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Appropriateness Criteria

Variant 1: Lactating female. Age 40 years or older. Breast cancer screening. Average risk.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 3 12
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 3 11
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 0 6 6 3 0 0
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
MRI breast without and with IV contrast abbreviated May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 10 2 2 0 0
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
US breast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 3 5 1 3 1 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 2 4 7 0 0 1 0 0 1
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 11 2 2 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 2: Lactating female. Age under 25 years. Breast cancer screening. Higher-than-average risk.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI breast without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 4 1 7 2 1 0 0
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 1 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 3 2 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 4 1 0 0 0 0 0 0
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 2 2 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 2 3 1 1 1 0 0 0
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 3: Lactating female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Digital breast tomosynthesis screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 1 0 1 0 2 8 3
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 1 0 1 1 3 6 3
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 4 5 6
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
MRI breast without and with IV contrast abbreviated Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 0 0 0 1 1 5 5 2
References Study Quality
36 (38416921) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
12 (38424810) 4
US breast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 2 1 1 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 3 2 4 4 0 0 1 0 1
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 9 3 3 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 4: Lactating female. Age less than 30 years. Focal pain or palpable breast mass. 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 0 0 0 4 11
References Study Quality
49 (38141239) 4
48 (37708073) 4
13 (31539269) 4
29 (32755376) 4
43 (32870133) 3
12 (38424810) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 4 2 7 1 1 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 3 3 4 3 6 1 1 0 0 0 0
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 5 1 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 1 0 0 0 0 0 0
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
69 (36348090) 3
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Variant 5: Lactating female. Age 30 years or older. Focal pain or palpable breast mass. 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] 7 7 0 0 0 0 7 1 1 3 4
References Study Quality
49 (38141239) 4
48 (37708073) 4
13 (31539269) 4
29 (32755376) 4
43 (32870133) 3
12 (38424810) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 2 5 8
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 1 0 1 5 8
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 8 2 3 1 0 0 1 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
69 (36348090) 3
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 2 1 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
Variant 6: Lactating female. Age less than 30 years. Clinically suspicious 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 0 0 0 3 12
References Study Quality
29 (32755376) 4
12 (38424810) 4
13 (31539269) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 4 4 5 0 2 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 4 4 4 0 2 1 0 0 0
References Study Quality
49 (38141239) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 4 1 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 4 1 0 0 0 0 0 0
References Study Quality
49 (38141239) 4
69 (36348090) 3
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 3 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 3 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 7: Lactating female. Age 30 years or older. Clinically suspicious 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] 7 7 0 0 0 0 6 2 1 1 6
References Study Quality
49 (38141239) 4
29 (32755376) 4
13 (31539269) 4
12 (38424810) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 2 4 9
References Study Quality
49 (38141239) 4
29 (32755376) 4
12 (38424810) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 3 4 8
References Study Quality
49 (38141239) 4
29 (32755376) 4
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 9 3 1 2 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 0 6 0 2 2 0 0 0
References Study Quality
49 (38141239) 4
69 (36348090) 3
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 8 4 2 1 0 0 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 8: Lactating female. Newly diagnosed breast cancer. Locoregional staging.
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] 8 8 0 0 0 0 0 1 3 8 3
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
76 (36832092) 0
12 (38424810) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 2 3 10
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
76 (36832092) 0
12 (38424810) 4
Mammography diagnostic Usually appropriate Moderate ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 3 11
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
76 (36832092) 0
12 (38424810) 4
MRI breast without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 2 3 2 7
References Study Quality
49 (38141239) 4
48 (37708073) 4
3 (31529255) 0
29 (32755376) 4
69 (36348090) 3
82 (37278853) 4
42 (30229271) 4
34 (28830193) 4
12 (38424810) 4
US axilla May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 4 2 3 1
References Study Quality
49 (38141239) 4
48 (37708073) 4
29 (32755376) 4
76 (36832092) 0
12 (38424810) 4
Mammography with IV contrast Usually not appropriate Strong ☢☢ 0.1-1mSv 3 3 4 3 3 2 3 0 0 0 0
References Study Quality
48 (37708073) 4
29 (32755376) 4
12 (38424810) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 0 0 0 0 0 0
References Study Quality
29 (32755376) 4
3 (31529255) 0
12 (38424810) 4
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 6 5 1 2 0 1 0 0 0
References Study Quality
29 (32755376) 4
12 (38424810) 4
Variant 9: Lactating female. Suspected breast infection or abscess. 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 Moderate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 12
References Study Quality
48 (37708073) 4
89 (31154537) 4
Digital breast tomosynthesis diagnostic May be appropriate Expert Consensus ☢☢ 0.1-1mSv 6 6 0 1 0 0 6 2 2 2 3
References Study Quality
48 (37708073) 4
Mammography diagnostic May be appropriate Expert Consensus ☢☢ 0.1-1mSv 6 6 0 1 0 0 6 2 2 2 3
References Study Quality
48 (37708073) 4
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 10 5 0 0 0 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 4 0 0 0 0 0 0 0
References Study Quality
48 (37708073) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 0 0 0 0 0
Sestamibi MBI Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 2 0 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.