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Appropriateness Criteria

Variant 1: Rectal cancer. Locoregional staging. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pelvis transrectal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 6 10 1
References Study Quality
58 (23280021) 3
23 (20103950) 3
59 (21176897) 3
60 (17294198) 3
36 (21802588) 1
61 (21920011) 3
63 (21795480) 3
64 (21550864) 3
22 (18697365) 4
65 (17674104) 3
66 (9276704) 4
62 (30736712) 3
MRI pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 17
References Study Quality
36 (21802588) 1
30 (21225363) 3
31 (21135417) 2
32 (21671218) 3
33 (21674192) 2
34 (22271205) M
35 (23049209) 2
37 (22156868) 2
38 (20464422) 3
39 (22434494) 3
40 (23571146) 1
41 (17329685) 1
42 (19388124) 2
43 (17463134) 3
44 (17504336) M
45 (17504337) 3
46 (22426259) 2
47 (21913017) 4
48 (21876084) 2
49 (21590453) 3
50 (21509631) 2
51 (21475011) 4
53 (21926843) 3
54 (21327602) 3
52 (28691219) 3
57 (29570375) 3
55 (28900855) 4
56 (28497665) 3
MRI pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 6 3 6
References Study Quality
36 (21802588) 1
30 (21225363) 3
31 (21135417) 2
32 (21671218) 3
33 (21674192) 2
34 (22271205) M
35 (23049209) 2
37 (22156868) 2
38 (20464422) 3
39 (22434494) 3
40 (23571146) 1
41 (17329685) 1
42 (19388124) 2
43 (17463134) 3
44 (17504336) M
45 (17504337) 3
46 (22426259) 2
47 (21913017) 4
48 (21876084) 2
49 (21590453) 3
50 (21509631) 2
51 (21475011) 4
53 (21926843) 3
54 (21327602) 3
52 (28691219) 3
57 (29570375) 3
55 (28900855) 4
56 (28497665) 3
CT abdomen and pelvis with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 0 15 2 0 0 1
References Study Quality
8 (19571705) 2
23 (20103950) 3
22 (18697365) 4
16 (8646512) 3
18 (9568652) 1
17 (15376205) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
21 (31305437) 4
CT colonography May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 0 0 2 9 5 1 1 0 0
References Study Quality
27 (29137613) 3
FDG-PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 7 5 4 1 0 0
References Study Quality
28 (29378659) 4
29 (26828149) 3
CT abdomen and pelvis without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 3 7 2 3 0 0 1 0
References Study Quality
8 (19571705) 2
23 (20103950) 3
22 (18697365) 4
16 (8646512) 3
18 (9568652) 1
17 (15376205) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
21 (31305437) 4
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 4 12 0 0 0 0 0 1
References Study Quality
8 (19571705) 2
23 (20103950) 3
22 (18697365) 4
16 (8646512) 3
18 (9568652) 1
17 (15376205) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
21 (31305437) 4
Variant 2: Rectal cancer. Locoregional staging. Postneoadjuvant therapy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI pelvis without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 2 16
References Study Quality
8 (19571705) 2
42 (19388124) 2
46 (22426259) 2
47 (21913017) 4
48 (21876084) 2
49 (21590453) 3
50 (21509631) 2
51 (21475011) 4
83 (28473079) 4
84 (31939890) Good
99 (31490825) 3
101 (30403572) 3
103 (30280248) 3
90 (30327166) 3
100 (29668301) 3
91 (29337774) 3
85 (29043428) 4
92 (28786006) 3
89 (28237642) 3
80 (28177989) 4
102 (27959622) 3
86 (27331883) 4
97 (27055660) 3
82 (26953983) 3
81 (26747329) 4
87 (27489868) 3
88 (21343320) 2
94 (31386575) 3
93 (30844347) 4
95 (25243543) 3
96 (19403848) 4
98 (19830503) 4
MRI pelvis without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 6 2 6 2
References Study Quality
8 (19571705) 2
42 (19388124) 2
46 (22426259) 2
47 (21913017) 4
48 (21876084) 2
49 (21590453) 3
50 (21509631) 2
51 (21475011) 4
83 (28473079) 4
84 (31939890) Good
99 (31490825) 3
101 (30403572) 3
103 (30280248) 3
90 (30327166) 3
100 (29668301) 3
91 (29337774) 3
85 (29043428) 4
92 (28786006) 3
89 (28237642) 3
80 (28177989) 4
102 (27959622) 3
86 (27331883) 4
97 (27055660) 3
82 (26953983) 3
81 (26747329) 4
87 (27489868) 3
