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Appropriateness Criteria

Variant 1: Female. New palpable, unilateral, axillary lump. Initial imaging of the axilla.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 0 14
References Study Quality
37 (29083988) 3
36 (26626499) 4
Digital breast tomosynthesis diagnostic May be appropriate Strong ☢☢ 0.1-1mSv 4 4 1 1 4 3 4 2 0 1 0
References Study Quality
28 (25058084) 3
24 (23345348) 2
25 (23620367) 2
26 (23255766) 3
27 (23844366) 3
29 (28523569) 3
Mammography diagnostic May be appropriate Expert Consensus ☢☢ 0.1-1mSv 4 4 1 0 6 4 3 1 0 1 0
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 7 2 3 0 2 0 1 0 0
References Study Quality
34 (16244803) 2
35 (10894136) 1
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
34 (16244803) 2
35 (10894136) 1
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 4 0 0 0 0 0 0
References Study Quality
23 (26761528) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 9 3 3 0 0 0 0 0 0
References Study Quality
23 (26761528) 4
CT chest abdomen pelvis without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 2 0 0 0 0 0 0
References Study Quality
23 (26761528) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 1 0 0 0 0 0 0
References Study Quality
33 (27813620) 4
30 (26050348) 3
31 (19771506) Good
32 (23890400) 3
Variant 2: Female. New palpable, bilateral, axillary lump. Initial imaging of the axilla.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 0 2 12
References Study Quality
37 (29083988) 3
20 (26847811) 3
41 (1503012) 4
40 (15344978) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 1 5 1 4 2 0 0 0
References Study Quality
32 (23890400) 3
7 (-3182246) 4
21 (-3194181) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 1 5 3 2 2 0 0 0
References Study Quality
7 (-3182246) 4
21 (-3194181) 4
MRI breast without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 9 1 1 1 2 0 1 0 0
References Study Quality
34 (16244803) 2
35 (10894136) 1
39 (19822403) 4
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 0 0 0
References Study Quality
34 (16244803) 2
35 (10894136) 1
39 (19822403) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 6 0 1 0 0 1 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 2 1 1 0 0 0 0 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 4 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 2 1 1 2 0 0 0 0
References Study Quality
38 (23002144) 4
Variant 3: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 5 6 0 0 1
References Study Quality
59 (25797740) 2
60 (27896640) 3
61 (28427743) 3
63 (25667099) 3
58 (24859939) 2
54 (29279156) 3
5 (28898379) 1
55 (24074422) 3
56 (23628226) 2
57 (25205303) 3
62 (21597359) Good
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 7 1 2 3 1 1 0 0
References Study Quality
51 (23359240) 4
50 (25727555) 4
53 (24687378) 3
48 (29516387) 4
7 (-3182246) 4
52 (31885585) 4
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 0 0 0 0 0
References Study Quality
51 (23359240) 4
50 (25727555) 4
53 (24687378) 3
48 (29516387) 4
7 (-3182246) 4
52 (31885585) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 0 1 0 0 0 0 0
References Study Quality
45 (30797241) 3
44 (28890415) 3
47 (28236777) 1
46 (31685110) 4
7 (-3182246) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 13 3 0 0 0 0 0 0 0
References Study Quality
45 (30797241) 3
44 (28890415) 3
47 (28236777) 1
46 (31685110) 4
7 (-3182246) 4
CT chest abdomen pelvis without IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
45 (30797241) 3
44 (28890415) 3
47 (28236777) 1
46 (31685110) 4
7 (-3182246) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 2 0 0 0 0 0 0
References Study Quality
48 (29516387) 4
46 (31685110) 4
7 (-3182246) 4
49 (20140703) Good
Variant 4: Female. Newly diagnosed breast cancer, 2 cm or less, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 13
References Study Quality
83 (26711795) 1
90 (23664535) 3
85 (22972506) 2
86 (29972239) Good
87 (29381381) 1
91 (27206399) 3
58 (24859939) 2
54 (29279156) 3
62 (21597359) Good
81 (18955508) 3
82 (16632729) 4
84 (23436877) 2
88 (23515655) 3
89 (24455284) 3
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 6 2 0 5 0 2 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
MRI breast without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 7 1 1 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 4 1 0 0 0 0 0 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 3 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 6 2 0 0 0 0 0 0
References Study Quality
71 (23672678) 2
70 (30504372) 2
67 (28984814) 2
75 (28208155) 3
69 (28139203) Good
72 (27015862) 3
78 (27069160) 4
68 (26722071) 3
74 (26219608) 3
73 (25298170) 4
76 (30017264) Good
77 (26537078) 3
49 (20140703) Good
Variant 5: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-negative. Initial imaging of the axilla following diagnostic mammography or DBT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 6 1 2 3
References Study Quality
59 (25797740) 2
60 (27896640) 3
92 (26314782) 4
61 (28427743) 3
63 (25667099) 3
58 (24859939) 2
54 (29279156) 3
5 (28898379) 1
6 (-3182230) 4
55 (24074422) 3
56 (23628226) 2
57 (25205303) 3
62 (21597359) Good
