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Appropriateness Criteria

Variant 1: Adult female or male or transfeminine (male-to-female) or transmasculine (female-to-male). Physiologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 1 0 0 0 1 0 0
References Study Quality
28 () 3
29 (8167884) 4
Ductography Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 1 0 0 0 1 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 2 1 0 0 1 1 0 0
References Study Quality
28 () 3
29 (8167884) 4
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 0 1
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 0 0 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 0 0 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 0 0 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
FDG-PET breast dedicated Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
References Study Quality
28 () 3
29 (8167884) 4
6 (6277258) 4
7 (15467662) 4
Variant 2: Adult male or female 40 years of age or older. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 0 1 2 10
References Study Quality
31 (20657228) 4
30 (17646365) 3
38 (10394864) 3
3 (21116634) 3
9 (26102400) 3
23 (12648684) 3
39 (20079481) 3
12 (14634510) 3
17 (12620904) 3
37 (10644102) 3
24 (-3099428) 4
40 (30392600) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 1 0 0 3 9
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 1 0 0 0 0 0 0 3 10
References Study Quality
31 (20657228) 4
30 (17646365) 3
3 (21116634) 3
9 (26102400) 3
28 () 3
23 (12648684) 3
16 (16164940) 3
1 (1947092) 4
2 (15908532) 4
34 (18566169) 4
33 (15797293) 4
32 (10887256) 3
11 (-3099474) 4
Ductography Usually not appropriate Strong ☢☢ 0.1-1mSv 1 1 8 2 2 0 1 0 1 0 0
References Study Quality
44 (17896158) 3
42 (9587119) 4
43 (-3101778) 4
23 (12648684) 3
39 (20079481) 3
16 (16164940) 3
1 (1947092) 4
41 (16848840) 2
45 (11089460) 3
Image-guided core biopsy breast Usually not appropriate Strong Varies Varies 1 1 11 0 0 1 1 0 0 1 0
References Study Quality
54 (17924407) 3
44 (17896158) 3
30 (17646365) 3
52 (26249144) 3
58 (16632727) 3
59 (17090707) 3
60 (20868897) 4
13 (9780989) 3
9 (26102400) 3
23 (12648684) 3
39 (20079481) 3
57 (19565246) 3
61 (26243343) 3
17 (12620904) 3
55 (15756351) 1
56 (10789774) 2
24 (-3099428) 4
40 (30392600) 4
Image-guided fine needle aspiration breast Usually not appropriate Limited Varies Varies 1 1 11 0 0 1 1 0 0 1 0
References Study Quality
54 (17924407) 3
55 (15756351) 1
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 2 1 0 1 1 0 0 0
References Study Quality
48 (25433415) 2
51 (25123174) 3
44 (17896158) 3
52 (26249144) 3
3 (21116634) 3
46 (-3099493) 4
47 (-3099494) 4
49 (25685810) 2
12 (14634510) 3
32 (10887256) 3
50 (18705577) 4
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 0 0 0 0 0
References Study Quality
48 (25433415) 2
51 (25123174) 3
44 (17896158) 3
52 (26249144) 3
3 (21116634) 3
46 (-3099493) 4
47 (-3099494) 4
49 (25685810) 2
12 (14634510) 3
32 (10887256) 3
50 (18705577) 4
FDG-PET breast dedicated Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 0 0 0 0 0 0 1
References Study Quality
41 (16848840) 2
53 (17659240) 3
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 3: Adult male or female 30 to 39 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 3 9
References Study Quality
64 (17690501) 4
63 (23096195) 3
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 3 2 8
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 1 10
References Study Quality
64 (17690501) 4
65 (23182522) 3
19 (19735390) 4
63 (23096195) 3
40 (30392600) 4
Ductography Usually not appropriate Strong ☢☢ 0.1-1mSv 2 2 7 3 3 0 1 0 0 0 0
References Study Quality
44 (17896158) 3
42 (9587119) 4
43 (-3101778) 4
23 (12648684) 3
39 (20079481) 3
16 (16164940) 3
1 (1947092) 4
41 (16848840) 2
45 (11089460) 3
Image-guided fine needle aspiration breast Usually not appropriate Limited Varies Varies 1 1 10 2 1 0 0 0 0 0 1
References Study Quality
54 (17924407) 3
55 (15756351) 1
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 8 3 2 0 0 1 0 0 0
References Study Quality
48 (25433415) 2
51 (25123174) 3
44 (17896158) 3
52 (26249144) 3
3 (21116634) 3
46 (-3099493) 4
47 (-3099494) 4
49 (25685810) 2
12 (14634510) 3
32 (10887256) 3
50 (18705577) 4
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 0 0 0 0 0
References Study Quality
48 (25433415) 2
51 (25123174) 3
44 (17896158) 3
52 (26249144) 3
3 (21116634) 3
46 (-3099493) 4
47 (-3099494) 4
49 (25685810) 2
12 (14634510) 3
32 (10887256) 3
50 (18705577) 4
FDG-PET breast dedicated Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
References Study Quality
41 (16848840) 2
53 (17659240) 3
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 1 1 0 0 0 0 0 0
Variant 4: Adult male younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 3 9
References Study Quality
3 (21116634) 3
40 (30392600) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 5 8
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 1 5 7
References Study Quality
1 (1947092) 4
2 (15908532) 4
40 (30392600) 4
Ductography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 2 1 1 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 0 0 0 1 0 0 1
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 0 0 1 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 1 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 5: Adult female younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 2 0 11
References Study Quality
69 (26274736) 3
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 2 5 2 0 5 0 0 0 0
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Ductography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 1 1 1 0 0 0 0 0
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 2 5 2 0 5 0 0 0 0
References Study Quality
67 (2267387) 3
68 (3763885) 4
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 0 1
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 13 0 0 0 0 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 0 0 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
Variant 6: Adult transfeminine (male-to-female) patient 30 years of age or older. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 1 0 3 9
References Study Quality
3 (21116634) 3
40 (30392600) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 1 0 1 0 4 1 7
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 1 0 1 0 3 1 8
References Study Quality
1 (1947092) 4
2 (15908532) 4
40 (30392600) 4
Ductography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 9 3 1 0 1 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 11 1 1 0 0 0 0 0 1
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 0 1
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 1 0 0 1 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
Variant 7: Adult transfeminine (male-to-female) patient younger than 30 years of age. Pathologic nipple discharge. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 1 0 2 10
References Study Quality
3 (21116634) 3
40 (30392600) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 4 7
References Study Quality
30 (17646365) 3
35 (26133221) 2
36 (33411577) 3
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 1 2 4 7
References Study Quality
1 (1947092) 4
2 (15908532) 4
40 (30392600) 4
Ductography Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 2 1 0 0 0 0 0 0
Image-guided core biopsy breast Usually not appropriate Expert Consensus Varies Varies 1 1 11 2 0 0 0 0 0 1 0
Image-guided fine needle aspiration breast Usually not appropriate Expert Consensus Varies Varies 1 1 12 1 0 0 0 0 0 1 0
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 1 0 0 0
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 0 0 0 0 0 0
FDG-PET breast dedicated Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 1 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.