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Appropriateness Criteria

Variant 1: Pregnant female. Age 40 years or older. Breast cancer screening. Any 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 2 2 11
References Study Quality
8 (30392595) 4
3 (37708073) 4
2 (32755376) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 3 11
References Study Quality
2 (32755376) 4
17 (34903436) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 12 0 0 0 0
References Study Quality
2 (32755376) 4
21 (23116728) 2
20 (25329763) 3
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 7 4 1 1 1 0 0 0 1
References Study Quality
11 (-3188535) 4
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 1
References Study Quality
11 (-3188535) 4
7 (23345353) 4
3 (37708073) 4
MRI breast without and with IV contrast abbreviated Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 1
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 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
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
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 0 0 0 1
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 2: Pregnant female. Age less than 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
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 2 1 11 0 0 0 0
References Study Quality
2 (32755376) 4
20 (25329763) 3
21 (23116728) 2
Digital breast tomosynthesis screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 3 1 0 0 0 0 0 0
Mammography screening Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 11 3 1 0 0 0 0 0 0
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 12 3 0 0 0 0 0 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 1 0 0 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without and with IV contrast abbreviated Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 2 0 0 1 0 0 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 1 0 1
MRI breast without IV contrast abbreviated Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 0 0 1 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 0 1 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 3: Pregnant 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 0 1 1 0 2 5 6
References Study Quality
2 (32755376) 4
3 (37708073) 4
8 (30392595) 4
Mammography screening Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 1 1 0 2 5 6
References Study Quality
2 (32755376) 4
US breast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 10 2 0 0 0
References Study Quality
2 (32755376) 4
20 (25329763) 3
21 (23116728) 2
Mammography with IV contrast Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv 1 1 8 2 2 2 1 0 0 0 0
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 1 0 0 0
References Study Quality
7 (23345353) 4
11 (-3188535) 4
MRI breast without and with IV contrast abbreviated Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 1 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 0 1 0 0 1 0 1
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
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 0 0 1 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 4: Pregnant 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 1 0 14
References Study Quality
2 (32755376) 4
7 (23345353) 4
24 (21343518) 3
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 8 4 1 0 2 0 0 0 0
References Study Quality
23 (34798561) 4
22 (37236740) 4
8 (30392595) 4
3 (37708073) 4
2 (32755376) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 8 4 1 0 1 1 0 0 0
References Study Quality
2 (32755376) 4
10 (26341843) 4
22 (37236740) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 11 2 0 1 1 0 0 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 1 0 0 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 0 1 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 1 0 1 0 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 5: Pregnant 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] 9 9 0 0 1 0 0 2 2 0 10
References Study Quality
2 (32755376) 4
7 (23345353) 4
10 (26341843) 4
22 (37236740) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 4 2 4 5
References Study Quality
23 (34798561) 4
22 (37236740) 4
8 (30392595) 4
3 (37708073) 4
2 (32755376) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 4 2 3 6
References Study Quality
2 (32755376) 4
22 (37236740) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 1 1 1 0 0 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 1 0 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 0 1 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 6: Pregnant 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 1 2 12
References Study Quality
2 (32755376) 4
7 (23345353) 4
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 2 2 0 0 2 0 0 0
References Study Quality
2 (32755376) 4
3 (37708073) 4
8 (30392595) 4
22 (37236740) 4
23 (34798561) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 2 2 0 0 2 0 0 0
References Study Quality
2 (32755376) 4
10 (26341843) 4
22 (37236740) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 1 1 0 1 0 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 1 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 0 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 1 0 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 7: Pregnant 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] 9 9 0 0 0 0 1 1 2 1 10
References Study Quality
2 (32755376) 4
7 (23345353) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 1 3 4 7
References Study Quality
2 (32755376) 4
25 (36436958) 4
3 (37708073) 4
8 (30392595) 4
23 (34798561) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 8 8 0 0 0 0 0 1 3 4 7
References Study Quality
2 (32755376) 4
25 (36436958) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 0 2 0 0 1 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 1 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 8: Pregnant 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 axilla Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 5 8
References Study Quality
26 (34469221) 4
27 (31714846) 4
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 2 1 1 3 8
References Study Quality
2 (32755376) 4
3 (37708073) 4
7 (23345353) 4
8 (30392595) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 0 4 11
References Study Quality
2 (32755376) 4
3 (37708073) 4
8 (30392595) 4
23 (34798561) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 0 1 3 11
References Study Quality
2 (32755376) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 9 2 0 1 1 1 0 1 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 1
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 1 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 0 1 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 9: Pregnant female. Breast infection or abscess suspected. 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 1 0 14
References Study Quality
2 (32755376) 4
7 (23345353) 4
Digital breast tomosynthesis diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 6 6 0 0 1 1 4 7 0 1 1
References Study Quality
2 (32755376) 4
Mammography diagnostic May be appropriate Limited ☢☢ 0.1-1mSv 6 6 0 0 1 1 4 7 0 1 1
References Study Quality
2 (32755376) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 4 0 0 0 1 0 0 0
References Study Quality
11 (-3188535) 4
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 1 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 0 1 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 2 0 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 10: Pregnant female. Palpable breast mass. US findings are probably benign. 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 breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 1 2 1 10
References Study Quality
2 (32755376) 4
7 (23345353) 4
28 (32816258) 4
US axilla Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 1 0 0 0 0
Digital breast tomosynthesis diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 8 2 2 1 0 2 0 0 0
References Study Quality
2 (32755376) 4
3 (37708073) 4
8 (30392595) 4
23 (34798561) 4
Mammography diagnostic Usually not appropriate Limited ☢☢ 0.1-1mSv 2 2 7 3 2 1 0 2 0 0 0
References Study Quality
2 (32755376) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 2 0 0 0 1 0 0
References Study Quality
11 (-3188535) 4
Image-guided core biopsy breast Usually not appropriate Limited Varies Varies 2 2 7 5 1 0 1 1 0 0 0
References Study Quality
2 (32755376) 4
Image-guided fine needle aspiration breast Usually not appropriate Limited Varies Varies 1 1 8 4 1 1 1 0 0 0 0
References Study Quality
3 (37708073) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 1 0 0
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 1 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
Variant 11: Pregnant female. Palpable breast mass. US findings are suspicious or highly suggestive of malignancy. 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 Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 2 2 3 8
US breast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 3 1 1 2 7
References Study Quality
2 (32755376) 4
7 (23345353) 4
Digital breast tomosynthesis diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 1 1 3 10
References Study Quality
2 (32755376) 4
3 (37708073) 4
8 (30392595) 4
23 (34798561) 4
Mammography diagnostic Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 2 1 3 9
References Study Quality
2 (32755376) 4
Image-guided core biopsy breast Usually appropriate Limited Varies Varies 9 9 0 0 0 0 0 0 1 2 12
References Study Quality
2 (32755376) 4
Image-guided fine needle aspiration breast May be appropriate Limited Varies Varies 5 5 1 0 0 4 9 0 1 0 0
References Study Quality
3 (37708073) 4
Mammography with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 2 0 0 2 1 0 0 0
References Study Quality
11 (-3188535) 4
MRI breast without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 13 1 0 0 0 0 0 0 1
References Study Quality
3 (37708073) 4
7 (23345353) 4
11 (-3188535) 4
MRI breast without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 1 0 0 0 1
Sestamibi MBI Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 0 0 0 1 0 0 0 0
References Study Quality
18 (-3197536) 4
19 (35523526) 4
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.