accessed May 8, 2023.
  4. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Squamous cell skin cancer. https://www.nccn.org. Updated March 10, 2023. Accessed May 8, 2023.
  5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Uterine neoplasms. https://www.nccn.org. Updated April 28, 2023. Accessed May 8, 2023.
  6. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Uveal melanoma. https://www.nccn.org. Updated May 4, 2023. Accessed May 8, 2023.
  7. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Vulvar cancer (squamous cell carcinoma). https://www.nccn.org. Updated December 22, 2022. Accessed May 8, 2023.

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  1. UpToDate, Inc. Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer. https://www.uptodate.com. Updated March 31, 2023. Accessed April 26, 2023.
  2. UpToDate, Inc. Adjuvant treatment of high-risk endometrial cancers. https://www.uptodate.com. Updated March 2023. Accessed April 27, 2023.

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  1. UpToDate, Inc. Brachytherapy for low-risk or favorable intermediate-risk, clinically localized prostate cancer. https://www.uptodate.com. Updated March 2023. Accessed April 27, 2023.
  2. UpToDate, Inc. Cancer of the nasal vestibule. https://www.uptodate.com. Updated March 31, 2023. Accessed April 27, 2023.
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  2. UpToDate, Inc. Clinical presentation, diagnostic evaluation and management of malignant central airway obstruction in adults. https://www.uptodate.com. Updated March 2023. Accessed April 27, 2023.
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Review Date: 05/25/2023
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Review Date: 05/25/2023
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Appendix A – Residual tumor (R) classification
RxThe presence of residual tumor cannot be assessed
R0No residual tumor
R1Microscopic residual tumor
R2Macroscopic residual tumor
Appendix B – TNM Staging System for Prostate Cancer

Primary tumor (T) Clinical T (cT)

Clinical T (cT)
T categoryT criteria
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
T1Clinically inapparent tumor that is not palpable
T1aTumor incidental histologic finding in 5% or less of tissue resected
T1bTumor incidental histologic finding in more than 5% of tissue resected
T1cTumor identified by needle biopsy found in one or both sides, but not palpable
T2Tumor is palpable and confined within prostate
T2aTumor involves one-half of one side or less
T2bTumor involves more than one-half of one side but not both sides
T2cTumor involves both sides
T3Extraprostatic tumor that is not fixed or does not invade adjacent structures
T3aExtraprostatic extension (unilateral or bilateral)
T3bTumor invades seminal vesicle(s)
T4Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall

Pathological T (pT)

T categoryT criteria
T2Organ confined

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T3aExtraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck
T3bTumor invades seminal vesicle(s)
T4Tumor is fixed or invades adjacent structures other than seminal vesicles such as external sphincter, rectum, bladder, levator muscles, and/or pelvic wall
Note:There is no pathological T1 classification.
Appendix C – Child-Turcotte-Pugh Classification
Points Ascribed
Parameters123
AscitesGrade 1-2 (or easy to treat)Grade 3-4 (or refractory)
Hepatic EncephalopathyGrade 1-2 (or induced by a precipitant)Grade 3-4 (or spontaneous)
Bilirubin (mg/dL)Less than 22-3Greater than 3
Albumin (g/dL)Greater than 3.52.8-3.5Less than 2.8
Prothrombin time (seconds greater than control) or INRLess than 1.71.7-2.3Greater than 2.3

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Appendix D – Tumor staging for penile cancer (TNM staging)

T categoryT criteria
TXPrimary tumor cannot be assessed
TONo evidence of primary tumor
TisCarcinoma in situ (penile intraepithelial neoplasia [PeIN])
TaNoninvasive localized squamous cell carcinoma
T1Glans: Tumor invades lamina propria. Foreskin: Tumor invades dermis, lamina propria, or dartos fascia. Shaft: Tumor invades connective tissue between epidermis and corpora regardless of location. All sites with or without lymphovascular invasion or perineural invasion and is or is not high grade.
T1aTumor is without lymphovascular invasion or perineural invasion and is not high grade (ie, grade 3 or sarcomatoid)
T1bTumor exhibits lymphovascular invasion and/or perinerual invasion or is high grade (ie, grade 3 or sarcomatoid)
T2Tumor invades into corpus spongiosum (either glans or ventral shaft) with or without urethral invasion
T3Tumor invades into corpora cavernosum (including tunica albuginea) with or without urethral invasion
T4Tumor invades into adjacent structures (ie, scrotum, prostate, pubic bone)

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Appendix E – Eastern Cooperative Oncology Group (ECOG) performance status

Performance statusDefinition
0Fully active; no performance restrictions.
1Strenuous physical activity restricted; fully ambulatory and able to carry out light work.
2Capable of all self-care but unable to carry out any work activities. Up and about >50% of waking hours.
3Capable of only limited self-care; confined to bed or chair >50% of waking hours.
4Completely disabled; cannot carry out any self-care; totally confined to bed or chair.