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Pretreatment Evaluation and Follow-up of Invasive Cancer of the Cervix
Variant: 1
Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI pelvis without and with IV contrast | Usually Appropriate | O |
| FDG-PET/MRI skull base to mid-thigh | Usually Appropriate | ☢☢☢ |
| US pelvis transvaginal | May Be Appropriate | O |
| MRI pelvis without IV contrast | May Be Appropriate | O |
| CT pelvis with IV contrast | May Be Appropriate | ☢☢☢ |
| FDG-PET/CT skull base to mid-thigh | May Be Appropriate | ☢☢☢☢ |
| US pelvis transabdominal | Usually Not Appropriate | O |
| CT pelvis without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 2
Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI pelvis without and with IV contrast | Usually Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest with IV contrast | Usually Appropriate | ☢☢☢ |
| FDG-PET/MRI skull base to mid-thigh | Usually Appropriate | ☢☢☢ |
| FDG-PET/CT skull base to mid-thigh | Usually Appropriate | ☢☢☢☢ |
| MRI abdomen without and with IV contrast | May Be Appropriate | O |
| MRI abdomen without IV contrast | May Be Appropriate | O |
| MRI pelvis without IV contrast | May Be Appropriate | O |
| CT chest without IV contrast | May Be Appropriate | ☢☢☢ |
| US abdomen | Usually Not Appropriate | O |
| US pelvis transabdominal | Usually Not Appropriate | O |
| US pelvis transvaginal | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 3
Initial treatment response assessment of cervical cancer after chemoradiation.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI pelvis without and with IV contrast | Usually Appropriate | O |
| MRI pelvis without IV contrast | Usually Appropriate | O |
| FDG-PET/MRI skull base to mid-thigh | Usually Appropriate | ☢☢☢ |
| FDG-PET/CT skull base to mid-thigh | Usually Appropriate | ☢☢☢☢ |
| MRI abdomen without and with IV contrast | May Be Appropriate | O |
| MRI abdomen without IV contrast | May Be Appropriate | O |
| CT abdomen and pelvis with IV contrast | May Be Appropriate | ☢☢☢ |
| CT chest with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| US abdomen | Usually Not Appropriate | O |
| US pelvis transabdominal | Usually Not Appropriate | O |
| US pelvis transvaginal | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| CT abdomen and pelvis without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 4
Surveillance of treated cervical cancer in asymptomatic patients.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI pelvis without and with IV contrast | Usually Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest with IV contrast | Usually Appropriate | ☢☢☢ |
| FDG-PET/MRI skull base to mid-thigh | Usually Appropriate | ☢☢☢ |
| FDG-PET/CT skull base to mid-thigh | Usually Appropriate | ☢☢☢☢ |
| MRI abdomen without and with IV contrast | May Be Appropriate (Disagreement) | O |
| MRI abdomen without IV contrast | May Be Appropriate (Disagreement) | O |
| MRI pelvis without IV contrast | May Be Appropriate | O |
| CT abdomen and pelvis without IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| CT chest without IV contrast | May Be Appropriate | ☢☢☢ |
| US abdomen | Usually Not Appropriate | O |
| US pelvis transabdominal | Usually Not Appropriate | O |
| US pelvis transvaginal | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
Variant: 5
Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI abdomen without and with IV contrast | Usually Appropriate | O |
| MRI pelvis without and with IV contrast | Usually Appropriate | O |
| CT abdomen and pelvis with IV contrast | Usually Appropriate | ☢☢☢ |
| CT chest with IV contrast | Usually Appropriate | ☢☢☢ |
| FDG-PET/MRI skull base to mid-thigh | Usually Appropriate | ☢☢☢ |
| FDG-PET/CT skull base to mid-thigh | Usually Appropriate | ☢☢☢☢ |
| MRI abdomen without IV contrast | May Be Appropriate | O |
| MRI pelvis without IV contrast | May Be Appropriate | O |
| CT abdomen and pelvis without IV contrast | May Be Appropriate (Disagreement) | ☢☢☢ |
| CT chest without IV contrast | May Be Appropriate | ☢☢☢ |
| CT abdomen and pelvis without and with IV contrast | May Be Appropriate (Disagreement) | ☢☢☢☢ |
| US abdomen | Usually Not Appropriate | O |
| US pelvis transabdominal | Usually Not Appropriate | O |
| US pelvis transvaginal | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
Panel Members
Summary of Literature Review
Introduction/Background
Discussion of Procedures by Variant
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
A. CT Pelvis With IV Contrast
A. CT Pelvis With IV Contrast
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
B. CT Pelvis Without and With IV Contrast
B. CT Pelvis Without and With IV Contrast
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
C. CT Pelvis Without IV Contrast
C. CT Pelvis Without IV Contrast
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
D. FDG-PET/CT Skull Base to Mid-Thigh
D. FDG-PET/CT Skull Base to Mid-Thigh
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
E. FDG-PET/MRI Skull Base to Mid-Thigh
E. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
F. MRI Pelvis Without and With IV Contrast
F. MRI Pelvis Without and With IV Contrast
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
G. MRI Pelvis Without IV Contrast
G. MRI Pelvis Without IV Contrast
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
H. US Pelvis Transabdominal
H. US Pelvis Transabdominal
Variant 1: Initial local staging of pretreatment cervical cancer; assessment of local tumor extension (T staging) for any clinically visible lesion.