96 (24663048) 4
MRI breast without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 1 2 1 2 8 1 1 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
92 (26314782) 4
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
MRI breast without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 1 0 0 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 4 2 1 0 0 0 0 0
References Study Quality
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 4 1 0 0 0 0 0 0
References Study Quality
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
CT chest abdomen pelvis without IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 5 1 1 0 0 0 0 0
References Study Quality
93 (14722036) 1
94 (25214641) 2
7 (-3182246) 4
95 (27129866) 2
Variant 6: Female. Newly diagnosed breast cancer, greater than 2 cm, with clinical node-positive. Initial imaging of the axilla following diagnostic mammography or DBT (prior to treatment).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 13
References Study Quality
59 (25797740) 2
60 (27896640) 3
92 (26314782) 4
105 (29705286) 1
61 (28427743) 3
63 (25667099) 3
58 (24859939) 2
54 (29279156) 3
7 (-3182246) 4
55 (24074422) 3
62 (21597359) Good
103 (19933672) 3
104 (20047809) 3
MRI breast without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 9 1 1 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
CT chest abdomen pelvis with IV contrast May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 2 1 8 3 0 0 0 0
References Study Quality
51 (23359240) 4
50 (25727555) 4
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
95 (27129866) 2
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 1 1 2 9 2 0 0 0
References Study Quality
102 (23220901) 4
93 (14722036) 1
94 (25214641) 2
71 (23672678) 2
99 (29137072) 2
73 (25298170) 4
95 (27129866) 2
100 (21364034) 3
101 (22011459) 3
MRI breast without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
References Study Quality
79 (27842679) 3
15 (24220324) 2
48 (29516387) 4
69 (28139203) Good
80 (27161063) Good
7 (-3182246) 4
52 (31885585) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 7 8 1 0 0 0 0 0 0
References Study Quality
51 (23359240) 4
50 (25727555) 4
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
95 (27129866) 2
CT chest abdomen pelvis without IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
51 (23359240) 4
50 (25727555) 4
92 (26314782) 4
47 (28236777) 1
14 (28161935) 3
7 (-3182246) 4
95 (27129866) 2
98 (25846421) 3
Variant 7: Female. Breast cancer, greater than 2 cm in size, at mid-treatment of neoadjuvant chemotherapy, with initial clinical node-negative disease but now presenting with new palpable axillary lump. Imaging of the axilla at mid-treatment.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 12
References Study Quality
86 (29972239) Good
109 (28314842) 2
Digital breast tomosynthesis diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 3 3 4 3 5 1 0 0 2 0 0
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 4 4 4 1 0 0 2 0 0
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 4 5 0 2 1 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 1 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 5 0 3 0 0 1 0 0
References Study Quality
108 (28267534) 2
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 7 1 1 0 0 1 0 0
References Study Quality
108 (28267534) 2
CT chest abdomen pelvis without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 1 1 0 0 0 0 0
References Study Quality
108 (28267534) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 3 2 0 0 0 1 0 0
Variant 8: Female. Breast cancer, greater than 2 cm in size, clinical node-negative. Imaging of the axilla after completion of neoadjuvant chemotherapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 1 2 7 2 1 1 0
References Study Quality
129 (25646192) 3
130 (19345896) Good
7 (-3182246) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 2 1 3 1 8 0 1 0 0
References Study Quality
124 (23297042) Inadequate
127 (20224378) 3
126 (21947592) 3
122 (20143266) 2
123 (29877048) Good
121 (27451892) 2
112 (30048319) 3
125 (30152746) 4
128 (31956542) 2
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 7 1 4 0 2 0 0 0 1
References Study Quality
113 (30396666) 3
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 7 1 4 0 1 1 1 0 0
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 0 3 0 1 0 0 0 0
References Study Quality
124 (23297042) Inadequate
127 (20224378) 3
126 (21947592) 3
122 (20143266) 2
123 (29877048) Good
121 (27451892) 2
112 (30048319) 3
125 (30152746) 4
128 (31956542) 2
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 1 2 0 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 2 3 0 0 0 0 0 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 1 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 3 4 0 0 0 0 0 0
References Study Quality
114 (22734080) Inadequate
118 (21960111) Good
112 (30048319) 3
115 (26981529) Good
116 (23714689) Good
117 (28477166) Good
119 (30714256) 3
120 (31826976) 2
Variant 9: Female. Breast cancer, greater than 2 cm in size, clinical node-positive. Imaging of the axilla after completion of neoadjuvant chemotherapy and prior to surgery.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 1 2 3 7
