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Breast Imaging During Lactation

Variant: 1   Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
Procedure Appropriateness Category Relative Radiation Level
Digital breast tomosynthesis screening Usually Appropriate ☢☢
Mammography screening Usually Appropriate ☢☢
MRI breast without and with IV contrast May Be Appropriate O
MRI breast without and with IV contrast abbreviated May Be Appropriate O
US breast Usually Not Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
MRI breast without IV contrast abbreviated Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 2   Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
Procedure Appropriateness Category Relative Radiation Level
MRI breast without and with IV contrast May Be Appropriate O
US breast Usually Not Appropriate O
Digital breast tomosynthesis screening Usually Not Appropriate ☢☢
Mammography screening Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast abbreviated Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
MRI breast without IV contrast abbreviated Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 3   Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
Procedure Appropriateness Category Relative Radiation Level
Digital breast tomosynthesis screening Usually Appropriate ☢☢
Mammography screening Usually Appropriate ☢☢
MRI breast without and with IV contrast Usually Appropriate O
MRI breast without and with IV contrast abbreviated Usually Appropriate O
US breast Usually Not Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
MRI breast without IV contrast abbreviated Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 4   Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢
Mammography diagnostic Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 5   Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 6   Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Not Appropriate ☢☢
Mammography diagnostic Usually Not Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 7   Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 8   Lactating female. Newly diagnosed breast cancer. Locoregional staging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic Usually Appropriate ☢☢
Mammography diagnostic Usually Appropriate ☢☢
MRI breast without and with IV contrast Usually Appropriate O
US axilla May Be Appropriate O
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Variant: 9   Lactating female. Suspected breast infection or abscess. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US breast Usually Appropriate O
Digital breast tomosynthesis diagnostic May Be Appropriate ☢☢
Mammography diagnostic May Be Appropriate ☢☢
Mammography with IV contrast Usually Not Appropriate ☢☢
MRI breast without and with IV contrast Usually Not Appropriate O
MRI breast without IV contrast Usually Not Appropriate O
Sestamibi MBI Usually Not Appropriate ☢☢☢

Panel Members
Basak E. Dogan, MDa, Lonie R. Salkowski, MD, PhD, MSb, Susan P. Weinstein, MDc, Stacey Bartell, MDd, Sona Chikarmane , MDe, Elizabeth H. Dibble, MDf, Katerina Dodelzon, MDg, Shari Goldfarb, MDh, Claudia Kasales, MD, MHAi, Jean M. Kunjummen, DOj, Cherie M. Kuzmiak, DOk, Santo Maimone, MDl, Mitva Patel, MDm, Lisa V. Paulis, MDn, Kahyun Yoon-Flannery, DO, MPHo, Alana A. Lewin, MDp
Summary of Literature Review
Introduction/Background
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (ie, only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (ie, more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
A. Digital breast tomosynthesis screening
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
B. Mammography screening
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
C. Mammography with IV contrast
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
D. MRI breast without and with IV contrast
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
E. MRI breast without and with IV contrast abbreviated
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
F. MRI breast without IV contrast
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
G. MRI breast without IV contrast abbreviated
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
H. Sestamibi MBI
Variant 1:Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
I. US breast
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
A. Digital breast tomosynthesis screening
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
B. Mammography screening
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
C. Mammography with IV contrast
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
D. MRI breast without and with IV contrast
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
E. MRI breast without and with IV contrast abbreviated
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
F. MRI breast without IV contrast
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
G. MRI breast without IV contrast abbreviated
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
H. Sestamibi MBI
Variant 2:Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
I. US breast
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
A. Digital breast tomosynthesis screening
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
B. Mammography screening
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
C. Mammography with IV contrast
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
D. MRI breast without and with IV contrast
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
E. MRI breast without and with IV contrast abbreviated
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
F. MRI breast without IV contrast
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
G. MRI breast without IV contrast abbreviated
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
H. Sestamibi MBI
Variant 3:Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
I. US breast
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
A. Digital breast tomosynthesis diagnostic
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
B. Mammography diagnostic
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
C. Mammography with IV contrast
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
D. MRI breast without and with IV contrast
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
E. MRI breast without IV contrast
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
F. Sestamibi MBI
Variant 4:Lactating female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.
G. US breast
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
A. Digital breast tomosynthesis diagnostic
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
B. Mammography diagnostic
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
C. Mammography with IV contrast
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
D. MRI breast without and with IV contrast
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
E. MRI breast without IV contrast
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
F. Sestamibi MBI
Variant 5:Lactating female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.
G. US breast
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
A. Digital breast tomosynthesis diagnostic
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
B. Mammography diagnostic
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
C. Mammography with IV contrast
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
D. MRI breast without and with IV contrast
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
E. MRI breast without IV contrast
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
F. Sestamibi MBI
Variant 6:Lactating female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.
G. US breast
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
A. Digital breast tomosynthesis diagnostic
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
B. Mammography diagnostic
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
C. Mammography with IV contrast
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
D. MRI breast without and with IV contrast
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
E. MRI breast without IV contrast
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
F. Sestamibi MBI
Variant 7:Lactating female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.
G. US breast
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
A. Digital breast tomosynthesis diagnostic
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
B. Mammography diagnostic
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
C. Mammography with IV contrast
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
D. MRI breast without and with IV contrast
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
E. MRI breast without IV contrast
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
F. Sestamibi MBI
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
G. US axilla
Variant 8:Lactating female. Newly diagnosed breast cancer. Locoregional staging.
H. US breast
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
A. Digital breast tomosynthesis diagnostic
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
B. Mammography diagnostic
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
C. Mammography with IV contrast
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
D. MRI breast without and with IV contrast
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
E. MRI breast without IV contrast
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
F. Sestamibi MBI
Variant 9:Lactating female. Suspected breast infection or abscess. Initial imaging.
G. US breast
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.