I. US Pelvis Transvaginal
I. US Pelvis Transvaginal
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
D. CT Chest With IV Contrast
D. CT Chest With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
E. CT Chest Without and With IV Contrast
E. CT Chest Without and With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
F. CT Chest Without IV Contrast
F. CT Chest Without IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
G. FDG-PET/CT Skull Base to Mid-Thigh
G. FDG-PET/CT Skull Base to Mid-Thigh
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
H. FDG-PET/MRI Skull Base to Mid-Thigh
H. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
I. MRI Abdomen Without and With IV Contrast
I. MRI Abdomen Without and With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
J. MRI Abdomen Without IV Contrast
J. MRI Abdomen Without IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
K. MRI Pelvis Without and With IV Contrast
K. MRI Pelvis Without and With IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
L. MRI Pelvis Without IV Contrast
L. MRI Pelvis Without IV Contrast
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
M. Radiography Chest
M. Radiography Chest
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
N. US Abdomen
N. US Abdomen
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
O. US Pelvis Transabdominal
O. US Pelvis Transabdominal
Variant 2: Initial systemic staging of pretreatment cervical cancer; assessment of lymph node and distant metastases (N/M staging).
P. US Pelvis Transvaginal
P. US Pelvis Transvaginal
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
D. CT Chest With IV Contrast
D. CT Chest With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
E. CT Chest Without and With IV Contrast
E. CT Chest Without and With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
F. CT Chest Without IV Contrast
F. CT Chest Without IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
G. FDG-PET/CT Skull Base to Mid-Thigh
G. FDG-PET/CT Skull Base to Mid-Thigh
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
H. FDG-PET/MRI Skull Base to Mid-Thigh
H. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
I. MRI Abdomen Without and With IV Contrast
I. MRI Abdomen Without and With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
J. MRI Abdomen Without IV Contrast
J. MRI Abdomen Without IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
K. MRI Pelvis Without and With IV Contrast
K. MRI Pelvis Without and With IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
L. MRI Pelvis Without IV Contrast
L. MRI Pelvis Without IV Contrast
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
M. Radiography Chest
M. Radiography Chest
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
N. US Abdomen
N. US Abdomen
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
O. US Pelvis Transabdominal
O. US Pelvis Transabdominal
Variant 3: Initial treatment response assessment of cervical cancer after chemoradiation.
P. US Pelvis Transvaginal
P. US Pelvis Transvaginal
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
D. CT Chest With IV Contrast
D. CT Chest With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
E. CT Chest Without and With IV Contrast
E. CT Chest Without and With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
F. CT Chest Without IV Contrast
F. CT Chest Without IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
G. FDG-PET/CT Skull Base to Mid-Thigh
G. FDG-PET/CT Skull Base to Mid-Thigh
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
H. FDG-PET/MRI Skull Base to Mid-Thigh
H. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
I. MRI Abdomen Without and With IV Contrast
I. MRI Abdomen Without and With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
J. MRI Abdomen Without IV Contrast
J. MRI Abdomen Without IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
K. MRI Pelvis Without and With IV Contrast
K. MRI Pelvis Without and With IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
L. MRI Pelvis Without IV Contrast
L. MRI Pelvis Without IV Contrast
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
M. Radiography Chest
M. Radiography Chest
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
N. US Abdomen
N. US Abdomen
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
O. US Pelvis Transabdominal
O. US Pelvis Transabdominal
Variant 4: Surveillance of treated cervical cancer in asymptomatic patients.
P. US Pelvis Transvaginal
P. US Pelvis Transvaginal
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
A. CT Abdomen and Pelvis With IV Contrast
A. CT Abdomen and Pelvis With IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
B. CT Abdomen and Pelvis Without and With IV Contrast
B. CT Abdomen and Pelvis Without and With IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
C. CT Abdomen and Pelvis Without IV Contrast
C. CT Abdomen and Pelvis Without IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
D. CT Chest With IV Contrast
D. CT Chest With IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
E. CT Chest Without and With IV Contrast
E. CT Chest Without and With IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
F. CT Chest Without IV Contrast
F. CT Chest Without IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
G. FDG-PET/CT Skull Base to Mid-Thigh
G. FDG-PET/CT Skull Base to Mid-Thigh
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
H. FDG-PET/MRI Skull Base to Mid-Thigh
H. FDG-PET/MRI Skull Base to Mid-Thigh
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
I. MRI Abdomen Without and With IV Contrast
I. MRI Abdomen Without and With IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
J. MRI Abdomen Without IV Contrast
J. MRI Abdomen Without IV Contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
K. MRI Pelvis Without and With IV contrast
K. MRI Pelvis Without and With IV contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
L. MRI Pelvis Without IV contrast
L. MRI Pelvis Without IV contrast
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
M. Radiography Chest
M. Radiography Chest
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
N. US Abdomen
N. US Abdomen
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
O. US Pelvis Transabdominal
O. US Pelvis Transabdominal
Variant 5: Evaluation of known or suspected cervical cancer local recurrence or distant metastatic disease. Follow-up imaging.
P. US Pelvis Transvaginal
P. US Pelvis Transvaginal
Summary of Recommendations
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.
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.” |
||
References
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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.