88 (21343320) 2
94 (31386575) 3
93 (30844347) 4
95 (25243543) 3
96 (19403848) 4
98 (19830503) 4
US pelvis transrectal May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 3 4 2 3 5 1 0 0
References Study Quality
63 (21795480) 3
64 (21550864) 3
22 (18697365) 4
104 (29848812) 3
108 (29857861) 3
107 (29944579) 2
106 (27858916) Good
105 (26323642) 3
109 (10950005) 4
CT abdomen and pelvis with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 0 13 3 0 0 1
References Study Quality
8 (19571705) 2
23 (20103950) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
72 (26855391) 3
67 (20452636) 3
68 (22497951) 4
69 (18589355) 3
70 (26130666) 4
71 (-3192240) 4
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 10 5 0 0 0
References Study Quality
78 (31229791) 3
72 (26855391) 3
74 (26711129) 4
73 (22644560) 3
75 (18424814) 3
76 (31833807) 4
77 (20190455) 4
79 (25181962) 2
CT abdomen and pelvis without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 5 6 2 1 1 0 1 0
References Study Quality
8 (19571705) 2
23 (20103950) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
72 (26855391) 3
67 (20452636) 3
68 (22497951) 4
69 (18589355) 3
70 (26130666) 4
71 (-3192240) 4
CT colonography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 0 5 12 0 1 0 0 0 0
CT abdomen and pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 1 3 13 0 0 0 0 0 1
References Study Quality
8 (19571705) 2
23 (20103950) 3
19 (19949791) 3
20 (21110194) 2
24 (22100372) 3
25 (22281979) 2
26 (22271004) 3
72 (26855391) 3
67 (20452636) 3
68 (22497951) 4
69 (18589355) 3
70 (26130666) 4
71 (-3192240) 4
Variant 3: Colorectal cancer. Staging for distant metastases. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT chest with IV contrast and MRI abdomen with IV contrast Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv 8 8 1 0 0 0 2 3 2 8 2
CT chest abdomen pelvis with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 16
References Study Quality
110 (20392584) 2
117 (21263087) 2
118 (23150701) 2
17 (15376205) 3
112 (1914737) 3
114 (15841734) 3
113 (11152779) 2
116 (15044747) 2
120 (10421258) 3
115 (16484347) 2
111 (21293130) 3
122 (20175945) 4
121 (20151212) 4
123 (20607759) 4
124 (22169348) 4
119 (27779994) 3
CT chest with IV contrast and MRI abdomen without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 5 1 0 2 2 8 4 1 0 0
CT chest without IV contrast and MRI abdomen with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 6 6 1 0 0 1 4 5 2 5 0
CT chest without IV contrast and MRI abdomen without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 5 1 0 2 5 7 2 1 0 0
CT chest abdomen pelvis without IV contrast May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 6 3 5 1 1 0 0
References Study Quality
110 (20392584) 2
117 (21263087) 2
118 (23150701) 2
17 (15376205) 3
112 (1914737) 3
114 (15841734) 3
113 (11152779) 2
116 (15044747) 2
120 (10421258) 3
115 (16484347) 2
111 (21293130) 3
122 (20175945) 4
121 (20151212) 4
123 (20607759) 4
124 (22169348) 4
119 (27779994) 3
FDG-PET/CT skull base to mid-thigh May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 1 3 10 2 1 0
References Study Quality
130 (21867996) 3
125 (21472100) 3
126 (17387540) 3
127 (17148724) 2
128 (21431987) 2
129 (17610107) 4
131 (19486092) 2
132 (17195075) 2
133 (20960208) 3
134 (19419820) 2
CT chest without and with IV contrast and MRI abdomen without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 2 4 8 2 2 0 0 0 0
CT chest abdomen pelvis without and with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 2 1 13 1 0 0 0 0 1
References Study Quality
110 (20392584) 2
117 (21263087) 2
118 (23150701) 2
17 (15376205) 3
112 (1914737) 3
114 (15841734) 3
113 (11152779) 2
116 (15044747) 2
120 (10421258) 3
115 (16484347) 2
111 (21293130) 3
122 (20175945) 4
121 (20151212) 4
123 (20607759) 4
124 (22169348) 4
119 (27779994) 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.