References Study Quality
143 (23846781) 3
141 (27411945) 3
140 (30366878) 4
87 (29381381) 1
139 (28704697) 3
8 (26811528) 2
10 (26649589) 3
142 (25891674) 4
88 (23515655) 3
138 (31897672) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 5 7 1 1 0 0
References Study Quality
124 (23297042) Inadequate
121 (27451892) 2
112 (30048319) 3
137 (30152744) 2
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 4 5 2 0 0 0 0 1
References Study Quality
113 (30396666) 3
131 (30673338) 4
Mammography diagnostic Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 2 2 4 5 3 2 0 0 1 0 0
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 1 2 0 0 0 0 0 0
References Study Quality
124 (23297042) Inadequate
121 (27451892) 2
112 (30048319) 3
137 (30152744) 2
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 1 1 0 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 10 3 2 0 0 0 0 0 0
CT chest abdomen pelvis without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 0 0 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 3 3 2 1 1 0 0
References Study Quality
102 (23220901) 4
134 (25458227) 4
118 (21960111) Good
117 (28477166) Good
119 (30714256) 3
120 (31826976) 2
132 (29758503) Good
133 (27401897) Good
135 (22761341) 3
136 (22037787) 3
Variant 10: Female. Newly diagnosed locally recurrent breast cancer. Initial imaging of the axilla following diagnostic mammography or DBT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 7 4 2 2 1
References Study Quality
154 (31558898) 4
MRI breast without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 3 8 2 1 0 0
References Study Quality
156 (26744477) 3
158 (27902592) 3
157 (31161975) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 3 7 5 0 0 0
References Study Quality
7 (-3182246) 4
155 (27428888) Good
MRI breast without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
References Study Quality
156 (26744477) 3
158 (27902592) 3
157 (31161975) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 0 0 0 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 4 1 1 1 1 0 0 0
References Study Quality
92 (26314782) 4
7 (-3182246) 4
154 (31558898) 4
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 8 5 2 1 0 0 0 0 0
References Study Quality
92 (26314782) 4
7 (-3182246) 4
154 (31558898) 4
CT chest abdomen pelvis without IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 0 0 0 1 0 0
References Study Quality
92 (26314782) 4
7 (-3182246) 4
154 (31558898) 4
Variant 11: Female. Suspicious axillary node on mammography or ultrasound. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US-guided core biopsy axillary node Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 10
References Study Quality
86 (29972239) Good
US-guided fine needle aspiration biopsy axillary node Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 0 3 4 7
References Study Quality
63 (25667099) 3
62 (21597359) Good
MRI breast without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 3 3 0 3 2 1 0 0
References Study Quality
123 (29877048) Good
34 (16244803) 2
35 (10894136) 1
39 (19822403) 4
MRI breast without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 1 0 0 0 0
References Study Quality
123 (29877048) Good
34 (16244803) 2
35 (10894136) 1
39 (19822403) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 0 1 0 0 0 0 0
CT chest abdomen pelvis with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 2 1 1 1 0 0 0
References Study Quality
47 (28236777) 1
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 8 3 3 0 1 0 0 0 0
References Study Quality
47 (28236777) 1
CT chest abdomen pelvis without IV contrast Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 1 0 1 0 0 0 0
References Study Quality
47 (28236777) 1
FDG-PET/CT skull base to mid-thigh Usually not appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 6 1 3 1 3 1 0 0 0
References Study Quality
160 (22474203) 1
33 (27813620) 4
159 (12355001) 4
31 (19771506) Good
32 (23890400) 3
39 (19822403) 4
Variant 12: Female. Suspicious axillary node on any other imaging modality (excluding mammography and ultrasound). Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US axilla Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 3 2 9
References Study Quality
83 (26711795) 1
90 (23664535) 3
85 (22972506) 2
87 (29381381) 1
58 (24859939) 2
54 (29279156) 3
55 (24074422) 3
62 (21597359) Good
84 (23436877) 2
88 (23515655) 3
89 (24455284) 3
103 (19933672) 3
104 (20047809) 3
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 2 4 8
References Study Quality
161 (28710582) 2
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 1 1 3 4 6
References Study Quality
162 (22227922) 3
US-guided core biopsy axillary node May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 5 5 1 0 2
References Study Quality
59 (25797740) 2
60 (27896640) 3
86 (29972239) Good
61 (28427743) 3
63 (25667099) 3
62 (21597359) Good
US-guided fine needle aspiration biopsy axillary node May be appropriate Moderate O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 7 5 1 1 0
References Study Quality
86 (29972239) Good
163 (17033920) 2
164 (12736105) 3
165 (12618878) 3
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.